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When 59- year- old Uma Khetan underwent a gall bladder surgery in August, her family wasn't unduly worried about the expenses — she had a ₹ 2- lakh cashless health insurance policy, in addition to ₹ 50,000 accumulated as no- claim bonus through two years. The policy was from New India Assurance. Yet, she had to pay the greatest part of the expenses from her own pocket. Though the final bill was ₹ 1.3 lakh, the approved amount was only ₹ 60,000. Khetan was prepared for a marginally higher bill, as she had opted for a single room, while her policy allowed only a shared room. But the huge bill took her by surprise. From the beginning, it was clear only 80- 85 per cent of the cost will be paid. What I didn't realise was the cost of all services such as the doctor's visiting fees, the surgeon's fees, tests, etc, were linked to the room category. This led to the final bill being inflated. Today, most insurance companies, have caps or limits for room rent. You must be aware of this when you buy the policy because all subsequent charges are linked to the cap. This is something you can't negotiate later. So, even if you have a cashless policy, it might not be entirely cashless. You would have to pay a deposit to the hospital before being admitted. After this, the hospital would verify the sum assured and the limit for room rent and each ailment with the insurance company or the third- party administrator (TPA) concerned. Only after the hospital receives this information would the patient be admitted. The policyholder's deposit is used to pay for items the policy wouldn't cover. Also, if the final bill exceeds the amount approved, the hospital reduces the balance from the deposit. Earlier, many complained patients with health insurance policies were charged higher rates by hospitals. This led to disputes between the insurance company and the policyholder while the claim was being reimbursed, with the company questioning the high charges. But in the case of cashless policies, as a patient is admitted only after the amount is approved, it is possible for companies to fix the limit beforehand, says Gandhi. Today, insurance companies bargain with hospitals to offer better packages to their customers, says Vivek Desai of HOSMAC, a healthcare management consultancy. This is possible because insurance companies promise huge volumes in return for lower rates. In the long run, it is good for consumers. For a hospital, this is attractive because usually about 30 per cent of the patients could have serious complications for which treatment costs might exceed the cost of the package previously negotiated and entered into. Big hospital chains apart, smaller hospitals, too, are signing such agreements with insurance companies. For their customers, insurance companies are able to negotiate and secure discounts of at least 10 per cent. For instance, in the case of an appendicitis surgery, if the rack rate is about ₹ 30,000, a patient with a cashless package could be charged ₹ 25,000. In some cases, even if a policy does not cover out- patient- department charges, a company might recommend ahospital for treatments that don't require hospitalisation, provided they are offered a good deal. This is a valueadd for customers; for the hospital, it means an assured number of patients. For customers, a lower amount under the package means a lower claim and, therefore, alower premium during policy renewal. While the direct beneficiary is the insurance company, the indirect beneficiary is the patient But there is a catch. It is possible not all hospitals under the rates, says Sanjay Dutt, ICICI Lombard General Insurance. There are agreed rates between the hospital and the company. But these are available only for cashless treatment, not for reimbursement. Even then, it may not be available in all networked hospitals. It would be offered by hospitals that have more traffic because the number of claims would be higher. Discounts could be five- 20 per cent and would vary from hospital to hospital. Sometimes, the rate could vary depending on which TPA is handling the claim, says Gandhi of Emkay Insurance Brokers. " The negotiating power of the TPA also comes into the picture because some of them have large networks and, therefore, can negotiate better. The TPA is also crucial to how quickly your approval or final bill settlement comes through. It depends on the systems used by the TPA. With more and more companies switching to in- house claims processing and settlement, there are fewer cases of delayed claim settlements. Even public sector health insurance companies have set up a joint inhouse TPA for claim settlements. But despite all these benefits, there could be cases in which the patient is overcharged or charged for aprocedure that wasn't necessary. For instance, some of Khetan's expenditure was unanticipated— there were two co- surgeons for the surgery, while the insurer approved only one. My family or I were not consulted. But frankly, we would never have gone against the decision of the surgeon, since we, as patients, feel doctors know best. However, all network hospitals might not offer this and you have to pay more if you exceed the cap on room rent | ||
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Invest in Tax Saving Mutual Funds ( ELSS Mutual Funds ) to upto Rs 1 lakh and Save tax under Section 80C.
Invest Tax Saving Mutual Funds Online
Tax Saving Mutual Funds Online
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