You can break your bank account when you are ready to pay for health insurance. The cost to have coverage seems to keep going up and if you have a pre-existing condition then you are going to have to get two more jobs to pay for it. There are places who offer insurance at rates that will not cause you to move to another country. You must be patient and search around before making a final decision on who to use for your insurance provider.

First look online and get quotes so that you can compare these cost and go with the affordable option. You will be surprised that when you take your time to search for a great rate most of the time you will find one. Do not be scared away if you see a high rate because there is always a cheaper alternative.

Talk with family and friends to see who they use for health insurance. You can find some great low cost options this way and remember that they have already spent the time to find an affordable insurance. In some cases they may be part of a group like at there work and they may get a good rate there but you can be assured that you know someone that has an individual plan and went through this same process and you. Remember that finding cheap health insurance is not hard to do but you need to build a network to find the low rates. Do not be scared to talk to people you know because they might have the perfect insurance at the right price.

The cost of buying health insurance is high. There are many families who cannot pay the high premiums, and therefore do not insure themselves or their families. Many other families feel that they are healthy and do not require a health insurance policy. Calamities can strike anytime and then, they realize how important it is to have insurance, even if just in case of an accident.

People, who cannot afford health insurance are often eligible for low-cost health insurance policies. Health insurance means protection against any accidents, diseases, and viral infections. Getting a health insurance does not mean buying expensive policies. One can also opt for cheap and low budget health insurance plans.

There are many companies that offer a cheap health insurance plans. But apart from companies, there are also many local insurance agencies that give low-income families, a complete package for securing their health. Some of these local agencies offer health insurance that covers dental, eye care, and emergency care. Some insurance companies just offer health insurance coverage.

Many insurance companies consider situations and give the best, correct, and cheap health insurance policies that suit the needs of the family, and also come under the specified budget. It is very important to compare the best health insurance deals, to get the cheapest policy compared to the rest.

The Internet is regarded as one of the other choices, to look up for the cheapest plans relating to health insurance. Many companies advertise online to promote and encourage families, to take cheaper and low cost health insurance plans. People can request online for the best quotes available and can compare the two. It is always advisable to take the quotes, compare them with the others available and then opt for the one that suits the needs of a person.

Before insuring yourself for your health, you must know what health insurance is. It is a kind of insurance wherein they pay your medical expenses when you are sick or have some injury.

Working people mostly have their health insurance shouldered by their company where they are working. This is called group health coverage. Some companies also include their workers family for inclusion in these plans.

There is health coverage where in it covers the hospitalization stay, medicines, doctor visits, and inpatient and outpatient procedure. But that depends on what kind of insurance you have. These are some of the benefits you can get from it.

Health insurance falls in 2 categories, namely:

The Major plans: These kinds of plans have broader ranges of services which include both inpatient and outpatient. Mostly in this category, the benefits you can get are cover in hospital stays, emergency treatment, x-rays, medicine, surgeries, laboratory test, and mental health services. This kind of health insurance have higher premium rate.

The Basic plans: In this category plan, usually covers the everyday cost of your medical treatment. Although this also cover the hospital stays, surgeries, emergency treatment, etc but there is a limit, if ever you exceed to the limit then the individual have to pay for the balance.

Most individual look for the best health plan that gives the most benefits with the lowest and flexible cost that fits to their budget and family needs. If possible, all the great or good benefits are in one health insurance plan.

The different kinds of health insurance, namely:

Traditional Health Insurance: This kind of coverage is based on fee for services. This means, pay the itemized medical services that they rendered or you receive. Traditional health insurance has 2 parts which are:

1) Hospitalization: This cover hospitalization with defined expenses incurred while you are confined. The insurance in which will pay for all the covered services rendered by the hospital staff and if the insurance benefit is a fee-for-service then the payment will be fixed sum regardless to the actual expenses incurred.

2) Medical or surgical: This cover the medical care other than the bill from the hospital and the services include treatment charges, doctor visits, lab test, x-rays, etc. Usually the medical surgery requires co-payment by the insured.

Preferred Provider Organization (PPO): This kind of health plan seek to give both benefits of traditional health plans and the money savings of health management organizations.

