Medicine halfway to the policy – Newspaper Kommersant No. 39 (7484) of 03/07/2023

Clients of Russian insurers faced frequent refusals to provide some services under voluntary medical insurance (VMI) policies. According to experts, the problem lies in the growing unprofitability of this segment, including against the backdrop of rising prices for medical care. Defending your rights for clients can take months.

In February, customer complaints about insurers in the VHI segment became more frequent, according to Banki.ru data. Their number has doubled compared to January. In most cases, clients complain that the insurer does not agree on medical services that are covered by the policy under the terms of the contract.

In particular, since the beginning of the year, RESO-Garantiya has stopped coordinating the majority of examination appointments with doctors, one of the company’s clients claims. “The program provides access to any doctor from the list of complaints. In fact, this is not so. They require a referral to a specialist. Having received a referral, they again do not agree on an appointment with a narrow specialist, referring to the absence of grounds and an insured event, ”complains the client of Ingosstrakh. “During the next approval of the same service (the same insured event), I encountered the fact that employees over the phone voiced different reasons for the refusal of approval,” writes a SOGAZ client. Clients of AlfaStrakhovanie also faced similar problems.

In SOGAZ, AlfaStrakhovanie, RESO-Garantia did not respond to requests from Kommersant. Ingosstrakh assured that they “do not see violations and consider complaints.” The company did not reduce the range of services covered by the VMI policy in 2023, they added. The Central Bank noted that the regulator receives complaints on this issue, but they are “single”.

Experts believe that complaints have become more frequent due to a decrease in the attractiveness of the segment for insurers. According to Tatyana Nikitina, senior director of ratings for financial companies at the NRA, one cannot exclude the growth factor of unprofitability (an increase in the share of insurance payments in the volume of premiums received), which has become the reason for complicating the process of coordinating medical services. Such refusals serve to reduce unprofitability, says Andrei Mikhailin, head of the corporate insurance department at Soyuz Insurance.

According to the results of the first nine months of 2022, the fees of large insurers for VHI remained almost unchanged compared to last year. But the Central Bank already noted at the end of the first half of the year that the average insurance premium had dropped below 2,000 rubles. and customers preferred inexpensive truncated programs (see Kommersant of December 1, 2022).

According to lawyers, the actions of insurers are not always a violation of the contract. Dmitry Gorbunov, a partner at the Rustam Kurmaev & Partners law firm, notes that contracts usually specify in detail what is an insured event and what is not, meanwhile, sometimes insurance companies do not take into account the nuances, and clients believe that purchasing a policy opens the door to absolutely everything. offices, although this is not always the case.

For example, if the contract states that toothbrushing in the dental office is included in the policy, and the client applies for it, in fact the insurance company may not agree on the procedure, since it is carried out for aesthetic, and not for medical reasons, the expert notes.

And in such a situation, according to Irina Kuznetsova, Irina Kuznetsova, the lawyer of the ICA “Aronov and Partners”, it will not be easy for consumers to defend their rights. Nevertheless, the standard scheme consists of three steps: a claim to the insurer, an appeal to the financial commissioner, and only then to the court. You can add another “complaint to the Central Bank as a separate leverage”, points out Ms. Kuznetsova. But such a process can take many months and the cost of doing it may exceed the economic effect, she believes. The service of the Financial Ombudsman did not respond to Kommersant’s request.

Julia Poslavskaya, Ekaterina Volkova