Continued from Part 2.

Monday, December 19, 2011, Manik showed up at Alexandra Hospital for his long-delayed knee operation. He was nervous, as anyone would be undergoing his first surgery. An operating theatre was ready and waiting for him. He changed into a gown and was placed in a gurney while surgeons and nurses scrubbed up.

Then someone noticed that the Letter of Guarantee (LOG) from the employer had not been signed. This piece of paper is the employer’s undertaking to pay for the medical treatment; it is commonly the sand thrown in to jam up the gears of the system.

Urgent phone calls were made to the employer, to Manik’s lawyer and to Transient Workers Count Too (TWC2). The employer, when finally reached, said that he didn’t realise that an LOG needed to be signed.

“As if one would issue a cheque without signing it,” was TWC2 exco member Debbie Fordyce’s astringent comment.

A new LOG, with signature, was eventually faxed over to the hospital, but by then it was too late for the operation to commence. There wasn’t enough time left before other patients’ appointments clashed. And so the precious time of highly-paid surgeons and nurses and the expensive resource of operating theatre time were wasted. As for Manik, he was on an emotional roller-coaster as he went  home.

Waste of resources

This incident reminded your correspondent of a similar incident with another migrant worker, Amran. He too had a broken leg, for which a magnetic resonance imaging (MRI)  scan was scheduled. The nurse told him not to be late for the appointment.

“There’s a long queue for MRI appointments. If you are late or fail to make the appointment, we can’t give you another appointment until several weeks later,” she said. That would only mean treatment for his leg would be delayed.

An LOG was requested from his employer weeks in advance. Yet, by the day of the appointment, no letter was forthcoming, and the precious MRI appointment slot was wasted. Without an MRI result available in time, all his subsequent orthopaedic consultations had to be rescheduled. Much paperwork resulted.

Singapore spends a lot of money on shiny new equipment for our hospital system. We employ medical professionals at high cost. Hospitals run at close to 100% occupancy and many other patients have to wait in line for appointments. And yet we have the Ministry of Manpower (MOM) designing an LOG process that serves little purpose except to waste resources.

The theory underlying the system may well be that for treatment to proceed, three elements must be in place:

  • the treatment must be medically necessary
  • the patient must provide informed consent
  • somebody must agree to pay for it

The LOG is perhaps designed as documentation for the third undertaking.

However, it is misconceived. The law already mandates that an employer of a Work Permit holder shall be responsible for his medical care, and so long as the first two elements are in place, the third must follow. Section 3 of Part II of the Employment of Foreign Manpower (EFMA) Regulations says:

3. The employer shall be responsible for and bear the costs of the foreign employee’s upkeep and maintenance in Singapore. This includes the provision of medical treatment, except that the foreign employee may be made to bear part of any medical costs in excess of the minimum mandatory coverage if —
(a) the part of the medical costs to be paid by the foreign employee forms not more than 10% of the employee’s monthly salary; and
(b) the foreign employee’s agreement to pay part of any medical costs is stated explicitly in the foreign employee’s employment contract or collective agreement.

As an aside: The 10% co-payment would almost never apply because (i) foreign work permit holders are paid so little and (ii) the vast majority do not have written employment contracts (probably because employers wish to be contractually liable for as little as possible.)

If a worker complains to MOM about his employer failing to provide an LOG, MOM is often seen to ask for a doctor’s certification that the treatment is “necessary”. Once a doctor so certifies, MOM will lean on the employer to provide an LOG. But what this only proves is that MOM itself recognises that once the first two aforementioned elements are in place, the third is automatically activated. That is, the employer is legally liable to pay for the treatment.

The process of issuing an LOG thus serves little purpose. It gives the semblance of a veto to the employer when he has no such power. The semblance however triggers attempts to exercise that imaginary veto, which then has to be overridden — thus involving much extra work, delays and waste. A more absurd system can hardly be imagined.

TWC2 has proposed that the aforementioned Section 3 of the EFMA Regulations be amended or interpreted to require employers of work permit holders to furnish a blanket guarantee for all necessary medical treatment at any public hospital or polyclinic. That blanket guarantee should be provided right at the beginning, in conjunction with an application for a work permit. Following that, a medical guarantee card should be issued to the worker at the same time as a work permit card is formally issued by MOM. The validity of this guarantee should not be cancellable so long as the worker is in Singapore and is not transferred to another employer.

At the polyclinics and public hospitals, only a simple form should need to be filled up. It should have:

  • references to the work permit number and details on the medical guarantee card, including employer’s name
  • a certification that the treatment is medically necessary
  • a consent by the worker to receiving the treatment

Polyclinics and hospitals should invoice the employer for the cost of consultation, procedures and prescriptions.

The employer can always protect himself against this unlimited liability through the purchase of insurance. MOM already requires that employers purchase insurance though TWC2 is of the view that the minimum amount stipulated  is too low — but that’s a separate issue. In fact, the existing requirement to purchase insurance only shows up the absurdity of having to issue individual LOGs for each and every procedure.

Operation rescheduled

After the fiasco of a missing signature, Alexandra Hospital gave Manik a new date: Monday, January 9, 2012. In the weeks leading up to this new date, many phone calls were made and letters written again to obtain a new LOG.

The LOG that the employer finally faxed (too late) to Alexandra Hospital on December 19 could not be used to cover the cost of the January 9 operation, a fact that once again highlights how ridiculous and wasteful the present system is.

Up till the week before January 9, the new LOG was not forthcoming. There was a real risk of having to reschedule again. Only at the weekend did TWC2 get confirmation that one had been issued, and with a signature.

Manik was rolled into the operating theatre at 2 p.m.. The operation completed successfully by 5 p.m., he was moved to a ward for the night.

In complete contrast to his experience with MOM and the unfriendly and inefficient processes MOM has created, Manik loved our public healthcare system. The nurses were good to him; so good he didn’t want to be discharged. Even when he had gone home, the hospital called a day later to check on him. He appreciated the care and concern.

Amran came over to visit too.

The doctors had told Manik that even though they had repaired the ligaments, he might not make a full recovery. “Maybe 50 percent, he say,” Manik told your correspondent.  Would the outcome have been better if he had received prompt attention? It’s been fourteen months since the accident.

That itself raises a host of other questions. Unable to work as his leg slowly healed, how was Manik going to sustain himself? Do our laws offer any protection? Are our laws enforced? Or do we throw newly discharged patients out on the streets to beg? What other absurdities lie in wait amidst our foreign worker policies?

To be continued.