Five-year old Luka has spastic palsy (quadriplegia) and is unable to walk. He lives with his mother and grandparents. In the Iashvili Children’s Hospital, doctors told Luka’s mother that there was a chance for Luka to improve his condition with surgery.
But the Insurance Company, Irao, refused to finance the operation, because the outcome was questionable. So Nino, Luka’s mother, applied for help to the Health Insurance Mediation Service (HIMS), a private NGO that attempts to resolve disputes between clients and insurance companies. The mediator studied the case, and had intensive meetings with Irao’s representatives.
The insurance company decided to finance Luka’s surgery in November 2008. Now Luka is beginning to be able to walk.
Health Insurance Mediation Service, part of the Georgian Insurance Association, tries to settle misunderstandings and disagreements between the clients and insurance companies, avoiding court.
Anybody who has health insurance can call 555-115 and get consultations and assistance for free, according to Archil Tsertsvadze, head and mediator of the Health Insurance Mediation Service.
The organization was established on the initiative of the Georgian Insurance Association, with the help of the Ministry of Labor, Health and Social Affairs of Georgia, and with the support of the United States Agency for International Development’s (USAID) project Co-Reform, in March 2008.
In 2007 the Ministry of Labor, Health and Social Affairs of Georgia started a state insurance program for the socially unprotected population, as well as for teachers, armed forces and public officials.
The Georgian government sees the private health insurance system as the major method for financing health care in the future. In 2009, two-thirds of the population will have health insurance.
“During the year of 2009, the state will insure another 900,000 citizens,” said Sopho Lebanidze, head of the Health Care Department at The Ministry of Labor, Health and Social Affairs of Georgia.
The organization serves citizens insured by the State health insurance programs, as well as by the private sector insurance companies, either individually or in corporate (employee) groups.
The Health Insurance Mediation Service is located under the N. Baratashvili bridge on the left bank of the Mtkvari River. A mediator, three health insurance specialists, a lawyer, an administrator, an IT specialist and a database and reporting manager make up the staff of the organization.
Lela Serebryakova, Health Insurance Regulation Program Manager at CoReform, praised the staff of the mediation service.
“These are people who not only thoroughly understand health insurance, but also they care,’’ she said.
The mediation service’s goal is not only to resolve disputes, but also to inform consumers who have health insurance.
“People have a serious deficit of information in this field. A person may think that he or she deserves a benefit, and in reality does not. Or just on the contrary, deserves it, but does not know about it. Besides resolving the disagreements, the main function of this organization is giving more information to health insured citizens,” said Tsertsvadze.
The job of the mediator is to be objective, professional and impartial.
“In the process of making a decision, the mediator is absolutely autonomous. The board of the Georgian Insurance Association does not interfere,” said Devi khechinashvili, President of the Georgian Insurance Association.
There are three categories of applications in the Health Insurance Mediation Service: 1. Forwarding: When the application is out of the mediation’s competence. For example, if an insured person applies directly to the Health Insurance Mediation Service, without applying first to the company or ministry, the mediator asks the person to apply to the other departments first.
2: Explanations: The organization gives information to the insured person and gives direction on what to do next.
3. Disagreements: The Health Insurance Mediation Service studies the documents, the case, and after that comes to a conclusion, and tries to resolve the disagreement.
“We have to discuss 20-25 applications every day. Most of them are of the first and second categories,’’ said Lia Memarnishvili, a health insurance specialist at mediation service.
According to an agreement with insurance companies, the mediation service can tell the company to carry out certain obligations, when the dispute involves less than 1,000 lari.
“But if the sum is higher, then the mediation service’s conclusion is a recommendation [not an order],” said Tsertsvadze.
According to the documents, from May to November 2008, 1,332 people applied to the mediation service. From September to November, cases were resolved in favor of the insured consumers 51 times in disputes and 21 cases in explanations. The resolutions were valued at 82,950 lari ($51,800). During the same period, cases resolved in favor of the insurance companies amounted to 201 in the explanation category, and 1 in the dispute category, with the total value of the cases put at 108,200 lari ($67,000).
“In the second category, explanations, the insurance companies turned out to be right more often, because people are less informed about their insurance terms and procedures, or what they can expect the insurance company to pay for” said Nino Zhorzholadze, database and reporting manager at the Health Insurance Mediation Service.
The relationship with insurance companies has been positive, both sides say.
‘’They are not biased, we trust them and of course take their recommendations into consideration,” said Khatuna Silagadze, Social Programs Manager for GPI Holding.