Onus on insurer in disputes

| 08/10/2014

(CNS): If a health insurance provider refuses to cover a medical procedure on the grounds that it was not medically necessary, the onus is on the insurance company to prove it, according to Superintendent of Health Insurance Mervyn Conolly. The regulations in the health insurance law outline what is 'medically necessary', however, there are instances where the healthcare provider and the insurance provider may not see eye-to-eye concerning the diagnosis and treatment of the patient, Conolly told CNS, but in those cases the Health Insurance Commission (HIC) always puts the onus on the insurance provider to justify why that particular procedure is not medically necessary and to prove, with evidence to support their claims, that the care provided was really for the comfort and convenience of the patient or that it was not the appropriate level of treatment of that procedure.

“Then that is something that we would take up with the healthcare provider,” he said, “but we are usually able to work through most of those complaints without it escalating any further.”

In an instance of a true emergency where the healthcare provider has to provide treatment at that point of time, it is usually not contested by the insurer, Conolly explained. “It is usually the elective procedures that are planned where you could have those concerns as to whether it was medically necessary or not,” he said.

In these cases the doctor would generally seek a pre-certification from the insurance regarding the surgery or procedure that they are planning to carry out so that the insurer has the opportunity to look at it before they actually receive the claim, and if there any concerns they will then contact the healthcare provider, usually 24 to 48 hours before the procedure is actually carried out.

“Again, the onus is on the insurance provider to prove that it is not medically necessary,” Conolly stressed. “I can't recall too many instances where, once we put the facts together, that the insurance providers have not supported it.”

The approved insurers have their own medical consultants that they use to defend their position on the matter, he said. “In that case, you would have the medical consultants speaking directly to the physician, and a lot of cases are resolved in that way.”

He added, “The last thing we want to see is that the patient is negatively affected under these circumstances. In other words, if the medical procedure is necessary we want to defend that person.”

The Health Insurance Commission now has the power to impose administrative fines up to $1,000 for both employers and insurance companies for infractions of the health insurance law. If the accused person or company wants to challenge the HIC decision or if the matter is not resolved administratively, it will still end up in court but if it escalates to this level, the offender could end up with a much bigger fine imposed by the magistrate – up to $30,000 in some cases

The new powers given to the HIC, which kicked in at the beginning of this month, gives teeth to the commission for the first time. Conolly said they like to resolve cases before they get to the point where there is no cooperation and they end up in court, so having the administrative fines available as an additional tools to resolve matters is very useful. Only about 20% of cases end up in court, he noted, and they hope that these new powers will reduce that.

The HIC receives complaints about insurance providers not paying all the time, he said. The commission will then look at the benefit plans that that complainant has and assess the benefits that individual is entitled to under the contract. Ninety-five per centof the time they are able to resolve the matter, he said.

“Where the insurer is clearly not honoring the contract, in those cases we will definitely decide in favor of the insured person and require the insurer to honour the contract,” he maintained.

However, he said that in about half the cases taken to the commission it's because the insured people don't understand what benefits they are entitled to. He said that very often people don’t even read their plan of benefits. “And it's only when they go to the healthcare provider that they realize that they are not covered under the benefits, or if they are, they find that they are not covered to the level that they expected.”

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  1. Anonymous says:

    The entire US healthcare system is overpriced, overrated and over here. Cayman should not have used this system. When you get hospitals, physicians and the like running all the tests they can to bump up the bills, rather than what is necessary, and charging huge fees, its a mess.

  2. Anonymous says:

    I was unable to access the comment field on CNS' "Medicare-type health insurance being proposed" article a few days ago, therefore my comments are intended for that subject.

    CNS: The article and comments are on CNS Business and I have posted your comment there.

    Medicare-type health insurance being proposed

  3. Anonymous says:

    I have worked in a doctors office in the USA for a friend of mine who invested a total of 12 years to become a very well respected doctor in his field, just to be told by some insurance desk pusher when medical procedures were required or not. If you think that the insurance companies always consult experts before making a decision you are wrong. In fact, many insurance companies in the States have a dirty little secret where they turn down claims a couple of times before finally processing in the hope that the insured will just get frustrated enough and pay out of their own pocket.

    What really needs to happen in Cayman is that every doctor and dentist MUST accept the insurance cards and deal with the insurance companies. None of that pay upfront and claim back BS!

    • Anon says:

      And when the insurance companies doesn't pay, the doctors are left holding the bag. Because the patients' attitude is that they don't want to pay for services THEY have received. 

      • Anonymous says:

        I think that the OP's implication is that 'the insurance companies must make clear on their cards what is covered – perhaps via electronic means – so that the doctors and patients know what is covered; but within those pre-set limits the insurance companies must honour their committments once they receive a bill from the doctor without niggling'.