Point of Service Plans: In this kind of plan, the policy holder or the certified holder are allow to visit out of network or the non participating doctors for a fee.

Health Management Organizations (HMO) This provides coverage of certain health care services required by members of organization which include access to primary care physician, emergency care, and hospitalization if needed.

Health Savings Accounts: This plans provide to a certain kind of arrange coverage of a certain health care services which required by the member of the organization.

If you know the effective way to locate and secure affordable health insurance for individuals, you can greatly enjoy a lot of advantages.

Everything is rising and this is never ending. One of the worst hit is the rising premiums for medical insurances. As a result of the rising cost of premiums, many people even considered dropping this part of their spending from their regular expenses. However, they do not realize that giving up their health care insurance can mean disaster for the future if they are to seek medical attention. Therefore, it is important to find health insurance for individuals that are affordable to save us for any future headaches.

You do not need to get most of the health insurance policies available on the market as it will be a financial burden. All you need is just to find affordable medical insurance products that can meet your medical needs. It is better to invest on one now to prevent any nightmares in the future. Luckily, there are ways to bring these premiums down. Below are some effective ways to cut down on the premiums your need to pay.

Healthy Lifestyle For A Lower Premium

If you are a smoker, quit it right away. Health insurers normally impose higher premiums for those who smoke. This is because smoking is never good for health and in the long run may require you seek medical attention. Smokers will generally incur higher expenses for the medical attention they seek and hence this makes sense that their premiums are usually higher.

Getting A Group Insurance

If you are employed, you should get a group insurance if your employer offers one. It is a mistake that many people opt out for such a group insurance plan. These people do not know such health policies are in fact less expensive than individual health option. They are of lower premiums and the health coverage may not necessary be bad. In fact, most of these group insurances even provide better coverage at a lower cost compared to an individual policy.

Get A High Co-Payment Policy

Choose health insurance for individuals that require high co-payment. Co-payment is the portion you need to fork out from your pocket when seeking medical attention. Do not mislead that high co-payment contributes to a higher cost. If you calculate for the long term, it is definitely more worth it as it can cut down your monthly premium greatly. Especially if you are young and seldom get sick, such policies can help you save a lot.

Looking for a family health insurance can be a real daunting task. Not only do you have to look forwards to a plan that suits the individual needs of each member, but the medical plan should be affordable and comprehensive as well.

Family plans are costlier than individual plans because they cover more number of people. So if there is a couple, it is a better idea to go for individual plan for each of them. But if the family in question is larger and includes more people, then going in for a family health plan would turn out to be much cheaper than insuring every member individually.

Getting a medical plan that is perfect for the entire family can get really difficult. What is right for one member may not be so for the other. So to get a policy that is adequate for all them is not easy.

The approval of a family policy and the premium to be paid will depend on various factors. These include:
• The number of members in the family
• Amount of deductible chosen
• Pre-existing medical conditions
• Prior hospitalizations
• Chronic illness
• Family history

A review of all this information will help is assessing the appropriate health insurance coverage needed for the family.

A family insurance is advantageous as there are additional benefits that are a part of the policy. Apart from that family insurances are generally cheaper than other plans. One can either buy a family insurance plan on his own or can access it through his employer. Companies often provide family medical insurance to their employees at a subsidized premium.

The types of family health plans are similar to the options available in individual plans. There are basically two types of family medical plans.

a) Indemnity family plan: It offers more affordable rates and access to the largest network of physicians. However the shortcoming of such a plan is that the deductibles are hefty and one has to pay the majority of medical bills up front till the deductible is reached.

b) Managed healthcare plans: These are gaining popularity and have replaced indemnity family health insurances in almost all spheres. Managed health plans include HMOs, PPOs and PoS plans.

Managed healthcare plans are affordable and they offer comprehensive coverage. But the problem with such family plans is that one has to consult doctors within the preferred network of healthcare service providers. One can consult doctors outside the network, but at a higher price. If one’s family doctor is a part of the network provided by the insurance company, then there is no deal like it.

Family health insurance plans offer the advantages of group plans coupled with the personalised services of individual plans. However they are cost effective only when you have a large enough people to cater to.

Courtesy the insurance companies, the malaise that was until recently the exclusive preserve of senior citizens has now become universal in its applicability.

