Health Insurance: Covered and Un-covered

16.JUN.06

No insurance covers everything, so you need to know what your insurance might not cover:

PRE-EXISTING CONDITIONS

Many policies exclude these completely. Some companies will cover them once you have not needed treatment for a specified period of time e.g. one year. Other companies might cover you only up to a fixed annual limit, which would be lower than full policy benefits.{{more}}

Don’t try to conceal information about pre-existing conditions. It will come out anyway, sooner or later, and you don’t want your entire policy to be invalidated!

NON – PRESCRIPTION MEDICATION

Insurance companies continue to pay only for “Prescription” medication. This means no reimbursement for “over-the-counter” (O.T.C) medication which you buy off the pharmacy shelf.

They apply this rule, even if your doctor has prescribed the O.T.C medication, and this often causes frustration. Some medications require prescription, others don’t.

ALTERNATIVE MEDICINE

If your medication is not approved by the Federal Drug Administration (F.D.A) don’t expect to be paid. These might be Herbal, or Traditional medicines, or certain treatments such as Chiropractic or Acupuncture which some insurers still do not accept. Homeopathy is also not yet accepted by many insurers.

REASONABLE AND CUSTOMARY CHARGES

Just because you paid (pay) EC$1,000 for certain treatment, it doesn’t mean that your insurance company must pay this to you. Many companies keep lists of “normal” charges and only pay the “reasonable and customary” (R & C) amount.

The best way to avoid an unpleasant surprise is to obtain a Treatment Estimate in advance, and discuss this with your insurance company before having treatment.

This gives you the chance to explain any special circumstances. Their lists of charges are said to be reviewed regularly, and you can ask how up-to-date are their “reasonable and customary” charges.

OVERSEAS TREATMENT

Not every treatment is available locally. Obtain a letter from a suitable Specialist, confirming your need. Some insurance companies ask for two such letters. Do this in advance. Even in emergency situations, ensure that the insurance company is fully informed.

If not, or if you simply choose to go overseas for treatment, they may only pay you what the treatment may have cost locally.

NECESSARY AIRFARES

Most policies cover these, but there are limits. Typically, two return journeys are accepted per year, perhaps to an annual maximum of EC$3,000. Ask in advance so that you’re not disappointed.

AVOID SURPRISES

Ask questions before you take the insurance, not when you’re claiming. Ask to see the Benefits in writing, and get the Benefits you really need. Don’t rush, and don’t hesitate to ask for advice.

The annual Caribbean Insurance Conference was held last week in Jamaica, so next time we’ll look at latest developments in Health Insurance in the Caribbean.