…One late night you are suffering with some uneasiness along with chest pain and in an emergency your wife takes you to the nearby hospital without checking any network hospital or non-network hospital list of your health insurance policy. But obviously at that point of time, your wife thinks of your life, so it is not her fault. By fluke, you are in a hospital that is a network hospital for your health insurance policy. So all your worries are now released, and they have an insurance desk to look after the insurance facility and you have told them that we have an insurance policy with a cashless facility. I guess you are thinking everything is sorted now. No, not at all, the worst reality is now starting from here. I want to highlight one thing here that if you would like to switch your hospital after taking primary first aid, you can do so however, the hospital will not going to do that by giving lots of harsh excuses of patent’s health and of course you do not want to take a risk as well and even at that time nobody is going to flip the policy papers.
Now the patient is diagnosed with a heart attack and needs to undergo angiography and angioplasty. At this point of time nothing is left to decide except to go for surgery. The role of the billing department has now involved asking some amount as admission fees, emergency ward fees, in deposit fees and so on. The insurance desk is emphasizing that you will get everything as you have Rs. 15,00,000 sum assured so, pay as per billing desk demand. Remember the movie scene from Gabbar is Back. Pay first to get started with treatment. You think that insurance will reimburse whatever you pay. One more point is when you are in a cashless facility with a network hospital, you are not asked to pay anything and the duty is paying and handling all these things are of the TPA and Insurance desk in the hospital.
The cons of this is that you never know what is going on with the insurance part and nobody is going to tell you or give you any information and every hospital has their own set of room name, room number, ICU ward, MICU etc., so you even do not know where exactly you are kept in unless/until the final bill come because you are now victim of heart attack and collusion of Insurance Company, TPA and Hospital.
Everything is done, your surgery, your hospitalization documents, your discharge summary etc. Now you are handed over a huge bill of Rs. 4,00,000 and still you think that you have a sum assured of Rs. 15,00,000 so not to worry. However, the fantasy is clean bold by TPA that they have only sanctioned you Rs. 1,80,000 rupees by furnishing the reason of the PPN Package deal with the hospital. In most of these cases, there is a chance of a second heart attack by these kinds of words from the TPA side.
You do not know PPN Package at all and now you are the victim of a lengthy process of documentation for fighting this fraud. It is absolutely fraud because, you are not told about PPN package and rate, you are asked to take maximum sum assured with almost high premium, you are not allowed or asked to switch hospital, you are asked for cash despite having cashless facility, you are not provided with proper guidance at hospital insurance desk, you are not informed well in advance before your surgery about the estimate cost and estimate claim sanction.
These are all about hospitalization bills only, but what about other benefits which insurance companies have specified as features of health insurance plans? No health insurance companies are going to take this initiative by themselves because in most cases people leave the claim settlement and reimbursement process due to being unaware of the policy knowledge, time-consuming process, lots of documentation and so on and insurance companies are going to take the benefits of these.
The question is what is the purpose of the insured going to a network hospital if the TPA/insurer approves cashless for less than half of the hospital charges? If the TPA/insurer has really negotiated the package rates with the network hospital, the insured does not have to pay from own pocket.
The case shows that the purpose of PPN hospital is defeated. Why does the insured have to suffer? What is the value add provided by TPA if there is a colossal difference in what it agreed with the PPN hospital for package rates and what the hospital is charging the patient?
Who is supposed to pay for the hospital bill charges for room, operation theatre, medical supervision, nursing charges, lab charges, pharmacy, doctor visiting charges, laparoscopy charges, ECG and Injection? The TPA and hospital agreement for package rates seems to be just a farce.
It is an irony that financial advisors tell customers to buy adequate mediclaim cover as part of proper financial planning. The customer buys Rs 15 lakh cover thinking that they have covered their risk. But after paying a premium for 12 years, the policyholder is repaid with a nasty surprise of TPA/insurer paying less than half of the hospital bill.
The question that Insurance Company should introspect is whether it would have treated corporate mediclaim customers the same way? Corporate mediclaim customers are often rolled out a red carpet with additional benefits like maternity and cashless treatment at hospitals where retail customers are kept out. It is because a retail customer does not have any bargaining power. The insurer gives a damn if the policyholder wants to renew the policy or not.
Final Words/ Our Recommendation
If you buy a health insurance plan from public sector health insurance companies, educate yourself about the concept of PPN rate and keep your sum assured accordingly. This will help you avail cashless settlement at the networking hospital. One more thing, I would like to highlight that you can choose TPA so check and research which have a good claim settlement ratio and also check if insurance companies have in-house claim settlement desks. When you buy a health insurance policy, check out the PPN hospitals list in advance and also discuss with your spouse about this so when in an emergency he/she knows in which hospital you or insured person need to be taken. Also check with a TPA card, and keep in a safe place for easy access.
There are lots of victims of partial claim settlement even after availing of services in a network hospital. In this case insurance companies will raise their hands stating that they are helpless since the TPA refuses to oblige. So, go to the insurance ombudsman. If true, then it is nothing but a mockery of the system. Then what is the meaning of having a grievance redressal system? When did the TPA become so powerful that they can overrule the insurance company which employs them? Insurance companies will be made answerable to the reasons for claims denial/partial settlement. They can no longer hide behind the veil of TPA.
Please note this is a real case, and it is ongoing for the reimbursement process, we will enlighten the final verdict on this in our upcoming issue. What happened in that and what we can do for you in case you are facing similar challenges.
If you have any challenges regarding your Health Insurance Policy Claim Settlement or Reimbursement, please write to us on firstname.lastname@example.org or email@example.com and we will highlight your issue and also try to help you.