Times of India
11 March 2010
By Vijay Chavan

Why He can’t Restassured
Insurance firm denies cashless facility to patient at KEM citing ‘wrong disease’ hospital won’t discharge him unless bill is paid
The date February 14 might make the world go weak in their knees, but for 32-year-old Sandeep Gaud, it’s a black day. For, on this day, Gaud was admitted to King Edward Memorial (KEM) Hospital, Rasta Peth, after complaining of ‘uneasiness’ and that’s when his ordeal began.

The Ordeal
Gaud holds a medical insurance of up to Rs 1 lakh from New India Assurance Co. Ltd. (NIA) with policy number: 152500/34/09/11/00002354.

Initially diagnosed with swine-flu-like symptoms, he was treated and NIA sanctioned Rs 13,000. After further medical tests, he was found to be suffering from lung infection. Treatment began and KEM later produced a bill amounting to Rs 80,000 on February 24. KEM intimated New India Assurance’s Third Party Administrator (TPA) Medi Assist about the expenses on the same day. Medi Assist refused to pay up and asked the hospital to collect the money from Gaud, saying he has a ‘history of heart disease’.

At the time of going to press, the amount had touched Rs 90,000. Interestingly, Medi Assist had sanctioned Rs 11,000 on December 27, 2009, for the same ailment that Gaud is being treated for. When Medi Assist stuck to its stance, KEM refused to let Gaud go home. KEM has said Gaud will be allowed to go only if he gives them a post-dated cheque of the same amount. Gaud is unable to work in his tailoring shop in Khadki Bazar and he is the sole earning member of the family. All his savings have been used up for his treatment.

The Insured’s Plaint
Gaud said, “The hospital bill and bed charges are increasing by the day; but New India Assurance is denying the cashless facility to me. Even now, as I am talking to you, the bill has risen to Rs 90,000. This, despite the fact that I have been paying regular instalments for my policy. On the other hand, the hospital authorities are not discharging me till I pay the bill or give a post-dated cheque. But where will I get such a huge amount from? I came to this hospital because the insurance company assured me cashless treatment.”

He added, “I have been in the hospital for the past 25 days and in big trouble as I am the sole breadwinner for my family. My savings have dried up and I see no way out other than ending my life.”

Gaud said, “Interestingly, I was admitted in the same hospital for the same ailment on December 27, 2009. At that time NIA had sanctioned my bill of Rs 11,000. But I wonder why they are not helping me now. I was told that this policy covers all diseases. Even the KEM authorities are not co-operating with me. This is nothing but cheating on part of NIA.”

Insurance Company’s Version
Mirror talked to Purushottam Pagedar, branch manager, Medi Assist India Pvt Ltd, who said, “Due to some technical problem, the cashless facility was not made available to the concerned policy holder. But he can apply for reimbursement after submitting the medical bill to the company.”

Hospital Speaks
Harsheela Mansukhani, general medical administrator, KEM, said, “The hospital has no role in the denial of insurance by the company. In this particular case, the patient was suffering from swine flulike symptoms when he was admitted. Later, it turned out to be lung infection. The TPA had earlier sanctioned Rs 13,000, but when the bill amount went beyond Rs 80,000, we approached the TPA. The company officials told us that Gaud has a history of heart disease and his symptoms are related to heart disease, so they cannot give him the cashless facility.”

She added, “With the help of Dr M K Kale from the Chest and Allergies department, we tried to convince the TPA that the patient’s current condition has nothing to do with heart disease. But they told us to collect the entire bill from the patient, who, they said, would be reimbursed later. We are co-operating with the patient and giving him different convenient options to pay up and end his awkward position.”

Just Plain Cheating: Activist
Sameer Khan, president, International United Human Rights Association (IUHRA) said, “Even though KEM authorities are saying that the patient’s condition has no linkage with heart disease, why is NIA denying Gaud’s claim? In the earlier incident, when he was admitted in the same hospital for the same ailment in December 2009, he was given the cashless facility. When the expenses began to rise, the company backed out. This incident has raised a lot of questions on the credibility of such insurance companies. They are playing with the life of common people who regularly pay installments so that they are assured of good quality medical treatment.”

Procedure for Availing of Cashless Facility

• For availing of a cashless facility, the insurers must have a tie-up with a network of available hospitals across the country.The insured can benefit from this facility only at these hospitals.The policy kit has a list of these hospitals
• The insured must intimate the TPA 72 hours before a planned admission and within 24 hours of emergency admission through the hospital’s insurance helpdesk
• The hospital should fax the paperwork duly signed by the insured and the attending physician to the TPA’s office along with relevant medical records
• For medical scrutiny, the TPA may ask for additional medical records. The TPA shall fax the hospital the pre-approval/authorisation, provided the claim is admissible
• Through TPA, the insurance company will settle the bills directly with the hospital and the non-admissible charges such as attendant fees, telephone charges etc will be borne by the insured
• If TPA rejects a cashless facility, it can be claimed later through the reimbursement mode
• If one chooses a hospital which is not a part of the insurer’s network, still one can get reimbursement from the insurer directly