How doctors rob insured patients

By DANN OKOTH

NAIROBI, KENYA: A new breed of gold-diggers are stalking Nairobians—and they are not the cheap or sleazy type — they are suave professionals who callously steal from you by the stroke of a pen.

But it is not just individuals who are affected by the growing insidious scheme as professional doctors also set back companies by millions of shillings every year in fraudulent insurance claims.

These doctors work in cahoots with insurance agents or companies to defraud unsuspecting clients through dubious medical diagnosis, procedures and prescriptions.

They have perfected this art by hiding behind well-documented records, references and charts. Only a well-trained nose will smell a doctored rat here.

Three C-Sections in a row

So next time you visit a doctor and you are on a medical insurance cover, seek a second independent opinion if your prognosis appears a little strange – and the intervention or medication being prescribed appears far too drastic or costly – because you are likely being scammed.

Investigations by The Nairobian reveal that the unscrupulous physicians then claim their share of the loot from insurance companies who would have recovered hefty sums in insurance claims from companies under their coverage.

Rebecca* (not her real name) shudders even today as she narrates how she was made to go through three Caesarian Sections in a row, when she could actually have given birth normally.

Caesarean section or C-section is a surgical procedure in which one or more incisions are made through a mother’s abdomen and uterus to deliver one or more babies, or remove a dead foetus.

The procedure is only done when the life of either the mother or the baby is at risk. The procedure costs anything between Sh200,000 to Sh1.5 million in most private hospitals in Nairobi.

Insurance allocation

wiped off by Sh1.7m bill

But for Rebecca, this was routine procedure whenever she visited a leading private hospital in Nairobi to deliver her baby. She had a specific doctor who saw her at the hospital and her insurance cover catered for nearly every type of treatment offered at the hospital including an option for C-section.

“What worried me most is that I was quite healthy up to my last trimester in all the three pregnancies, only to be told a few days before delivery that I may have to go for C-section,” she says.

“The doctor made it appear so serious that it scared the wits out of me. My husband and I had no choice but to go for it,” she added almost in tears.

What is more, she explains, the last C-section she underwent at the hospital led to further complications that required her to be hospitalised for a period of one and half months.

“The bill that came, about Sh1.7 million, wiped off my yearly insurance allocation and it was only March. I had to shoulder the bills for any subsequent hospital visits,” she says.

And now doctors have warned her she can never give birth normally again after the series of C-sections.

“I have since changed doctors, but the new gynaecologist has warned me I may never give birth the normal way again,” she says.

Doctors say such women risk internal bleeding and even death if they attempt virginal delivery, reason being that their uterine muscles have been weakened by the repeated incisions and would crumble and tear under the pressure of pushing.

“Although I do not plan to have any more babies, I am sad that my doctor did this to me simply because he wanted to earn extra money,” Rebecca says.

Bottomless insurance cover

But the scammers have now discovered an even more fertile ground in wealthy Nairobi women who cannot give birth.

These also seem to have bottomless insurance cover allocations — which offer a cushion to the scammers’ clandestine activities.

Another victim who spoke to The Nairobian told of how she had always wanted a baby, but discovered she was infertile. Together with her husband, she sought advice from a gynaecologist who recommended a test tube baby or In Vitro Fertilisation (IVF).

IVF is a technique in which a woman’s eggs and a sperm are fertilised in a laboratory and then implanted in her womb.

But with a successful rate of between 20-23 per cent, often the process is a trial and error mission.

However, after ten attempts, and a staggering Sh25 million later, and no baby, Clarice (not her real name) gave up. But the failure also cost Clarice her marriage.

Costly source of pain

The medical procedure, which was first done successfully locally in 2006, is now being sought by millions of women who cannot conceive conventionally, but for a tidy sum of Sh800,000 or more per procedure in some clinics.

The operation has become a costly source of pain or happiness for many families.

 “I knew the success rates were always very low,” says Clarice. “But the doctor would just not give up. Apparently, he kept urging us to keep trying. Now I realize he was just after the insurance money given that he was a private doctor. It cost me my marriage and my life, so to speak,” she says.

But it is not only through procedures like C-section and IVF that these crooked doctors rake in millions.

There are those who prescribe expensive medicine willingly even though cheaper options would have done the job perfectly.

In the medical world, when it comes to treatment, there is the first line, second line and third line drugs used to treat various diseases.

Doctors always go for first line medicine on a patient’s first visit or according to medical history.

But some doctors, keen to scheme out as much as possible from covered patients, go for second or third line treatments or prescribe very expensive options just to make a quick buck.

A few rotten apples

“I visited a popular children’s hospital in Nairobi with my three-month-old daughter who was sick,” another victim, who identifies himself only as Onyango, told The Nairobian.

“I was shocked to hear the doctor put her on medication for three months for what I came to learn was a simple ailment.”

He says he sought a second opinion from another doctor, who prescribed medication that cleared the ailment in just three days.

While doctors agree there are a few rotten apples among them who do unethical things for financial gain, they maintain a majority in the profession uphold their professionalism.

Several attempts to contact the Medical Practitioners and Dentists Board for comment before this publication, failed.