Surgery - Medical Insurance Benefits

[Chirimoya]

O'Boy, I am currently pondering between Universal and Humano and was leaning towards Universal because they won't cancel if I ever reach 75 years of age.
Now I am at a total lose. I have been reading all of the medical insurance threads and pretty much decided on the Universal Exclusivo Plan. It is there best plan and will cost me about RD 5000 per month which includes 80% prescription coverage.
Back to the drawing board.....anyone with a suggestion.

The depressing thing is they're supposed to be among the best. But - the fact they can get away with sh!tting on you and you remain powerless to do anything about it means that it could happen with any company.

You're paying for peace of mind - after what they did, we no longer have that. We were lucky that the surgery they refused to pay for was quite minor. But if the worst happens and one of us has to have costly treatment, we feel that their word means nothing and that's why we stopped paying. A bit like cutting off our nose to spite our face, I know...

 

[waytogo]

The depressing thing is they're supposed to be among the best. But - the fact they can get away with sh!tting on you and you remain powerless to do anything about it means that it could happen with any company.

You're paying for peace of mind - after what they did, we no longer have that. We were lucky that the surgery they refused to pay for was quite minor. But if the worst happens and one of us has to have costly treatment, we feel that their word means nothing and that's why we stopped paying. A bit like cutting off our nose to spite our face, I know...

If it's any satisfaction to you, what they did to you will now cost them 5000 per month from me. I will look elsewhere....

 

[bayaguanaman]

Re post above (22), your comment may indeed be the best soloution of all, and what leverage we could all have when negotiating a new contract or renewal if we were armed with the list of companies used by DR1 members, with all the positive and negative comments available. I use Universal for the boss indoors, and to be fair she is getting great coverage at the moment, but what does annoy me is that the likes of Farmacia Irena (Savana Larga) wont accept the insurance for medications yet a small corner farmacia further down Savana Larga will and give 80% discount I think.

This being with a policy which costs RD 25k per year, but as I said all in all the consultants used are top drawer. ( Another thing too as it comes too mind, the scans for the babies are covered at the Gyn and Obs clinic in Independencia yet they are not in the scanning section of Abel Gonzalez, yet we have minor works done in the IVF section on the 2nd floor and it is covered by insurance ( mine share I had to pay as I don't have (yet) coverage in the DR). Anyway, as I am about to head back I need to start looking at the various deals available soon.

 

[dv8]

but what does annoy me is that the likes of Farmacia Irena (Savana Larga) wont accept the insurance for medications yet a small corner farmacia further down Savana Larga will and give 80% discount I think.

working with insurance does not pay off at all. pharmacy will get 20-30% straight away (patient's share) and they may not see insurance's share for weeks or even months.

 

[Tarheel]

Comparison

Just to show how far ahead the DR is in comparison to the US in health care:

1) I am 62 years old, in excellent health and operate a one man S corporation.

2) My monthly premium is $578 per month x 12 = $6,936 ($255,245 RD).

3) To keep my premiums at a reasonable level I have a $10,000 deductible
with a 50-50 copay on the next $10,000. So my out-of-pocket expenses
before the insurance kicks in I have to pay $15,000 ($552,000 RD).

4) So my policy can cost me $21,936 ($807,245 RD) annually if I have major
medical expenses.

5) But it gets better. I cannot go to any doctor I want; only to doctors
within the network. Going to a doctor out-of-network costs more or if
I go to a out-of-network hospital that would trigger a penalty.

But there are people up here that think we have taken their freedom away by enacting National Health Care.

 

[Chirimoya]

If it's any satisfaction to you, what they did to you will now cost them 5000 per month from me. I will look elsewhere....

It will be satisfying when I tell them, definitely. La lucha contin?a. They're being non-responsive in the hope that we will get tired and give up.

We're now insured again, this time with Humano (RD$42,000 for the year), and we decided to throw in the helicopter rescue cover - RD$49 per person per month, so for a family of three that's just an additional RD$1,764 per year.

 

[whirleybird]

Just to show how far ahead the DR is in comparison to the US in health care:

1) I am 62 years old, in excellent health and operate a one man S corporation.

2) My monthly premium is $578 per month x 12 = $6,936 ($255,245 RD).

3) To keep my premiums at a reasonable level I have a $10,000 deductible
with a 50-50 copay on the next $10,000. So my out-of-pocket expenses
before the insurance kicks in I have to pay $15,000 ($552,000 RD).

4) So my policy can cost me $21,936 ($807,245 RD) annually if I have major
medical expenses.

5) But it gets better. I cannot go to any doctor I want; only to doctors
within the network. Going to a doctor out-of-network costs more or if
I go to a out-of-network hospital that would trigger a penalty.

But there are people up here that think we have taken their freedom away by enacting National Health Care.

That sounds like a horror story to me - a Brit, who is entitled to any health care in the UK which is urgent at no charge now as it is what we paid for all our working lives - the UK National Health System is superb in any emergency.

