Do I have to pay doctor before surgery?

| 14/03/2019 | 4 Comments
Ask Auntie, CNS Local Life, Caymanian status

I’m hoping you might shed some light on the recent practice of health services requiring full payment for a procedure and then the patient expected to be reimbursed by the insurer. Case in point: our son has a scheduled knee surgery and we’re having to pay the anaesthesiologist in full before the surgery is to proceed; we are then expected to seek reimbursement from our insurance provider. The argument is the health professional has previously had trouble with payment from insurance companies. Besides in principle being against the very essence with the purpose of having health insurance, is this even legal?


Auntie’s answer: Actually, it is not legal. Under the law it is the responsibility of the health practitioner or health care facility to submit claims to the insurance company for payment of a patient’s treatment, after any deductibles, coinsurance or other charges that exceed the standard fees allowed.

An official with the Health Insurance Commission explained that the Health Insurance Regulations (2017 Revision) 15(4) specifically say that when someone shows an insurance identification card to a provider and it is established that a contract of health insurance exists, “any claim under the contract in respect of the covered medical benefit shall be deemed to be assigned to the health care facility or the registered medical practitioner”.

In simpler terms, that means the provider must submit a claim to the insurance company for reimbursement and the patient should not be paying the full amount up front. But if an insured person provides a receipt or other evidence of payment of the benefit, then the insurance company needs to pay him or her whatever it is liable for under the contract.

In addition, Section 21 of the Health Insurance Law (2018 Revision), “Approved insurer shall pay benefit directly to health provider”, covers the same points.

But more importantly for you, the official added, “The commission would invite you to file a formal complaint with the department so that this matter can be investigated.”

The telephone number for the HIC is 946-2084 or you can email HIC@gov.ky. Please let me know if the HIC is able to help you.

The laws mentioned above can be found on the CNS Library

Send questions to auntie@caymannewsservice.com

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Category: Ask Auntie, Health Insurance Questions

Comments (4)

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  1. Anonymous says:

    Note that if you can & do pay up front the costs may be less! Weird but true. Then you submit the claim to the insurance company.

  2. Anonymous says:

    I have this problem all the time. I did try to email the HIC, but it seems that like most government departments, replying is optional. I had to cancel a surgery because the cost was too much.

  3. AA says:

    We used an Ob/Gyn from TrinCay to attend a childbirth and they required us to prepay the overage (what is above the standard fee, not the full amount) of the Doctor’s fee. Is that also wrong?

  4. Anonymous says:

    Sec. 20 of the 2018 law is the place that says the health care provider must bill the insurer first. That is the provision relevant to the problem.

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