A healthy balance between insurers, doctors and patients

Peter Donnelly

• Last Updated: April 20. 2009 9:09PM UAE / April 20. 2009 5:09PM GMT

The health insurance industry in the UAE is a minefield, and that state of affairs is not limited to this country. If you’re an individual looking for medical coverage, the prospect of finding the right insurance policy can be daunting. If you’re a doctor, there is enormous pressure to meet the needs of the patient in ways no longer limited to treatment: today it also includes addressing the financial cost in real terms for that patient. If you’re an insurer, providing policies that offer a level of health care that meets expectations and is cost effective is a thankless task.

@body arnhem:It’s apparent that these three distinct groups will often be at loggerheads and it comes as no surprise that fraudulent health insurance claims are a regular occurrence in the UAE, as The National reported earlier this year.

This is partly because many of the policies offered by insurance companies cover the bare minimum in terms of treatment and individuals covered by such policies may find themselves in dire straits if they become seriously ill. When someone in this situation requires treatment that isn’t covered by their insurance, it is natural to expect a level of fraud.

It’s a complex issue but there are two fundamental aspects that can be addressed initially. The first relates to cost: basically you get what you pay for. When one considers that health insurance premiums in the United States are in general two to three times higher than those paid in the Middle East, it puts into perspective the level of treatment that will be made available. If a policy holder in the US is willing to pay US$3,000 (Dh11,000) annually, then someone paying about $1,000 each year in the Middle East can’t expect the same level of care. From that $1,000, remove costs related to administration, marketing, sales and profit for the insurance company and there is little left to cover medical expenses for the policy holder. But this isn’t to say that premiums in the US should be used as a model for others to follow. The consensus there is that costs are spiralling out of control and many argue that there are unnecessary treatments being covered. The answer appears to be to find a balance.

In the UAE part of the problem is that in general individuals don’t actually know what is and isn’t covered by their health insurance policies, especially when it comes to policies provided by employers. For the most part individuals find out only when they are hit with a medical bill. Health insurers themselves should make it clear what each policy doesn’t cover (instead of putting it in small print) as opposed to highlighting what is covered, and they should also be more vocal about the need for clients to pay more to receive better treatment.

The second issue that needs to be addressed is linked to the expectations of policy holders. To a large extent it’s up to individuals themselves to push for specific treatments to be included in their policies. I recently spoke to Dr Albert Losken, a cosmetic and plastic surgeon at the American Academy of Cosmetic Surgery Hospital in Dubai. We discussed insurance coverage and he mentioned the example of breast reconstruction for breast cancer patients who have undergone mastectomies in the United States. He said that although reconstruction is considered to be a cosmetic procedure it has become standard practice.

“Breast reconstruction is common now. Seventy per cent will get reconstruction after mastectomy,” he said. “Physically and psychologically it’s better to get reconstruction. There’s no functional benefit, but they choose to do it. It makes them feel better and insurance covers reconstruction by law after mastectomy.

“Insurance covers reconstruction by law” is the key phrase here. Initially, because reconstruction wasn’t considered to be a necessary component of the overall well-being of the patient, insurance policies didn’t cover it. Through public awareness campaigns, most notably driven by Oprah Winfrey, the American television talk show host, the public demanded that breast reconstruction be covered. It’s a success that shouldn’t be overlooked in this part of the world.

It’s time for patients and the public at large to push for better health insurance coverage. Breast reconstruction is only one example, and there are many other areas that could be considered.

For example, try claiming the cost of visiting a nutritionist from your insurance company. We live in a society where long-term chronic disease has become prevalent, and obesity and diabetes are rife. One would think a nutritionist would be in the perfect position to offer advice to patients about their eating habits with the long-term goal of helping prevent these types of diseases.

Unfortunately insurance companies don’t view it this way. Moreover, policy holders aren’t willing to pay more until they discover their coverage isn’t as broad as they first thought, and by then it can be too late.

There has to be greater communication between medical practitioners, insurance companies and the public over this issue. The responsibility cannot be placed on the Government to find solutions. The authorities in the UAE have repeatedly shown that they will develop policies to meet the needs of a booming population, but expecting legislation to be introduced that tackles health insurance fraud is the equivalent of putting a plaster on a gaping wound.

Insurers must start marketing the concept that a rise in premiums will deliver better health care, and the public must become more vocal about their expectations when dealing with their insurance companies, their doctors and also their employers. Until this happens fraud will remain a common practice.

Peter Donnelly is a science correspondent in the life science division at IIR Middle East