Are medical insurers scamming Kenyans?

Viola* was my classical hide-and-seek patient! She would come by when her heavy menstrual periods were causing her grief and she needed an immediate solution, promising to be back for definitive management. The next time I would see Viola was during the next emergency.

One day, while on a field assignment out in rural Western Kenya, Viola bled so heavily she had to be evacuated for emergency care. The bleeding was controlled but she also needed a blood transfusion. After being released from the hospital, she came straight to my office and demanded to have the surgery she had put off for three years.

Viola had uterine fibroids. She also desired fertility, hence the need to preserve her uterus. We scheduled her for a myomectomy, to remove the ever-growing fibroids. She had a generous medical cover but, thankfully, she had never needed to use it much.

We filled in the pre-authorisation forms requesting approval for the procedure and it was granted, but with a cost cap. On further enquiry regarding the cap, Viola was assured that the cost would be adjusted as necessary during her discharge.

Viola was admitted on a Thursday evening, prepared for surgery and was in theatre at dawn. The procedure was prolonged due to the multiple fibroids and unduly excessive bleeding. This is a recognised common complication of myomectomy. She was transfused blood during surgery and while in the post-anaesthesia care unit and she did well. Three days later, Viola was ready to go home.

This is where the drama started. The insurer refused to undertake the total cost for Viola’s treatment, covering only 60 percent of the amount. Viola’s discharge was delayed in the hospital until late in the night as she made frantic calls to her human resource manager to deal with the insurance. Eventually, at 9pm, the insurance finally gave in and agreed to pay her bills in full.

Viola is not alone. Perez* underwent a similar experience. She worked in procurement at her workplace and one thing she was keen on is the maternity benefit for their employees. She had struggled with the previous insurer just when she was having her last child and would not wish for the same to her colleagues.

On paper, the maternity package looked great. The insurance premium the company forked out was to ensure that they could access care in premium luxury hospitals in the country during delivery of their babies. Perez was therefore stunned when a colleague from the finance department called to say that she was stuck in hospital.

The poor lady had undergone a caesarean section and though her full hospital invoiced bill was still below her benefit limit, the insurance had only agreed to pay 80 percent of the total cost, saddling her with an unexpected bill to pay out of pocket. Perez was livid! Despite having a total of 62 employees and families covered, this was the only person having a baby in the financial year!

Merely on paper

Many people with an insurance cover from the local insurance companies are facing these hurdles daily. What is signed on paper is not what is delivered during the time of need. This has led to an exodus where companies with financial muscle are opting to pay more and get reliable medical covers for their employees from international insurers.

It is obvious that those tasked with the responsibility of negotiating for the medical covers do not have sufficient knowledge on what the insurance clauses mean, until they are stuck with a bill that they shouldn’t be having to pay.

It is even worse now that many insurance companies are beginning to opt for procedure packages. They now want specific procedures to be done under a fixed amount of money, without taking cognisance of the fact that procedures sometimes vary once underway, leading to a rise in costs.

This is the current approach in countries like the US, where a hospital is paid a total package. The hospital then has to fit its total costs into the budget and still account for a profit margin. The end result is that at some point, something has to give and the entity paying the price remains the patient.

With the steadily rising cost of drugs, medical technologies and equipment, occasioned by inflation and the rising cost of the dollar for our mostly imported inputs, it is expected that the cost of healthcare can only go up. For medical insurers to imagine that they can cut back on the cost of care is not only unrealistic but also in bad faith.

It is time everyone took responsibility. As the insured, know the product being presented to you before you sign across the dotted line. Consult if you must, from those who understand the industry. On the other hand, the insurer also needs to honestly explain the product they are selling so that there are no surprises. Even more importantly, honour the claims in full without short-changing patients. Do right by the client!

Dr Bosire is an obstetrician/gynaecologist