Times of India
30 April 2011
By Manthan K Mehta

Despite Major Overhaul Of Health Insurance Sector, Hospitals & Companies Continue To Short–Change Policyholders
As if being struck by a grave malady and getting hospitalised was not bad enough, patients these days are facing further trauma at the hands of insurance companies that frequently reject claims on one pretext or another.

At times, insurers take issue with the "steep doctor’s visitation fees" and, at times, they disapprove of policyholders getting "admitted in higher category rooms". There are even instances of claims being turned down on the grounds that the "hospital had been blacklisted".

Ask Jyotindra Dave. The 69–year–old underwent knee–replacement surgery last year at a plush south Mumbai hospital, where "the cost of the surgery is uniform, irrespective of the class of accommodation". His bill ran up to Rs 2.8 lakh, but the third–party administrator (TPA) settled only Rs 1.6 lakh after invoking the reasonability clause. What this means is that the TPA thought the hospital charges were not reasonable and customary. "I wrote many letters to the insurance company, but I received no reply," said Dave.

Not one to give up, Dave filed a complaint before the Insurance Ombudsman. "It has been more than six months since I filed the application, but neither has the matter come up for hearing nor have I heard from them. Ideally, the matter should have been disposed of within three months."

Shameed Akhtar (name changed) suffered a similar ordeal. "I underwent joint–replacement surgery at a south Mumbai hospital. The final bill included doctors’ visitation charges at the rate of Rs 5,000. The doctors had visited on six occasions. But the TPA said that it can only reimburse visitation charges at Rs 1000 per visit."

There are scores of such stories scattered across the city. Citizens who bought a mediclaim policy and diligently paid their premiums were eventually snubbed when the time came for the insurance companies to do their bit.

Vasanti Sanghvi (name change), who suffered from the cancer of the uterus, underwent a surgery this year at a hospital that billed her Rs 86,000. The insurer, however, agreed to refund only Rs 48,000. "This, despite the fact that I had never used the policy since taking it a decade before. When I asked about the no–claim bonus, the TPA said that they only consider the sum assured amount and do not calculate or adjust the no–claim bonus."

In another case, a woman’s claim was rejected because the Ahmedabad hospital she chose for treatment had been blacklisted. The insurance company, of course, informed her of the blacklist after the surgery.

Times View
Ordinary patients have been at the receiving end of huge–and unreimbursed–bills ever since the medical insurance sector went in for a major churning. Both insurance firms and TPAs seem to have realized that the tightening of screws has not hit hospitals, often accused of inflating bills, but the patient.

They are now trying to set in motion a system of redress but the clamour for reimbursement and less ad–hocism in settling claims is growing by the day. Insurance firms and TPAs as well as hospitals need to realise that all the changes need to be geared towards benefiting the consumer (in this case, the patient).

There needs to be a transparent system to address grievances without red tape; those who decide insurance policies need to keep in mind that harassing people already in hospital–or their equally distraught kin–is unethical and insensitive.