I am talking about the vagaries of what you may be called upon to pay as renewal premium on your health insurance policy.

In case of senior citizens, every renewal has, for quite some time now, become a hurdle. Through overt, and even covert, means, insurance companies had generally been making it known to senior citizens that they are quite an unwanted risk, and the insurance companies are ‘obliging’ these worthies by offering them renewal of their policies. If, for any reason, the senior citizen has missed out on the renewal date and the policy has lapsed, the hurdle becomes a nightmare. In any case, if you thought your renewal premium will be the same as what you paid last year since you have not made any claim this year, well, you may have to think again when your insurance company tells you your renewal premium is ‘loaded’. You have become a year older, haven’t you? That’s enough reason for a loading. And a loading of what percentage?? Anybody’s guess. You are almost completely at the mercy of the moods of the insurance company executive who ‘underwrites’ your renewal, since there is no prescribed, leave alone publicized, basis or pattern for this loading.

And now, you don’t have to be a senior citizen but a member of the sprightly brigade in the fountain of youth and yet suffer the same fate – all because, after years of paying premium, last year you ended up in a hospital and in the process, preferred a claim. In my elementary insurance education I had learnt that insurance companies ‘spread the risk’, they are indeed spreading this risk of loading the renewal premium here to the not-so-senior citizens too.

Following a claim, you would probably be prepared mentally to pay a higher renewal premium, but what you are not prepared for is the staggering hike – garbed ‘claim loading’ – that your insurance company asks you to bear. How staggering? Depends on the same mood of the same underwriter!

I have been hearing and reading lots of voices on this, suggesting various measures from meek submission – ‘thank your stars you are at least getting your renewal’ – to mighty legal action through Public Interest Litigation. The PIL lobby however piped down quite a bit when the incumbent Hon’ble Chief Justice of India, on taking oath, immediately followed it by a statement that he will not look kindly upon ‘frivolous’ PILs.

Meek submission is for the cowards willing to be cowed down by the might of the insurance companies; PIL is for the Don Quixotes. Even if your PIL is admitted by a stroke of luck – if you are that lucky, the unassailable mood of the almighty underwriter ought to have already worked in your favour – and proceeds to result in a favourable judgement, that may benefit just a few, and that too by way of an ‘interim’ relief!!

Is there no scientific way for you to have a go at this Goliath – of whimsical loading on your renewal premium – and bring him to his feet? Some workable solution between pleading for mercy and preferring litigation?? Good news is, there is.

You wanna beat them, you need to think like them.

How is it your insurance company is able to pose a ‘take it or leave it’ attitude when it comes to your health insurance renewal? ‘Cause your renewal premium is a minuscule drop in the ocean of their premium base, and not getting your renewal cheque will not impact the insurance companies top line even just a way wee bit. So, bluntly put, you are dispensable!

Insurance is a number game; the larger your number, the more significant you are to your insurance company.

Great, so how do you, the individual, manifest into a large number? Go forth and multiply?? Clone yourself into a million yourselves???

Don’t worry, I am not suggesting anything of that kind.

Am I suggesting you ride the general discontent of other renewal victims like you, be the leading lion and herd all these people together and start a movement??

Not a bad idea, except that I would believe you also have a few other mundane things like your career and home to invest your time and energy into.

If the solution is large numbers, and I am not advocating you initiate creating these large numbers, what am I saying?

Simple, the large numbers are available to you on a platform, and all you need to do is latch on to this instead of reinventing the wheel.

Have you heard of insurance brokers? Have you come across a dedicated health insurance broker? Look for one and place your renewal through this broker. This broker is already offering large enough volumes to the insurance companies that the insurance company cannot simply throw figures at this broker. Not just because this broker is more significant in premium size than you, the individual; but, and more scientifically because, for every renewal of a policy in which there had been a claim, this broker offers a dozen other renewals of claim free policies. This broker is already an aggregator of several renewals and therefore, your post claim renewal, placed through this broker, is seen by your insurance company in the backdrop of all the claim free renewals and fresh insurances that are also given by this broker to your insurance company. So, suddenly, you seem to matter. While this broker may not be able to completely do away with the loading in some cases, he will ensure that the loading, if unavoidable, is reasonable and not arbitrary, by effectively taking up your cause and case with your insurance company. So, with such a broker representing you, your renewal premium will be in the realms of predictability than astrology.

