When 61-year-old Latha was admitted in Chennai바카라s Sooriya Hospital for COVID-19 treatment in July, her family didn바카라t expect the cost could take away all their savings. She was there for a month, and the hospital raised a bill for Rs 14 lakh. Latha, who had health insurance from Star Health and Allied Insurance Company Limited, asked the company to reimburse the bill. The company didn바카라t refuse to pay, but asked the hospital to rationalise the treatment cost. Agreeing to pay only Rs 4.4 lakh, Star Health wrote to the hospital, 바카라As per the government order that has been reinforced by the Tamil Nadu government, such exorbitant billing shall be taken to the notice of the government.바카라 The hospital agreed to settle for Rs 4.49 lakh.
General Insurance Council, a body representing health insurance companies, has filed some such bills in the Supreme Court to dispel the notion that they are refusing to settle claims. If lack of transparency in hospital billing is allowed to continue, the council said, 바카라insurance companies would be constrained to increase premium, which would make health insurance policies unaffordable for the common man, leading to a further reduction in the penetration of health insurance that is still at a lower level in India.바카라 The council바카라s submission was in response to Supreme Court advocate Sachin Jain바카라s PIL, demanding 바카라cost-related regulations for the treatment of COVID-19 at private hospitals바카라. After this petition was filed in April, the Centre and state governments put caps on treatment cost, but patients continue to suffer as insurance companies and hospitals are in a deadlock. The matter is still pending before the court.
In the past eight months since the pandemic hit the country, hospitals, patients and health insurance companies have been at the loggerheads over cashless treatment for one reason or the other. Many patients who paid from their own pocket after being denied cashless facilities by insurance companies are fighting to get their bills reimbursed.
The exorbitant cost charged by hospitals has been a major reason for the disputes. Initially, many insurance companies dragged their feet on covering treatment cost for Covid, arguing that a pandemic was never part of their health package. This prompted the Insurance Regulatory Authority of India (IRDAI) to issue 바카라guidelines for handing of claims reported under coronavirus바카라 on March 4. It clarified that if an insurance company covered hospitalisation in its package, it 바카라shall ensure that the cases related to coronavirus disease (COVID-19) shall be expeditiously handled바카라.
Post-clarification, it looked like having a mediclaim was the best answer to the pandemic. However, as hospitals kept the treatment cost high, insurance companies continued to cut corners. Private hospitals said Covid led to a huge increase in the cost of treatment due to factors peculiar to this highly virulent disease. They claimed, for instance, that 20-30 per cent of the staff was not available because they were either in quarantine (mandatory for seven days after seven days of work), or in 17-day isolation as per the government바카라s protocol, after being infected.
Consumables Make the Cut
Almost all insurance companies don바카라t cover the cost of consumable items in their health policies. 바카라Consumables are usually, but not restricted to, medical aid/equipment that have to be discarded after use. The cost incurred from the consumables is directly billed to the patient (if not covered in the health insurance policy),바카라 states TATA AIG on its website. It further says that in 2016, the IRDAI reviewed a list of 199 items (originally listed in 2012) that are 바카라non-payable바카라 from the insurer바카라s perspective. 바카라The list, however, just serves as a guideline and the insurers have the freedom of including or excluding any or all items from this list when it comes to policy coverage,바카라 it adds.
In the pre-Covid era, consumable components used to be very small in treatment, so policy buyers never bothered to find out its finer details. But Covid requires the use of PPE kits, face mask, sanitisers etc during treatment. Many hospitals diverted a substantial part of treatment under the consumable head. For instance, PPE kits and face masks worn by doctors and nurses during treatment, sanitisers and personal care products for patients, disinfectants and housekeeping items바카라all become a substantial part of the overall treatment cost. As Covid patients are not allowed family attendants, hospitals are free to claim whatever they wanted in the name of consumables.
The caps on treatment cost following Jain바카라s PIL and measures such as fixing the number of PPE kits in 24 hours for one patient came as a respite. For instance, in Delhi, the cost for hospitals (accredited with the National Accreditation Board for Hospitals & Healthcare Providers) was capped at Rs 10,000-18,000 per patient depending on severity of infection. In the absence of any dispute redressal mechanism, however, many hospitals continue to overcharge.