        To put it another way, the doctor needs an easy way to determine that you are covered for 80% of the x-ray to see if your arm is broken. You pay the 20% and walk out the door with your arm in a sling but no cast since its just a sprain. Then the insurance company doesn't disagree with paying the doctor when they submit the other 80%, i.e., the insurance company doesn't question  if the doctor couldn't have determined that it was just a sprain without doing the x-ray.


        I can imagine there is a grey area in/beyond that simple scenerio but hopefully we can all agree that the simple scenerio should be the starting point?

      • anon says:

        It's not that reason alone. Sometimes the bills are just beyond anything they can afford. When procedures add up to a bill like $3700 and you make $7 per hour, you can't just pay in full right away.

  4. Anonymous says:

    This is how the world works:

    Companies need to make huge profits, politicians are there to help them and we provide the money.

  5. Anonymous says:

    I recently went to the DR for a routine annual checkup – they recommended a few preventative checks  be done as per my age and family medical history. The insurance company came back saying in their opinion the tests were not necessary. What gives them the right to overrule  a Drs decision?

    Insurance companies are some of the biggest crooks in Cayman and they are playing with our health while their profits are very healthy

    • Gordie says:

      I cannot agree with the sentiment. Unless your insurance specifially covers check-ups (which would be unusual) you need to pay for your own annual "physical" – which can be as simple or as grand as you choose. Medical insurance is to pay for treatment of health problems. Sure it makes sense to have checks to see potential problems and take measures to ward them off, but it is unreasonable to expect insurers to meet this cost unless stipulated in the insurance contract (Yes, even though it may save them a bigger claim down the line.)

      • Anonymous says:

        It's not that unusual. The insurance plan at my place of employment carries full coverage for a reasonable amount of annual preventative procedures (prostate exams, mammograms, etc.). It's a fairly common plan carried by many other employers as well. Most insurance companies now have some small annual amount ($400-600) dedicated to that as their risk assessments probably show it's more profitable to pay that small bit annually than hundreds of thousands later for previously undiagnosed, major ailments. This is of course assuming the employee hasn't chosen to enrol in the equivalent of the "emergency coverage only" plan to pay a smaller premium.

      • Anon says:

        Under the Health Insurance Law of the Cayman Is all policies must have at least CI$200 for routine (I.e. Preventative) care. Some major medical policies have up to CI$800 for this benefit. 

    • Anonymous says:

      Insurance Companies in Cayman (and the USA) are still 20 years behind when it comes to preventative check-ups. While the rest of the developed world has learned and understood that preventative check-ups saves the insurance companies millions in the long run (cause issues are more likely to be caught early on), inCayman, we still wait until someone is about to kick the bucket before the insurance drips in.

    • SKEPTICAL says:

      A very short-sighted policy for the insurance company. They may reap the whirlwind if a serious and expensive condition is subsequently discovered, for which they DO have to pay, and which could have been pre-emptied and treated on the basis of the test results.

  6. SKEPTICAL says:

    The demographics in Cayman do not favour multiple Health Insurance providers, all scrabbling for Profits and Returns on Capital – the population just ain't big enough. From day one, the Government should have looked to appoint a single company, adequately capitalized providing mandatory Minimum and Premium levels of coverage, which could have obtained appropriate re-insurance  cover in the international markets to protect against occasional catastrophic claims. We are all paying for the cost of sustaining multiple providers who as indiduals are hard pressed to be profitable, and will do anything to avoid paying out on borderline claims. 


  7. Anonymous says:

    Can't help feeling a universal health care system would be a lot simpler. All the developed countries of the world have it, in addition to private health care. This evening I learned that in the U.S. "system" (the one in which a third of their population have no proper health care and you can actually die because you haven't got the lolly for an operation) there is not only a part A and B – there is also a part C and D!

  8. Anonymous says:

    Every time I go to my GP or Dentist there is some annoying carried-forward outstanding balance to settle from some insurance company squabble with the medical provider from a previous visit.  Sometimes hundreds of dollars. Something has to change.  This is a step in the right direction.

    • Anonymous says:

      That's why all developed countries have universal health care. You simply cannot put something as fundamental as health care in the hands of businesses. It just doesn't work, for obvious reasons.

  9. Anonymous says:


    They have a licence to rip us off and they are heavily defended by the health insurance commission. I am so tired of the scams and down right dirty behavior. They just take our money and expect to give little to nothing in return. As far as I am concerned they need some serious regulating

    • Anonymous says:

      But that's what businesses do – charge as much as possible and provide as little as possible. Which is why nobody in their right minds entrusts a country's complete health care system to them. The health of a country's population is too vital a matter to be left to the greed of the private sector, whose bottom line is, let's face it, to maximize profits.