Mediclaim- Making sense of the fine print

MEDICLAIM 

Making sense of the fine print 

July 13, 2014 

Insurance companies, hospitals and patients are constantly at loggerheads when it comes to medical insurance claims. While medical insurance is a must in these times of super specialty facilities that come at a super cost, private hospitals and doctors have not been averse to taking advantage by spiking the bills of those who are covered by mediclaim. Herald Review makes a diagnosis of the many pitfalls concealed in the policy fine print 


LISA ANN MONTEIRO  


Medical insurance has come into India in a big way. Yet we are still novices when it comes to making claims or making sense of the fine print, something people in the West have grown really adept at. One of the most common errors committed by Goans being treated under medical insurance is when the person who is hospitalized decides to upgrade to a better room which isn’t covered by one’s policy.

The patient decides he will merely pay the difference in the room rates but what he doesn’t realize is that in a special room, it is not only the room rent but all charges— doctors fees, operation charges, nurses charges, and so on, that increase. When faced with a large bill that the insurance company refuses to pay, the patient cries foul.

Hospitals today offer rooms that are not unlike hotel rooms. General rooms, semi special rooms, special rooms and deluxe. Some also offer suites, all at a price of course.

Each policy comes with clauses and the lower the sum assured of one’s policy, the more clauses/ terms and conditions the policy will have.

Pre- existing diseases are also a cause for much exasperation for patients.

Certain policies don’t allow patients to claim insurance for pre- existing illnesses like cataract, prostrate, hernia, piles, stones in urinary system, certain tumours, stones in gall bladders, skin disorders, varicose veins among others until the waiting period ( usually around three years from the date of the inception of the policy) has passed.

Being upfront about your medical history and health may mean you pay a higher premium but insurance agents suggest this is the only way forward.

The health checkup required to be taken before making a policy is very comprehensive where ultrasound, chest x- rays, blood tests are all carried out to detect illnesses. “ You shouldn’t lie about being a smoker or alcoholic because tests can tell whether you were a smoker, and doctors’ records will have the history of the patient.

People making false claims get caught at the time of reimbursement, when insurance companies cancel the claim,” an agent said.

Tourists engaging in adventure sports who meet with accidents in Goa are often dismayed to find out that their treatment at the hospital is not covered under their medical insurance policy. Certain policies cover adventure sports while others don’t.

Some policies cover disasters and acts of nature while others don’t. “ Don’t pay a pittance and expect the company to insure you for everything,” an agent says.

One patient recalls visiting the hospital for an angiogram and being told that she could do an angioplasty procedure too, if she had insurance. Problems also arise when people seek treatment from hospitals not empanelled with the insurance company. Extra tests are requested and extra procedures recommended to inflate costs.

“ These hospitals usually follow unethical practices. Empanelled hospitals cannot do this because people from the insurance company are visiting the hospital periodically and auditing practices there. They check closely for frauds, especially when the company offers their patients cashless transactions,” Ashwin Furtado, Manager at Apollo Hospital says.

With insurance companies keeping a close watch, doctors complain that they cannot function independently.

Dr Suresh Dubashi, surgeon and director Vintage Hospital says insurance companies not only in India but the world over dictate terms to the doctors.

“ They try to tell us how to treat our patients. I’ve operated on one person twenty times in a period of forty days. Each patient’s case is different.

You cannot equate the cost of good treatment. Once a patient almost 80 years old came to the hospital with diarrhea and I requested for an ECG. The insurance company asked me why the ECG was required for him.

What’s the qualification of this man, asking me this kind of question?” Malika Essani, an insurance agent from Margao says it is critical to renew one’s medical insurance policy on time. “ If you delay any sickness in between will be treated as pre- existing illness. The client will lose his bonus and may be asked to make an entirely new policy.” Many insurance companies also have TPAs ( Third Party Administrators) who are in charge of settling claims on behalf of insurance companies.

A medical practitioner advised against making a policy with a company that has TPA. In the case of TPAs, a client at the time of claims cannot speak to the insurance company but has to deal only with the TPA and this can be problematic. “ The one performance criteria for TPAs is how efficiently they run the business for insurance companies. The more money they save the better will be their relation with the company. Hence they sometimes do whatever they can to reject claims,” a doctor said.

The Goa government spent Rs 18.48 crore last year on mediclaim for 1461 people. Major claimants were for cardiac surgeries and the government expects this to reduce after the setting up of the super specialty cardiac unit at GMC. The government mediclaim offers financial assistance to the maximum extent of Rs 1.50 lakh per illness for super specialties, treatment for which is not available in state government hospitals. In the case of open heart surgery, kidney transplants and neurosurgery, the patient can claim up to Rs 3 lakh. For cancer the upper limit is Rs 5 lakh and for bone marrow transplant disease it is Rs 8 lakh.

Government mediclaim is only offered to those who have been staying in the state for a minimum of 15 years and whose annual household income is less than Rs1,50,000 per annum. A fraudulent income certificate from the Mamlatdar has allowed others to take advantage of the scheme.

Apart from mediclaim, the Goa government also offered health insurance Swamajayanti Aarogya Bima Yojana introduced by the Digambar Kamat government in 2011. With ICICI Lombard as the implementing agency, the scheme provided a cover of Rs 60,000 per family. ‘ Resident Population’ under the policy was defined as a person residing in Goa for more than five years and pre- existing diseases were to be covered from day one. It was stopped on January 31 last year.

A new medical insurance policy is being framed by the BJP government, Deen Dayal Swasthya Suraksha Yojana, where the ceiling benefit will be raised. Health Minister Laxmikant Parsekar said the new policy has reached the finalization stage and will be tendered in a fortnight’s time.

“ It was tendered earlier, but has thereafter gone through many changes and so it has to be retendered.” He declined to give out any more details about the new policy. Review Bureau