Times of India
27 March 2010
By Payal Banerjee
Pune, India

KVteacher can’t help hospitalised spouse with her medical policy
Insurance firm refuses cashless facility saying policy is ‘fresh’, hospital won’t discharge him till bill is paid.Amount has now reached Rs 2.5 lakh
Yet another cashless medical insurance policy holder is stuck in a limbo. Mirror had in its March 11, 2010, issue reported about the plight of 32–year–old Sandeep Gaud who was stuck in KEM Hospital after his insurance firm refused cashless policy citing ‘wrong disease’.

Now, a 59–year–old Alandi Road resident is stranded in Inlaks & Budhrani Hospital since March 12 after he was refused cashless facility by an insurance firm stating that his policy is ‘fresh’. The hospital is not releasing him till all the dues are paid. And even as the stalemate continues, the amount of the bill is rising by the day. At the time of going to the press, it was Rs 2,57,233.

How it all began
Dr Uday Shankar Prasad works with Inlaks and his wife Sangeeta (51) is a teacher with Kendriya Vidyalaya, Southern Command. Sangeeta told Mirror, “I had gone to the Indian Overseas Bank, Pune Cantonment branch, to withdraw my salary when I saw a big hoarding inside the bank about the cashless healthcare policy of Universal Sompo General Insurance Co. Ltd in a joint venture with IOB. On making enquiries, I got to know that they will issue me a cashless card, which will enable me to avail cashless facility in their registered hospitals. So, I took the plan A which covered me and my husband on December 30, 2009. They asked us general health–related questions and said that no medical check–up was required. The pamphlet given by them mentions cashless hospitalisation. My husband was working in Lokmanya Hospital, while the policy was taken. But later, he joined Inlaks on January 11, 2010. While getting employed, Inlaks conducted his pre–medical examination which mentioned that his blood pressure and pulse rate were normal. The X–ray report was also normal.”

She added, “On March 5, he started suffering from cough and cold. On March 10, he consulted a doctor and started taking medicines for bronchitis. On the morning of March 12, he got breathless due to chest pain and was admitted to Inlaks’ ICU. On the same day, I filled up Form 7 of TTK Healthcare, the third party administrator for the policy, and submitted it to the hospital. From his X–ray report, doctors suspected swine flu and his throat swab was sent for testing and an ECG was done. When his condition worsened, he was put on the ventilator.”

Sangeeta said, “On March 13, I contacted Lizit Mohan from whom I had taken the policy. He said the policy cannot be used in this case as it is a fresh policy. This was not mentioned in the policy nor told to me verbally. On March 15, the H1N1 report came negative. On the same day, the hospital issued an interim bill of Rs 56,580, w h i c h we forwarded to TTK. On the same day, an angiography conducted on my husband showed a blockage in one of his arteries and an angioplasty was conducted. In the meantime, I had submitted all the required information, but I got a letter on March 16 stating ‘fresh policy, hence cashless benefit not possible and can be considered for reimbursement with all supportive documents’.”

She added, “The bill amount has touched Rs 2,57,233 and the hospital has asked us to pay up. I can’t pay such a huge amount. My brother Sangam Sinha met Mohan, who referred him to senior manager of IOB Aundh branch J Balakrishnan. He, in turn, sent an email to the TTK Chennai office. We also sent an email to the managers of the insurance company and TTK to reconsider the case. We also approached the Grahak Panchayat’s city office for help through their advisor Vijay Sagar.”

She said, “We got to know that a representative of the insurance company had come to the hospital for verification. Till today, we have not got any communication from the insurance company or TTK. The hospital has again sent us a reminder and and my husband has been refused discharge until we settle the bill. We have been repeatedly contacting the concerned officials, but nothing has been done yet.”

Vidya Rajesh, assistant manager, TTK Healthcare TPA Pvt. Ltd, Chennai, said, “The patient was admitted for bilateral pleural effusion for conservative treatment in Budhrani Hospital. A cashless request was sent to us, but it was rejected as it was a fresh policy. But, we again referred the case to the insurance company and the case was rejected by them based on their opinion on March 16. But now, we have sent an email to the hospital after the insurance company asked us to get some specific details based on which a fresh decision will be taken.”

Sameer Prabhudabholkar, assistant manager for Universal Sompa General Insurance Co Ltd, Mumbai said, “We have raised certain deficiencies in the matter and we have again asked for certain documents for our scrutiny. After that, we will reconsider the case.” J Balakrishnan, chief manager, IOB (Aundh branch), said, “At the time of taking the policy, Sangeeta had signed a proposal form where it was clearly mentioned that we will not undertake any responsibility about the insurance policy. Our role was just to sell the policy. The claims have to be considered by the insurance company.”

Billing officer of Inlaks, Uddhav Jadhav, said, “From day one, we are in touch with the insurance company and other concerned authorities. We had submitted the patient’s pre–employment hospital check–up report. Despite that, they rejected the cashless facility. Now, they have sent us an email asking for certain information, which we are sending them. We can’t release the patient unless the bill is paid — by the insurance firm or the patient.”

Why insurance problems arise
Basically, problems related to cashless insurance policies arise due to miscommunication between policy holder and company. When policy holder takes a policy from any health insurance company, it is the duty of that company to explain all implications of that policy in detail instead of giving information just about the facilities which the company is going to provide to the policy holder. Many times, the policy holder has misunderstandings about the policy due to inadequate knowledge about the implications of the policy. It also creates problems for the hospital administration in billing and discharge process.
— Dr Sujata Malik,
Medical director, Ruby Hall Clinic

Problems in cashless health insurance policies mostly arise due to patients’ miscommunication with the insurance company. Many patients do not inform insurance company about their medical history at the time of taking the policy and when it comes to getting the benefit of that policy, company rejects it as per their rules and regulations.To avoid such problems, we have appointed a counsellor who counsels relatives of the patients at the time of admission and explains to them all the implications of the policy.
— Dr Deepa Divekar,
Medical director, Sahyadri Hospital

Most individual mediclaim policies clearly mention that pre–existing ailments will not be covered for a specified period, which may have been done in this case and on the basis of which, the TPA is using its discretion of denying cashless policy. It does not mention that they are refusing to consider for reimbursement. In this case, it is obvious that the condition is not of recent origin. Heart blockages develop over a period of at least five to 10 years. In our experience, most TPAs would probably take the same stance.
— Sainath Pradhan,
Senior manager (marketing), Jehangir Hospital

When policy holders opt for a policy from any health insurance company, they generally don’t have adequate knowledge.At times, they don’t read the fine print where the clauses go against their interests. So, this leads to misunderstandings between the policy holders and the insurance company and that’s how people land up in trouble.
— Vijay Sagar,
Advisory, Grahak Panchayat, Pune
Inputs by Dipti Barve