'My Question is When the Saudi Government Made Health Insurance Mandatory Why are All Health Services Not Covered in Such a Scheme?'
Wednesday, 16 August 2006
RIYADH: As the deadline for mandatory health insurance approaches, polyclinic managers paint a bleak picture for their future survival, mostly because of the health insurance companies' indifferent attitude towards them.
According to Abdullah Sharif, Director of Cooperation Council for Health Insurance (CCHI) at Ministry of Health, all foreign workers will be covered under the mandatory health insurance scheme within the next six-month period.In May, Sharif told The Saudi Gazette "less than 50 percent of the six million expatriates were covered under the mandatory health insurance scheme."
There are also reports that the Ministry of Health has linked up the insurance policy with the renewal of foreign residency permits, commonly known as iqamas - creating an unpredictable large number of future polyclinics, as most of their expatriate customers now pay cash.
Because of the approaching deadline the polyclinic managers paint a bleak picture for the future of small and medium-sized healthcare providers.
They said this was mostly because of the indifferent attitude adopted by some of the health insurance companies with which they signed contracts.
Moidu K.T. from another polyclinic told The Saudi Gazette the major problem with some of the insurance companies was the long delay or refusal for the reimbursement of medical bills submitted to them.
"The refusal to reimburse medical bills by some of the insurance companies at times goes up to 60 percent. Long delays in reimbursement of bills is another problem," Moidu said.
Besides, the patients holding insurance cards are not happy, particularly when they are informed that the pathological test required should be approved by the concerned insurance company.
"The patients are not happy and sometimes they quarrel with the counter receptionists," he said.
He said sometimes the approval request for a clinical test either takes a long time or is never gratified with a response.
Echoing similar remarks Abdul Kareem Fizi, Administration Manager of another polyclinic said some of the insurance companies refuse to reimburse the medical bills even after prior approval.
There are around 500 small and 200 big polyclinics operating in Riyadh alone.
One specialist at a large polyclinic, requesting anonymity, said in his case, despite prior approval from an insurance company and refusal for reimbursement is costing his company dearly.
For the time being the polyclinics are happily or unhappily managing because most of the expatriates they treat pay cash, he said.
"If such a practice continues and medical bills are not reimbursed by insurance companies, management holds us accountable," he said.
Insurance companies offer a totally different story, putting all the blame on the management of polyclinics for violating rules.
An official at one insurance company said medical bills are refused only because the polyclinics fail to follow the rules and conditions mentioned in the agreement.
For instance, he said polyclinics offer dental care to patients, while in fact such a service is not covered under the agreement.
"At other times polyclinics submit the bill without attaching the copy of insurance card," he said.
"How can they expect the reimbursement when they violate the basic rules of the agreement?"
He said his company has agreements with 260 polyclinics and 150 major hospitals. You can understand why the complaints of delayed or refused reimbursement are coming only from the polyclinics "simply because polyclinics don't follow the conditions."
"We don't have any disputes while reimbursing medical bills of around SR500,000 to SR600,000, to hospitals, which can be compared to the compensation of hardly SR5,000 to SR6,000 for some polyclinics," he said.
It would be win-win situation if polyclinics strictly adhere to the conditions of the contract, he said. He said insurance companies prefer to do business with polyclinics more than large hospitals because of the huge cost differences between the two.
Moreover, the health insurance company official suggested that the polyclinics are required to improve their healthcare services to better serve patients. "In most of the small- and medium-size polyclinics there are no specialists available. Besides, the doctors appointed at these clinics are not well qualified," he said.
The health sector in Saudi Arabia is turning out to be exceedingly competitive and only those that offer the best healthcare services will survive in the market, he said.
K.T. says his polyclinic is gearing up to work under the worst circumstances. He said the polyclinic will survive the cutthroat competition. The insurance companies will come to know that the current approach adopted by them is in neither interest of any of the parties.
First, the insurance companies are required to change their evaluation of bills' reimbursement procedures. He said most companies appoint part-time medical professionals for reimbursement purpose, which is causing most of the delay in reimbursement.
"The insurance companies should understand that polyclinics hardly charge SR75 for an ultrasound examination while for the same test hospitals charge SR300," he said.
Fizi described the whole business as a vicious cycle.
However, Saleh N. Al-Omair, Manager Taj Medical Insurance, National Company for Cooperative Insurance, (NCCI) which holds the lion's share of the health insurance market had earlier said that health insurance policy is a contract that companies signed with health insurance agents.
Kamal Omar, a Sri Lankan sales and marketing executive at a company said his company provided him with a health insurance card but when he visits a hospital he is informed that not everything is covered.
"My question is when the Saudi government made health insurance mandatory why are all health services not covered in such a scheme? My company gave me a health insurance card, but whenever I visit a hospital I am told such and such health problem is not covered, which forces me to shell out money from my own pocket," he said.
He said dental services and many skin ailments are not covered. Moreover, pharmacies at most of the hospitals do not dispense the medicine prescribed by his doctors - and offer cheaper alternatives.
"Usually, everything is covered but the healthcare services not offered are those that are excluded in such a contract," Omar said.
For instance, he said if an employer does not buying maternity services as part of the contract then women employees of a company end up paying for all maternity-related services.
By Shahid Ali Khan
© The Saudi Gazette 2006
