alexa Devil is in the details: Do you know what your insurance covers? - Daily Nation

Devil is in the details: Do you know what your insurance covers?


The fine print in your medical insurance policy

Many people have no idea what their benefits include

Cassandra* was livid. She paced the hospital corridors holding a terse conversation on the phone with her insurance agent. She could not believe what she was hearing.

Cassandra grew up as an only child. She was the apple of her father’s eye. She was hardworking, smart and a shrewd businessperson. By the time she was starting college, she had worked part time at her father’s company.

After graduation, she joined the company as a junior employee and over a period of 15 years worked her way to the top. Her father was grooming her to take the reins. His only regret was that her marriage had not worked out, but he was grateful for the grandchildren and the cordial relationship maintained with his former son-in-law.

The firm had contracted a medical insurance provider and with her father getting older and his health shaky, Cassandra had ensured her parents had a premium policy under the senior management package. She ensured there was provision for chronic illness care, considering her father was already hypertensive.

Last year, Cassandra’s father was admitted to the hospital for observation for a 48-hour period. His neurologist thought he had suffered a transient ischaemic attack. Loosely translated, he had a temporary mini-stroke. He responded well to treatment and went home after full recovery. He even took time off work to rest and play golf. It was as good a time as any to start the process of passing the mantle to Cassandra.

MENTALLY ILL

Unfortunately, this was not to be. Five months later, Cassandra’s mother was involved in a freak accident and she died. It was a traumatic time for the family, especially since they now only had each other. The loss hit them hard.

After the crowds had left and the home was empty, Cassandra noticed her father was not doing well living alone. Together with her children, she moved back home. He resumed work to escape the long empty hours. This seemed to work.

However, his blood pressure told a different story and his physician was not happy. A change of medication did not do much to keep the blood pressure stable and eventually he had to see a psychiatrist to assess him for depression. Being old-school, Cassandra’s father refused, saying he was not mentally ill.

One afternoon, her father’s secretary frantically called her. He had suddenly complained of inability to hold his pen. He was terrified and he asked the secretary to call his daughter. Cassandra called the ambulance and within minutes she was riding in the van holding her father’s hand, begging him not to leave her. He was rushed to the intensive care unit with a diagnosis of a stroke. This time round, it was the whole nine yards.

Amid the beeping of the monitors and puffing of the ventilator, Cassandra whispered a million prayers for her father to live. She was not ready to lose a second parent. Tears flowed freely. She barely remembered signing papers and surrendering his medical insurance card.

It was a stormy week before the old man began to recover. He came off the ventilator and proceeded to the ward. He handled his recovery with the determination.

It was during this intense period that Cassandra was notified that her father’s insurance company would not honour the claims generated from his admission. The company said the stroke was a pre-existing condition, considering he had previously suffered a similar condition and hence was not eligible for cover. Cassandra went ballistic.

Cassandra’s story is not unique. Many private insurance clients have undergone such painful experiences, when the security they thought they had, was pulled out from under their feet at the time they needed it the most, leaving them destitute.

Most Kenyans are only able to access private insurance through their employer. A majority of employers never involve their employees when they are signing contracts with the insurance providers. For this reason, many have no idea what their benefits include.

STAY AFLOAT

Many human resource persons who sign on the dotted line have no capacity to understand the fine print that constitutes exclusions to the contract. A middle aged HR manager will buy in to the deal when he is assured his diabetes treatment will be paid for, yet he has no idea the cover will only provide for a dismal maternity cover for those who are still starting a family.

A CEO whose children are independent adults will not ensure that the outpatient cover adequately provides for full vaccination of children up to the age of five because he is not in the phase of his life where he worries about that. A young single man may not know the importance of a chronic disease and pre-existing condition clause when he has never raised a child with cerebral palsy.

Medical insurance, despite being conceived to alleviate the financial burden occasioned by ill health, is still a business, with bottom lines and balance sheets that must look a certain way. For this reason, the contracts are designed to minimise the risk of loss to the provider too, while remaining competitive.

Being a binding document, the client has no room to reverse anything until the expiry of the contract. This means that in the event the client did not understand the fine print and all that was implied, he is left holding the short end of the stick at the most vulnerable moment of his life.

In addition, while many industries have revolutionalised with technology, changing client needs, ease of doing business and labile economic environment, the insurance industry is possibly one of the slowest to embrace change. This definitely comes at a cost both ways.

Illness is generally a step away from poverty for most Kenyans. For this reason, it is time to take these documents more seriously. Companies can consider inviting doctors and lawyers to the table when negotiating these contracts, to guide them in interpreting the fine print. They need to assess the needs of their employees, so as to be able to get the very best product for the money paid out.

On the other hand, insurance companies seriously need to review their business strategy when it comes to medical insurance. Considering the market share is extremely small with no incentive to expand it, it is going to be a tall order fighting to stay afloat with so many dissatisfied customers.

Dr Bosire is an obstetrician/gynaecologist