The Cashless/Cash Margin
Hospitals and mediclaim companies have also engaged in a dispute of different sort with patients at the receiving end. Hospitals say capped treatment cost is applicable only when the patient pays and gets it reimbursed from the insurance company later. In case of cashless treatment, in which insurance companies pay on behalf of patients, hospitals insist upon standard charges. 바카라We have a pre-existing agreement with insurance companies under which we have defined room tariff and various other charges. So we demand the agreement should come into play in case of cashless treatment,바카라 argues a CEO of a reputed hospital. 바카라Another reason is that insurance companies pay after two months. So, we can바카라t give government rates to them.바카라
Hospitals say some insurance companies pay the rates as per their contracts, but some don바카라t바카라and this has become a bone of contention. Health insurance companies ask policyholders to pay the hospital first and then claim reimbursement as it is cheaper than cashless treatment. However, patients who have paid from their own pocket complain that insurance companies avoid making the full settlement. For instance, a 61-year-old patient was billed Rs 3.73 lakh for 10 days of Covid treatment in Delhi바카라s Moolchand Hospital, but his insurer HDFC Ergo allegedly reimbursed only Rs 1.24 lakh. The insurance company held that it would pay according to the treatment rate capped by the Delhi government. 바카라Protecting the interest of our customers is of prime importance to us and we continue to ensure that no customer is impacted,바카라 says an HDFC Ergo spokesperson said. 바카라We honour all policyholders바카라 claim as per the Covid treatment protocols issued by ICMR and cost benchmark issued by the respective state governments,바카라
Who바카라ll Bell the Cat?
Jain finds fault with the government for not having a regulatory mechanism to redress the dispute. 바카라This is the crux of the problem. State governments have regulated the price, but what is the redressal-mechanism? If a hospital charges in violation of the capped-rate, where will I go to complain and how soon will my complaint be addressed? That바카라s what I am going to tell the court in the next hearing so a robust mechanism can be developed,바카라 says Jain.
There have been many such cases in which patients applied for reimbursement, but insurance companies refused it on one pretext or the other. In some cases, reimbursement was denied on the ground all ailments had not been disclosed at the time of buying the policy. 바카라We have seen that in some cases people hide pre-existing diseases at the time of buying the policy,바카라 says Dr Aafreen Soudagar, CEO, Kalsekar Hospital. 바카라A few of them contracted Covid and disclosed their health history to the hospital during admission. When these documents were submitted to the insurance company for claim settlement post-treatment, it was denied on the ground that the patient didn바카라t disclose health history.바카라
Arjun Deshpande, founder-CEO of Generic Aadhaar, a company that provides medicines at affordable cost, says insurers cannot just wash their hands off the situation caused by the pandemic, especially when people are facing hardships to survive. 바카라As per government guidelines, the insurance company should immediately respond if Covid patients or their family approach it for reimbursement. If insurers are failing to meet expectations as money circulation has slowed down in the global economy, then they should reach out to the government for financial assistance, instead of letting the policyholders suffer,바카라 he adds.
According to insurance expert Manish Jain, many hospitals have closed cashless services due to limited staff and patients are forced to pay for their treatment. 바카라In such circumstances, they are at the mercy of insurance companies for claim reimbursement. Despite price capping, hospitals continue to charge a high fee and concentrate more on the consumable part so patients end up paying for a major chunk of treatment from their own pocket. In the absence of prompt action from the regulator, the only option people are left with is to buy a policy that covers consumables without any limitations,바카라 he says.
Many patients and legal experts feel that IRDAI is not engaging with policyholders and seeking inputs from them while developing rules and regulations for insurance companies. They demand that the regulator should come up with a mechanism to take feedback from a number of policyholders to address changes that are urgently required. 바카라This will not only give confidence to the policyholders for buying new policies, but also increase the insurance business and bring down the insurance cost,바카라 says consumer rights activist Bejon Kumar Mishra. 바카라When IRDAI was formed in 1999, it was engaging with policyholders like us and there used to be regular consultations on policies and regulations. This has been totally missing for the last 10 years.바카라