The care we have received at CMC hospital, Sosua has also been exceptional but the payment structure is different which is why it is essential to have some form of health insurance in this country.

 

[MikeFisher]

Must you be a resident of the DR to purchase the insurance. We spend 5 or 6 months every winter in the DR and I wonder if we can obtain coverage.

Thanks for your response.

Suzanne

you do not need to be a Resident,
you can get the coverage from ARS Humano with Your Passport.
I have under my Company name now 15 People registered, including 2 Non Resident Foreigners.
Myself and the Mrs use ARS Humanosince long for us and the Kids, never found a Hospital or Doctor who did not work with them.
I have their Plan Platinum, RD$3.650.- per Month/US$1.200.- per Year, it even has inclusions when I travel outside of the DR(did never use that due my anyways existing Insurance in Europe), pays many Meds and has high Yearly coverage Limits.
my Friends and Wifes and their Kiddies on my card have the so named Royal Plan, that's a more Basic Plan, costs just RD$945.-/US$310.- per Year.

my Sister in Law had a few weeks ago on that cheap Royal Plan a Surgery which included a 4 Nights at the Hospital, all meds/drugs etc etc included, the only Pieces she had to pay out of her own Pocket been RD$180.- PESOS at the Hospital and RD$190.-PESOS for the prescriptions.
I don't know what all would have cost without Insurance, I did not check the Bill, I just sent my Wife with a good amount of backup money to the Clinic to bring Her Home and when they told me on the Phone what the Clinic asked for I stopped to think about a Bill, lol.

within our small Crowd of together insured Persons, youngest is 1 Year old, the Grandpa is myself with 46yrs, we used over the Years Doctors and Hospitals in Santiago, Higuey, San Pedro and every existing Clinic in Punta Cana, including the above mentioned Hospiten, til Today they all and always accepted the Insurance, they are right upon Consultation on the Phone with the Insurer and let you know right away what the Total Bill for the Planned Stuff is and how much of that is covered and how much would be Yours.
2 weeks back I also asked at their Mainoffice in bavaro(at the Plaza Tobacco on the Mainroad near the Riu Resort, left side the large Glass Groundfloor Office, big letters ARS on) about their Flight Ambulance Plans after I read the Topic about the Flight Ambulances here on DR1, they include the max Plan for the Flight Amb for RD$110.- Pesos per Month per Person, something we plan to add to our existing Plans by October 1st.

Chiri,
that's a Bummer to hear about a Experience as Yours in case of a Insurer.
I would of course not Bet my Life to swear on any Insurer, but til today since years our experience with ARS Humano is Top, I hope you catch the same good experience when switching to them.

or better:
let's take the best Insurance ever,
and that's the one we pay during all our Life but never need it.

Mike

 

[MikeFisher]

Unfortunately, we had more than our 'fair share' of experience with medical insurance, hospitals and specialists in our just over 4 years in the DR.

It appears that each of the insurance companies excel or give a better deal in certain aspects - some are more prepared than others to pay higher specialist fees whilst others will more happily pay for pharmacy medicines (when, as dv8 stated, that particular drug on the prescription is covered).

We have used the insurance of Monumental and have their 'Estallar' plan + dentist which is one down from their top plan and found that, on average, they meet approximately 80% of the inpatient bills. However, if you happen to have a specialist who charges exoribitant rates such as Dr. Jose Ceara at Union Medica, Santiago (who was unable to diagnose correctly anyway) then Monumental will only cover a reduced percentage of his fees.

For an outlay of just RD$ 1200 per month each, this has to be worthwhile and I will give a simple example - I spent 3 days in CMC, Sosua in June with cellulitis. Whilst there I received excellent attention and medication in the form of antibiotics, pain killers and a blood transfusion, so nothing really exotic. The total bill for my stay was RD$ 27,000 and Monumental paid around RD$ 24,000 and we paid the balance of RD$ 3,000 so I got more than my 80% on that occasion.

One word of warning though - if you ever need an ambulance to take you from one hospital to another and they, as in the ambulance company, do not have a reciprocal agreement with the particular insurance company, do not let a friend pay and have their name on the receipt or you will never be able to claim it back from the insurance company and I say that from experience back in August of 2008 and I am sure that BB with remember the incident too!!

that's a very Important Point,
I would myself not have thought of that.
thanks
Mike

 

[MikeFisher]

It will be satisfying when I tell them, definitely. La lucha contin?a. They're being non-responsive in the hope that we will get tired and give up.

We're now insured again, this time with Humano (RD$42,000 for the year), and we decided to throw in the helicopter rescue cover - RD$49 per person per month, so for a family of three that's just an additional RD$1,764 per year.

right on Chiri.
please keep in mind that their RD$49.- per person per month Heli/flight Ambulance steps only in when involved in a Car Accident, at least that been what I understood after the first explanations.
that's why I actually lean towards the extra 60 pesos per month per person to get their premium Flight Ambulance Plan.
Darn,
if a Thief shoots my Azz here at Home I have the Heli Landing Place right on the Pier in front of the Door, lol.

