Medical Tourism

            Medical Tourism
   Or… how to enjoy a free trip to Ecuador 

Our first trip to the Andes included Quito and Cuenca in June 2010. We fell in love with Cuenca’s charming people, old world architecture and gentle climate. We had learned to reimburse our travel costs during previous trips to Montevideo, Uruguay. Bloggers were also a prolific source of information.

Like many self employed folks we saved premiums by having a $5,000 deductible on our U S Blue Cross coverage and using a HSA for tax deductible reimbursements. So we were out-of-pocket on most medical, dental and vision expenses. Now let’s see how many interesting experiments we can complete in a few days.

                                              Ecuador Cost          USA approx.        
 1 .Vision exams-both of us           $20 x 2 = $40                          $  150 

2. Bi-focal lenses –Gary only                          54                               150

3. Specialist office visit                  $ 25 x 2 = 50                               400

4. Bone density Scan-GE                   40 x 2 = 80  Just like at home  240

5. Ultra Sound – neck                                      36                              150

6. Lab CBC, calcium, parathyroid, Vit D         52     All is well          200+

7. Meds                                              11 x 2 = 22                                80

8. Massage – ahhh                            15 X 2 = 30   Discount for 2     130

9. Manicure (why not?)                      5 x 2 = 10                                 30

10.Haircut – Gary (a risk?)                               5    Looks great!         15

                Totals                $ 329  Saving covers airfare  $1,545  

We met some very interesting and friendly locals.  And delighted in many delicioso meals. 

 And we learned of their culture. Yes, you could enjoy similar savings in many countries in Latin America or Asia.

       Don’t just be a tourist… Be medical (and cultural) tourist!     

                                                                            Rejoicing,   Gary

                    

Health Insurance - Coopera

                  Health Insurance – Part III

                                 Coopera

Medical care in Cuenca is excellent.  Sue and I have enjoyed friendly professional care from specialists, dentists, opticians, labs, and pharmacies. A trip to the doctor also no longer requires a degree in medical billing and coding to understand insurance coverage. And all at a fraction of costs in the US.    But, we are always looking for new ideas and further savings.

Our Coopera membership gave us excellent fresh organic fruits and veggies as described in our December blog. They also function as a credit union and now offer a health plan. So, in June we signed up for the health plan for $2.62 monthly drawn from our account. No handouts or colorful brochures were available, so we’ll figure it out later. We have three month waiting periods for many services, so when the student is ready…an English speaking guide will appear.

Gringo grape vine tells us about Cuenca Referral Network (dot com), so we sign up as associate members. Thanks, Brian. Their site provides a link to Coopera’s. Can this be true?

Office visits for routine medical are two bucks.    Ditto dental. Reimbursement of medical costs (up to $400), lab and drugs is at 80%. Yes, even hospital care…after four  monthly payments of the grand sum of $2.62. There is only one way to know if this is true and functional...

 So, off we go to the tiny town of San Joaquin, located half a mile east of the largest Coopera market. The road is under total reconstruction, so a short walk from the highway is required.    TA DA!      Hidden away off the dirt path is a modern beautifully landscaped traditional white building with tile roof. Financial offices are in front; medical offices are behind the rear courtyard. Juan speaks excellent English and  helped me with a 10.5% CD.  Dr Pena provided my exam also in English. And Veronica cleaned my teeth. Total cost was four dollars for pleasant and efficient care!  We really enjoyed these friendly Cuencanos.

Oh yes, my cuerpo Jubliado  required lab tests and a medication for about $25 each. I chose Monte Sinai three blocks from our apartment off Avenida Solano. Did you know a 10% discount appears if you display a SuperMaxi or Monte Sinai discount card (Chamber of Commerce members)?  And our 80% reimbursement will be posted to our Coopera account next month.

     Life is tough… then you move to Cuenca!         Rejoicing,  Gary

Health Insurance Part II

         Medical Insurance in Ecuador – Part Two

                         

                     Policy We Purchased & Why

We may be typical of healthy North American Expadorians nearing retirement, so here is our thinking. I am 62 and Sue has fewer laps around the sun (late 50's). We take no serious medications nor have pre-existing conditions. Economy, some US coverage, quality of carrier (and agent), and continuation past 70 are priorities.

Policies with several agents were considered. Now for the boring, but important details by insurer.

Pan American offered a high end international policy with full US coverage at US medical cost reimbursement within their US network. Unlimited maximum coverage. However, cost was over $600+/month. Since our annual time in NC will be well under the 90 days allowed by our Cedula, we will skip the nuances.

Best Doctors offered a similar plan.

