Fri | Apr 20, 2018

Insurance Helpline | Health-care funding a complex undertaking

Published:Sunday | February 12, 2017 | 12:00 AMCedric Sephens
Thomas Smith, managing director of Maritime General Insurance Brokers Limited, speaks at the launch of the partnership with Premier Assurance Group to distributes two health care plans for the American company, on February 2, 2017 at the Spanish Court Hotel in New Kingston.

The responses that I received to last week's article, 'Insurance buyers need another Fitz Jackson in the House', were varied.

Unfortunately, however, I did not receive a single comment from a sitting member of Parliament, including the gentleman from South St Catherine.

Is no one willing to provide the leadership to try to improve the situation for health-insurance consumers? Or, is the lack of interest because the subject affects less than 20 per cent of the population?

One noteworthy response to the article not including the friend who posted it on Facebook was from two persons who work with MGI Insurance Brokers. Their company, in association with US partner PA Group, launched two health insurance plans on February 2, called Caribcare and Caribcare Plus.

I decided to review those plans in today's article in the context of last week's discussion about the state of the local health insurance market.

Funding the cost of health care at the national level is a very complex job as members of the former Obama administration will confirm, and the Trump administration and Republican members of Congress are slowly discovering. Chairman of the National Health Fund, Chris Zacca, who was asked by our government to study the subject, is in the same boat.

The operations of privately run companies that fund healthcare costs can also get very complicated if they are to meet shareholders' demands for profit and meet the needs of consumers and health care providers.




Several features of the service-delivery mechanisms of the new plans stand out. These include:

n A commitment in the policy to provide 24/7 and 365-day after sales service that has as its goals: helping claimants to understand the benefits to which they are entitled; responding to requests about the status of their claims; and providing help in locating a medical service provider by way of email, telephone of fax.

- The provision of case management clinical support and review

- Access to search globally for health insurance providers.

- The capability to provide evidence of insurance by way of an ID card at any time.

- The ability to submit claims online.




There are also many aspects of the two plans that I like. These are:

1. The waiting period before coverage begins is 60 days. Comparable plans range from 90 to 180 days;

2. There is guaranteed renewability of the contract because of claims history or age provided the premium is paid on time or unless either party irrefutably decides not to renew;

3. Eligible insured persons should be under the age of 74 years and 11 months.

4. Prescription drugs are covered at US$2,000;

5. No penalties will be imposed for using services outside of the local provider network.

6. Benefits that are received inside of the provider network overseas will be paid at 100 per cent of Usual Reasonable and Customary Charges (UCR);

7. Emergency/routine dental and optical benefits are covered at 50 per cent to 100 per cent of UCR up to US$2,000;

8. Overage dependents are covered up to the age 26 years while attending school;

9. There is no lifetime maximum for this plan and individuals are afforded up to US$3,000,000 as an annual limit;

10. Insurers have guaranteed a turnaround time for new applications within 48 hours if no further medical evidence is required;

11. Claims will be settled within 15-20 working days unless there are extenuating circumstances;

12. Coverage for new born children

13. Coverage for children with disabilities;

14. Mental health treatment;

15. Rehabilitation for physical, occupation and speech therapies;

16. Wellness benefit up US$300 after 12 months and every two years thereafter;

17. HIV/AIDS treatment contracted to medical professionals as a result of an accident;

18. Worldwide coverage.




When I looked at the premium for a person in my age group I recalled the fire-engine red, expensive, European-made two-litre car that I drove from Mona to Norbrook a few days ago. At the end of the short journey, I wish that I had the opportunity to have driven it from Kingston to Negril.

I was very disappointed not to have stress-tested the engine on the road leading from Porus to Mandeville to see how the car performed. Alas, this was not to be. The price was way out of my reach unless, of course, I won the Super Lotto.

Prices for the health plans run from US$1,200 to $1,800 per person in the 31-35 age group; US$1,436 to US$2,140 in the 41-45 age bracket; and US$2,197 to US$3,108 in the 51-55 age cohort. A 61-year-old applicant will pay an annual premium that is some 214 per cent more than someone half his/her age.

The fact that the plan is written at Lloyd's in the United Kingdom and not by some fly-by-night foreign insurer is somewhat reassuring. On the other hand, one of the defects of the policy is the absence of a local dispute resolution mechanism.

To summarise, the newly launched plans address many of the imperfections in the local health insurance market that was the subject of last week's article.

Unfortunately, however, they only target a very small part of the market. Leadership from someone either from outside or inside the industry is required to disrupt the status quo.

- Cedric E. Stephens provides independent information and advice about the management of risks and insurance. For free information or counsel, write to: