BajaNomad - IMSS denying expats chronic disease care

IMSS denying expats chronic disease care

Mengano - 11-25-2011 at 11:09 PM

A growing number of Lakeside residents who signed up for voluntary affiliation with the Instituto Mexicano de Seguro Social (IMSS) are up in arms over recent policy changes that have translated into cutbacks in palliative care and the supply of free medications for all types of chronic ailments. In some cases, both new and long-time IMSS subscribers report being completely booted out of the government health care system without prior notice.

While complaints about medical benefits have been most prevalent at the Chapala IMSS clinic, similar situations have been reported at the Jocotepec facility as well. Infuriated clients blame their problems on Chapala medical director Sandra Melgoza Oliva, criticizing her for arbitrary decisions that have compromised the low-cost health care to which they were accustomed.

The Reporter interviewed Melgoza this week to get her side of the story. She acknowledged radical changes in attending voluntary subscribers have been implemented since she took charge at Chapala’s UMF 40 about a year ago. However, she argues that the beefs stem primarily from her strict application of IMSS regulations, some of which were patently ignored in the past.

She also categorically denies that she or the IMSS system as a whole discriminate against foreigners, stressing that Mexican citizens who sign up under the elective program are subject to exactly the same restrictions and eligibility requirements. She underlined that persons enrolled in IMSS under obligatory employment benefits receive more ample coverage than independent subscribers.

Book in hand, the doctor justifies her interpretation of patient care criteria by pointing to Title Three of the Reglamento de la Ley del Seguro Social (the adjutant rulebook of the Social Security Law) which spells out the guidelines for elective enrollment in IMSS.

Article 81 specifies that applicants must submit to medical examinations and tests as required to determine their state of health, as well as completing a questionnaire regarding health status.

Melgoza explains that up until recently many new enrollees were accepted into the system on the basis of the responses to questionnaire, without ever undergoing the physical exams, thereby allowing some ineligible candidates to slip through the cracks. Furthermore, it appears that some people who paid IMSS fees for years without ever taking advantage of health services are now being required to make up for other glitches in their paperwork and preliminary steps of the affiliation process. As a result, some have been rejected outright.

Article 82 lists the pre-existing, chronic and degenerative ailments that preclude admittance for health insurance coverage, including malignant tumors, complications of diabetes mellitus, liver, kidney, heart, and lung diseases, substance addiction, psychiatric disorders and HIV-Aids, among others.

Article 83 refers to time restrictions on treatment provided to patients who have given birth, been diagnosed with benign tumors, or undergone certain types of surgery prior to joining IMSS.

Article 84 outlines limitations on medical treatment and services under the elective IMSS scheme. Voluntary subscribers are not covered for preventive medical exams requested by the beneficiary; treatment for chronic ailments that require permanent therapeutic control; and treatment for sequels deriving from prior injuries or pre-existing degenerative diseases. That would encompass common ailments such as hypertension, diabetes and cancer, among others. Other exclusions include cosmetic surgery; fertility treatments; medical care for self-inflicted wounds or injuries sustained from practicing high-risk sports; dental care other than extractions, cleaning and fillings; hearing aids; corrective lenses or corrective ocular surgery.

Essentially, as Melgoza explains it, under voluntary IMSS affiliation, beneficiaries qualify for treatment and free medication (when available) in cases of acute illness and emergency health crises, and little else.

Melgoza says that she deals daily with complaints about her unbending enforcement of IMSS regulations. She regrets the personal aggravations of patients who are now being denied privileges to which they were accustomed, though perhaps not duly entitled. Nonetheless, she and physicians on the staff are obligated to adhere to the rules. She sees a great deal of misunderstanding among foreigners, which she accredits to the language barrier and to private intermediaries who take fees for handling their IMSS inscriptions without properly explaining pertinent requirements and limitations.

The Reporter consulted with several of those intermediaries, including some who have gone over Melgoza’s head to register complaints from their clients about services rendered at lakeside IMSS facilities.

Ajijic lawyer Adriana Perez said that she met with high-level IMSS officials in Guadalajara just this week in an attempt to sort a host of problems expats have experienced over recent months in regard to administrative procedures and patient management.

She said that the officials appear to agree that Melgoza has overstepped the boundaries of her authority in canceling health care coverage for some expatriate beneficiaries and denying certain services and regular meds to others. They indicated that persons who have been enrolled in IMSS for more than three years cannot be expelled from the system automatically without being sent for a full medical evaluation beforehand. Persons who have enjoyed long-term coverage with no restrictions should continue qualifying unless doctors are able to determine that they suffered from chronic conditions prior to enrollment.

Perez stated that the biggest headache at the moment is a huge backlog in the scheduling of physicals for new applicants. She has a list of more than 30 clients who have been waiting many months to get appointments. In addition, she asserts that Melgoza seems to be giving the run-around to foreigners. In some cases the Chapala clinic has been remiss in providing applicants with the written referrals needed to get in the door for pre-scheduled medical exams at the regional IMSS hospital in Tlajomulco.

The lawyer is hopeful that Melgoza’s superiors will resolve the situation favorably in the near future. In the interim she recommends that new applicants hold off on filing for IMSS affiliation until matters are settled. Those already in the system are advised to punctually pay up annual renewals to maintain their seniority.

http://www.guadalajarareporter.com/news-mainmenu-82/lake-cha...

JESSE - 11-25-2011 at 11:37 PM

And this has NOTHING to do with BAJA, we don't have that problem.

RichBaja - 11-26-2011 at 07:59 AM

The post is appreciated.

DENNIS - 11-26-2011 at 08:28 AM

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Originally posted by JESSE
And this has NOTHING to do with BAJA, we don't have that problem.

Isn't IMSS, Social Security, a national agency? :light:

Hook - 11-26-2011 at 08:44 AM

Thanks for the post. Great info.

Apologies for not living in Baja and appreciating this article. :rolleyes:

DENNIS - 11-26-2011 at 08:46 AM

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Originally posted by Hook
Apologies for not living in Baja and appreciating this article. :rolleyes:

Yeah....Shame on you. :lol:

Mengano - 11-26-2011 at 09:25 AM

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Originally posted by JESSE
And this has NOTHING to do with BAJA, we don't have that problem.

Yeah, right. Except for a certain senior BajaNomad with Seguro Popular as his backup catastrophic medical insurance plan, who happened to have had his head bashed in, his jaw broken and his teeth smashed out last September and then was denied coverage at IMSS in Ensenada. I seem to remember a Chinese fire drill around here trying to raise private funds to cover what should have been covered by the IMSS.

But, other than that, as Jesse says, "this has NOTHING to do with BAJA, we don't have that problem." That is advice you can rely on from a reliable, honest Nomad. :rolleyes:

Woooosh - 11-26-2011 at 09:36 AM

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Originally posted by Mengano

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Originally posted by JESSE
And this has NOTHING to do with BAJA, we don't have that problem.

It's the same as car insurance or health insurance in the USA. They will issue a policy based on your application and accept the premiums- but if they investigate when you eventually file a claim they can and will deny your policy is legit. Everything is fine- until you file a claim. Very Baja related imho.

Mengano - 11-26-2011 at 09:45 AM

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Originally posted by Woooosh
It's the same as car insurance or health insurance in the USA. They will issue a policy based on your application and accept the premiums- but if they investigate when you eventually file a claim they can and will deny your policy is legit. Everything is fine- until you file a claim. Very Baja related imho.

Does anybody remember all those ex-pats who had houses destroyed by the hurricanes in the Mulege area? They carried property damage insurance for years. But when they filed a claim it was denied, based upon some vague statement that their homes were "non-standard", or something like that. They had no place to even appeal. The thread is still around here somewhere.

