CASHLESS INSURANCE? - Carry cash when going to hospital next



Have a health insurance policy from a stateowned insurer? The next time you make a claim, re- member to carry some cash even if you have a cashless policy, es- pecially if you are visiting a big private sector hospital.
Four state-run insurers have withdrawn cashless facility from many private sector hospitals in- cluding big names such as Apol- lo Hospitals, Max hospitals, Bat- ra Hospitals and Escorts. This was first reported by The Times of India. The reason, according to the insurance companies, is the twin rate card that some hospi- tals run. They charge patients carrying an insurance cover higher for the same procedure than others who may not have an insurance policy. Says N.K.
Singh, general manager, Orien- tal Insurance Co. Ltd: “Current- ly, two rates are being quoted by the hospitals. For patients having insurance, a slightly escalated rate is charged. To sustain these escalated claims, we would have to increase our premiums. Also, this is not good for policyholders as he also loses out by way of a decreased sum insured for that year.“

With claims as high as 130-140% of premiums, the com- panies have been working on a solution for some time. Now, Oriental Insurance, New India Assurance Co. Ltd, National In- surance Co. Ltd and United In- dia Insurance Co. Ltd have formed a preferred provider net- work (PPN) of hospitals that have agreed to charge within a certain price band. The PPN hos- pitals will continue to enjoy the cashless facility, but those out- side, and this is where you need to begin worrying, will not. The big hospitals mentioned earlier are out of PPN for now as negoti- ations are still going on and that is where most of the urban mass affluent go with their ills and ail- ments. You will have to resort to the earlier practice of paying up at the hospital and then claiming reimbursement.

Considering that 60% of the health insurance business is still handled by state-run insurers, there is a huge chance that you will be affected by this change in rules. In order to bring some standardization in the way hos- pitals charge, state-run insurers have entered into pricing agree- ments with empanelled hospi- tals. Adds Singh: “We have spo- ken to our empanelled hospitals and have agreed on a fixed rate for 42 major medical procedures.
The rates have been agreed upon depending on the hospital cate- gory, which is decided by the lo- cation, number of beds and facil- ities offered. All the hospitals that have agreed to this rate come under PPN and we will continue to offer cashless facility to them.“

Since the big names are con- spicuous by their absence in this list of PPN and they account for 80% of the claims, a crisis is brewing in the industry and you are going to pay the price.

For those of you who prefer to go to one of these hospitals but have a health policy with a state- run insurer, the claim procedure may not be as smooth as it used to be. You will now have to be an active interface between the two parties and get your medical ex- penses reimbursed. Here's a quick guide to what you would need to do in such a situation.
Reimbursement process Typically, a health insurance policy reimburses expenses in- curred during, before and after hospitalization. When you need to make a claim through the re- imbursement mode, you need to file all the original documents with your third-party adminis- trator (TPA), the intermediary who settles the claim between the hospital and the insurer.

These documents include dis- charge summary report, investi- gative report, scans, bills and receipts. In order to file the claim, you need to inform your insurer within seven days from the day of discharge and file the claim within the next 30 days.

Says Deepak Mendiratta, managing director, Health and Insurance Integrated, a health insurance consulting organiza- tion: “For planned medical pro- cedures, insurers may also want you to intimate them 24 to 48 hours before you get admitted.
However, after about a month your insurer may refuse to settle your claim unless you have a strong reason for delaying the claim filing procedure.“

The TPA gets your documents validated. On the non-medical side, your credentials are checked and on the medical side, TPAs look out for any policy exclusions or pre-existing diseas- es. Normally, this process takes about a month after which you get a cheque.

Remember that this process can get terribly delayed if the TPA finds any disparity and rais- es a query. The disparity could arise on account of non-submis- sion of original documents or in- complete documents, claim on account of a pre-existing disease or a policy exclusion (the list of ailments that are not eligible for the cover as per your policy doc- uments). The onus of filing the claim rests on you and, there- fore, you need to ensure that you have all the documents in place. However adds M. Ramadoss, chairman and managing direc- tor, New India Assurance, “Of the total claims paid, only 35-40% are cashless currently.
We have begun sending out our new list of PPN to policyholders.
However in case of an emergen- cy and in case the policyholder has not received the PPN list, cashless treatment can be agreed upon.“ Cashless process If your hospital comes under PPN, you will still be able to avail the cashless facility. Though standardizing rates are still being worked out, that may not affect your claim process because you are not supposed to spend a sin- gle rupee on your own. In the hospital, you have to show your TPA card and fill the authoriza- tion form. The hospital then takes it up with the TPA. The TPA will check the documents and approve or reject the author- ization. In the meantime, you will be admitted to the hospital and your treatment will begin. If the TPA rejects the authoriza- tion, you will have to foot the bill and then follow up with the TPA.
On approval, your treatment is cashless.

At present, private insurers are not a part of the PPN system.
Says Neeraj Basur, director, fi- nance Max Bupa Health Insur- ance Co. Ltd: “We don't have TPAs and we directly engage with the hospitals. This helps us to know their pricing and there- fore we can assess if they are charging more from policy- holders.“ Mint Money take In case you have a claim com- ing up in the near future and have a policy from state-owned insurers, choose your hospital carefully or organize cash before you check in.

source;livemint