Dear Claudienne,

I got your e-mail address from a co-worker and I am wondering if you can help me with an issue I am having with Sagicor Medigap.

I had a heart attack on the 8th of November 2016. I was admitted at the Kingston Public Hospital and on the 9th of November I was taken to the Heart Institute for an angioplasty operation to be done.

Before the angioplasty procedure was done, a payment had to be made to the hospital.

The cost of the operation was US$12,440 (J$1,598.540.00)

I paid J$45,000 and my sister paid US$500. When I gave them my Sagicor/Medigap health card I was told that they did not accept Medigap.

The angioplasty operation was needed to clear a valve in my heart and to put in a stent. I was told that the operation would not begin until they got the outstanding amount or got a commitment for the balance to be paid by a certain time.

The Heart Institute operated on me on December 19, 2016 after they got a commitment letter from my workplace.

My workplace paid the Heart Institute over $800,000 but I have not been able to pay them the outstanding amount.

I then went to the Sagicor office at the Winchester Medical Complex to find out if I could make a claim for the amount of money I had already paid the Heart Institute. If I was successful in the claim my intention was to use the money I got from Sagicor to pay the outstanding amount I owed the Heart Institute.

When I outlined the situation to the clerk at the Sagicor office she told me that the Medigap insurance did not cover private institutions such as the Heart Institute.

On three different occasions I went back to the Sagicor office at Winchester Medical Complex and each time I was told that there was nothing they could do.

Having no other way of finding the money, I left the office confused and frustrated.

The Heart Institute then handed over my debt to a collecting agency. When it was handed over to the agency the amount I owed was $741,040, but the amount I am now owing is one million dollars.

After some time had elapsed my spouse went to the Sagicor Winchester Medical Complex and on this occasion the clerk told her that I needed to bring documentation from the hospital to the insurance company.

I got the documentation and returned to the Sagicor office but was again told that because the operation was done at a private hospital, Medigap insurance did not cover it. However, after I explained that my wife was instructed to tell me to bring the documents, a supervisor checked the documents and told me that Medigap was covered but that the time frame for me to claim had long passed. When I told her that I had been told several times that the Medigap did not cover my operation, she said there was nothing she could do.

On hearing this I felt despondent and as if I was getting another heart attack.

Meanwhile, the collection agency has been calling me and is saying that it is going to seize assets.

However, I don’t have the money to pay the hospital. Hence, I am seeking your help in this manner.

OI

Dear OI,

Tell Claudienne made Sagicor aware of your plight in February 2018 and note that they have been working with you to have the matter settled. You informed Tell Claudienne of the difficulties you were experiencing in getting certain documents from the Heart Institute that Sagicor had required you to get.

In an e-mail to the Heart Institute dated April 19, 2018, Tell Claudienne stated the following: “OI says that Sagicor needs a breakdown and copies of the receipts from the collection agency. He said that the collections agency has told him that it will have to get the information from the Heart Institute.

OI said he has already paid the Heart Institute $800,000, US$500 and $27,000 and also needs copies of the receipts for these three payments he has made to the Heart Institute.

Your assistance to help OI to obtain the documented evidence of these transactions speedily will be greatly appreciated.”

On April 25, 2018 Tell Claudienne received the following e-mail from the administrative manager at the Heart Institute:

“OI apparently has sought advocacy from the Tell Claudienne column at the Jamaica Observer. You, in turn, have made contact with us in response to same.

In order to provide context, it is important to first share how the Heart Institute of the Caribbean (HIC) executes its mission.

HIC provides world-class cardiovascular care at a fraction of the cost at institutions of similar calibre and reputation internationally. HIC operates an open access to care model, which means patients are not turned away in a life-threatening emergency due to inability to pay. We accomplish this by using a cross-subsidy approach. What that means is a portion of each payment goes to keeping the facility open and operating at the highest levels. Our goal is always to meet or exceed international standards.

Another portion of each payment is donated to the Heart Institute of the Caribbean Foundation (HICF), which applies its resources toward subsidising care for indigent patients. These donations are the only source of revenue currently for the HICF. In this way we meet our mission of improving the access to and the quality of cardiovascular care to the citizens of Jamaica.

Without patients who receive assistance/subsidies fulfilling their responsibilities there will be no funds available for other needy patients to access future foundation assistance.

