When Medical Aid Becomes an Inconvenience… Clients Report Ridiculous Shortfalls

The Sunday Mail

Veronique Gwaze

There is no good time to be sick, but it is certainly the worst!

Apparently, the difference between a patient with or without health insurance has become more or less the same.

At least 1.8 million people are registered medical aid recipients with 38 medical aid companies affiliated with the Association of Health Funders of Zimbabwe (AHFoZ).

Of this total, just over a million pay their subscriptions in local currency.

However, health service providers seem to be colluding to “punish” anyone who produces medical aid coverage in their establishments.

Porous

Normally, health insurance is supposed to cover members on a rainy day, but that is not the situation.

Policyholders literally find themselves between a rock and a hard place as the supposed coverage has become porous, exposing patients to paying cash in the event of a shortfall.

Holders of local currency health insurance policies are forced to additionally pay huge sums of US dollars (USD), or the equivalent, for services rendered.

The situation is improving in both public and private health facilities.

Deficits are not unique to Zimbabwe. However, the way medical aid service providers are responding seems to be spiraling out of control.

While some have resorted to openly denying patients medical aid, others are simply charging ridiculous shortfalls of up to US$125 per session.

“I recently fell ill and needed urgent medical attention. I needed a head scan to be accurate. I went to Avenues clinic, presented my valid medical aid card, but they couldn’t help me despite the terrible condition I was in.

“Instead, the clinic demanded a payment of $250 (cash) or $120 forfeit of my first mutual medical aid before I could be treated,” Phillipa Mukome recounted after her traumatic ordeal.

The high loads left him with no choice but to look for another facility.

“I then went to an oncology center located close to the first clinic I had visited. They accepted my policy, but this time with a loss of 50 USD since I pay my subscriptions in local currency. »

Terrence Zimbeva also faced bad experiences after falling ill.

A private health facility he has visited over the years with no issues regarding his medical help, this time only asked for a cash payment of $150.

Unable to shell out that much, Zimbeva went to Parirenyatwa Hospital.

Unfortunately, the main hospital staff did not attend to him but referred him to their private ward.

“I was asked if I had a medical aid plan in USD or local currency. It was the first time I encountered this question,” Zimbeva said.

“After learning that it was not a USD plan, I was advised to personally go to the medical aid head office and negotiate with them to give me some money to pay the service.

“It’s impossible and suddenly I had a torrid moment. I suffered until a relative had to come to my aid with a cash payment. The saddest thing is that I didn’t I’ve never skipped my monthly subscriptions, but we’re getting a raw deal.

Stinking

In some cases, vendors charge foregone revenue well above the actual price of the product or service.

Nester, who is Zimbeva’s sister, has a typical case.

“I was asked to pay a $40 loss for prescription drugs. However, I then found out later that the same medicine cost no more than US$20 when paid for in cash.

“I didn’t understand the logic. It made no sense! It seems they are now penalizing patients for using medical aid. I had no choice but to go the money route,” she said.

The government said it was seized of the matter and was meeting with stakeholders for a lasting solution.

“We are dealing with the problem. We have crucial meetings scheduled where we need to discuss key issues and find a way forward. However, I can’t anticipate much,” the Minister of Civil Service, Labor and Social Affairs, Professor Paul Mavima, said in an interview late last week.

Resolving the dispute between health funders and health insurance companies is key to ending this deficit crisis, or at least improving the situation.

Many policyholders wonder if it is still worth paying for their medical aid subscriptions if they end up paying virtually cash for health services and medications.

Medical aid companies argue that the shortcomings and challenges are the result of an unfavorable pricing structure that currently exists in the market. They note that health service providers peg their fees to the US dollar and parallel market exchange rate, which automatically creates a disparity for local currency policyholders.

The black market rate, they add, rises spontaneously in relation to wage adjustments.

As a result, some of them are now encouraging the public to migrate to USD policies.

“We also alluded to the fact that medical service providers tend to set their base price in USD. So the review we are conducting is to try to align the ZWL medical benefits we provide to members with that. that medical service providers charge when they convert their USD price to ZWL,” (sic) reads in part from a recent communication from First Mutual Health to its customers.

“For members who generate or have access to US dollars, we strongly encourage you to convert your medical aid plan or arrangement to US dollars.

“Under such an arrangement, the levels of medical benefits in USD and contributions in USD are stable, which simplifies the task from a planning and budgeting point of view. Shortfalls, if any, are predictable and relatively less significant.

A source from the Premier Service Medical Aid Society (Psmas) said difficulties in the process of applying for, authorizing and obtaining payments from medical aid societies also compounded the problems.

“The situation can be improved if the complaints process is shortened. As it stands, service seekers find themselves on the recipient side, but also note that medical aid societies and health service providers are in trouble. It’s an unusual trading environment.

Exit

AHFoZ expects service providers to continue to accept local and USD policies.

The Association’s chief executive, Shylet Sanyanga, said there are uniform standard tariffs (rates) that should be used for the purpose of seeking medical aid.

“Medical Aid Societies pay the tariff and any excess would generally be a loss of revenue. This therefore means that the patient bears the surplus-deficit. It is in the interest of those concerned to seek clarification on the charges collected at the point of service,” Ms Sanyanga said.

She added that cash payment rates are at the discretion of service providers.

“We also invite customers to compare prices and services, including those of medical aid service providers. Medication and consultation costs differ from one establishment to another.

High fees, Sanyanga added, often lead to an early exhaustion of the individual’s respective annual limit.

This in turn means that policyholders will have to pay in non-refundable cash for the rest of the year for exhausted benefit categories.

Some say the Insurance and Pensions Commission’s (IPEC) plan to have medical aid schemes under its purview could help ensure the public is covered when hospitalized for medical treatment.

IPEC would have the technical capacity in terms of specialized expertise required for the management of insurance funds.

“Cabinet decided they wanted to have a separate regulator for this (Medical Aid Schemes).

“That’s all we know. We don’t know who will be the regulator and, like everyone else, we are waiting for a communication,” said IPEC public relations officer Lloyd Gumbo.

Currently, medical aid societies are regulated by the Department of Health and Child Care under the Medical Services Act.

In South Africa, only 16% of the population would benefit from private medical aid, the rest depending on public health.