After clamping down on hospitals allegedly overcharging patients
holding cashless mediclaim policies, insurers have started restoring
such facilities selectively. Still, the incident highlights the need to
be careful while selecting a health policy which offers cashless hospitalization. Currently, insurance companies and hospitals are
attempting to standardize the rates charged by hospitals.
In
regular health insurance, the hospital issues a bill, which is settled
by the patient, and the insurance company reimburses the amount later.
In cashless mediclaim, patients can be hospitalised and treated without
any cash payment. The insurance company pays the sum directly to the
hospital. Hospitals which are part of the insurance company's preferred
provider network are eligible to offer cashless hospitalisation
facilities.
Last month, four public sector insurers slashed the number
hospitals which could treat cashless policy holders, saying many
hospitals were overcharging patients holding cashless mediclaims. This
led to many customers being turned away by the hospitals or asked to pay
upfront before hospitalization.
Insurance Regulatory and
Development Authority (Irda) chairman J Hari Narayan recently confirmed
what many patients already knew: that some hospitals overcharge cashless
mediclaim holders with needless tests and procedures. Narayan quoted
data from Irda's Insurance Information Bureau at a recent Ficci
healthcare insurance conference which showed that while average charges
for a medical procedure under the reimbursement category were Rs 25,000,
these go up to Rs 33,000 in cashless schemes. "A regulatory mechanism
needs to be in place to address the complaints of overcharging," he
said. The regulator also said that an insurer who violates his contract
with the policy holder can be fined up to Rs 5 lakh.
Be that as
it may, consumers will have to be careful in selecting a cashless
mediclaim policy. Various policies are available, matching one's
requirements and budget. One needs to first define his own requirements
like critical illness, injuries from accidents, hospitalisation expenses
or outpatient department (OPD) expenses and the level of insurance.
Most insurers have family floater plans, which provide insurance cover
for self, spouse and two children under a single policy.
After
selecting a suitable policy, it is important to read the fine print to
spot what all remains undisclosed. One has to check details of the
expenses which will be reimbursed like diagnostic and medication costs.
In
most cases, OPD expenses can be claimed only as a reimbursement and not
on a cashless basis. For those looking to cover expenses beyond
hospitalisation, some companies offer policies which take care of OPD
and pregnancy-related expenses too. Most of these policies come with
sub-limits.
If you see value in an outpatient policy, check the
list of exclusions and sub-limits applicable to the ones that are
admissible. These policies cost more than a regular or a floater policy.
You can also opt for a hospital cash policy, which provides daily
hospital allowances, which are otherwise not part of hospital bills.
After
you purchase the policy, continue with the same insurer. Since there is
no insurance portability in India, switching to another insurer would
mean losing the no-claim bonus accumulated with the earlier insurer and
cover on illnesses that have a four-year waiting period. Customers above
45 have to go through medical tests even if they have never made
claims. While some insurers selectively waive the pre-existing disease
clause, one needs to check all these facts before switching.A certified financial planner says unless there is a
well-defined insurance portability mechanism, the customer has to be
careful in switching insurers, especially if it is in the private
sector.
Earlier, all mediclaim policies covered hospitalization,
with sub-limits for room charges, medicine and doctor's fees. The
sub-limits prompted customers to be prudent while selecting rooms,
doctors and other facilities during the hospitalization process. Trouble
began when insurers removed sub-limits to lure more customers. As a
result, customers started moving to high-end hospitals.
Bajaj
Allianz Life Insurance MD & CEO Kamesh Goyal notes that some
hospitals have a twin billing system, which patients don't question as
they are covered. "We don't realise the inappropriate health practices
will hit customers in the long run," he adds.
The sole purpose of
buying a health policy is to meet any unexpected illness or
accident-related expenses. As health-care expenses surge, one must look
for a cover which provides a combination of packages that not only cover
curative expenses but also preventive care.