You may have some bonuses thrown in too.

This dedicated health insurance broker will have the wherewithal to offer you multitudes of services related to your health insurance – like renewal reminders, claim services like cashless coordination and so on – absolutely free! And he will even go beyond just health insurance but be your health partner too, offering several health related services – not just curative but, more importantly, preventive!

Afterall, while it is a sensible thing to always carry an adequate health insurance, to stay healthy and avoid getting into a hospital is an altogether better thing, right.

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News Flash:  “The General Insurance Public Sector Association consisting of four major state-run insurance companies – United India, New India, Oriental Insurance and National Insurance have decided to stop cash-less hospitalization in most hospitals”

Shock and outrage were the two words that described the reaction of most of the customers and media reports on this piece of news.  We demanded to know how insurance companies could take such a decision, one fine day and what would the customer do. 

Before the delisting of hospitals from the PPN by the Public health insurance companies, media and the industry experts were congratulating the sector for the phenomenal growth. It is this decision which has caused large amount of backlash from the all around- Customers, hospitals, media and other insurance experts.

Let’s understand the issue:

There have been various reports about the overcharging by the hospitals and the lack of standard pricing. The TPAs as well as the hospitals have been blamed by everyone for being the perpetrators for the huge losses faced by the industry. Without as much as warning, the public health insurers have delisted most of the hospitals from their PPN.

Insurers’ Stand: Insurance industry faces losses worth thousands of crores each year now, this year the losses further plummeted and the Insurance industry is blaming the lack of standardized pricing in hospitals along with the trend of hospitals to overcharge the insured patient for the losses.  GIPSA has also criticized the TPAs overall efficiency in keeping the claims down.

Hospitals’ Stand: The corporate hospitals believe that they are been unfairly targeted by the health insurance company, they argue that the price they charge is proportional to the quality of care they provide. Since the kind of care in a 100 bed, hospital with latest technology will be different than a 15 bed hospital, cost of healthcare in a large, private hospital is more. 

TPA’s Stand: They have been blamed for everything from inefficiency to making fraudulent claims. There is immense amount of pressure on TPAs to bring down the claims and there is talk that the PSUs may opt for a single common TPA. 

Customer’s stand: Customers are caught in the crossfire between Hospitals and Health insurance companies and they feel cheated. Since Cashless facility is limited to extremely small number of hospitals, they have to pay the medical bills through their own pockets.

With Brokers being the neutral as well as a catalyst in the health insurance industry, here is opinion of Sudhir Sarnobat, Founder of Medimanage Insurance Broking Pvt. Ltd on this issue:

Whether Health insurance companies are justified in delisting the hospitals in the middle of the policy:“The policy periods are of one year and at any point you take decision, it’s going to be mid-term for some members and hence, we cannot hold insurer responsible for this. People look at benefit of insurance claim and that’s the core product that insurer is not refusing. If insurer finds issues with non-core benefits, they have right to tinker with them.

Also, the Health Insurance in India currently in nascent stage and hence, the stable decision making would take little time. One MUST not forget that this portfolio is loss-making and hence, under pressure to reduce losses, insurer is taking some sudden decisions as they are not worried about consumer reactions”  

On Corporate Hospitals taking advantage of the system: “I think that these corporate hospitals have taken advantage of the system and not negotiated rates when insurance is their single largest customer. It’s actually clash of egos and I think after 3-6 months, both Insurers as well as Hospitals will come to sense and will resolve this in amicable manner when the industry bodies will act as mediators. I think IRDA may also step in”.

On Grading of Hospitals: “The grading is very common concept and it will help manage the cost of treatment well and will help in creation of centers of excellence. Why should a person go to Lilavati (Premium hospital in Mumbai) hospital for Hernia just because he has bought 5 Lakh or 10 Lakh cover. It’s a secondary care procedure and hence, should be managed in secondary care hospital.”

On, the impact of this moves on the customer: “This (move) may bring the malpractices and over-billing to check. However, I would maintain that you need to have tertiary care hospitals in network as smaller hospitals do not have the facilities, infrastructure and manpower to manage complex procedures. “

On 10.3% of Service tax for Cashless Facility: “That’s not fair as its additional burden. It’s discriminatory as it’s meant for Cashless Insurance patient only. But as it’s a decision by Union Government, the consumer forums/bodies should take it up with Government.”

