The medical care provided by the Costa Rican Social Security System (Caja) is controversial – some people swear by it while others swear about it! Following is a broad comparison of the medical protection afforded by the National Insurance Institute (INS) and by the Caja.
Nature and Scope of the Institutions. INS, like any insurance company, affords coverage to people who contract insurance and pay the premiums.
The Caja’s primary function is to give health care to enrolled people by means of its hospitals and clinics. Costa Rican labor law states that all employers must enroll their employees in the Caja. As coverage is extensive to the employees’ dependents, most Costa Ricans are covered.
Amount of Coverage. INS’s medical insurance policies have a limit as to the maximum amount it will pay per year or per ailment; once that limit is used up, the policyholder has to cover his own expenses.
The coverage afforded by the Caja is openended, with no limits.
Payment vs. Reimbursement. With most INS policies, you have to pay, up front, for treatment of minor ailments, and then claim for reimbursement. For expensive treatments, you pay the deductible only, and the rest is handled by the hospital, doctor and INS.
With the Caja, there is no payment for treatments, unless you want to upgrade one of its services. For example, if you are to undergo surgery at 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 policies all have deductibles, basically to discourage people from claiming for insignificant items or treatments.
Payment of claims is based on “usual and customary” rates for every fore seeable
type of surgery or service.
The Caja gives necessary medical attention within its facilities without payment or deductibles.However, the Caja’s bureaucracy and seemingly interminable lines discourage patients from using the Caja service for minor treatments or items.
Pre-existing Conditions. INS excludes, forever, all ailments the applicant has at the time of buying a policy, and any sickness or condition the applicant had in the past and that has a habit of recurring. Examples: 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 medical policies in colones 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 declare by means of a notarized affidavit that their legal residency is in process. Applicants must be under 70 for colón-based policies and under 66 for dollar-based policies. All INS plans cut off at age 100, but premiums rise terribly above age 75.
The Caja will insure only 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.
The cost of Caja coverage is either a percentage of an employee’s wage or, in the case of non-wage-earners, 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. However, there is a list of “affiliated” providers, and it behooves you to stick to those.
The Caja gives medical care through its own hospitals and clinics. You are assigned the hospital or clinic that corresponds to your address, where you will be attended by the doctor who happens to be on duty.
In case of ailments that are not life threatening, there is generally a waiting period of several months for appointments or for hospital beds.
Medication. With INS policies, you can buy prescribed medication anywhere – even abroad or over the Internet.
The Caja has its own pharmacies where patients can obtain their prescribed medication, no charge. However, supply is irregular, and Caja pharmacies often 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. Recent statistics show that the average life expectancy in Canada is 78; in the United States it is 77, and in Costa Rica it is 76 – an excellent average for a third-world country, despite attrition resulting from 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 providing service through the Caja are the same ones you would get through private practice – in other words, they work part-time for the Caja. But Caja hospitals tend to be overburdened, and there is often a delay of several months for an appointment or a hospital bed.
Coverage Outside Costa Rica. INS policies give coverage abroad. Coverage under the colón-based medical policies is not very good, but the dollar-based INS Medical plans are designed for either regional or worldwide coverage, and do a pretty good job abroad.
The Caja coverage is only for Costa Rica, as it provides for treatment only in Caja hospitals or clinics.
Preventive Care. INS’s colón-based medical policies do not provide for preventive care: no yearly checkups, 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 policyholder’s second year.
Caja service includes preventive care and tests.
Summary of Advantages of INS and Caja Coverage. With INS, you can choose your own doctor and hospital; there is coverage abroad, no waiting for surgery, the best private hospitals and a full spectrum of medication; the system is efficient; and it pays for private hospital rooms.
Caja coverage includes pre-existing conditions; there is no age limit, no deductibles, unlimited coverage and no claim process or paperwork; preventive care is covered; and the cost is lower than INS premiums.