Pescador - 11-26-2011 at 10:24 AM

Quote:

Originally posted by Mengano

Yeah, right. Except for a certain senior BajaNomad with Seguro Popular as his backup catastrophic medical insurance plan, who happened to have had his head bashed in, his jaw broken and his teeth smashed out last September and then was denied coverage at IMSS in Ensenada. I seem to remember a Chinese fire drill around here trying to raise private funds to cover what should have been covered by the IMSS.

But, other than that, as Jesse says, "this has NOTHING to do with BAJA, we don't have that problem." That is advice you can rely on from a reliable, honest Nomad. :rolleyes:

Your recall is terribly faulted which may in fact be showing your prejudice. Ron had Seguro Popular which did fine for coverage, but they did not have the services he needed at the general hospital in Ensenada and he ended up in a private hospital which did not accept his coverage of Seguros Popular.
IMSS has always had a problem with pre-existing conditions which is no different than any of the companies I used to write health insurance in the United States with. It puts everything out of whack in terms of expenses. I had friends in the Lakeside district and they were given coverage because of faulty underwriting at the time of signing up with IMSS and a lot of that was done with brokers who "helped you through the application and issue process.
So this hospital finds that they can not treat the people the program was designed for in the first place and they have to do something or go broke. But somehow it is all the fault of the Mexican system.

Pescador - 11-26-2011 at 10:27 AM

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Originally posted by Mengano

Does anybody remember all those ex-pats who had houses destroyed by the hurricanes in the Mulege area? They carried property damage insurance for years. But when they filed a claim it was denied, based upon some vague statement that their homes were "non-standard", or something like that. They had no place to even appeal. The thread is still around here somewhere.

This was a true case of selling insurance and then faulting on payment of claims. These policies were sold by Bancomer Bank to people who had fideocomisos and after the claims were turned in, they completely denied all claims. There were houses at Punta Chivato which were paid by the same policy and the same company so it would be very interesting to see exactly what happened. But again, it is a little unfair and prejudicial to paint the whole scene with the same brush.

Mengano - 11-26-2011 at 10:47 AM

Quote:

Originally posted by Pescador
Your recall is terribly faulted which may in fact be showing your prejudice. Ron had Seguro Popular which did fine for coverage, but they did not have the services he needed at the general hospital in Ensenada and he ended up in a private hospital which did not accept his coverage of Seguros Popular.

Nothing could be farther from the truth. Maybe some day BajaGringo will jump in and tell the story. There are some people on this board who know the true story, but who are sworn to secrecy. Maybe at least they can jump in and tell you that you have that story wrong.

Udo - 11-26-2011 at 10:54 AM

Trust me...it is NOT just Baja related. I'm living it at this time with TRAVELER'S insurance.

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Very Baja related imho.

Woooosh - 11-26-2011 at 01:07 PM

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Originally posted by Mengano

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That is a long story and brutal thread. Short version (as I understand it) is the first responders didn't think Ron's injuries were survivable and they focused on saving Cristina. Ron went to the closest place that wasn't busy saving Cristina- which turned out to be a private hospital.

Bajahowodd - 11-27-2011 at 05:05 PM

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Originally posted by Woooosh

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Originally posted by Mengano

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I believe you are correct!

Mengano - 11-27-2011 at 05:31 PM

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Originally posted by Bajahowodd

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Originally posted by Woooosh

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Originally posted by Mengano

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I believe you are correct!

I understand you once may have sold insurance in the US, Howard. Say you wrote a medical insurance policy for a client with Kaiser's HMO, and your client had an emergency and was taken to Kaiser, who determined they could not handle it so they sent your client to Sharp hospital. Would you expect your insured client to pay the Sharp hospital and doctors bills out of his own pocket?

A simple YES or NO answer will suffice.

As a follow-up question, if you answered YES, do you think your client has a really good lawsuit against your for gross negligence or fraudulent inducement for writing him a policy that did not cover him for what he expected?