Medical treatment costs substantially less in Jamaica than in the United States. Radiographer Yvonne Williams prepares a patient for a CAT Scan at the Mobay Hope Hospital in Rose Hall, St. James. - PHOTO BY CLAUDINE HOUSEN
Question: I am enrolled in a local health insurance plan. The premium is paid by my employers. My wife and two children have also joined the plan. The younger of the two children was recently diagnosed with a rare congenital disease. My doctor said that the child should be taken to Miami for treatment. A friend told me that overseas treatment is covered under the plan. Please investigate and advise me - urgently.
- T.P., Kingston 10
Answer: Your health insurance plan shares at least one thing in common with a local motor policy. Both are designed for the Jamaican market. The American health care delivery system is vastly different from ours. Unlike the costs of most consumer goods, which are much cheaper there than here, United States medical expenses are dearer. Local expenses are a fraction of those in the U.S. Plans designed for the local system generally assume local medical and other costs. All things being equal, it is likely that you will have to dip into your savings or get a loan to pay for your child's treatment in Miami.
Your health plan won't cover all of the costs you will incur overseas. Exactly how much depends on the terms of your employers' contract. In theabsence of the policy I will give you information to discuss with your human resource specialist or insurer.
DOCTOR'S LETTER
Ask your doctor to write a letter confirming his diagnosis. It should also state in clear terms why your child should go overseas instead of getting treatment here. All of the specimen plans that I have seen go to great lengths to say that "payments shall be made in the same currency in which the premiums were received - unless otherwise agreed." The intention is clear:
Hard currency payments are not the norm unless the premiums were paid in that currency. Also, other provisions state that the covered expenses should be "usual, reasonable and customary".
Benefits provided under health plans are for fixed amounts. In other words, insurers set limits on how much they will pay for different benefits. In one section of the contract - referred to as the basic plan - monetary limits are imposed for (a) room and board [hospitalisation]; (b) surgery; (c) doctor's home, office and in-hospital visits; (d) specialist consultations; (e) diagnostic services; (f) maternal care and (g) prescription drugs. The limits represent the maximum amounts that insurers will pay, varying according to the type of benefit and from plan to plan.
Some plans also have major medical coverage. This is in addition to the basic plan. The former 'sits' on top of the latter. Coverage is triggered when the limits under the basic plan have been exhausted. It pays 80 per cent of the costs in excess of the limits in the basic plan. The consumer pays 20 per cent. Major medical generally includes all of the things covered under the basic plan. It is usually subject to one big limit which is stated in millions of dollars or fractions of millions.
BENEFITS
Once you understand the structure of your protection, it is fairly easy get a fix in dollars and cents on the size of the benefits to which your child is entitled. This should give you a good idea of how much you are likely to recover from insurance. It will also help you to determine the size of the gap for which funding may be necessary, either from your savings or a loan.
Obtain the blessings of your insurers in writing before taking your child abroad for treatment. This way you are likely to avoid nasty surprises down the road.
Although insurers do not like it, negotiate an interim payment - since big bucks are likely to be involved. Insurers do not like doing this for all sorts of reasons. However, sometimes they can be persuaded to do things 'outside of the box' with a little nudge from the employer.
Cedric E. Stephens provides independent information and advice about the management of risks and insurance. If you need free information or counsel to help you solve a problem, write to The Financial Editor, or contact Mr. Stephens directly at aegis@cwjamaica.com.
