Minimum qualifications for health insurance intermediaries must be introduced to ensure all customers achieve better healthcare outcomes, advisers have argued.
The panel at Health & Protection’s Middle East international private medical insurance (IPMI) roundtable unanimously agreed that standards of many intermediaries need to be increased in Dubai.
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Those gathered at the Sky View Hotel in the shadow of the Burj Khalifa in downtown Dubai passionately voiced their hopes for regulators to fulfil their commitments and agreed they wanted to be a part of improving the industry together.
Dubai’s unique characteristics have driven the situation that made the arguments from around the table so heartfelt and necessary.
The emirate has a population of 3.5 million people, with around 200 broker firms active in the market and an estimate of more than 4,000 advisers.
A compulsory minimum requirement for health insurance was fully introduced six years ago but with the vast majority of cover arranged through the workplace it has led to divided populations.
With regulators being less hands on in some areas or delaying action, this has given the opportunity for poor or uneducated practices to slip in as a race to the bottom for the mass market ensued.
But with the arrival of the pandemic and resulting heightened sense of awareness around personal and public health, concerns around those practices have been magnified and a strong desire for improvement is being demanded.
THE DUTY OF CARE
Chartered Insurance Institute (CII) regional director MEA, Central and South Asia Gaenor Jones noted the Covid pandemic had given customers the urgency to scrutinise their health cover more closely with some receiving alarming results.
“They may have investigated or gone to claim on policies and realised they’re not covered for certain events,” she said.
“They go back to the adviser and ask: ‘Why didn’t you tell me this?’ and the advisers, just reply ‘You should read your policy’. But come on, your duty of care is to look after your client, to give them the best advice.”
However, the pandemic also appears to have spurred the more conscientious members of the adviser community to step-up, with Jones reporting the CII saw a big uptake of people taking more professional qualifications.
She added that with new businesses moving into the region post-Covid, there was likely to be growing demand for recognised qualifications from advisers as firms bring expectations from other countries.
“We’re seeing lots of new companies entering the region, but they are not going to look at people that have not got the correct credentials,” she continued.
“If you want to go and work for a multinational or international brand, you’ve got to have professional qualifications. In any established market you’ve got to have a professional qualification. So why is that not happening here?”
HAVES AND HAVE-NOTS
The answer to that appears to be tied up in several reasons, one of which is the divided nature of the buyer market.
“There are sophisticated buyers who may be from Europe or any other more developed, mature markets who will ask the right questions and look for the right thing, looking for value, due diligence and fulfilling their duty of care,” explained Malakut associate director of employee benefits division Michael Plaugmann.
“Then you’ve got probably where the mass of the market is, which is a race to the bottom.
“Their views tend to be: ‘I don’t care about all that, it’s mandatory, I have to put cover in place, so I want cheap’. We spend a lot of time fighting those fights, unfortunately.”
Plaugmann added that those sophisticated buyers who rode out the pandemic in generally good financial health maintained their good quality, typically international health insurance plans.
“Then you’ve got the others who jumped around. We get the infamous five or six hours per client who are just racing to try and chop costs because the pandemic hit them hard,” he continued. “They’re SMEs, they’ve laid off staff, and that’s where I have spent a lot of my time in the last few years. So there’s quite a wide difference between what people are looking for in the market.”
The differences between clients willing to spend on better quality cover and those who are not are underpinned by some of the starker actions undertaken by other insurers operating in the region.
With the mandatory plans limited in benefit coverage, it can mean in-effect no coverage at all for some employees.
“There are clients that want to buy low salary band or minimum benefits where the insurance companies are not even giving medical cards out to employees,” said Lifecare International group commercial director MEA Amber Musson-Thorp.
“They know it’s not even going to be used because the co-pays are 40% for the working population and the staff can’t afford to spend that 40% or go to a hospital inside these networks.
“Some clients just don’t care – they just want to tick a box for a mandatory solution. It’s difficult to have that conversation,” she added.
DIVIDED POPULATIONS
Nasco regional customer development director Diana Haydar echoed the difficulties in working with some clients and said it was not fair to only blame advisers for poor outcomes
She highlighted that while some advisers may not be providing the best service, there were also insurers selling poor benefits and hospital and healthcare providers providing poor services without being well regulated or monitored.
“In many employers you have this social inequity; the senior management have these international high cover plans and then you have the rest of the workforce with very poor benefits,” she said.
“When management comes to advisers, what can we say to them? The employer doesn’t care about benefits for the rest of the staff – they are only premium driven.
