GIC and Association of TPAs do not know the exact number of hospitals offering cashless mediclaim. With hospitals in Pune, Pimpri and Chinchwad stopping cashless mediclaim due to unacceptable government insurer package rates, retail consumers will suffer at the cost of corporate insurance
On 20 November 2014, the Bombay High Court (HC) had directed the General Insurance Council (GIC) as well as the Association of Third Party Administrators (ATPA) to place on record the particulars about the number of hospitals/nursing homes/clinics which have accepted the cashless mediclaim insurance policy. But, at the 16 December 2014 hearing of a PIL filed by social activist Gaurang Damani, GIC as well as ATPA were not in a position to indicate the exact number of hospitals/ nursing homes/clinics which have accepted the cashless mediclaim insurance policy, because there is an overlap in many cases, of hospitals offering cashless for different insurance companies.
The HC noted that it would be worthwhile to have one agency preparing the list of hospitals/nursing homes/clinics which have accepted the cashless mediclaim insurance policy and which could give an unique identification number to each hospital/nursing home/clinic so that all relevant information pertaining to that hospital/nursing home/clinic can be collated. The petitioner (Mr Damani) stated that the Insurance Information Bureau (IIB) is an agency set up by Insurance Regulatory and Development Authority (IRDA) and, therefore, such information should be available through the IIB. IIB shall respond to the above suggestion in due course.
But, the important point is that just the count of preferred provider network (PPN) hospitals is not the only parameter. PPN is a network of providers who agree to negotiated rates on 42 or more specified procedures. For example, government insurer New India Assurance has 165 hospitals versus private player ICICI Lombard has 94 hospitals offering cashless hospitalisation in Mumbai. The key point is that ICICI Lombard PPN has tertiary care in major Mumbai hospitals like Lilavati hospital, P D Hinduja National hospital, Breach Candy hospital, Kokilaben Dhirubhai Ambani hospital, Asian Heart Institute and so on. These hospitals are missing from the government insurer PPN, which has a lot of eye hospitals and smaller nursing homes.
Effective 1 December 2014, private hospitals in Pune and Pimpri Chinchwad have discontinued cashless treatment facility to individual policy holders of government insurance companies. However, big hospitals will continue offering cashless facility to corporate policyholders. This is in-line with government insurers who stopped cashless in July 2010 for retail policyholders in metros Mumbai, Delhi and so on, but continued it for group insurance customers. It shows that insurers give better facilities to group insurance than to individual policyholders. Retail policyholders are made to suffer with the ongoing differences between the insurance companies and the hospitals over the rates for standard procedures.
Government insurers have restricted cashless facility to Mumbai, Delhi and other metro hospitals in PPN. With private hospitals in Pune not accepting the rates offered to different hospitals for standard procedures, the insurance consumers will have to suffer. The hospitals feel that the offered rates are too low. Moreover, private hospitals with strength of less than 50 beds will not extend cashless facility to all types of policy holders.
In the next part, we will argue the reasons as to why IRDA should repeal Sec 12(b)(i) of the health insurance guidelines, which gives TPAs the leeway to recommend to the insurer whether payment should be made towards a claim settlement.