| Plan 16 is the medical insurance policy INS has been selling
since 1990, and a lot of people from the foreign community
have obtained coverage through the Canadian Club, the American
Legion and the ARCR. INS advised that, starting with the renewal
at January 1, 2005, some new rules apply to this policy. Some
of them look good, some not so good, but, in balance, the
changes iron out some of the bugs. At the same time, the premium
rates, which are in colones, have increased by about 20 percent,
which is reasonable just a tad above what inflation will probably
rack up to in calendar year 2004.
Outlined below are the nuts and bolts of Plan 16. After each
paragraph, in CAPITAL LETTERS, are comments regarding the
changes INS has made.
WHO CAN BE INSURED?
Anyone up to age 100, regardless of legal status in Costa
Rica. Applicants over 69 must undergo an examination by an
INS doctor. It takes INS about three weeks to study applications;
you can't pay until your application is accepted. The policy
goes with the calendar year; if someone applies and is accepted
part way through the year, the yearly premium is prorated.
NO CHANGES.
WHAT DOES THE POLICY PAY FOR?
It covers expenses due to sickness, accident or childbirth.
Outpatient services are paid for up to 10 percent of the insured
amount, per year. The rest of the policy, the other 90 percent,
is for hospitalization, surgery, pre- and post-operative care,
private room, food, support systems, intensive care, rehabilitation,
ambulances, home care, therapy, medication, etc. In case of
death, 50 percent of the insured amount is paid to named beneficiary.
Please note that there is no payment for checkups or preventive
maintenance, NO CHANGES.
WHAT DOES IT EXCLUDE?
Pre-existing conditions. Nonprescribed expenses. AIDS. VD.
Medical expenses as a result of cataclysmic events, fighting
except in self-defense, tournament sports, martial arts and
other dangerous activities. Accidents when under the influence
of alcohol or drugs. Mental or nervous disorders. Checkups.
Allergies. Stress. Plastic surgery. Only accident related
eyeglasses, dentist's bills or reconstructive surgery are
paid. Some ailments (e.g. glaucoma, cataracts, ENT, women's
reproductive organs, breasts, asthma, hernias, pregnancy,
prostates, stones, osteoporosis) have a 12- month moratorium
during which claims are not allowed. HERE WE SEE A CHANGE:
GLAUCOMA AND CATARACTS WERE NOT PREVIOUSLY SUBJECT TO THE
MORATORIUM.
HOW MUCH DOES IT COST?
You can choose from three levels of insurance. The insured
amount refers to the maximum amount INS will pay for your
health in the calendar year. Premiums depend on the level
of insurance, and on the age and sex of the insured.
THESE RATES REFLECT THE 20 PERCENT INCREASE /HOWEVER, IT
IS NOT EXACTLY 20 PERCENT, AS FIGURES HAVE BEEN ROUNDED.
Group policies for companies cost about 12 percent less.
Associations or clubs, (ARCR, American Legion, etc.) get about
6 percent off. Cost of renewal may increase if there is a
high claim/premium ratio. ANOTHER CHANGE HERE: DISCOUNTS FOR
GROUP POLICIES USED TO BE GREATER.
HOW DOES THE POLICY WORK?
In case of ambulatory care (when hospitalization is not needed),
you must pay for your care and later submit an INS claim form
signed by you and your main doctor, attaching original receipts
and corresponding prescriptions for medicines, treatments
and lab tests. Your agent will push your claim through INS,
which usually pays after three to six weeks, based on usual
and reasonable charges. If you require hospitalization, a
week before you go into hospital, through your agent you should
obtain a pre authorization from INS, which will negotiate
prices with your care giver. When released from hospital,
you must show your insurance card and so pay the deductible
only. If you didn't get the pre authorization, you must pay
the entire bill and make a claim as described above. IMPORTANT
CHANGES HERE: A NETWORK OF PROVIDERS USED TO ACCEPT PATIENTS'INSURANCE
CARDS AND COLLECT ONLY THE DEDUCTIBLE FROM THEM, AND THE NETWORK
PROVIDERS WERE SUPPOSED TO ABIDE BY A PRICE LIST IMPOSED BY
INS. NOW, THERE ARE NO NETWORK PROVIDERS, THERE IS NO OFFICIAL
PRICE LIST, PAYMENT OF CLAIMS IS BASED ON USUAL AND CUSTOMARY
PRICES,”AND INSURANCE CARDS CAN BE USED ONLY FOR AILMENTS
REQUIRING HOSPITALIZATION IN CASES WHERE PRIOR APPROVAL (PREAUTHORIZATION)
HAS BEEN OBTAINED FROM INS.
DEDUCTIBLE?
The general deductible is 25 percent. In some cases, such
as claims from abroad, or if you buy a patented medicine when
a generic equivalent is available, the deductible can be 30%.
-MORE CHANGES: GENERAL DEDUCTIBLE USED TO BE 30 PERCENT;
THERE WAS NO DIFFERENCE BETWEEN PATENT AND GENERIC MEDICINES;
AND THERE WAS NO DEDUCTIBLE ON SURGEON's FEES.
For additional information contact the author of this last
section, David Garrett, at 233-2455 or E-mail: info@segurosgarrett.com.
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