“It’s not always about the fault of the adviser, it’s really a cycle the regulator should look at so even if you have a very poor level insurance, it should have better minimum benefits.”
On that point, Haydar welcomed the move by the Dubai Health Authority in July 2021 to issue an upgrade to its basic health insurance plan to include coverage for mental health along with other treatments.
However, this wider coverage has yet to be implemented, something which all the panel were keen to see actioned as soon as possible.
There was also hope from the panel that the realities of the pandemic, in which more than 2,300 United Arab Emirates (UAE) residents have died so far, would spur action against that race to the bottom.
In particular, it was hoped that local regulators would step in and become more interested in the situation and fulfil their mandate of qualifications for advisers.
“People now realise we are human and an awful lot of people did die,” noted AES International director of health and protection Damien Walsh.
“Then you see the gaps that are in some policies and realise the people who have international cover were very, very well looked after, but others weren’t.
“I think that proper regulation whereby people can give objective advice will help stop the market getting into a race to the bottom, because it is about our health and we are about human beings.
“It’s not nice to say to somebody, you’re not covered for that because the financial controller didn’t look at the table of benefits, they just looked at the bottom line.”
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REGULATOR ON HOLD
It may be somewhat unexpected to hear advisers calling for more intervention from regulators but the panel was near unanimous in its backing for this to happen.
Indeed, in 2015 the Dubai Health Authority (DHA) published its Standards for Health Insurance Intermediaries which included the need for advisers to meet sufficient training and compliance levels.
But this did not specify any particular achievements or requirements. The standards also included reference to the potential introduction of mandatory qualifications.
“Permitted Health Insurance Representatives (PHIRs) commit to comply with any requirements issued by the concerned regulators to attain professional qualifications that may be mandated,” the regulator said.
Then in December 2020 the Dubai Insurance Authority, which has subsequently merged with the central bank, issued draft regulations with criteria for roles from the top to bottom of intermediary firms.
These range from chief executive through to branch executives and sales staff and include a variety of certificates and educational requirements.
For example, sales executives must hold a Certificate Degree from the CII or equivalent institution.
However, the process of enforcing minimum qualifications appears to have halted there, meaning the situation remains that anyone can be hired off the street today and be a broker selling products to customers tomorrow.
‘IT’S NOT CONTROLLED RIGHT NOW’
“The regulator should introduce this requirement of a certain qualification to be able to give advice, it’s not controlled right now,” said Lifecare International chief commercial officer Nausheen Popat.
“To educate everybody from brokers to the actual clients into understanding the importance of qualifications, there’s got to be that minimum requirement from the regulator.
“Because what happens is ten of us can ensure we’re giving good advice, we’re recruiting the right people, but then there’s 50 firms that are not.
“So then you’re in that same cycle constantly where your clients are being advised by someone else and get themselves into a mess, and they come back and you sort them out.
“How do you educate everybody at the same time? There’s got to be that little minimum, absolute minimum requirement to come from the regulator,” she added.
Others echoed that sentiment, emphasising that as mandatory health insurance was implemented by the regulator, it should be the regulatory bodies which do the same with qualifications for advisers to ensure appropriate service for all buyers.
“We did reach a point where the DHA started to evolve and become that governing body that we were actually looking for, but it was a stop and start situation,” said Nageen Sattar director of regional client services at Pacific Prime.
“We had forums, we had platforms where we were able to voice our concerns and opinions, but that has all sort of just become non-existent, it’s just disappeared.”
But there was also a recognition that advice firms, along with working to support the regulator to increase standards, should be following these best practice approaches themselves.
Firms should be hiring those with qualifications, allowing their staff to pursue qualifications and increasing the wider talent pool in the region, the panel agreed.
Nageen urged intermediaries to ask themselves if they are really practicing what they are preaching in this regard and how they support their employees.
“Are we actually offering these opportunities, qualifications, engagement, or enhancing that talent pool? It has to come from within,” she said.
“We need to be a bit more agile as well. When we’re talking about qualifications, when we’re talking about giving everyone the opportunity, we also have to give them the time and embed that into their benefit packages.
“Are we giving study leave or are we giving floating days that allow them personal development?”
HYGIENE FACTOR
This approach was backed by the panel, who recognised the need to be pushing the development of their teams and the wider industry for continual improvement.
And there was acknowledgement that this was also required to maintain the credibility of the intermediary profession – to be seen as advisers rather than brokers.
AES International’s Walsh agreed that intermediary firms should be funding the cost of qualifications for employees and that this was something clients would expect as a minimum.