Humana offered a tempting variety of plans which changed by the time of our purchase decision. Policies and prices change here like in the fast moving US marketplace. However, you had to buy the expensive underlying "first dollar" coverage to be eligible for the catastropic coverage.

Salud won us over with a combination of features and policies. Their separate cancer plan has no deductible, continues in force throughout our lifetime, with unlimited maximum coverage. Cost $17.50 monthly apiece. So we can live to 100 and get inflation proof coverage (unless they change the policy).  You know, nothing is guaranteed forever!   A six month waiting period applies before coverage kicks in.

We skipped the first dollar, small co-pay plan that would cover the first $11,000 of claims due to the cost and our risk tolerance.

Our final choice was a $10,000 deductible with $128,500 in coverage with $55,000 accidental death insurance. Total premium for us both is $98/month. Coverage is reduced to 30% at age 70. Who knows what Medicare or private care will look like in even a few years?

Yes, a waiting period of 3 months for hospitalization; immediate coverage for accident or emergencies. And you may use any hospital. US coverage is paid at Ecuadoran medical costs (20% to 40%  US costs) - a common provision in Ecuador.

We may later add a small first dollar plan to assist in the first $10,000 in claims exposure. Meanwhile, office visits average $25 in Cuenca.

Future postings:

* A new plan offered by Banco Pichincha and Santa Ines Hospital

* Coopera's new small claim, first dollar coverage for $2.62 in monthly premium

* Homeowners coverage; earthquake, theft, etc.
           Salud,    Gary

Health Insurance

            Medical Insurance in Ecuador – Part One

                          Basics and Background

My twenty years in North Carolina medical insurance sales passed very quickly amid constant government interference, regulations, and politics. I remember the basic considerations well: Deductible, co-insurance, co-pays, networks, exclusions, pre-existing conditions, underwriting at issue or at claim processing, preferred rates, maximum coverage per year/lifetime, company ratings, age pricing, history of premium increases, and most importantly agent integrity. And then there is taxation/deductibility, health savings accounts. Group coverage has several additional considerations.

Ecuador has interesting twists on many of these issues. They use waiting periods and broadly defined pre-existing conditions due to the difficulty of obtaining physician records of medical history. The US Medical Information Bureau (MIB) for sharing claims history does not exist here, so underwriting (medical history review) may occur after the claim is submitted. Surprise!

Baby boomers are uncertain of Medicare’s cost cutting in the future. A quick return to the US may be impractical for many medical conditions. Quality is excellent here, but some procedures and drugs may not be available.  Policies often end at age 70 or become dramatically reduced. And what about “long term care”?   Then there is medical inflation.  Oh well, we cannot eliminate all risks!

Policy design is quite different in Ecuador, due to different considerations of family economy, culture, social security, and entitlements. Medical records have lesser importance in a low litigation society. And a cash-based society expedites care and eliminates much bookkeeping. Care delivery looks like the “good old days” in North America. Rarely do we encounter long waits with clip boards/laptops, medical transcriptionist, holdup or billing/medical records staff.

Bi-lingual multi-line agents with understanding of US customs and expectations are rare in Ecuador. Maybe this blog will help!

                        How to Shop Health Insurance

Since my experience is limited to the Andes city of four rivers, I’ll start here. Pleeease, folks, give me your feedback on any errors or omissions. As usual, check more than one source!

Shop a variety of agents, policies and companies. Get referrals. Tell your prospective agent exactly what you are looking for and your premium range. Ask several times and be patient. Will the agent help with claims? Do they maintain office hours? Expect clear and definitive answers – do not be rushed by the language barrier.

Questions to ask your prospective agent:

            How long in health insurance business?  Companies represented?
            Will agent help with claims process?  Office staff and hours?

            What is Company size, rating, etc?  How long in health insurance in Ecuador?
            Waiting period for office visits; hospital admission?

Hospital network required. Out of network % covered.

             Underwriting (medical review) requirements?

Guaranteed renewable? (can policy be cancelled

Does policy end or reduce at age 70 or 75?

Residency required?
             Is a separate cancer needed (lifetime coverage, unlimited claims)?

Coverage in US, other countries. At Ecuadorian costs or US

Definition of "reasonable and customary" costs for reimbursement?
Definition of  pre-existing?

Additional International Policy questions:

Maximum limits for major illnesses vs costs in EC and US

Policy issued in US or EC (under EC or US law)

How long is business- in what countries?

Next week:   What coverage did we purchase and why?
                          Salud,     Gary

Joy of July

I’ll Be Seeing You

Let’s be sentimental. Enjoy the pictures below, and see if some song doesn’t pop up regarding Cuenca, the people we meet, the experiences we’re having.  For us, the song “I’ll Be Seeing You” comes to mind.

