This year alone, Transient Workers Count Too came across three workers who had sustained head injuries. In dealing with the emergency, a part of their skulls had to be removed. With only soft skin covering the unprotected part of the brain, they were left exposed to future injuries.

These three stories relate to the commentary, Mind the gap:  No system in place to help workers needing costly medical care

 

Majibar Hakim

Majibar suffered a sudden loss of consciousness on 21 March 2011 as a result of an epileptic fit. He was sent to Raffles Hospital’s emergency department where he underwent an urgent decompression craniectomy. He remained in the intensive care unit (ICU) for a few days on mechanical ventilation. With gradual recovery he was able to breathe and feed himself, and was sent for physiotherapy. When he was discharged on 8 April 2011 his condition was stable. He could walk with the support of a stick, but was left with reduced power and coordination on his left side.

His hospitalisation costs came to $62,675.72, paid for by his employer.

His condition continued to improve to the point that a casual observer might not notice the paralysis on his left side. But he was left with a large cranial defect; in the area of his craniectomy only a thin layer of skin covered his brain as bone had been removed here. The employer didn’t think they were responsible for reconstructive surgery, known as a cranioplasty, to replace the missing bone. Incredibly, the neurologist at the hospital that treated him didn’t think it necessary either.

When TWC2 raised the issue of protecting Majibar’s brain by replacing the missing portion of his skull, Majibar’s doctor at Raffles Hospital wrote to the Ministry of Manpower (MOM) saying,

The indication for the closure of the skull defect… has no definite medical purpose. The procedure is neither life-saving nor life-prolonging. There are many patients who have chosen to have a residual skull defect indefinitely rather than subjecting themselves to additional neurosurgical procedures, with all the attendant risks and costs, and none are the worse off…Therefore, in my opinion, closure of the skull is not mandatory, and is for cosmetic reasons only… There is no reason for this surgery.

However, two other neurosurgeons, one at Mount Elizabeth and one Tan Tock Seng Hospital, argued the procedure was necessary:

He will, from a neurological point of view, require cranioplasty, that is, replacement of bone flap that was removed from initial surgery. This is for protective reasons as he is already ambulating independently.

He has a skull defect from the surgery. As he is ambulant and mobile, it would be essential for the skull defect to be replaced for protection against future head injury.

One neurosurgeon explained that patients who are permanently bedridden, in a coma, or in very poor health might be advised against this operation. Given that Majibar walks around normally, takes public transportation, is young, healthy, and expects to marry and have children, replacing the missing portion of his skull would be seen as essential. Protecting Majibar’s brain is the primary concern here, not his cosmetic appearance.

The second doctor supporting reconstructive surgery was willing to defend his stance on the necessity of the operation in court if necessary.

Our discussions with the Ministry of Manpower following the employer’s reluctance to fund the reconstructive surgery focused on the necessity of the operation.  MOM used the Raffles Hospital’s doctor’s statement asserting that this was a cosmetic procedure to argue it was not necessary.  TWC2 shared the opinions of the two other neurosurgeons explaining that the cranioplasty was medically necessary.

Later MOM used a different argument, saying that the amount paid and the time lapsed exempted the employer from any further payments.

Seeing there were no possibilities for Majibar to get the reconstructive surgery he required, a TWC2 volunteer sponsored Majibar on a visit pass so that he could remain in Singapore for the surgery.  TWC2 covered the $20,000 cost of the operation out of our emergency medical fund, the Care Fund. The operation was performed at Mount Alvernia Hopsital by Dr Tang Kok Kee on 3 August 2012, Majibar is recovering well and returned to Bangladesh on 28 September 2012.

There are cases where other companies have offered a letter of guarantee for this operation for their workers, but only after asserting that the operation is unnecessary. TWC2 sympathises with the employer burdened with medical bills that surpass his insurance limits. At the same time, TWC2 has very limited capacity to subsidise critically needed expensive procedures when the other parties involved — the employer and the insurance companies — refuse to pay.

What the issue boils down to is that of a gap in the social safety net. How does Singapore provide for humane care for low-wage workers who have come to contribute to our economy as construction workers, shipyard workers, cleaners and domestic help?

These three cases discussed here highlight the gaps and unmet needs.

 

Mosa Kalimolla Siraj

Mosa started working in Singapore at the age of 18. At least, this is the age stated in his passport. He might have been even younger since young men often put an older age on their passport thinking this will improve their chances of being accepted for employment. On 14 December 2011, at the passport age of 20, he was involved in a serious accident at his workplace. His head hit against a wall with great force in an accident involving a scissors lift.

At Changi General Hospital, doctors performed a:

….right decompressive craniectomy, removal of depressed skull fragment, wound debridement & insertion of ice probe.

A CT (computerized axial tomogram) scan of the head was done which revealed comminuted depressed fractures of the right tempor-parietal bones with haemorrhagic contusions seen in the right frontal, temporal and parietal lobes. A subdural hematoma is seen in the right frontal lobe with scattered subarachnoid haemorrhages and generalized cerebral oedema.

By the time he was discharged, one and a half months later, the hospital bill stood at $33,885.45. The company paid half in late December, and the remainder in mid February.

