Patients caught in crossfire between TPAs, doctors and insurance companies

A full-blown war between doctors and TPAs over fees and unpaid dues has left hospitalised patients stranded. Its time regulators stepped in

Policy-holders who have been admitted to Mumbai hospitals are trapped in the midst of a raging battle between city-based doctors and third-party administrators (TPAs), who facilitate medical insurance. This is due to doctors’ unhappiness with the low consultancy fees being allowed by a couple of TPAs for reimbursement under medical insurance plans.

Miffed over the outrageously low rates and unpaid dues from these TPAs, about 1,500 nursing homes and doctors under the banner of the Association of Medical Consultants (AMC), recently decided to boycott TPAs completely. This drastic measure meant that patients in hospitals covered by these TPAs could not avail of cashless facilities, putting them under severe difficulty.

KG Krishnamoorthy, chief operating officer, Future Generali India Insurance explains, “It appears that some of the TPAs have gone ahead and offered some rates to doctors. According to doctors, these rates are far lower than what they charge, which means that the TPAs have not reached an agreed rate. From the doctors’ side too, some of them keep on charging different rates depending upon the type of clients. This has been a practice in hospitals whenever a patient is admitted, whether he is insured or not and which type of room he takes.

Sometimes the rates the hospitals charge are unreasonable. The TPAs are trying to control the claimed cost. There are complaints from hospitals also that there is a huge backlog in the money TPAs are supposed to pay up.”

Apparently, the Insurance Regulatory and Development Authority (IRDA) sought to soothe frayed nerves in a hurriedly-called meeting between the doctors and TPAs. The doctors have given the concerned TPAs a month to clear pending dues and rework tariffs altogether.

Doctors and TPAs have been at loggerheads for a long time now; the crisis has only now reached boiling point. Lalit Kapoor, legal advisor of AMC reveals, “Consultants are facing a major problem, with the money owed to them not being given on time. As per the agreement, they are supposed to pay up within 30 days. But they don’t. They take at least two-three months to clear their dues. Sometimes, no payments are received.”

Putting the onus of payment delays on insurance companies, a senior official from e-Meditek, one of the boycotted TPAs said, “After receiving the files for payments, we process the claim. After processing we upload the details to the insurance companies and then the claims are paid by the insurance companies.

Most of the time, the payment from the insurance companies comes (in) late.”
He added, “We raise the bill on the insurance companies and from that the float is replenished to us, out of which we have to pay to the hospital. Usually it takes seven days from discharge. After receiving the file it doesn’t take more than seven days to settle the claim from our part. After that, most of the times, the insurance companies create the delays and then there is a lack of proper documentation which increases the delay.”

On the other hand, patients also face a lot of hassles in getting authorisation letters from the TPAs. Mr Kapoor alleged, “TPAs are supposed to give the authorisation within 24 hours. But this does not happen and patients are left fighting with the hospital officials.” He told Moneylife that the AMC has outlined fixed tariffs that they expect to be adhered to by the TPAs, failing which AMC could boycott its agreements with them.

The absence of regulation and government control in this area has only worsened the situation. KG Krishnamoorthy reveals, “There has been a request from insurance companies and TPAs to have some kind of standardisation on healthcare rates and even rating of hospitals. But no such rules have come in so far. We have requested the government and even tried to work with the regulator to put something in place. This is going on for the last six months but unless some intervention happens from the government (health ministry), the matter will go out of control. It is already outside the control of insurance companies.”

All this has even forced several insurance companies to do away with TPAs completely. “We have eliminated TPAs five years back to work efficiently and to lessen the turnaround time for the customers in cashless claims,” said Akshay Mehrotra, head of marketing, Bajaj Allianz.

It is now up to the IRDA to take a definite stand on the matter and put in place stringent regulations to check such unhealthy practices at hospitals and standardise tariff structures. Failure to do so will give sleepless nights to patients with cashless policies.

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    1 decade ago



    1 decade ago

    The TPA's really are not bothered about customers or customer service .They need to be thrown out . Try their helpline numbers and you get standard parrot like answers only .Cashless facility is indeed a mockery ALWAYS .End less queries one after the other is sought till the time a patient is discharged so as to DENY cashless facility . This is an art they have mastered at the cost of the premium paying customers .


