Insured, but still asked to pay first

Farha Yusof

Most of us buy medical insurance because we want some peace of mind.

If something happens and we need hospital treatment, the financial side is supposed to be one less worry.

That is what made a recent case I came across troubling. A patient had dizziness, nasal congestion and a nosebleed outside normal working hours. She needed treatment and went to hospital. The specialist on call happened to be a doctor who had treated her before.

But there was a problem. She was told the cashless facility under her medical coverage could not be used if that specialist treated her. She could pay first and seek reimbursement later.

On paper, that may look like an alternative. At the hospital counter, it can be a very different story. What if you simply do not have the money?

That was what bothered me about this case. Whatever disagreement existed between the insurer and the specialist, the patient had nothing to do with it.

There had been an audit. The insurer had taken action affecting the specialist’s cashless status. The specialist was challenging that action.

There may well be legitimate issues for both sides to resolve. Insurers have every right to scrutinise claims and control healthcare costs. Doctors cannot expect to be exempt from those processes. I am not in a position to decide that dispute, and that is not really the point.

The patient did not conduct the audit. She did not make the insurer’s rules. She certainly did not decide which specialist would be on call when she needed treatment.

But she was the one who felt the effect of the dispute. That seems to me the part we should talk about more.

Covered but not cashless

We sometimes speak about medical insurance as though having coverage settles the question. It does not always work that neatly.

There is a difference between being covered for treatment and being able to get that treatment without paying for it yourself first.

If you have enough savings or a credit card with a high enough limit, paying first and claiming later may be inconvenient but manageable.

But not everyone is in that position. For some families, finding several thousand ringgit at short notice is simply not possible. The money might eventually be reimbursed, but that does not help much when payment is needed now.

Then there is continuity of care. If you have been seeing the same specialist, that doctor already knows something about your history and treatment.

Of course, patients sometimes have to change doctors. But in an urgent situation outside normal hours, there may not be much choice anyway. You may simply get the specialist on call.

So what is a patient supposed to do when that doctor cannot treat them on a cashless basis? Find another doctor? Pay first? Delay treatment?

Who protects patients?

These questions become much less theoretical when you are the person sitting in the emergency department.

None of this means a medical card should give someone unlimited cashless treatment with any doctor they choose. Insurers need panel arrangements. They need claims procedures. They need ways of dealing with disputes.

But patients need protection too. If a specialist’s cashless status changes, what happens to patients already under that doctor’s care? Are they informed? Are they given practical alternatives? And should there be some arrangement for urgent cases where the affected specialist is the doctor on call?

There are mechanisms for insurers, doctors and hospitals to work through disputes over medical claims and guarantee letters. That is necessary.

But while institutions follow their processes, somebody still has to deal with what happens at the hospital counter.

Most patients will know very little about the arrangements between an insurer, hospital and specialist. I do not think it is reasonable to expect otherwise. They know they bought medical insurance. They paid their premiums. They have a medical card in their wallet or phone. And when they are sick enough to need hospital treatment, they expect it to mean something.

Perhaps that is why I kept thinking about this case. The patient had done what many people are told to do: get medical coverage before you need it. Then the day came when she needed it.

And then the most important question was not whether she had insurance but whether she could afford to pay first.

Farha Yusof (a pseudonym) writes on society, history and public institutions in Malaysia, and on constitutional life with a particular interest in the relationship between law, power, identity and everyday life in Malaysia.

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