"Cathedral bells were tolling 

And our hearts sang on

Was it the thrill of Cuenca

Or the April dawn?

Who knows if we shall meet again

But when the morning 

Chimes ring sweet again

                          I'll be seeing you

                  In the old familiar places

         That this heart of mine embraces..." 

Things couldn’t be sweeter to us right now, as we learn Spanish with 15 other Americans in our weekly class with Deke, our American teacher.  Wow, can he speak well!  And he’s SO patient with all of us. Sarah is also stretching us with daily Spanish lessons. We are eager to communicate with our many new friends in their language.

Our guest, Sarah Riddle is also having the time of her life.  She works each afternoon at Fundacion CLIF – a ministry for “after school” kids, whose parents are working or not available for them.  She is helping them with their homework and teaching English.  English Second Language is her major in college.  So her Cuenca summer is proving to already be most memorable.  For more information of how you could be involved, call us – we’d love to introduce you to Bolivar Ramon. CLIF also provides training for parents and business executives.

We were invited Monday to a July 4^th celebration – American style. 

Yes, we had hamburgers, hot dogs, chips, baked beans…One of the ladies baked a cake, decorating it like the American flag. 

Wow – the cake was fabulous.  We invited our Ecuadorian friend, Diana who got “teary eyed,” as we sang “My Country Tis of Thee,” and then, “The Star Spangled Banner.”  We all talked about how we really do love our native USA and continue to pray for it.

Our weekly Bible Study is now covering Paul’s letter to the Colossians.  We’ve been so blessed to meet with this group each week.  Anyone is welcome to come.

Bill McDonald, CEO of Unsion Television invited us to come on a program last Friday to share our personal story of Gary’s proposal to me years ago.  This was such a neat experience for us, being on Spanish TV, yet only speaking English!  Fortunately Bill and his assistant, Tania interpreted for us! 

Did anyone go to Corpus Christi or what we call, "The Sugar Fest!"?  Tents and tents of goodies, sweets, surrounding the new Cathedral.

Here’s a short video clip of a bit of fun we are having with our new Ecuadorian, Pablo Lozano.  Pablo is a young musician, with a degree in music composition, and owns a small recording studio. He is worship leader at Bill McDonald’s new fellowship called “6:08.”   When it comes to games though, you’ll see how the competition kicks in.

Guayaquil

                             Sarah’s   arrival                    18 Junio 2011

 Tuesday we enjoyed a scenic 3.5 hour OperAzuay van ride down the Andes with Keith and Josh Yancy to Guayaquil. A brief review of the internet, a travel guide, and maps resulted in  an easy plan. We checked in to the friendly and bilingual City Plaza Hotel, Boyaca 922 y Rendon ($76 including 12% taxes, 10% service charge), then strolled along the 2 mile length of the Malecon 2000. This river front was beautifully rebuilt with monuments, museums, fountains, gardens, shops, elevated viewing areas and numerous restaurants.

 

New Andes Highway complete with curbs and cattle!

We enjoyed the 1842 Moorish clock tower and the (semicircle) Hemicilo de la Rotonda commemorating the meeting of two Latin American liberators Simon Bolivar and San Martin.

Time did not allow this compulsive tourist to visit the neoclassic historic Las Pinas neighborhood or Santa Anna Hill with 444 steps and lighthouse.  (Please excuse my North American keyboard lacking accent marks).

 The broad muddy Guayas River had no afternoon traffic except a tugboat, barge and the three-masted Pirate Morgan touring sailboat waiting for an evening tour. The gigantic port must be downstream. Our camera was lonesome in our Cuenca condo. Sarah took a couple of shots.

Beautiful hotel room's view!

Six blocks upstream from City Plaza Hotel we found Seminario (Iguana) Park strewn with all sizes of these so-ugly-they-are-pretty reptiles. After a while even Sue liked them, but who wants to pet scales!

We enjoyed a quiet evening meal of pork chops, rice, green beans, salad with a complementary glass of Merlot at the hotel. Atillio & Sara, the friendly managers joined us. They also have a home in Paris and a fisherman’s hut in Galapagos. I was urged to buy a car and tour the southern beaches from Salinas to Puerto Cayo.  On Isla de la Plata it’s whale watching season.

Introducing Sarah, "the bag lady!"

Now to the Aeropuerta for the 9:30 pm Miami flight…well, make that midnight. The aircraft was delayed, Sue had left her neck pillow on the van, the hotel shuttle left without us, and Sarah’s single fifty pounder was left in Miami. A dozen calls and four days got it to Cuenca.  Sound familiar?

