The Hindu Business Line : Mediclaim policies: Smooth settlement still far away

Is the cashless treatment facility being extended under the individual mediclaim policy offered by various insurance companies presenting limitations to the policy-holders in availing medical attention, especially in emergency situations?

It appears so if one notices the dilemma that haunts both the hospitals empanelled to provide the medical services and the third party administrators (TPAs), the intermediary between the insurance companies and the insured, that handles the policy-holders' data and their claim settlements.

The dilemma for hospitals springs from the doubt as to what extent the bills of cashless treatment cost incurred on the patient-policy-holders would be allowed and what portion of the bill would be rejected by the TPAs/insurers at the final settlement. In the case of the TPAs, their dilemma centres on inadequate patients profile including their pre-existing diseases and the treatment information from the hospitals, which often proves the stumbling blocks in timely clearing the bill settlement.

CII session

These issues came to the fore at an interactive session with hospitals and the TPAs organised under the aegis of the Confederation of Indian Industry (CII), Coimbatore chapter here today. The meet was jointly led by Mr R.C. Sharma, Insurance Ombudsman from Chennai (for Tamil Nadu), Mr K.S. Ramalingam, convener of the CII Coimbatore's Healthcare panel, and Mr Jayakumar Ramdoss, Chairman of CII Coimbatore.

This is the second interactive meet the CII held in recent months here in which a good number of hospital administrators, representatives from three TPAs and major insurance companies took part.

The delays encountered by the hospital administration in securing the preauthorisation needed from the insurers through the TPAs to proceed with treatment of the patients often put the former in an unenviable situation, especially when the latter were to be given emergency treatment. Patients compelled to be admitted in the week-ends would be really worse off because of the non-working of the offices of the insurers. In most cases, the authorisation from the TPAs would not come in time causing anxiety to the hospital. This is besides the delay in getting the reimbursement of the bills from the insurers, which in several cases gets extended beyond the assured 30 days, the physicians and the hospital management representatives present in the meet argued.

But the members of the TPAs maintained that TPAs who are finally accountable to the insurance companies could hardly proceed in the matter unless they get adequate information on the patients and the line of treatment to be given, though the TPAs would never question the line of treatment or the judgment of the physician on particular treatment procedure.

Dr Ramalingam felt in an acute emergency situation when the doctors themselves would not be in a position to inform upfront on the cost of the treatment, the hospital extending cashless service may not be possible, in such case the patients could be advised to pay and get the reimbursement.

Mr Sharma said that while the penetration of individual mediclaim policy still remained low and highly driven by urban population, the pre-existence of disease among the insured has been the single largest factor for the dispute in claim settlements. He also clarified that the benefits of the mediclaim could not be denied in respect of cases of emergency treatment on the basis of not giving the medico legal certification as the accidents could have occurred domestically or outside homes.

A senior executive medical consultant from TTK Healthcare Services Pvt Ltd, one of the TPAs suggested that standardisation of hospital tariffs, especially the surgical costs for major illnesses among hospitals and upfront cost information would bring about a vast difference in the arena of medi-claim disputes.

In response to this, the CII Coimbatore's healthcare panel head said the CII would call for a uniform room rent for inpatient and a common rate for specific surgeries for the hospitals in Coimbatore to help the mediclaim policyholders.

More Stories on : General Insurance | Health | Tamil Nadu

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