Health insurance is a legal right under Cayman law with all employers being required to ensure their employees have healthcare coverage.
Under the Health Insurance Law (2005 Revision), the employer, at a minimum, is required to pay 50 per cent of the premium of a basic or standard insurance policy and the employee pays the other half.
By law, the employer is obligated to provide the basic or standard plan available from an approved insurance company, which pays a maximum of $25,000 in medical fees for each episode of illness; no more than $100,000 in medical fees during a single calendar year; and up to $1 million during the lifetime of the insured person.
But what if an employee wants to upgrade to a premium plan or wants to go with a different insurer?
Health Insurance Commissioner Mervyn Conolly says that employees would have to have a good reason to want to opt for a different plan or insurance provider, but that there is nothing in the law to prevent them from doing so.
“If an employer already has an established plan of benefits with an approved insurer, then the employee would have to give that employer a good reason why he or she would want to go to another approved insurer. I’m not saying it is not possible, but at the end of the day, the employer would certainly have to be convinced that there is a good reason for them to go elsewhere,” he says.
If an employee wants to opt for a premium policy rather than the standard one, he or she may have to pay the difference in the premium as the law only requires an employer to pay a minimum of half the basic policy premium.
“Most approved insurers would want to do some underwriting for anyone who is applying for a more comprehensive level of benefits,” Conolly says.
The usual cost for an individual for a standard or basic plan, which excludes vision, dental, and out-patient visits, is $105 a month while a premier plan, which includes dental, vision and out-patient visits, can cost up to $475 a month for an individual.
According to the law, the health insurance should cover the employee, his or her unemployed spouse and children.
While basic insurance policies provide coverage for treatment overseas, the amount they cover is often not enough to cover the expenses of the treatment.
To get treatment overseas, two medical doctors must give written confirmation that a patient needs the required treatment and that it is not available in the Cayman Islands.
People who are unemployed and indigent are covered by the Cayman Islands National Insurance Company, or CINICO.
Health minister Mark Scotland recently said that the government was spending more than $1 million a month to send indigent individuals for health care overseas due to a lack of insurance or under-insurance.
Conolly says basic insurance policies covered overseas care, but admitted that with the current cap of $25,000 per episode of illness, coverage is limited.
Amendments to the Health Insurance Law and regulations are underway, according to health minister Scotland who told members of the Legislative Assembly earlier this year that the Health Insurance Commission had recommended the $25,000 cap per episode of illness be removed.
He is also proposing addressing the portability issue in the law which effectively allows insurance companies to deny coverage to people moving from one job to another if they have a pre-existing condition.
The proposals include increasing maximum coverage for in-patient and out-patient services, as well as emergency transportation for patient air lift. The current benefit is limited to $4,000 per calendar year for medical air lift – the proposal would increase this to $15,000.
The proposals also seek to eliminate a loophole that allows health insurers to treat pregnancy as a pre-existing health condition and allow retired people to buy standard health insurance coverage without any underwriting.
The amended regulations would also enable the Health Insurance Commission to fine employers who do not pay for workers insurance without taking the case before a magistrate. Fines for non-payment convictions in Summary Court would double or triple in most cases.
Conolly says any employee whose employer was failing to pay for health insurance should contact the commission to lodge a complaint.
What is not covered
The standard health insurance contract may legally exclude a number of treatments. These include the treatment of an illness or injury which the individual had failed to disclose in writing, consultations for infertility treatments or sexual dysfunction or sex changes.
Also excluded are contraceptives, sterilisation, treatment for injuries sustained in a war, and following certain sports and treatment for obesity or weight reduction.