Mike

 

[Adrian Bye]

it might be good to include the stories of lambada and rick in this thread about the quality of DR healthcare.

 

[waytogo]

What is ARS Humanos age limit whereas you will not be renewed?

 

[mountainannie]

What is ARS Humanos age limit whereas you will not be renewed?

According to my agent, Universal is the only one which will cover you after 70 without question. The others will renew til 70 and then PERHAPS (depending on your health)

We should also be very clear that the post 64 coverage is limited to either 360,000 pesos a year or 3 million for the life of the policy. This does not seem like a lot to people who are used to having 2 and three million DOLLAR policies - so if you have a chronic condition - well, I would guess that you would have some high anxiety here.

I do not know what the medicare benefits are - where they stop - if they ever do. But you could run through your policy here with one big illness, and that is a fact that everyone should bear in mind.

In the States, we still spend the bulk of our medical money -(it used to be 2/3rds of it!) in the last year of life. It used to be that the bulk of our bankruptcies were from medical bills.

Here they seem to have a much more realistic approach which is to keep you going til the end of your natural lifespan then --- exit gracefully stage left.....This keeps the prices down for everyone. A much more sensible approach, I think, than keeping our shells going til we have run through all our money and sit drooling in a chair, not knowing the names of our relatives.

 

[waytogo]

According to my agent, Universal is the only one which will cover you after 70 without question. The others will renew til 70 and then PERHAPS (depending on your health)

That is exactly why I WAS going through them. But after reading what Chirimoya went through, what's the point. I am 62 and don't think it wise to wait any longer, but what good is a hassle free renewal at 70 if they don't pay.
This is getting difficult when you hear highly rated companies are refusing payment AFTER AN AUTHORIZATION.
It's starting to sound like the lotto, gee I wonder if I have the winning ticket....
Last week I had gone to ARS Universal with Don (SantiagoDR) and his wife and did all the paperwork and at the very end, I walked out. They wanted my credit card number to pay quarterly (automatically) and I refused to give it to them.
I said I wanted to pay cash and they said NO....I have read to many horror stories about your credit card numbers floating around out there. Really confused on how to pick the right company and how to pay securely.

 

[mountainannie]

That is exactly why I WAS going through them. But after reading what Chirimoya went through, what's the point. I am 62 and don't think it wise to wait any longer, but what good is a hassle free renewal at 70 if they don't pay.
This is getting difficult when you hear highly rated companies are refusing payment AFTER AN AUTHORIZATION.
It's starting to sound like the lotto, gee I wonder if I have the winning ticket....
Last week I had gone to ARS Universal with Don (SantiagoDR) and his wife and did all the paperwork and at the very end, I walked out. They wanted my credit card number to pay quarterly (automatically) and I refused to give it to them.
I said I wanted to pay cash and they said NO....I have read to many horror stories about your credit card numbers floating around out there. Really confused on how to pick the right company and how to pay securely.

I checked into Clinic Abreu with no preauthorization from Universal and they paid everything. Perhaps it was just an outpatient thing with Chiri or a group policy?

I pay my agent in cash every six months. When I first got the policy, they took my bank account (local peso) number for the guarantee. Then they IMMEDIATELY went and withdrew the other payment which was not due for six months. My agent had it refunded to me within a week.

So perhaps a lot of this depends on who your agent is?

 

[waytogo]

So perhaps a lot of this depends on who your agent is?

I went to the Santiago office and there were 2 women sitting behind their desks. Just waited my turn and that was that. This was an actual Universal office so I don't think they were agents but salespeople.
No problem paying cash the first quarter at their office, but she insisted on a credit card number or no policy would be written.

 

[Chirimoya]

No, it's not a group policy and what would "an outpatient thing" be?

The lesson for the future from this experience is that pre-authorisation by your agent (as opposed to the routine pre-authorisation by the clinic on the day) is essential. The other lesson is that if they can get away with shafting you, they will.

 

[waytogo]

So I get this right, you are saying always get the authorization from the clinic or hospital while you are there and not through the agent.

 

[mountainannie]

No, it's not a group policy and what would "an outpatient thing" be?

The lesson for the future from this experience is that pre-authorisation by your agent (as opposed to the routine pre-authorisation by the clinic on the day) is essential. The other lesson is that if they can get away with shafting you, they will.

Outpatient would mean that you were not admitted to the hospital overnight- say for something like a broken arm or stitches or the like.

I walked into the hospital and did not think to call my agent. I assume that they called the insurance company to check if they could admit me. I did ask if the insurance company was going to cover the expenses.

 

[mountainannie]

I went to the Santiago office and there were 2 women sitting behind their desks. Just waited my turn and that was that. This was an actual Universal office so I don't think they were agents but salespeople.
No problem paying cash the first quarter at their office, but she insisted on a credit card number or no policy would be written.

I think that it would be wiser to go through an agent since they are going to go to bat for you AGAINST the insurance company in order to keep your business.