Don’t fret if you meet in an accident as your public sector insurance company will still give you the desired cashless facility

People who had bought insurance cover from public sector health insurance companies can now use the cashless method for settling their claims. These policyholders will get cashless treatment in case of accidents or emergency in all hospitals, including those de-listed by the public sector insurance companies, according to an official.

“People who had an accident and those who are in need of any emergency hospitalisation would be allowed to take the cashless route for settlement of claims. We will also not restrict them (the insured) to the new preferred provider network (PPN) list of hospitals” an official from New India Assurance Company said.

The news that cashless insurance claims coming from accidents and emergency treatment would be accepted should provide a certain amount of relief to customers. Emergency hospitalisation here means any urgent need of medical treatment, which would lead to the patient going to the Intensive Care Unit (ICU).

According to an official from Meditek, a third party administrator (TPA) company, out of the total cashless claims from public sector insurance firms last year, only 10% came from accidents or ICU treatment while the remaining 90% came from planned admission. This may be another reason as to why the insurance company would prefer letting accident or emergency treatment be given cashless settlement as compared to planned admissions.

Earlier, public health insurance companies, which include Oriental Insurance Co, National Insurance Co, United India Insurance and New India Assurance Co, had decided to de-list some hospitals from their PPN claiming that these de-listed hospitals were making false claims and over-charging their customers. The public health insurance firms have nearly 80% of the total market share in this segment. These companies together collect premiums worth Rs900 crore but had to shell out Rs1,200 crore every year, making a loss of Rs300 crore annually.

Public health insurance companies have drastically cut down the list of hospitals in Mumbai, Delhi, Chennai and Bangalore. In Mumbai, top hospitals like Cumbala Hill Hospital, Breach Candy, Bhatia Hospital, Lilavati, Hinduja and Jupiter, have been taken off the list. In Delhi hospitals like Apollo, Fortis, Ganga Ram, Max or Medicity have also been scrapped for cashless settlement.

The decision of the four insurers to de-list some hospitals and not to allow cashless settlement created panic among a lot of customers.  Currently, TPAs have contracts with hospitals and are added as PPN on the insurance companies’ list.

However, public insurers have some issues with TPAs and are not happy with the manner in which claims are being processed and settled by them. This has resulted in the four insurers planning to start their own singular in-house process to handle cash settlements, according to the official from New India Assurance.

“We think there are multiple TPAs across various companies, which make the span of control wide for us. This also makes our task to focus and control difficult and we think we can do better than them,” he added.

According to the official, TPAs did not meet their expectations and were not able to bring down the treatment costs through negotiations with the hospitals. With their claims ratio around 115%, the four public sector insurers are exploring ways to minimise their claims outgo.

In the past, Moneylife had reported (http://www.moneylife.in/article/8/5146.html) how TPAs tried to push discount offers based on the number of patients admitted to a hospital and a policy of ‘best-preferred’ hospitals. Both these TPA schemes have been rejected by medical professionals and organisations. According to the discount offer policy being pushed by TPAs, hospitals would get a 10% concession if they were to provide Rs10 lakh of business; the best-preferred hospitals scheme will see TPAs choosing 50 hospitals for working with them. However, doctors complained that TPAs delayed payments and their processing information were not feasible. — Aaron Rodrigues