Long ago a health insurance company CEO told me, “every Indian needs health insurance.” I will add, ‘and cataract surgery cover.’

This is usually part of any hospitalisation cover in India, so let us look at some gritty points I encountered when a family member underwent cataract surgery.

It was a network hospital of his insurer, so he presented his insurance card and the hospital obtained a pre-approval for ₹25,000. In effect the insurer told the hospital, this is our guy and we will pay for this surgery.

Almost all hospitalisation policies have sub limits for cataract surgery but this policy was silent on it. So, ‘will the insurer pay the whole bill?’ was the next question.

Deposit for surgery

This hospital did not ask for any deposit before surgery, though I hear others do.

But at the time of discharge, they asked for a deposit of ₹68,000, the full cost of the surgery. Never mind the pre-approval, they said, once the insurance company pays us, we will refund it to you.

“So, cashless is meaningless?”, the patient asked me with irritation. I called the insurer with the same question and asked what the sub-limit was on cataract surgery under this policy (sum insured of ₹10 lakh).

The company rep said sub-limits are negotiated with each network hospital individually and ARE NOT shared with the insured!

(My own hospitalisation policy, from a different company states a flat limit of ₹50,000 regardless of sum insured. I can enhance it for a small premium and intend to do that. I did appreciate the transparency even if the coverage was lower).

Cashless treatment?

Back to the current case. “What about cashless?”, I insisted. He sidestepped that question and said reassuringly that once the hospital sends the claim, approval would be within an hour.

The hospital said they would send the claim the same afternoon and the doctor, on request, kindly agreed to not insist on payment until the review scheduled for the next day.

I say ‘kindly’ because the hospital could have ended up caught between two strangers and, having provided the service, been chasing up bills.

The insured was aghast that he too may well have been chasing up the hospital for a refund. Also, he had options of more sophisticated lenses but the opaqueness of his policy limited his vision. Much like cataract!

(The writer is a business journalist specialising in insurance & corporate history.)