Public insurers to allow cashless settlement for accidents, emergency treatment

Don’t fret if you meet in an accident as your public sector insurance company will still give you the desired cashless facility

People who had bought insurance cover from public sector health insurance companies can now use the cashless method for settling their claims. These policyholders will get cashless treatment in case of accidents or emergency in all hospitals, including those de-listed by the public sector insurance companies, according to an official.

“People who had an accident and those who are in need of any emergency hospitalisation would be allowed to take the cashless route for settlement of claims. We will also not restrict them (the insured) to the new preferred provider network (PPN) list of hospitals” an official from New India Assurance Company said.

The news that cashless insurance claims coming from accidents and emergency treatment would be accepted should provide a certain amount of relief to customers. Emergency hospitalisation here means any urgent need of medical treatment, which would lead to the patient going to the Intensive Care Unit (ICU).

According to an official from Meditek, a third party administrator (TPA) company, out of the total cashless claims from public sector insurance firms last year, only 10% came from accidents or ICU treatment while the remaining 90% came from planned admission. This may be another reason as to why the insurance company would prefer letting accident or emergency treatment be given cashless settlement as compared to planned admissions.

Earlier, public health insurance companies, which include Oriental Insurance Co, National Insurance Co, United India Insurance and New India Assurance Co, had decided to de-list some hospitals from their PPN claiming that these de-listed hospitals were making false claims and over-charging their customers. The public health insurance firms have nearly 80% of the total market share in this segment. These companies together collect premiums worth Rs900 crore but had to shell out Rs1,200 crore every year, making a loss of Rs300 crore annually.

Public health insurance companies have drastically cut down the list of hospitals in Mumbai, Delhi, Chennai and Bangalore. In Mumbai, top hospitals like Cumbala Hill Hospital, Breach Candy, Bhatia Hospital, Lilavati, Hinduja and Jupiter, have been taken off the list. In Delhi hospitals like Apollo, Fortis, Ganga Ram, Max or Medicity have also been scrapped for cashless settlement.

The decision of the four insurers to de-list some hospitals and not to allow cashless settlement created panic among a lot of customers.  Currently, TPAs have contracts with hospitals and are added as PPN on the insurance companies’ list.

However, public insurers have some issues with TPAs and are not happy with the manner in which claims are being processed and settled by them. This has resulted in the four insurers planning to start their own singular in-house process to handle cash settlements, according to the official from New India Assurance.

“We think there are multiple TPAs across various companies, which make the span of control wide for us. This also makes our task to focus and control difficult and we think we can do better than them,” he added.

According to the official, TPAs did not meet their expectations and were not able to bring down the treatment costs through negotiations with the hospitals. With their claims ratio around 115%, the four public sector insurers are exploring ways to minimise their claims outgo.

In the past, Moneylife had reported  (http://www.moneylife.in/article/8/5146.html) how TPAs tried to push discount offers based on the number of patients admitted to a hospital and a policy of ‘best-preferred’ hospitals. Both these TPA schemes have been rejected by medical professionals and organisations. According to the discount offer policy being pushed by TPAs, hospitals would get a 10% concession if they were to provide Rs10 lakh of business; the best-preferred hospitals scheme will see TPAs choosing 50 hospitals for working with them. However, doctors complained that TPAs delayed payments and their processing information were not feasible.

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COMMENTS

krish

7 years ago

VERY TRUE.

YET NOTHING WILL CHANGE.

THIS IS INDIA!

mkumar

7 years ago

UNION BANK OF INDIA OFFERS 'UNION HEALTH' POLICY TO IT S CUSTOMERS THROUGH A TIE-UP WITH PSU INS. CO.TPA IS SOMEBODY ELSE-CHANGED EACH YEAR!
TPA SENDS EAST INDIA'S HOSPITALS' LIST TO THOSE IN REST OF INDIA SINCE IT IS BASED AT KOLKATA.
WRITING TO UBI IS LIKE TALKING TO WALLS.
EVEN TO RENEW THE INSURANCE EACH YEAR, NO REMINDER COMES.WE HAVE TO CHASE THEM LIKE BUFFALOS!
WRITING TO CMD OF UBI PRODUCES NO RESULT. IT IS FORWARDED TO LOCAL BRANCHES WHO SHOW, AS AN INSULT TO INJURY, THEIR WRATH TO US FOR WRITING TO CMD (BIG SHOT, EH?!)!!!
THAT IS INDIAN SHTYLE OF INSURANCE NONSENSE!
IF WE HAVE TO CLAIM ANYTHING, WE DONT KNOW WHAT IS AWAITING US!