Now for Sarah’s orientation. We will enjoy her introduction to Bolivar and Ximena’s childrens ministry, Unsion TV, and the ”unchurch”(named 6:08) Saturday night at Mall del Rio.

Tourist notes:

*Previously we stayed at Grande Hotel on Diez de Agosto - well appointed and pet friendly.  

*Many have warned us: do not use a Guayaquil street taxi. Get one inside the airport, have your hotel call a taxi, or call one of the radio dispatched cabs (Taxi Fastline,SolService, Wayose).

Cargo - Part two

                                          Shipped !!

                                                      (part II)                                          8 June 2011 AD

Yes, cargo container…where was I? … We were enjoying, or rather using, an indeterminate delay to complete the condo remodeling. Contractors must be the same everywhere - just like another one of Dione Warwick's songs: "Promises, promises, all I get are promises, promises now - I don't know how..."  Delays, delays.  But that’s another story.

                              "Ding Dong, Cargo Calling!"

                              "Where's all this stuff gonna go?"

                                 "What a mess!"

             Guayaquil port indicated the reason for the delay was our container gained weight during shipment.  They allow for a 10% variance, but ours was 12%.   Sounds like they do not trust their scales.    Humm,  how can a sealed container gain 1000 pounds on the ocean voyage?

We had been warned multiple times about the port of G.  Never ship there, except as intermediate port of entry. Never allow the container to be opened in G.  Rumor was they enjoy misplacing items, adding daily storage charges, etc.   So, the “weight error” caused our 40 foot container to be opened.

After a week of unreturned emails, we mentioned using our attorney to unravel things.  Now, the container will arrive in Cuenca the next day, Saturday. Our two week time limit before extra charges ends Sunday. Yes, we received a review now. The previous Friday closed for Saturday voting (!?), no one works weekends, paper work, weighing twice, etc. So we hoped for an arrival on Monday at our condo.

 We needed to hire a translator for all meetings (usually to translate three sentences) and 5 strong young men to carry Sue’s piano and our furniture up two and a half flights of stairs. Next, a trip near the airport for customs. After a wait we were told to go to another office and wait for paperwork. The papers?  A  copy of each page of our passports to sign, perhaps because the shipper never asked for my Cedula number. The previous week we went to the Notary office, waited during his four hour lunch to sign a document stating I am the same person on my passport and on my Cedula.   Seems a bit redundant to me.

 We are getting closer.  Our late morning entertainment was watching our container contents being inspected and compared with our shipping inventory.  Five men patiently removed items from the middle to allow access to every item. Randomly, they opened a couple dozen boxes while we prayed. Our 39 page excel spreadsheet had been reworked several times due to lack of communication and changing rules, creating possible errors in details. The first two boxes had Bibles on top for our classes and study! The third caused smiles as they photographed Emily’s large creative Halloween pumpkin.     Ahh … all is well.

Our cargo will be trucked 4 miles, a 15 minute trip, to us at three pm. We can unload during the allowed two hours in time for the truck to return to G.  Let’s not incur another day of fees.

A t 3:20 we began cell calls. Our shipping rep was  “leading the trucker to our condo”.   At 3:40 they will “arrive in 15 minutes”.  At 4:00 “very close”. Then we saw the large trailer stuck a block away negotiating a tight turn from a small side street. Why not use the wider streets?  Then it slowly backed up for a detour around to a larger street. Next, we saw it heading for us and a row of neighborhood jacaranda trees. Two of our new Columbian friends ran down the street and climbed like monkeys on top of the cargo. They bent limbs and deftly lifted overhead cables unmindful of the risks incurred. Quite a show!

"There's some light at the end of the cargo..."

Our flurry of boxes and furniture, while the resting driver insisted he needed to leave by six pm, resulted in the complete loss of our planned strategy for proper placement of 200 boxes. But it’s all here. We’ll sort the mess after a good night’s sleep.

We hope to receive a refund of most of our $800 container deposit within a month.

                              What we would do differently?

·         Do everything in writing/email in both languages.

·         Obtain US trucker’s name and cell phone number. Verify every step, schedule.

·         Ask even more questions (even when they resist).

·         Obtain recent gringo referrals.  Shop more shippers for quotes and services.

·         Ask about route for final delivery, inspect for trees, wires, parking ,etc.

·         Allow more time for packing, listing contents of each box.

·         Verify every step. Who is accountable and how among all parties including, Cuenca shipping company, US port contact/scheduler, US trucker, “steamship line”, G port contacts, trucker. Each party may be independent of others!

·         Ask for list of all local and national holidays (this may surprise you!)

There were a number of other issues and problems I prefer not to put in writing. In defense of all parties, understand that the rules are constantly changing without notice.

May our readers gain insight from all our mistakes and omissions!