    1 decade ago

    The root cause of all this is the 'lust' and 'greed' for money mainly amongst Doctors. They descriminate patients who are insured and not insured, charging exhorbitant rates from those insured. Obviously, Insurance Companies are not going to watch it silently, being looted outright by these doctors. Hospitals do not charge differently whether you are insured or not. The room rates, medicine costs, etc remain standard. The doctors begin their loot the moment patient arrives in their clinic. Infact because of the insured patients, uninsured too now have to cough up more. Doctors started charging more for consulting, then even if no surgery or hospitalisation may not be required, they will scare the patient and relatives and make them go through expensive procedures, tests, surgeries, etc. This is typical in 'heart' cases where the doctor will first ask to hospitalise, then next step is to carry out 'angiography', then scare the relatives for major blockages and get 'angioplasty' or 'bypass' done, even if in most cases it may not be necessary.

    Doctors should earn but not loot. Then only this problem will end.

    nitin patel

    1 decade ago

    it is high time the legal fraternity came in large no t fight the case for customers. the tpa's insurance companies and the doctors are all takinf the patient for a ride

    ICICIdirect’s I-Saver brokerage plan irks customers

    Calculation of brokerage by ICICIdirect at the end of the quarter has made customers an angry lot

    ICICIdirect’s refund of excess brokerage remitted at the end of the quarter under its I-Saver plan is not going down well with its customers. ICICIdirect recently launched its two new brokerage plans—I-Secure (flat brokerage at 0.55% of total turnover) and I-Saver (slab-wise brokerage based on transaction volume/turnover).

    Under the I-Saver plan, ICICIdirect charges 0.75% of the total traded volume (applicable for turnover of less than Rs10 lakh in a quarter) or a minimum of 0.25% (on turnover of more than Rs5 crore), whichever is higher.

    The charges vary depending on the range of traded volumes. For instance, in the range of Rs10 lakh-Rs25 lakh, brokerage will be 0.70%; for Rs25 lakh-Rs50 lakh (0.55%); Rs50 lakh-Rs1 crore (0.45%); Rs1 crore-Rs2 crore (0.35%) and Rs2 crore-Rs5 crore (0.30%).

    If an investor opts for a slab-wise plan, the entity charges the highest brokerage slab of 0.75% irrespective of the transaction volume (single or multiple) in a single day and recalculates the correct brokerage only at the end of the quarter.

    “It is hard to believe that with financial systems around the globe becoming more and more automated and up-to-date, ICICI Securities is not able to pick up the right brokerage slab and calculate correct brokerage amount on the orders that were successfully executed earlier during the same day,” said Gyanesh Gupta, a customer of ICICIdirect. 

    “If any extra brokerage is charged and if it comes under that slab, it is credited in the customer’s account in the form of incentive in the next quarter,” said an ICICIdirect official.

    Moreover, existing customers of ICICIdirect were made to switch to the I-Saver plan and there was no way they could change the plan unless they informed the company.

    “I got an email from the company saying that my trading scheme had shifted to I-Saver and I had to use that plan for a quarter,” said an ICICIdirect customer, preferring anonymity.

    Mr Gupta also pointed out that although ICICIdirect runs a user-friendly website, its brokerage charges are among the highest compared to other brokerage houses. He has raised this issue with ICICI Securities since the last two months, but officials have been giving him a standard excuse of ‘system limitations’. Investors are made to wait until the end of a quarter to get the refund of excess brokerage that they have been charged previously.

    “Whenever you do a transaction, the brokerage is debited on a daily basis which is valid for one quarter. The brokerage charges are charged on the total traded value (buy and sell),” added the official.

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    niraj mittal

    10 years ago

    ICICI bank is charging too much brokerage charges on every purchase. they are showing 0.55% but they are charging 2.75% .. This is total dhokha with customers . You cannot earn any profit on selling of your equity shares , all profit they are eating nicely. On 1000 rs puchasing they are charging 27 rs . They are fake , beware of this bank . Please close ur account immediately . go to SBI or other bank.


    1 decade ago

    Chuck the provider if it cannot provide the services at the cost and level that is not up to the expectation. There are lot of providers with far less cost and greater service. Transfer your shares to the new demat accounts and it is easy. Investors must ring it in loud and clear.