Manoja

7 years ago

Well, wasn't this the reason given by SEBI while abolishing the entry load?? That the AMCs and the IFAs are taking the common man for a costly ride by charging an obscene amount of money, 2.25% to be precise, as entry load??

And wasn't it SEBIs contention that fee charged directly by the IFA to the client will bring in transparency and also reduce the cost to the final consumer??

And did we not see a large number of messages congratulating SEBI for this stupendous decision???

Whatever logic SEBI gave out for the MFs holds good for the charges levied by the hospitals too.

Is there transperancy in their charges? Are they really conducting all the tests with the honest intention of helping the patients? Are they charging the patients the right amount of money? Are the patients aware of how and why and what they are getting charged with? Are their service standard on par all the times? Is there no case of negligence from the doctors??

So many questions... but suddenly the middle class India has started voicing their protest against this decision by the insurance companies. Why? Because it hurts their interests directly.

Have the insurance companies said that they will not honour their commitment of paying the cost of the medical treatment? No. All that they have said is they will REIMBURSE the cost of the hospital charges. Anything wrong with that??

Arun Prasad

7 years ago

Cashless insurance facility has been withdrawn by insurance companies for many patients seeking medical treatment in the bigger hospitals in India. Reason given is that the hospitals have been inflating the bills. Re-imbursement of bills would continue as if this will solve the problem of inflated bills. Why not target the culprit hospitals and doctors with inflated bills rather than deny patients the facility.

The inability to remove bad apples does not mean that you throw away the basket. Next we will hear that cars have been banned as road accidents lead to death !!

One would have believed the insurance companies had it not been for the following 2 riders.
Corporate policies i.e. if you are working in a big office that takes big insurance covers for employees, would continue to get cashless benefits. It is only the relatively poor middle and lower middle class individuals who have made the mistake of giving premiums for the last 10-15 years would be denied the facility and they should produce lakhs of rupees for treatment and then hope that they would get it back from insurance companies without the help of consumer courts. We all know the procedure of re-imbursements in India specially when it involves a national body.
Only the large hospitals that have a transparent billing system have been excluded from the cashless facility. The smaller medical providers would continue to give the cashless benefits. So are we to assume that here bill manipulations are not possible or is it that vested interests are more easily looked after there ? So in one stroke, hospitals providing advanced / tertiary care which are internationally accredited would only be accessible to the rich and privileged. And as the smaller centres do not provide sophisticated investigations and treatment, your insurance is only good for simple and 'cheaper' diseases.
Message from insurance companies to the common man is clear: You can go to a smaller centre for cashless facility, but we know that you cannot get joint replacements, heart surgeries done there so we win there. As for the internationally accredited hospitals and tertiary care hospitals, that is reserved for those with corporate policies. You please continue to pay your premiums which we shall use to provide cashless facilities to the more privileged citizens of this country. Of course you can produce a few lakhs at admission into the bigger hospitals and our helpful babus shall 'help' you get the money back.

Another interesting message here is that investigations are mostly unnecessary and we should rely on subjective feeling like the pulse rate etc. While patients ( and courts) would like maximum usage of available investigations and technology to give objective evidence based diagnosis before and during treatment. Consultations with other specialists too seem to be a 'waste' of money. It is a shame how profitability seems to be the main criterion when it comes to using public money for the public. We are not talking of charity or government subsidies here.

Sorry, friends, I dont know who you are trying to fool here. You would have got more support if you had started a campaign of black listing doctors/ nursing homes and hospitals that make fake bills.

This is all against public interest ( any one listening ?)

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