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Why Does Your Medical Insurance Approval Take Time?

 

“I waited two weeks to find out if I really had cancer or not!” exclaims single mother Dina Ahmed (not her real name).  When she was informed that they detected a lump in her right breast during a routine mammography examination, Ahmed’s life flashed before her.  She was told that the radiologist believes that it is cancerous, however requested an MRI scan for further confirmation.  The MRI report would not be ready for another two weeks and Ahmed endured an arduous wait.

 

This incident may resonate with many patients in Dubai.  For a large number of people who are medically insured on the lower category networks in the UAE, approvals for expensive outpatient procedures take long and in many cases are denied. This begs the question why?

 

Whilst it is common to accuse the “big bad giant corporation” of wanting to save money and trying to get out of its commitment towards its policy holders, there are many other hidden factors at play.    

 

Unfortunately, the UAE has a high rate of insurance fraud.  In 2013, Booz Allen Hamilton Consultancy estimated that the UAE was losing more than Dh3.67 billion to health insurance fraud.  Procedures are requested and carried out by medical providers only to increase billings regardless of the medical need or outcome. Stephen MacLaren of Al-Futtaim Willis and Dr. Hany Afifi of Mega Scan Centre identified earlier some of the most common health frauds committed in the UAE:

 

Patients are handed inconclusive diagnostic reports so that further investigations are carried out and billings increased.  This is common in human-reliant procedures such as radiology where the doctor’s interpretation of the images is required and less common in machine-reliant tests such as blood analysis where numbers are undisputed.

 

This fraudulent approach is pushed further by some doctors who would exaggerate or falsify a diagnosis to charge for unnecessary procedures.  For example, concluding a lump or nodule is cancerous to request a biopsy (a more expensive procedure).  Needless to say, the patient’s wellbeing is completely disregarded.

 

These types of frauds are very hard to detect by medical insurance companies.  They need to review the patient’s history, the requesting doctor’s track record, the medical centre’s claim record etc. before concluding if the request is legitimate or not.  Medical insurance companies want to do right by the patients, but equally they do not want to lose money on unnecessary requests. 

 

In Ahmed’s case, her request was approved and she performed the MRI that the radiologist wanted.  However, until her approval came through, she sought out a second medical opinion from Dr. Hany Afifi who concluded from her initial mammogram that the lump was not cancerous.  The MRI report confirmed the same after two weeks.

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