All patients who get foundation assistance are made aware of the source of their funding.

Some more context: It is internationally accepted policy to not disclose the specifics of protected patient information with third parties, outside of referring physicians and insurance agencies. Outside of information necessary to pay claims, even insurance companies will require a release of information signed by the patient to get access to medical records.

As a result of our Privacy Policy, we will answer your questions in general as opposed to delving in to the specifics of OI’s case. Because we understand your interest in this matter based on the narrative related to you, we have provided OI a detailed summary. Though I am restricted from sharing this directly with you, OI is free to forward same on to you directly as he chooses.

In specific response to the questions posed to the Heart Institute of the Caribbean, several points of clarification can be made. OI was seen at the institute in early November 2016, and not in December 2016.

All insurances presented to us at any time by patients are billed. Patients who are unable to afford care in the absence of insurance or third-party payers are referred to the Heart Institute of the Caribbean Foundation (HICF) for assistance, as already noted. In some instances, despite having insurance, patients are still unable to afford care. The HIC Foundation attempts to provide subsidies even in this instance.

Without going into the specifics of any particular patient case, we can state unequivocally that the above remains true. We can also unequivocally state that at no time were we apprised of a valid secondary form of insurance until we were contacted by Sagicor a few weeks ago.

We can speak more specifically about our interaction with Sagicor.

It is our standard policy that the patient receive all copies of invoices AND medical records at the time of service. There was no deviation in OI’s case. There are never inordinate delays in providing billing information to patients. When we were asked by Sagicor to provide duplicate billing records, after informing them of our need to research this old claim, we spoke with OI who informed us that not only was he in possession of his billing records, he had provided same to Sagicor already. Despite this knowledge, we forwarded the billing records to Sagicor anyway as confirmation.

We will state here that any delay in providing medical records to a third party upon request are usually occasioned by a delay in the patient themselves providing the signed release, as is required, approving that we do so.

In closing, I would like to stress that we empathise with all patients who face challenges with the affordability of medical care. This is not just a local issue and is something economies all over the world struggle with. We at the HIC and the HICF are proactive in our endeavours to keep care affordable while still maintaining the high quality for which we are known and which patients deserve. We try hard for each and every patient every day and are justifiably proud of the quality of cardiac care we have been able to extend in our low-resource environment.”

Tell Claudienne notes that Sagicor has now settled your Medigap claim. You have e-mailed the Tell Claudienne column a copy of the letter Sagicor sent to you. The letter from the assistant manager, Employee Benefits Division, Group Insurance Services states:

“We wish to advise that we have completed our assessment of your claim related to angoplasty procedure done at the Heart Institute of the Caribbean on November 9, 2016.

Firstly, let me apologise for any misunderstanding that occurred during your initial discussion with our team members at our Winchester customer care location.

Despite the fact that the claim for service rendered November 9, 2016 was now outside of the stipulated 90-day submission period, Sagicor Life Jamaica Limited (Sagicor) decided to honour the claim.

We have now paid over to the Heart Institute of the Caribbean the sum of seven hundred and six thousand four hundred and fifty-eight dollars, eighty five cents ($706, 450.85) in accordance with your eligible benefits under the GEASO/Medigap policies. In addition, Sagicor has made a reimbursement to you in the sum of Seven hundred and five thousand, six hundred and sixty-four dollars 92 cents ($705,664.92).

Enclosed is our NCB cheque payable to you in said amount stated above.

We have now settled our obligations for this claim and any additional cost associated with the procedure will be fully at your expense.

With every good wish.”

Although the Medigap payment Sagicor made to the hospital has helped to pay off a substantial part of the money you owed for your operation, you still owe the Heart Institute a small sum. You also still owe the collection agency fee, plus interest on the loan. These payments, you said, you will make from the $705,664.92 reimbursement cheque Sagicor paid you.

Please try to make these payments as soon as possible, as the Heart Institute told Tell Claudienne that interest on outstanding amounts is incurred daily.

We wish you all the best.

Have a problem with a store, utility, a company? Telephone 936-9436 or write to: Tell Claudienne c/o Sunday Finance, Jamaica Observer, 40-42 1/2 Beechwood Avenue, Kingston 5; or e-mail: edwardsc@jamaicaobserver.com. Please include a contact phone number.