Comparación INS y C.C.S.S.

The medical care provided by Costa Rican Social Security (“La Caja”)is controversial: some people swear by it, other people swear about it! Following is a broad comparison of the medical protection afforded by INS and that of the Caja.

NATURE AND SCOPE OF THE INSTITUTIONS. INS is an insurance company, plain and simple. It affords coverage to persons who contract insurance and pay the premiums.

The Caja’s primary function is to give health care to enrolled persons by means of its hospitals and clinics. Costa Rican labour law says that all employers must enrol their employees in the Caja. As coverage is extensive to the employees’ dependants, most Costa Ricans are covered.

AMOUNT OF COVERAGE. INS’s medical insurance policies have a limit as to the maximum amount they will pay per year or per ailment, and once that limit is used up the policy holder has to cover his own expenses.

The coverage afforded by the Caja is open-ended, with no limits.

PAYMENT VS. REIMBURSEMENT. With most INS policies you have to pay, up front, for your medical care and then claim for reimbursement. With the more modern policies, only the deductible has to be paid up front, and the rest is handled my means of a card system.

With the Caja there is no payment for treatments unless you want to upgrade one of their services. For example, if you are to undergo surgery at the San Juan de Dios hospital, you can pay to have a private room in one of the special, more luxurious wings known as "Pensiones."

DEDUCTIBLES. INS medical plans have a system of deductibles, and payment of claims is based on a complex point system established for every foreseeable type of surgery or service.

The Caja gives necessary medical attention within its facilities without payment or deductibles.

PRE EXISTING CONDITIONS. INS excludes, forever, all ailments which the applicant has at the time of buying a policy, and any sickness or condition which the applicant had in the past and which has a habit of recurring for example, asthma, diabetes, malaria. Some other conditions have waiting periods starting at the date of issue of the policy, during which you cannot claim; for example, pregnancy and childbirth have a waiting period of 10 or 12 months.

The Caja has no restrictions in this regard. Someone can be at death’s door, purchase Caja coverage, and be treated right away.

ELIGIBILITY. INS’s Plan 14 and Plan 16 policies will insure anyone, man, woman or child, Costa Rican or foreigner, Resident or Pensionado, tourist or illegal alien. For the “INS Medical” plans, foreigners must have legal residency in Costa Rica, or to declare by means of a notarised affidavit that their legal residency is in process. Plan 14 and INS Medical have an age limit of 70, whereas Plan 16 cuts off at age 100.

The Caja will only insure Costa Ricans and foreigners who have legal residency status in Costa Rica. There is no age limit.

COST. The premiums of all INS policies follow an upward trend as the age of the insured increases. With the Plan 16 policy, every year INS jacks up the premiums and internal parameters of the policy in order to offset inflation.The most modern policy, “INS Medical”, is denominated in US Dollars, so premiums do not undergo inflationary adjustments.

The cost of Caja coverage is either a percentage of an employee’s wage or, in the case of non-wage earners, it is a fixed amount, regardless of the number of dependents. The rate decreases at age 55.

MEDICAL SERVICES. INS plans allow you to go to any doctor, hospital, clinic, lab, pharmacy, or provider of medical goods and services of your choice. But there is a list of "affiliated" providers, and it behoves you to stick to those on the list because their charges are regulated by INS.

The Caja gives medical care through its own hospitals and clinics. You are assigned the hospital or clinic which corresponds to your address, where you will be attended by the doctor who happens to be on duty.

MEDICATION. With the INS policies, you can buy prescribed medication anywhere – even abroad, over the Internet, etc.

The Caja has its own pharmacies, where patients can obtain their prescribed medication, no charge. But supply is irregular and most of the time the Caja pharmacies do not have available a full spectrum of medication.

QUALITY OF CARE. Health care in Costa Rica is excellent. Quality is hard to measure, but a good indication is life expectancy. In year 2000, average life expectancy in Canada was 78 years, in the USA it was 77, and in Costa Rica it was 76 – an excellent statistic for a third-world country. And take into account attrition due to our homicidal taxi drivers!

The service of private hospitals such as Clínica Bíblica, CIMA, and Clínica Católica is widely acclaimed.

The Caja has excellent equipment, and often the surgeons giving service through the Caja are the same ones you would get through private practice in other words, they work part time for the Caja and for their own practices. But Caja hospitals tend to be overburdened, and there is often a delay of several months for an appointment or hospital bed.

COVERAGE OUTSIDE COSTA RICA. INS policies give you coverage when you go abroad. The coverage afforded by the Colón-based medical policies is not very good, but the Dollar-based “INS Medical” plans are designed for either regional or world-wide coverage, and do a pretty good job abroad.

The Caja coverage is only for Costa Rica, as it only provides for treatment in their hospitals or clinics.

DEDUCTIBLES. INS policies all have deductibles, basically to discourage people from claiming for insignificant items or treatments.

The Caja service does not have any deductible. However, the Caja’s bureaucracy and seemingly interminable queues discourage patients from using the Caja service for minor treatments or items.

PREVENTIVE CARE. The Colón based medical policies do not provide for preventive care: no yearly check-ups, Pap tests, prostate examinations, etc. The Dollar-based “INS Medical” policies pay $100 for a physical and an eye test every year starting with the policy-holder’s second year.

Caja service includes preventive care and tests.

SUMMARY OF ADVANTAGES OF INS AND CAJA COVERAGE. With INS, legal residency is not required; you can choose your own doctor and hospital; there is coverage abroad; no waiting for surgery; the best private hospitals; a full spectrum of medication; the system is efficient; pays for private hospital rooms.

The Caja coverage does not exclude pre existing conditions; no age limit; no deductibles; unlimited coverage; no claim process or paperwork; preventive care is covered; cost is lower than INS premiums.