Vision care, like all insurance contracts, needs eyeballing

Insurance Helpline, With Cedric Stephens

Question: I am a member of a health insurance plan. My daughter is also on the plan. I took her to an optician last September. He recommended eyeglasses. I made a down payment of J$5,000. After a few days, l paid the balance of J$5,700. The claim form was filled out, signed and sent to my insurance provider's Montego Bay office. Two weeks later, l telephoned the Kingston office to follow up. I was told that a prescription should have been sent with the form and, therefore, my claim was not processed. I obtained and sent the prescription. I was told afterwards that since the date of the receipt was different from the date on the prescription the company would not settle my claim. Is this how insurers treat their customers?

- V.F., Montego Bay, St James

HELPLINE: An optician makes and sells or, to use a more technical term, dispenses eyeglasses or other devices to correct defects in vision. The reason for the non-payment of the claim that you made under the vision or optical benefits rider of your health insurance plan is that you used the services of an optician instead of an eye doctor or ophthalmologist.

Your health provider says that the person who supplied the glasses is not on their list of registered medical doctors. In practice, the separation between eye care professionals is often quite flimsy. Some eye doctors who prescribe eyeglasses operate under the same roof as persons who make and dispense them.

Eye doctors vs Opticians

Ophthalmology is a branch of medicine. It is about the working of and diseases of the eye. An ophthalmologist is a specialist in medical and surgical eye problems. He or she conducts eye examinations, diagnoses and treats conditions of those organs, performs operations as well as write prescriptions for medications, eyeglasses and contact lenses.

Eye doctors are trained as medical doctors. Opticians work on things, not people.

Ophthalmologists are required by law - The Medical Act, 1976 - like other persons who practise medicine to be registered. As far as I know, opticians are not.

There is also another group of eye-care professionals. They are called optometrists. They conduct eye exams and write prescriptions for eyeglasses and contact lenses.

It is impossible for me to form an opinion about the validity of your claim in the absence of specific information about your health plan. Your insurers, who I contacted, have not given me a proper technical explanation for their decision not to pay your claim based on what is written in the contract.

What I do know is that, generally, the benefits under this type of insurance are provided on the basis of what is medically necessary. Health-insurance contracts or policies are very complex documents that are founded in law and in the practice of medicine. They often list in very specific language the things that they will pay for - for example, hospital bills, surgery, doctor's services, private nursing and prescription drugs - plus the things that they will not pay for.

The Medical Council of Jamaica, the body that registers doctors, tells me that they issue practising certificates to ophthalmologists as well as other persons who practise medicine. Opticians and optometrists were not mentioned.

Could this be the reason why your optician indicated that they did not accept the health card that you submitted?

Discuss your problem with your employer's human resource or personnel manager. Find out more about the benefits that are provided under your health-insurance plan. When you have a clear understanding of what is covered under the plan and what is excluded, you are more likely to avoid J$11,000 surprises in the future.

Cedric E. Stephens provides independent information and free advice about the management of risks and insurance.aegis@cwjamaica.comSMS/text message to 812-7233