“It’s a hygiene factor,” he continued.
“Clients assume that you’re qualified to do your job and very often in our case, we’re not even asked. And even when we are asked, I’m pretty sure they don’t look at it.
“For me, the regulator has to set the minimum standards for entry, but I’m not a big fan of overregulation, I think it stifles innovation.
“So beyond the minimum standard, it’s about behaviours and that’s for us to self-regulate the behaviours of our people and make sure the way they operate is in accordance with best practices.”
Steve Clements, integrated and global solutions leader for Central and Eastern Europe, Middle East and Africa at Willis Towers Watson, agreed with the importance of assuring customers that advisers had reached a certain competence, but that it should not restrict creativity and innovation.
“Beyond that, I think we as an industry have got to be more creative about plan designs and how we solve problems for clients,” he said.
And he suggested there was probably a more economic-based reason for the regulator not having enacted its mental health coverage in the basic compulsory insurance.
“If we look at Saudi Arabia, they just enhanced their basic plan and insurers are pricing an extra 10% for the enhancements on top of medical inflation,” Clements continued.
“Medical inflation is already 10%, so that’s a 20% premium rise to put these nice things in. At some point we’ve got to say, what’s our priority?
“Are we going to spend our money on mental health or physiotherapy or something else, because there’s a finite budget. So we’ve got to be creative about where we spend the money and where we prioritise that budget.”
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BECOMING MORE SOPHISTICATED
This brought the subject of mental health and wellbeing to the fore and how to best address it.
The panel agreed that after the strain of the last two years mental health had lost much of its stigma for people to talk about, but there was still much to do in terms of education and support.
Several speakers noted the need to ensure advice firms were making support, facilities and time available for their staff to monitor and support their own mental health.
But Now Health International general manager – GCC Mayar Jaroudi said it was also vital to equip sales teams with the key facts and figures to help clients understand the need for mental health cover.
“How many advisers within our companies really understand what mental health is about? We all segregate our sales team, you will have people who understand and people who don’t,” he said.
“So you send the person who really understands the subject to make the client understand the need for mental health cover, about the benefits mental health support brings and how much retention they can get out of it.
“You need qualified people to do that.”
Jaroudi also argued this would not be a one-way street, believing that employers would become receptive to these conversations as they became more aware of the need to offer better cover.
“At the moment some clients are sophisticated some are not, but it’s inevitable they will all become sophisticated,” he continued.
“If you look back a few years back, they did not understand medical insurance when the government put in the mandates.
“Today, post-Covid, we see clients understanding more and more about medical insurance. It’s an inevitable change which we need to cope with, and bringing our talents and qualifications will be essential.”
INVESTMENT A VIRTUOUS CIRCLE
The panel agreed that this investment in training and quality service would be a virtuous circle but that it could take time and would need a collective movement from the industry to bring other businesses and customers along.
“Every single person sat around this table prides themselves on integrity and their professional brand and therefore, we invest in our own personal development and in the development of our teams,” Cigna chief distribution officer for Middle East and Africa Leah Cotterill said.
“For example, Cigna gives educational reimbursement programs of around $6,000 each year for each individual for whatever qualifications they want to do – I’ve got four people in my team doing MBAs.
“Consequently we then carry higher operating expenses because we do things right, like everyone else around this table, but the challenge is with the majority who don’t.
“As there is no requirement to do so, they continue in that circle and we then end up just focusing on the niche clients of the market, who think like us, who value the same things as we do.
“The challenge is how do we pull people out of that middle ground and encourage them in to this approach.
“I hate the idea of overregulation but things like this that help raise the quality probably also raises the price a little bit.
“It’s this whole concept where we’ve got a segment of the market who are doing the right thing and investing in the right things and bringing value and quality to like-minded buyers – how do we help expand that?”
This prompted encouraging words from one panellist that regulators would be willing to listen to industry voices but that representatives needed to be proactive to push the regulators to bring their proposed measures into action.
“As an ex-CEO of the Dubai Health Authority, I know how this government works,” said Health Beyond Borders CEO and founder Laila Al Jassmi.
“Now they have a lot of things in place and there are lots of things which we are not sometimes aware of, and there is a balance to be established.
“So approaching them, offering collaboration and helping to develop the standards, that can be one way of going forward and accelerating things faster.
“This is a tip that I can share with you because I was there for 23 years and I know how things have worked in the government.
“What I can say is that they will not approach you, but if you approach them, I don’t think you will get closed down.”
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