Alom (not his real name) comes to TWC2 downcast. He says that his doctor told him surgery will not be able to fix his broken finger. He just has to do some physiotherapy to improve functionality.
The open fracture was eminently fixable, so why did the doctor say that to Alom? In there lies a story of how Singapore’s employer-centric policies end up denying proper medical treatment for migrant workers.
Around 7pm on 25 October 2023, Alom was on a scissor lift (he wasn’t driving it) when his hand got wedged against a pipe. When the lift was raised again prematurely, his right index and middle fingers were crushed. The site safety supervisor attended to him and washed the wound. The manager arrived at about 9pm, but by then most general practitioner clinics were closed, so he wasn’t taken to a doctor. Alom was simply given paracetamol for his pain.
We do not know why the management didn’t send him to a hospital emergency department.
The following day, Alom was taken on a “doctor-shopping” tour. He was first taken to Bless Medical Clinic, which the website healthcare.com.sg describes as “a general practice medical clinic located at Boon Lay Shopping Centre”. A Google search pulls up photographs showing a a single shop unit. The doctor there examined the injury and said he couldn’t really help.
He was then taken to iCare medical centre, where at least they stitched up his wound and referred him to a specialist clinic.
That was the third place he was taken to: The Hand Centre (inLiven) where an X-ray was taken, revealing an open fracture. Alom was given medical leave and a letter to his boss saying that surgery was required within five days, no matter which hospital he went to.
The response of the employer, together with the agent, was to try to persuade Alom to go back to Bangladesh to get treatment. They would pay for treatment there, they said (if you’re inclined to believe that), and Alom could come back to work after recovery (if you believe that too). Alom was not persuaded.
On 2 November 2023, Alom went to Tan Tock Seng Hospital by himself. He was asked for a deposit before they would provide any treatment; he didn’t have the money. So, he went to Changi General Hospital where they gave him some simple treatment (both topical and oral) because they saw his wound to be infected. Changi Hospital also referred him to Singapore General Hospital.
On 3 November 2023, Alom went to Singapore General Hospital. There, they sorted his infection out and took new X-rays. They told him he needed a Letter of Guarantee to proceed with surgery.
In the context of migrant workers, a Letter of Guarantee is a letter from an employer to a hospital undertaking to pay for the major medical or surgical procedure that is needed. Since employers have to have bought Work Injury or Medical Insurance before they could obtain Work Permits for their foreign employees, they shouldn’t be out of pocket; the insurer will be the ultimate payor unless the hospital bill is astronomically high that it exceeds the insured value.
Despite what should have been a straightforward matter since Alom had been insured, much wrangling with the employer followed. In the meantime, Alom also launched a salary claim, and (according to Alom), the boss insisted that he withdraw the claim before he would countenance issuing a Letter of Guarantee. We do not know about the merits of the claim, but there was no reason to link the two issues. Under the law, the employer is responsible for medical treatment all the same.
Finally, Alom withdrew his salary claim and a Letter of Guarantee was produced on or around 27 November 2023, a full thirty-three days after the accident. Remember, the first doctor said surgery was needed within five days.
When Alom finally saw the doctor again a few days after the Letter was sent to the hospital, he was given the bad news that it was too late. With open fractures, immediate surgery is almost always required. Internal screws or plates (sometimes, external) have to be affixed to stabilise and align bones correctly as they heal. We believe Alom’s finger bone had started to join, but at an angle, such that it was no longer possible to realign them optimally. He is likely to be left with a crooked finger, and one that may never have the same strength as before.
What went wrong
It is good that the Ministry of Manpower is very strict about employers buying insurance. There are two kinds that employers of Work Permit holders have to have. The first is for work injury compensation, for which the statutory minimum coverage for medical expenses is currently set at $45,000. Such policies also have a component that provides for disability compensation which is payable if the worker has suffered permanent impairment (e.g. lost a thumb or lost an eye). The second type of insurance is medical insurance to cover treatment for health conditions that are not work injury-related. Here, the annual claim limit has to be at least $60,000, with a co-payment of 75% by insurers and 25% by employers for claim amounts above $15,000.
However, from the worker’s perspective, accessing any coverage is difficult. Employers remain gatekeepers; they can choose when to use the insurance and when not, because it is they who actually initiate a claim on the insurance company. Not the worker.
In Alom’s case, all the doctors he saw recognised that surgery was necessary. And quickly too. Yet, none would proceed without getting a Letter of Guarantee from the employer. There is little that will force the employer’s hand if he is unwilling, which in effect means that employers remain in control over whether or not a migrant worker gets appropriate medical care.
Says Debbie Fordyce, President of TWC2:
There’s something wrong with the system when employers are allowed to withhold urgent medical treatment even when doctors have advised it. If a broken bone isn’t stabilised early, we have no idea how that’s going to grow and impact his daily activities. It may well heal in an awkward manner. Causing delays in accessing treatment will exacerbate pain and harm the mental wellbeing of these men.
We can glimpse the initial motives of Alom’s employer. Their first reaction was to try to persuade Alom to go back to Bangladesh without getting treatment in Singapore. Then they set as a condition the withdrawal of the salary claim. Arguably, this was hardly the best time to launch a salary claim, but this was something that Alom initiated himself without consulting TWC2, so we do not know the details behind it. But the point we make here is that by having a system which gives employers control over when to utilise the insurance cover, it means that all sorts of conditions can be set by employers. The humanitarian objectives of requiring insurance cover are easily defeated. Or, as in this case, so badly delayed, they are rendered moot.
A little bit of information technology is all that is needed to improve the system. That and perhaps a bigger change of mindset.
All it takes is for the work injury and medical insurance policies to be listed on a site that can be securely accessed by worker, employer, insurer and accredited hospitals. The worker (as beneficiary) and the hospital (as care provider) should be able to jointly initiate a claim on a policy for medical costs. The employer should not be permitted to act as gatekeeper since their interest can be diametrically opposed to the worker’s. After all, it is the worker’s interest that the legislation is meant to serve, and it is thus important to ensure that operationally, it does exactly that.
The complication is that somebody needs to decide whether a claim falls under work injury or “medical” (i.e. not work injury), these being two different policies with different limits. Employers can even purchase these from two different insurers. This complication can be used to justify the gatekeeping role of employers: they need to decide which policy to claim against.
A cleaner way to solve this problem is to redesign the framework altogether, with one policy for disability compensation only, and another for all medical interventions whether work injury-related or not. That way, regardless of how to classify an injury, medical care can be given promptly by hospitals – simply by claiming against a single medical cover.