Times of India
17 February, 2010
By Sumitra Deb Roy
Mumbai, India

With stakeholders in medical insurance locking horns over remuneration, consumer activists feel that policy holders need to play a more proactive role if they want to get the best deal. Policy holders, said consumer activists, must make do their research before zeroing in on the policy or the insurance firm. In short, consumers need to make an informed choice.

Insurance facilitators like the Third Party Administrators (TPAs) are trying to imitate the West by gaining more control over the healthcare system. So far, they have only managed to partially control smaller entities such as nursing homes, secondary hospitals, etc. This is because bigger private tertiary care hospitals such as Lilavati, Breach Candy, Hinduja and Jaslok have not allowed the insurance providers to call the shots.

Recently, doctors under the banner of Association of Medical Consultants (AMC) unanimously decided to boycott TPAs who wanted to dictate the charges that doctors can charge. According to industry insiders, TPAs do not dare to negotiate with bigger private hospitals that mostly provide tertiary care.

A source from TPA Paramount Health Services, on the condition of anonymity, said that unlike smaller nursing homes, consultation charges of doctors or surgical charges in bigger private hospitals are never open for negotiation. TPAs have to accept whatever tariffs the hospitals deem fit, the source said.

But, experts feel, in a global economy, role reversals can happen. In the West, insurance companies dictate terms but the trend is yet to come here, said Pramod Lele, CEO of PD Hinduja Hospital. “As hospitals get more traffic of insured patients as against uninsured ones, insurance companies will automatically dictate terms even in hospitals here,” he said. Lele added that presently only 10% of patient traffic in his hospital is insured.

On the other hand, experts feel that standardisation or regulation of healthcare prices can help solve the problem. “Due to lack of standardisation, TPAs are overdoing price control in the name of regulation,” said Dr Lalit Kapoor, advisor, medicolegal cell of the AMC.

But, health activist Dr Arun Bal, said that price control in a private economy is next to impossible. “It’s the consumers who should decide what they want from the insurance policy and choose accordingly. The market will follow them,” he said.