    1 decade ago

    the brokerage plan can be changed only towards the end of a quarter and that too by calling up the call center - online option does not work in quarter end and once into the next quarter, it is too late to change!!

    Short rally to continue

    Strong Asian markets and positive global cues helped the Indian bourses to stay positive

    Indian markets gained momentum during the day on the back of strong Asian markets and positive global cues. At the end of the day, the Sensex shot up 188 points from the previous day’s close to 16,227 while the Nifty closed at 4,856, up 54 points. Tomorrow, we expect Indian markets to continue to remain in positive territory.

    At 12:00 hrs IST, the Sensex was trading at 16,064, up 25 points from the previous day’s close. However, at 14:00 hrs IST, the Sensex was trading up 128 points from the previous day’s close at 16,167.

    At the end of the day, FCS Software Solutions gained 2%, after the company fixed 2 March 2010 as the record date for a liberal 1:1 bonus issue.

    Hindalco Industries rose 3% after the company reportedly said that it hopes to complete raising Rs4,900 crore of debt in the next two weeks to achieve financial closure for Utkal Alumina Refinery, a 15 lakh tonne per annum project in Orissa.

    Maruti Suzuki India rose 2% on reports that the company expects a 20% growth in sales and hopes to double its exports to around 1.6 lakh units this fiscal ending March 2010.

    Spanco Ltd has been awarded the Rajasthan State Data Centre (SDC) project by the government of Rajasthan. The stock declined 1%.

    Bharti Airtel fell 5% on concerns that the company’s $10.7-billion offer for Kuwait-based Zain’s African assets could strain its finances.

    Tata Power and Korea East West Power have signed a memorandum of understanding to identify and execute operations & maintenance opportunities relating to third-party generation assets in Asia, the Middle East and Africa. The stock remained flat.

    Shri Lakshmi Cotsyn Ltd has announced that its wholly-owned subsidiary, Shri Lakshmi Defence Solutions Ltd, has entered into an agreement with Ukrinmash, a state foreign trade and investment firm of Ukraine, for the supply of 100 armoured vehicles to the UN mission. The subsidiary company has also entered into an agreement with Adcom Military Industries, Abu Dhabi, for marketing of the company’s armoured vehicles in the Middle East and Africa. The stock was down 1%.

    REpower Systems AG and EOLE-RES SA, one of the leading French wind and solar developers based in Avignon, have signed an agreement for the supply of 26 wind turbines. Suzlon Energy holds 90.71% stake in REpower. The stock was up 2%.

    L&T and Raytheon Company have teamed up in an L&T-led proposal to upgrade the Indian Army’s T-72 tanks. The stock was up 1%.

    As per reports, Pronab Sen, the government’s chief statistician, has said that the wholesale price inflation could cross 10% by end-March 2010, depending on how food prices behave in the next two weeks.

    Meanwhile, the government amended rules for foreign currency convertible bonds (FCCBs) to allow issuers to revise their conversion price, a move aimed at reducing price uncertainty in a volatile equity market. The change would give issuers a window of six months to adjust the conversion price of their bonds to the higher of either the two weeks’ average or the six months’ average of the issuing company’s stock. The decision unveiled by the finance ministry applies to companies that issued FCCBs before 27 November 2008.

    Ashok Chawla, finance secretary, said that the government has resolved the issues related to 3G wireless spectrum auction, but it is not sure if it would happen before the end of the current fiscal year ending 31 March 2010.

    During the day, Asia’s key benchmark indices in Japan, Indonesia and South Korea rose between 0.21%-1.08%. Most other Asian markets were closed for the second day in a row for the Lunar New Year holidays. Yesterday, US markets were closed for the Presidents' Day holiday.

    As per media reports, euro-zone states urged Greece on Monday to announce more deficit-control steps by mid-March if needed, but said nothing new on last week’s pledge to defend the country if debt market pressures spin out of control.

    At talks among finance ministers, Greece has reportedly asked the euro-zone to bear with its fiscal plans as announced, and warned that last week’s offer of support by European Union leaders may not be enough to stem a debt market squeeze on governments in the region.

    In premarket trading, the Dow was trading 32 points higher.

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