Friday, 27 November 2020

Caja Recognizes Communication Error In Denying Pregnant Woman Insurance Coverage

Typical EBAIS waiting room, plain but clean. Photo
Typical EBAIS waiting room, plain but clean. Photo

QCOSTARICA – After she was denied coverage at the Cartago EBAIS (free clinic), a pregnant Nicaraguan woman received an apology from the financial manager of the Caja Costarricense de Seguro Social (CCSS or Caja), Gustavo Picado, who said there was a miscommunication.

“We have special laws, we have to protect, in this country no child will be left unattended, in the case of the women, there was a misunderstanding,” said Picado.

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The situation arose when the pregnant Nicaraguan woman visited the Cartago clinic for medical attention, and was denied coverage under her husbands Caja coverage.

Yahaira Sanchez, who has been living in Costa Rica for the last four years and all the time married to a Costa Rican. Her husband is an insured worker and had taken the steps to include her in the coverage, but at the clinic he was told that she was not covered due to a new immigration law that his benefits could include his wife. Current residency law requires that all residents must join the Caja.

“We were told that I should have been paying before and my husband’s insurance, in this case, didn’t cover me,” said Sanchez.

Furthermore, the woman was told by the clinic that her child would not be covered either.

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“What worries me most is that I was told my child would be covered by the insurance, and we are not a wealthy family to afford private medicine,” she said.

According Picado, this situation will be corrected in the coming days.

EBAIS is short for Equipos Básicos de Atención Integral en Salud.  EBAISare local clinics run by the CCSS, providing medical attention to workers insured by the state social security system.

These clinics provide both primary and preventative health care to all of the individuals in a community. A typical EBAIS serves about 4,500 people, and there are over 1,000 EBAIS clinics in Costa Rica.

The EBAIS comprises at least one doctor, a nurse assistant and a technical assistant in primary care. The Ebais also counts with a support staff in pharmacy, social work, nursing, dentistry, health recor and laboratory. In some cases, it has nutrition and psychology services.  The EBAIS program was implemented in 1994, by the government of José María Figueres Olsen, as the first level of care by the CCSS. One of the highlights of the work of the EBAIS is the home visit.

There is no phoning ahead for an appointment. Typically everyone shows up before 7:00 am and get in line for an appointment time for later in the day – first come, first served.

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Few expats actually use the EBAIS system, partly due to their poor level of Spanish, also most do not understand how the system works, or feel the level of medical service is substandard.

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