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Complaint against CINICO healthcare policy
Investigation | 03 August 2023
Cayman Islands National Insurance Company (CINICO)
The complainant raised two issues in a complaint against the CI National Insurance Company (CINICO).
The complainant sought reimbursement after attending the A&E at CI Hospital. The complainant waited in the ER for more than an hour and stated they were never seen and then went to another hospital for care, which was paid out of pocket. The complainant also noted that CINICO policies require the patient to receive a referral to see a private doctor where, in the case of a medical emergency, that is practically impossible to achieve.
This complaint was unusual in that the Ombudsman (OMB) issued a special exemption under section 11(3) of the Complaints (Maladministration) Act to allow the office to investigate a matter which had already been reviewed by an appellate tribunal. It was determined that since the complaint involved an allegation that CINICO’s coverage policy itself was unfair and unjust, the OMB could investigate the complaint despite the appeal already having been heard. It was also noted that the matter would move directly to a formal investigation as there was nothing further which could be informally resolved in the complaint.
A formal investigation was opened into the complaint with both CINICO and the Health Services Authority (HSA).
The investigation concluded with a finding that CINICO’s healthcare coverage policy had been followed and that, given the nature of the injury in this matter, there was nothing unreasonable about the delay at the A&E section of the CI hospital. This finding was based on a review of HSA patient care policies, as well as ER practices elsewhere in the Western Hemisphere.
It was noted, however, that civil servants, private sector healthcare providers and the government administration itself had long desired the expansion of CINICO healthcare coverage to a preferred provider network outside the public hospital system. CINICO managers discussed plans to do so which were in place and due to be implemented in the first stage prior to the end of 2023.
As a recommendation in the complaint, the OMB directed staff to monitor the implementation of the network expansion which was announced by government in April 2022.