A tussle between insurance companies, TPAs and hospitals over a
standard treatment protocol is depriving patients of a cashless
health insurance cover. While the premium amount is rising, TPAs
(third party administrators) are increasingly rejecting cashless
claims and asking patients to pay hospital bills and promising to
reimburse the money later.

According to estimates, about 35% of patients are forced to get
the claim amount reimbursed, despite having cashless facilities.
“Since I have cashless insurance, I was not worried when I
admitted my husband for an emergency surgery in Secunderabad last
week. But to my horror, the insurance company asked me to pay and
claim reimbursement, while the hospital refused to budge unless I
deposited some money first,” said Sunitha Reddy, a local resident.

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An insurance expert said TPAs try to find lacunae and reduce
payments often, citing unnecessary medical tests and inflated
bills. For instance, if a patient has insurance cover for Rs 2
lakh and the hospital bill runs up to Rs 1.5 lakh, TPAs are
willing to pay only Rs 80,000.

“It’s a blind game as you don’t know now much you will get.
Cashless treatment has been stopped for many of the hospitals and
nursing homes. Consumer has to go for reimbursement that gives
discretionary power to TPA to refuse or reduce claims,” said
Gaurang Damani, a social worker based out of Mumbai. According to
modest estimates, out of 37 lakh claims made last year, about six
lakh claims are still pending.

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Based on a Public Interest Litigation filed by Damani, the
Insurance Regulatory and Development Authority of India (IRDA)
came out with consumer-friendly regulations for the entire medical
insurance (mediclaim) industry in February 2013, but it has not
been implemented yet.

Further, Damani says there was never any public audit of the
claims sanctioned by the insurance company and the actual amount
disbursed by TPAs. “Of late, a lot of people are being denied the
cashless facility because hospitals have an issue with the tariffs
and are unwilling to be a part of network hospitals unlike
earlier,” said Ramana Reddy, an Insurance expert. “People end up
paying anywhere from 20% to 40% of the bill. The bigger the
hospital, the larger the variation,” he added.

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Hospitals authorities, who are accused of inflating bills have a
grouse as well and say they are unhappy with the TPAs. They say
TPAs never honour payments to hospitals and cited nearly year-old
pending payments. But as per norms, they are supposed to complete
the payment process in 45 days.

TPAs now have started taking money for empanelment. Whoever is
obliging is paid well. This has come to the notice of AP Private
Hospitals and Nursing Homes Association (APNA) and a complaint was
lodged with IRDA,” said Dr Krishna Prasad, vice president, APNA. #KhabarLive