The Consumer Council of Fiji has called for urgent reforms in health insurance practices nationwide due to increasing concerns about the reimbursement-based health insurance model. This appeal follows consumer complaints regarding unjust policies from major insurance providers, which necessitate customers to pay for medical treatments upfront and then seek reimbursement later.
A study by the Council emphasizes the need for a more effective direct billing system that aligns with international standards, wherein insurers directly settle bills with healthcare providers within an extensive network. The analysis indicates that the current reimbursement model used by prominent insurers places significant financial strain on consumers, especially in emergencies or when ongoing medical treatments are needed.
Seema Shandil, CEO of the Council, noted that despite holding comprehensive health insurance policies, many consumers find themselves financially burdened as they have to pay out of pocket for medical services before receiving any help from their insurers. She pointed out that expecting Fijians to have between $2,000 to $5,000 available for upfront payments raises questions about the value of paying high premiums for insurance.
Shandil remarked that for many middle-income families, managing health insurance costs on top of their living expenses is already a struggle. She insisted that insurance should alleviate financial pressures, not add to them, and criticized the practice of requiring insured individuals to cover substantial medical bills upfront, followed by delays before reimbursement.
A particular issue raised concerns major private hospitals, where policyholders are reportedly required to make upfront payments for services, even when these facilities are listed as part of the approved provider network. This lack of clarity and service is eroding consumer trust, especially as these insurance companies tout their financial achievements while failing to address basic consumer needs.
The Council has drawn comparisons between Fiji’s health insurance models and best practices from around the world. In countries such as Australia and New Zealand, direct billing systems are prevalent, allowing insurers to pay healthcare providers straight away. This approach eliminates the necessity for consumers to make upfront payments, thus relieving financial burdens and enabling prompt access to healthcare services.
The Consumer Council is urging insurance providers to shift from the current reimbursement-based model to a comprehensive direct billing system, akin to those in Australia and New Zealand. Shandil also emphasized the need for insurers to enhance their communication and transparency by providing clear information about policy terms, including co-payments and exclusions, and informing consumers of any policy changes in advance.
The Consumer Council plans to engage in discussions with relevant insurance providers and government entities to prioritize these reforms and build a more consumer-oriented healthcare system.