Cashless Medical Claims Dispute between Hospitals and Insurance Companies

There was this furor over the withdrawal of cashless settlements, in case of Medical insurance policies by PSU insurers. Newspaper & Magazine headlines screamed sensationally - “take cash with you, even if you are cashless”.

The root problem has been around for long. Only that, it has now boiled over. Medical Insurance is an area where insurers have been making losses. Overcharging by hospitals and doctors & various frauds, has been prevalent, in those cases who have medical insurance.

Finally, PSU insurers pulled the plug and withdrew cashless settlement in all, but a selected list of Preferred Provider Network (PPN). This was met with howls of protest. FICCI came out strongly that the insurers cannot unilaterally withdraw something they have promised to their policyholders. Hospitals understandably protested. Policy holders got worried about this sudden turn of events.
Many policy holders were serenaded with offers from private insurers, who made a virtue of the fact that Cashless settlement are still available through them, across the board.

I have been poured with queries from people who want to know if they should go to private insurers, due to the cashless option being available across the board, in their case. I have been counseling them not to take hasty decisions, as

1) What has happened with PSU insurers can happen with private insurers as well, because the overbilling problem is faced by both
2) PSU insurers may soon negotiate with all major hospitals and bring them back on board – it’s just a matter of time.

PSU insurer’s premiums have generally tended to be lower and that is in the interest of the policyholder.

Policyholders have traditionally turned a blind eye to charges, as long as they could be covered by the policy. This is a serious mistake ethically and even in their interest. If there is overcharging, the balance amount in the Sum Assured available for claims in the year, reduces; also, premium can go up more due to the higher claims. It is in the interest of the policy holders to look out for padding in the charges.

We all have access to someone in the medical field. We can ask around and find out, how much a particular procedure could cost. One would at least get a ballpark figure, that way. Ideally, if it is not an emergency, find out in advance what the hospitals and doctors would charge for the particular treatment. If you have done this exercise properly, you could save a packet. Knowledge is power. The charges can be brought down, using these as bargaining chips. I know people who have done it.

Another odious practice is the principle of charging everything based on the class of room, one is admitted in. For instance, a person from general ward is charged less for the same procedure by the same doctor, in the same operation theater, with the same facilities as compared to another from a deluxe room. There is no logic here – it is just that those in deluxe room can afford to pay more. This is the system that has gained root and has been followed without questions. This is a matter the health ministry needs to address. Loot the rich (or relatively better off), seems to be the motto... Our government does that too - for paying taxes, you don’t get anything in return, except for the “possibility” of good governance, which is marked by its absence. For now, if you want to pay less choose the lower level room or general ward.

Insurance companies need to address it by negotiating with various hospitals, which they will, as it is a matter of survival. It is ironical that insurance companies are overcharged by hospitals, when they give them so much business. If anything, they should be given volume discounts. There is a saying which goes – the child that cries will get the milk. The insurance companies have only now started… hospitals & doctors will have to fall in line… or lose business to others who are sensible enough to see reason.

Feel free to drop in with your queries.

Regards
Team
Theequitymarkets

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Regards
Team
www.theequitymarkets.com