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Abu Dhabi, UAEFriday 14 December 2018

Delayed insurance approvals hold up patient surgeries

Insurers are seeking cheaper alternatives overseas as patients demand expensive care from visiting doctors

Coronary bypass procedures and laparoscopic surgeries are the most common treatments that insurers seek a second opinion for. American Academy of Cosmetic Surgery Hospital
Coronary bypass procedures and laparoscopic surgeries are the most common treatments that insurers seek a second opinion for. American Academy of Cosmetic Surgery Hospital

Delays to health insurance approvals on high risk surgeries is forcing some patients overseas for medical procedures, claim hospitals.

A culture of overspending and waste in healthcare has led to a more cautious health insurance environment, with patients now feeling the pinch.

Hospitals have reported more insurers requiring a second opinion, or seeking cheaper alternatives overseas for some surgeries, with industry insiders warning the trend could halt market growth.

Delays of up to six months have been reported, resulting in missed appointments with visiting doctors, who usually have packed schedules on short-term UAE visits.

“We find delays in approvals particularly when it is for a high cost surgery with most insurance companies,” said Dr Sharmila Jadav, a qualified GP who is now deputy director of Insurance at Zulekha Hospital.

“Insurers often ask for a second opinion before the surgery is approved, and at times they want to send the patient to their home country for the procedure as it is more cost effective, even when they consider the cost of travel and accommodation for the patient and their family.”

Patients have been forced to find alternative medical interventions in clinics in Thailand, Malaysia, India and Africa as insurers either failed to sign off approvals in time to secure the services of a visiting doctor, or rejected the claim outright.

“Generally, insurers try to do this with cases that are not high risk, but even then a longer turnaround time can be stressful for patients,” said Dr Jadav.

“It causes problems as the patient is already unwell, so any delays in getting the required treatment can prolong their discomfort and add to their stress.

“This in itself can worsen a patient’s condition. Sending patients home for surgery is not helping the plans to make Dubai a destination for medical tourism, as it is having the reverse effect.

“Cost is a major consideration now for insurers.”

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In 2016, Anglo Arabian Healthcare warned an oversupply of beds and systematic financial abuse threatened the futures of some care providers, with bed supply forecast to outstrip demand by up to 600,000 a year by 2021.

A focus on the most expensive high-end health centres could also result in a shortfall of beds available for low-income workers on basic insurance plans, experts at AAH warned.

A data-sharing scheme launched by Dubai Health Authority in 2016 is helping cut fraudulent claims, and insurers are being more careful about approving expensive surgeries with the best visiting doctors.

Coronary bypass procedures and laparoscopic surgeries are the most common treatments that insurers seek a second opinion for, that can delay approvals.

Iyyappen Kolappan, an insurance manager at Saudi German Hospital in Barsha, said delays are not uncommon but are usually resolved quickly.

“Sometimes, insurers want a second medical opinion before they will agree to a procedure, and we have had some issues in this area,” he said.

“Most hospitals are experiencing similar problems.

“The maximum for approvals that we experience are just 48 hours for most procedures, but it can be longer for more expensive or more complicated surgeries.

“They can take around seven days to get approvals for, which can have an impact in patients.”

One Dubai resident, who can’t be named, took out a Dh20,000 ‘diamond’ insurance plan with a national provider offering maximum coverage internationally for his family of wife and two children.

His wife was diagnosed with fibroids, non-cancerous growths around the womb, and needed urgent surgery.

Costs were estimated at Dh36,000 but the appropriate visiting doctor, who was one of the best available in the field, was only available in the UAE for a week.

The family were told they must wait six months before any surgery could be carried out under the insurance plan, with no reason given for the delay.

Six months later, after two follow up appointments, the patient was told the surgery would not be covered under the insurance plan as it was an existing condition.

“Insurers are being more cautious about offering approvals, as people in the UAE have got used to the health insurance model and have become used to seeking a second opinion,” said Stephen Maclaren, an Al Futtaim Willis Insurance Broker, a specialist in medical insurance.

“It can take months to get a second opinion.”

In 2017, HAAD introduced reforms to clampdown on patients self-referring to costly specialists, with adults asked to get a doctor’s referral to ensure a better diagnosis.

Adult patients aged 18-60 seeking a second or subsequent outpatient appointment for the same specialty within 21 days, without a doctor’s referral, will only be covered if the patient obtains pre-approval.

“When you are in the situation of needing healthcare, patients rely on hospitals and clinics being capable of using the system efficiently,” Mr Maclaren said.

“Patients get annoyed with insurers for not paying, but they don’t always realise that visiting doctors charge more for their services.

“It’s easy to blame the insurers, but in my experience, visiting doctors are usually at the top of their field and are nearly always more expensive to use.”

Dubai Health Authority had no comment to make.