Misuse of medical insurance system across the UAE

A third of people surveyed had been told to get tests that were not needed while fraudulent claims could be costing the region Dh3.67bn.

DUBAI //  Fatima M became suspicious after her new employer sent her for standard medical tests and doctors at the hospital she attended added a host of additional procedures she did not need.

"They started to do tests on me I had never heard of," said the 27-year-old government employee. "I had four or five eye tests alone and when I saw the eye doctor she signed off my papers without even looking at them."

When the hospital tried to bill Fatima for the extra tests, alarm bells rang and she refused to pay.

"The doctor begged me to just pay and claim it back from Daman. I refused because I knew it was not right."

Fatima is not the only patient to experience attempted medical insurance fraud. Almost a third of 450 people surveyed by 999 magazine said they had been advised to get unnecessary tests.

Of those surveyed, 81 per cent had medical coverage and 28 per cent said their medical bills were unnecessarily inflated.

About half said they knew people getting fake medical certificates so they could take sick leave when they were not ill.

"These numbers confirm what we suspected, that there is misuse of the system," said Dr Sven Rohte, chief commercial officer of Daman, a national health insurance company that insures 2.1 million members, representing 80 per cent of Abu Dhabi's insured public.

"You will find some fraud in every health care system around the world. Health care is an industry that turns over billions of dollars a year so it is relatively easy to pocket millions."

Fraudulent claims and insurance abuse could be costing the region as much as Dh3.67 billion while accounting for 30 per cent of all health insurance spending, according to estimates by consulting and insurance companies.

To stem the tide of fraudulent claims a number of measures have been taken, Dr Rohte said.

From the provider's side, Daman is putting medical establishments and prescription trends under the microscope.

"If doctors are constantly prescribing high priced medication we will investigate them."

Last year, Daman audited 595 medical service providers and investigated more than 1,000 claims. "In the end only eight to 10 doctors were taken to court as it is difficult to prosecute them," said Dr Rohte.

An obstacle to this is the seven-year-old legal framework for health insurance law.

"There is no clear definition of medical insurance abuse in the law," said Dr Rohte.

An important step in reining in unnecessary medical spending lies in the educating the patient.

"The problem is patients use their Daman cards like credit cards with no spending limit because they don't have to pay or even see their bills," said Dr Rohte.

Daman patients are able to review up three years of previous medical bills on the company website so they can assess whether they've been overspending or overcharged.

"Members can now investigate their own cases. If you went to the doctors for flu and you were billed Dh3,000, you should complain."

He says tools such as this one will create more transparency while targeting fraud through the increased involvement of the patients.

When asked about patients who habitually seek medical attention, Dr Rohte claims they too are on Daman's radar. "We have identified people who like to 'doctor hop'."

"Increased awareness is the key to controlling premiums," said Dr Rohte, which are rising at alarming rate causing the erosion of health insurance quality and causing some to go without coverage at all.