On whether this move to curtail hospitals in the Network list make Health insurance unattractive:
“It’s a need of the hour and once the insurance penetration and clout increases, hospitals will try to be compliant with Insurers’ requirements. This would bring in cost consciousness along with customer focus. The churning what we are seeing now is good for long term sustained development of the industry and hence, one should not look at this as negative or unattractive”.

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Hospitals overcharging Patients under Cashless Claims is under the media buzz since a few days.

Here is a quick post which reasons why Hospitals overcharge Cashless Claims:

No Contracted Rates with Hospitals:

TPAs do not have contract binding rates (treatment-wise) with Hospitals in their network. Globally, TPAs contract treatment-wise rates with each Hospital in their network. Treatment wise fixed rates would remove the disparities and anomalies that Hospitals currently enjoy. The core of the issue is TPAs lack negotiation power with Hospitals.

Why do TPAs lack negotiating power?

In India, more than 70% of the total hospital billing is still out-of-pocket and not through Insurance Companies or TPAs. Hospitals are overflowing with patients and therefore don’t depend on TPAs for their revenues. (Imagine a 100 employee TPA bidding to negotiate with a Hinduja, Apollo, Fortis or an Escorts?)

1). Insurance Companies under demands from Large Corporate Customers to list a large hospital, unconditionally pressure, TPAs to include certain hospitals into their network, without rates.

2). Add to this, TPAs are also under pressure to have a large and geographically wide list of close to 3500-4000 hospitals under their network. Due to such a large spread of hospital payments in the network, they cannot guarantee revenue to hospitals, which is the trump card for Health Claims Administrators worldwide.

3). Every division of a Government Insurance Company in a bid to offer the option of a TPA to large customers, use services of 6-8 TPAs. Customers are therefore spread across larger no. of TPAs.

4). Customers (especially Corporate/Group) want to decide their hospital. TPAs currently don’t take the healthcare responsibility of recommending hospitals. Hospitals therefore get ‘business’ on the decision of the consumer and not the administrator.

Delayed payments to Hospitals:

This is the justification each hospital will give. Insurance Companies (mostly Govt. and some Private) due to their internal deep rooted inefficiencies have been guilty of delaying payments to TPAs. TPAs being small sized companies depend on funding from Insurance companies and therefore in turn delay payments of the Hospitals. Some Hospitals in need of liquid cash, have been known to discount their authorized cashless claims with Banks and Financial Institutions, ofcourse at a cost. Every Hospital would be ready to reduce their costs if they are committed to payments in say, 30 days. 

Recently a new Insurance company has been sucessful in negotiating better rates with Hospitals on the contracted committments to pay on time, with interest penalties.

Lack of Uniform Grading:

There is no regulating apex body or uniform grading of hospitals in India, which makes contracting of rates with Hospitals all the more subjective and unscientific. Rates charges are merely based on location and popularity and not on the quality and consistency of the care and treatment.

Recommended Solution:

Apart from the recent kneejerk delisting/reduction in number of hospitals (to ones which agree to contracted rates), by Insurance companies, here are some solutions our experts recommend. 

1). Health Insurance premiums have grown by 10 times in 5 years. Insurance companies should work towards increasing their negotiating capabilities with Hospitals, by bringing revenue dynamics into picture.  

2). Govt. Insurance Companies should reduce the fragmented way in which it engages TPAs. This will bring more business to lesser no. of TPAs, and hence bring administrative and financial control on claims.

3). Insurance Companies should lobby with the Central Government and Ministy of Health and Welfare to bring in an apex body which enables self regulation and grading of Hospitals and other Healthcare providers.

4). Selection of Hospital Network should be based on quality of Healthcare. Like the “gatekeeper model” in the west, TPAs should be empowered to take responsibility of healthcare beyond negotiation of rates. They should be in a position to recommend the healthcare provider to the customer.  

