Kolkata: Hospitals are turning up the heat on insurers ahead of the Monday meeting where the West Bengal Clinical Establishment Regulatory Commission has summoned 11 health insurance companies. Sources in the health panel said the meeting aims to find out why complaints like cashless refusal and delays in claim approval are occurring and seeks to arrive at a solution.
Hospital administrators pointed out glaring gaps between patients' expectations from their health policy and what they receive at the actual time of need.
"For example, there is always a gap between billed amounts and reimbursed sums — with families routinely receiving only 80%-85% of the coverage. It is crucial that all stakeholders come together to build a system that is transparent, efficient and empathetic to the patient," said Woodlands Hospital MD & CEO Rupak Barua.
Hospital sources said the most aggrieved are individual policyholders, who constitute about 20% of all insured patients. "In a few cases, the reasons for cashless denial could really be flimsy, which makes it difficult for us as well as the patients. The most aggrieved are those with individual insurance, especially if their policy is with private insurers," said Peerless Hospital CEO Sudipta Mitra.
"We have also observed situations where, despite the declaration of past illnesses, any minor variation in the patient's current symptoms or clinical history at the time of admission leads to a refusal from the insurer," said Richa Debgupta, chief of strategy and operations at Fortis Hospital Anandapur.
"There are cases where claims are refused if the insurer perceives that the policyholder did not disclose a pre-existing ailment. We often have to write to the insurer giving reasons so that the case is reconsidered. Despite that, only about 50% of cases get reconsidered," said Ruby General Hospitals GM (operations) Subhasish Datta.
Hospitals also said patients are often forced to wait four to six hours post discharge for claim approvals. "The patient ultimately suffers," said Debgupta. There have even been complaints with the health commission about some hospitals charging patients for this waiting period.
On the other hand, an official of a leading TPA said there are instances where hospitals put up excessive bills in case of cashless claims. " Sometimes hospitals conduct unnecessary tests. So, we have to question such inclusions," he added.
Insurance firms also blame hospitals for delay in claim procedures. "Despite IRDA advice of cashless settlement within 3 hours, patients sometimes have to wait for 6-7 hours as hospitals take 4-5 hours to send documents during discharge," said an official of a PSU insurance company.