His employer told him that he would have to resume his work very soon after his surgery, and if he refused, he would be sent back home. To Mosa, this was not much of an option, and maybe it was not meant as one. To the worker, it seemed that the real intent was to repatriate him. The company did not give Mosa access to his medical reports or medical leave certificates. Nor did they inform him of the work injury compensation process.

They almost succeeded in deporting him. Fortunately for Mosa, a supervisor knew of the plan to repatriate him, and allowed him to escape the company’s confinement. Still recovering from the operation,  he spent several months sleeping in an MRT station and in back alleys of Geylang until his lawyer arranged a place for him to stay.

The company was no longer providing accommodation for Mosa when they issued a letter to the hospital on 20 March 2011 saying:

We would like to withdraw the Letter of Guarantee with immediate effect. The Work Injury Compensation Claim is capped at S$25,000, which we have paid more than the claim amount for the coverage of medical bills. The accumulated amount till date is more than $33,885.45 . . .  Therefore, my company will not be paying any more medical bill for the above-mentioned worker.

This raises the question whether a letter of guarantee can be unilaterally withdrawn after medical care had been provided under the guarantee. If guarantees can be unilaterally revoked, such a practice will leave hospitals saddled with bad debt in their financial accounts.

Even before this withdrawal of the guarantee above $25,000, Mosa had paid for his follow-up medical appointments from his own pocket, paying over $1,000. He borrowed the needed amounts from his uncle.

Then, mid-2012, when the question of an implant arose, TWC2 paid $790 for the scan needed for the implant, knowing that this payment was needed to get the process started for the reconstruction operation. Possibly because of media attention to the case (See TWC2’s report on the The New Paper double-page feature, 6 August 2012), and in spite of the earlier retraction of the guarantee, Mosa’s company later submitted a fresh letter of guarantee of up to $10,000 for the cranioplasty.

Mosa underwent the operation at Changi General Hospital on 18 September 2012, and was discharged on 24 September. The surgeon was Dr Irfan Nawaz. The picture (above right) is of him after his skull had been repaired.

As at the time of writing, Mosa’s boss has paid $10,000 of the $18,031.90 bill. TWC2 understands that Changi General Hospital’s policy is to recover the unpaid costs from the patient.

 

Md Lablu Md Rowshan Molla

Lablu underwent the same procedure for craniectomy as Mosa and Majibar. He had fallen from a ladder on 14 November 2011. His diagnosis is bone chilling in spite of the clinical wording:

Primary diagnosis: Extradural hematoma, [Right] parietal

Secondary diagnosis: Burst fracture of the thoracic vertebra, T12 burst; Fracture of temporal bone; SIADH, syndrome of inappropriate secretion of antidiuretic hormone; and MRSA infection of postoperative wound, Right craniotomy wound.

For Lablu’s two-month hospitalisation, the company paid almost $63,000, more than twice the $25,000 that they are required to pay under MOM guidelines. Lablu was discharged on 14 January 2012, two months after the accident.

Once Lablu’s condition had stabilised and he was discharged, the company was reluctant to bear any further costs, telling Lablu that his health was fine, he needn’t see the doctor any more, and that he’d have to handle any further treatment himself in Bangladesh. Having to pay such a hefty hospital bill for one injured worker is a huge burden for a small construction company. While it’s true that the skin stretched over his unprotected brain caused Lablu no major problems, it left his brain unprotected if he should ever fall or bump his head.

Dr Irfan Nawaz (same doctor who cared for Mosa) wrote his first note to Lablu’s employer on 23 May 2012 regarding reconstructive surgery:

This is to state that this man requires a PEEK implant for his [Right] cranial defect. This will cost 7-10 thousand dollars (implant cost). Operation will be separate. He will need to be admitted for one week about. Kindly please decide if you are agreeable and come down to clinic on Wednesday or Friday before 12 PM.

Lablu’s boss failed to visit the clinic on the recommended days.

Dr Irfan’s second note on 11 July 2012 to the employer was more adamant:

This is to state that Mr. Lablu underwent a right craniectomy 20 Dec 2011 for an infection after a right craniectomy for extradural hematoma 14 November 2011. Now his wound has healed well but there is a cranial defect. He will require a PEEK cranioplasty to address the defect. The operation is to protect his exposed brain mainly and to allow it to re-expand fully.

The company was angry that Lablu had engaged a lawyer, as if he should have been grateful that they had spent such a sum on the initial operation and not expect anything more. They felt that they had gone beyond what was necessary and that the involvement of a lawyer for compensation was unnecessarily hostile.

The cranioplasty operation, at Changi General, was performed on 27 September 2012, resulting in a bill of $19,221.50, not yet paid as at the time of writing.

Lablu is elated that his brain is finally protected and that he will be able to spare his family from knowing the severity of his injuries. His implant will last a lifetime Lablu solemnly declares, unlike money which can be here today and gone tomorrow. Health can’t be bought, but in this case, money did buy a neat piece of skull as well as peace of mind.

See commentary: Mind the gap:  No system in place to help workers needing costly medical care