5). Insurance Companies and TPAs should take into account demography and economics and scientifically fix a schedule of treatment-wise limits for cashless claims, in its policy condition.This way, Insurance Companies or TPAs would pay upto the limit and leave negotiation of the amount charged over the limit to the Customer. 

Do let us know if you have any questions or feedback. Write to Medimanage @ email [at] medimanage [dot] com.

Read Original Story

Preamble

Last 3-4 days, we have been seeing a lot of news in various media about cashless network hospital list being brought down to fewer in numbers & this list does not have big hospitals where the treatment cost is high & hence, have a greater need for their presence in list. We fear that these news items have created confusion in our members’ mind & hence, here is small explanatory note from our team.

Genesis of the thought process

Insurance companies have been witnessing inflated, fraudulent & unwarranted hospitalisations claims when the patient had declared that he/she has insurance cover & wishes to go for cashless treatment. Also, an analysis of cashless claims brought out pointer that 80% hospitalisations (by amount) happen in only 25-30% hospitals. The advantages of curtailed list are envisaged as follows:

1). Limited hospital list (around 450 all over India) would offer better administrative control.

2). TPAs can drive more business to small number of hospitals & hence, can demand volume discounts.

3). With better administrative control, all bad claims (fraudulent, inflated & unwarranted) can be reduced to a greater extent.

Methodology adopted

New India Assurance Company (it’s the largest, has major Health Insurance exposure and their current CMD has good rapport with other PSU Insurers’ CMDs) had taken the lead & appointed four of its empanelled TPAs as nodal TPAs (one for each region i.e. East, West, South & North) & asked them to draw a list of around 100-125 hospitals in each region. Only these PPN (Preferred Provider Network) hospitals would qualify for cashless treatment. PPN is a very common concept in west & helps insurer have better control over claims without compromising the quality of care.

 How it impacts you?

1). Currently, this does not impact corporate members as this arrangement is meant for only retail / individual policy holders.

2). However, looking at the success of this arrangement, soon, this may get extended to corporate policy-holders too.  

3). Currently, only New India, Oriental Insurance & United India have agreed for following this network. National Insurance has their own ideas about how to implement this & hence, declined to be part of this network as of now (see news mentioned above).

What are the shortcomings of this system?

1). Cashless treatment becomes very useful when the treatment is costly. With no tertiary care hospitals in major cities being part of this Preferred Provider Network, members would be forced to raise the funds for cost of treatment before the treatment starts.

2). Cashless treatment has been one of the major attractions which has helped increased Mediclaim penetration in Urban & Semi-Urban India. With these kind of restrictions, the new policy sales may suffer an impact which is detrimental to overall claims experience. (New policies sale brings in premium without any claims in its initial years which help insurance companies improve their claims ratio.)

3). There is no proper methodology adopted for selection of these hospitals & many network hospitals are in dark about this change. Without any bench-marking, the quality of care may deteriorate & just for want of cashless, members may have to face inefficient service levels.

What should be done to implement this better manner?

1. 1). A right mix of Tertiary, Secondary & Primary care hospitals should be ensured while finalising the city-wise Preferred Provider Network.

2. 2). A stringent & transparent criterion should be adopted for selection of hospitals which should broadly look at following features:

   a). No. of Beds
   b). Infrastructure & Manpower quality
   c). Certifications & Statutory Compliances like minimum wages, PF etc.
   d). Published rates for various treatment & acceptance of Insurance Tariffs
    

3. 3). A formal Third party annual audit & review methodology should be decided by the insurance company for these PPN hospitals.
4. 4). In case of occurrence of fraudulent practices, the hospital should be banned for a period of three years and even reimbursement at such hospitals should not be allowed.

Summary

Though the initiative taken up by insurers has shaken up the hospital industry & made the consumers anxious, we have reasons to believe that this is a start of much needed changes in the Health Insurance industry. What we expect is well thought-out strategy derived out of data available with the insurers & then an efficient implementation of the same in phased manner to ensure that the consumer is not hassled unnecessarily. 

