By Carlos Ramirez
Over the years as a broker I have seen the good and the bad in the insurance industry. The questions and problems that I have repeatedly run into have allowed me to create services that meet the needs of the market, especially those which fill the holes in the Ecuadorian private insurance sector. Many of the questions that have come up from customers over the years have a lot to do with the differences between health coverage in Ecuador and health coverage in the United States.
There are many ways to receive high quality private medical services in Ecuador from top-level professionals, 24 hours a day and seven days a week. These private clinics are part of the Ecuadorian health system but externally partner with insurance companies. This means that once a patient has received medical attention the clinic is not responsible for contacting the insurance company to obtain payment or reimbursement. This responsibility falls on that of the patient, or affiliate, and they must obtain the correct documentation of services in order to do so. This is the first major difference between the US healthcare system and Ecuador’s system. In the US, medical clinics and health insurance companies work together and the patient simply has to wait to receive a bill or reimbursement, more information about their next appointment, lab tests or referrals. In Ecuador, this type of communication between the clinic and health insurance company is not typical, despite the fact that the clinic and insurance company have contracted agreements.
Additionally, in the US, health insurance bills usually arrive directly at the patient's home address a few weeks after receiving medical care. The patient is then responsible for the remaining payment, if it was not covered by their insurance. If a patient cannot pay the full amount, insurance companies will typically allow for a payment plan to be put in place. Unfortunately, payment plans and different types of relief for medical bills do not exist in Ecuador and the patient is obligated to pay their deductible, copayment, non-covered expenses, and excess medical fees in full when requested.
In my time as a broker I have noted that some of the most common insurance plans in the US are MEDICAID, MEDICARE, and OBAMACARE, among others which vary in price depending on income and resources. People in the US tend to pay much higher monthly payments for private health insurance as well. This is a big change for many foreigners from the US when they arrive in Ecuador. In Ecuador, private health insurance is priced very reasonably and the only public, government insurance option is the IESS, which unfortunately is going through a state of economic crisis at the moment.
Technological advances and social development also account for some of the changes between the US and Ecuadorian health system. For example, in the US, medical insurance typically covers annual exams and check-ups. In Ecuador these same exams are not covered since they are considered preventative exams. This is a significant difference due to the technological, economic, and social development of the US which allows them to provide this service to the people who live there. Additionally, most medical clinics in the US have software that allows them to verify in real time the coverage that you have with your health insurance plan. Unfortunately, Ecuador does not have this level of technological infrastructure in place yet and you should be wary of health insurance brokers who offer to reimburse funds without proper documentation. Ecuadorian health insurance laws are clear and strict and must be followed by all companies whether national or international.
Another difference is access to pharmaceutical medicines within the private health care system. In the public health system, access to prescriptions is limited but generally includes paracetamol, ibuprofen, acetaminophen, omeprazole and other antacids, calcium and some types of psychiatric medicines. This is due to the current turbulent situation that the IESS, hospitals, and other public health centers are facing. In the US there are private health care plans that do not include coverage for prescriptions. Plans that do include prescriptions are normally priced higher or are a separate plan combined with principal coverage. Once coverage for prescriptions is obtained the patient can access their prescriptions at the pharmacy they choose or even have them sent directly to their home. In Ecuador the process is quite different, you must present all the correct documentation and you will be reimbursed on a monthly basis. Alternatively, you can go to a specific pharmacy that is authorized to sell medicine for mild and moderate diagnosis. One of the exclusions in Ecuador’s health coverage is that it typically does not cover psychiatric medicine, dermatological treatments without curative purposes, ozone therapy or care with podiatrists (in Ecuador this specialty is not recognized as a branch of medicine and a reimbursement of this type is only paid in the event that the podiatrist has a university degree as a general practitioner).
Reimbursement documentation can cause headaches for many expats and it can be a difficult process since this is generally not the responsibility of the patient in the US. Although it is true that the documentation process occurs directly between the clinic and the insurer in most cases, in the US, there are times when it does not. For example, there are times when specialists or certain doctors are not covered under one's insurance. This also occurs in Ecuador and if you see a doctor outside of your coverage area you must present the correct documentation in order to be reimbursed. Overall, in Ecuador, the law states that it is the patient's responsibility to present regulatory documentation to obtain reimbursement from a company. If one does not do so, or presents it after the 90 day limit, the company is not required to process any refund.
One of the most significant differences between insurance plans in each country is undoubtedly its cost. In the US it is reported that only 6% of the population has premium private insurance. This same insurance in Ecuador can be bought for half the price you are used to, with a much lower deductible than what you pay in the US. Although the US government provides insurance for the elderly and people with disabilities, these insurances do not always provide complete coverage and they find themselves in need of contracting supplementary plans to access medicine or certain doctors. In Ecuador these problems do not exist or are rare to encounter. This is a huge benefit to those who settle in Ecuador. Here, all policies include outpatient and hospital medical care, medicine, access to surgeries, physical rehabilitation, and additional dental or vision benefits.
The differences between the two systems are minimal, but it is what matters to you that is important. In a brief summary the main differences pertain to price, documents, coverage, and medicine. Always remember to first choose a broker and then a company that has a wide network of agreements at the national level. This will ensure that you have ample access to care and it will reduce the amount of documentation and paperwork you have to provide. After choosing a well connected company and broker I would suggest choosing a plan according to your economic comfort. I recommend this approach because you can find international insurance plans with high deductibles and quotes that will ultimately not be able to connect you to the medical services you actually need. If you choose a company that is well connected you will pay reduced deductibles and have broad coverage so that you will be able to receive health care anywhere you want in Ecuador. The process may seem daunting at first but it does not need to be complicated. The secret is to take the time to understand the system and then make it work for you.