In case you have any queries, please feel free to connect with me at sudhir [at] medimanage.com

About Medimanage:

Medimanage is India’s first boutique health insurance broker, with an integrated service model which provides Unbiased Health Insurance Advisory, Technology based delivery and Professional Claims Assistance. To know more contact purandar [at] medimanage.com

 

More interesting news just today

Public sector insurers to push for a common claims settling agency (http://economictimes.indiatimes.com/personal-finance/insurance/insurance-news/Public-sector-insurers-to-push-for-a-common-claims-settling-agency/articleshow/6154912.cms)

•  New Items for reference

Insurance Cos slash list of hospitals in Mumbai for making fraudulent claims(http://timesofindia.indiatimes.com/City/Mumbai/Insurance-cos-slash-list-of-hospitals-in-Mumbai-for-making-fraudulent-claims/articleshow/6145243.cms)

One PSU insurer stays with cashless Mediclaim

(http://timesofindia.indiatimes.com/India/One-PSU-insurer-stays-with-cashless-mediclaim/articleshow/6153259.cms)

Read Original Story

Health insurance companies are trying to salvage the losses which are just increasing each year and here is another of their moves. Public Health insurance Companies (Oriental, New India Assurance, United, National) have announced that they are taking down large number of the hospitals from their list of network hospitals to access Cashless service. From the 800 hospitals which were in the Preferred Provider Network in Mumbai, only 90 remain, all others have been delisted.

Even some of the most reputed hospitals- Breach Candy, Bhatia Hospital, Jupiter, Lilavati and Hinduja have been removed from their lists. There are similar names which have been omitted from other metros like Chennai, Bangalore and Delhi.

So what caused this move?

Cashless service is offered by health insurance to the customers to avail hospitalization in select hospitals without paying any fees. The customers show their TPA card, fill a form and the hospital then receive the amount from the TPA, which is an intermediary between Health Insurance Company and the customer. Since the TAT or the Turn Around time, for the entire transaction is just few hours, there is less- than-effective examination of the documents and the some hospitals and some customers manage to file fraudulent claims. Most of the times, hospitals used to inflate their bills and in absence of rate cards could charge different rates for the same treatment.

Since the losses faced by health insurance are now running into hundreds of crores, health insurance companies are tightening the reins around the TPAs and hospitals. After examining the claims they found many Hospitals had filed fake claims and some TPAs were also hands in glove in the exercise. General Insurance Public Sector Association (GIPSA) has come decided to take stringent measures and delist all hospitals which are guilty of these practices as well as have implemented a rate card for treatments across all the hospitals.

This move is surely going to affect the consumers who had many options to choose the hospitals to avail cashless service. Now they will be forced to travel far or go for reimbursement claims. We ask our experts about this move and its impact on the customer.

Sudhir Sarnobat, co-founder of Medimange Health Insurance Broking Ltd, agrees that this move seems to be a knee jerk reaction to the losses faced, he says “Though TPAs have identified some incidences where over charging has happened, one cannot ignore the fact that the Tertiary care treatment facilities are available in these(big) hospitals only.”

He says that the basic essence of Mediclaim is to take cover against large, unforeseen health risks which are being treated at such hospitals. “Raising Rs. 10,000-20,000 is possible but the cashless really becomes useful when the claim amounts are large. Insurance companies are hitting that part and creating major inconvenience (for the customer)” he rues.

As a solution to the problem of overcharging, he suggests that Insurers should have created a list of diseases which can be treated at such hospitals and negotiated rates based on the Sum Insured.

Should there be Talks?

Reports suggest that the hospitals are still not aware of their status in the network hospitals, which suggests that there were no talks between the hospitals and the health insurance companies. So we asked the experts whether there should have been discussions between the parties.

Mr. Sarnobat replied, “As the insurers are essential for health market to grow, so are the healthcare delivery institutions (read Hospitals and Nursing Homes). Currently, the insurers view the hospital with antagonized view which needs to be altered.” He feels that Association of the hospitals should take a pro-active measure and self regulate and engage in a dialogue with the insurers to get a fairer deal.

He thinks it is the individual ego that is stopping the two parties from an honest dialogue and the decisions are based on few incidences more than wide spread activities.

Customers- the ultimate losers

While taking the policies, most customers were told that they had plenty of options to choose their network hospitals from (many boosted as high as 4000 hospitals), suddenly they will find themselves in a soup where either they need to travel far for Cashless or pay from their own pockets through the reimbursement route.

So for now, it’s bad news for the Hospitals and even more so for the Customers!

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