New Delhi Did you think, if you have taken a mediclaim policy, you would be able to avail of cashless hospitalisation? Not really. Atleast, that is what Mr Jhunjhunwala realised when he went for a knee replacement surgery at Wockhardt Hospital. The total cost of the surgery was estimated to be around Rs 2 lakhs. But then to his utter shock, his third party administrator, TPA, sanctioned only Rs 80,000. This meant, he would have to cough up the balance amount himself and claim a reimbursement later.
Cashless hospitalization under mediclaim was introduced with an aim to enable policyholders to avail of medical facilities, without having to pay upfront and claim reimbursement later.
"We handle around 1,000 cases a day and around 10% of the Mediclaim policyholders receive a part sanction only. Apparently, a part sanction is quite common in the industry these days.
This depends on the policy terms and conditions. Many a times the TPA finds that the estimated cost mentioned by the doctor is exorbitant and the information of the break up of charges given therein is also not sufficient to sanction the entire amount.
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Such a practice of part sanctioning was introduced in the recent past, since the charges requested by nursing homes were arbitrarily high, many a times," said CEO, Paramount Healthcare Services, Dr Nayan Shah.
TPAs on receiving the request investigate to find out whether the amount mentioned in the request is ?reasonable? or ?exhorbitant? and investigations are done for the same.
Subject to various investigations TPAs many a times, sanction only part of the amount. And in such cases, the individual has to pay up the balance amount from his pocket and claim a reimbursement later.
Ask TPAs why this practise and most blame the hospitals.
Moneycontrol spoke to TPAs and they say, "We have observed that most of the hospitals hike up the bills when they know that the patient is insured. A bypass surgery at any of the leading hospitals in Mumbai would cost atleast Rs 2 laksh while an Angiography would be around 11/2 - 2 lakhs. Similarly a knee replacement would get you down by atleast 2 and a half lakhs, while an angiography would cost you Rs 50,000.
These could be lower in reasonably smaller hospitals." But if we sanction the entire amount at once, there is no control on the cost. And hence we sanction a part of the amount only. And we reimburse the balance in around 20 days time, after the bill is paid by the patient."
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But Krishna Chokhani, Insurance agent, New India Assurance chooses to differ. He says, "I receive atleast 5-6 cases in a month out of which in 2-3 instances, there is a part sanction from the TPA. He adds, "The balance amount is never reimbursed by the TPAs to the patient in 20 days. It usually takes over a month.
"Many a times the hospitals too are in favour of part sanction because they are able to get the money from the patient immediately, whereas the sanctioned money would take atleast a month. In most cases the reasons for a part sanction of the total amount by the TPA are, lack of clarity on break-up of charges given by the doctor and secondly, fear of misuse of funds by the hospital," he added.
Walder points out, "A part sanction is done in two instances. Firstly, when the TPAs find that the estimate of cost given by the hospital is way too high.
Secondly, when there are two parts to a medical treatment. For instance, in case of operations like the Angiography the TPA would sanction a part of the amount - let's say Rs 25,000 initially and subsequently depending on the findings of the report, the patient would need to go in for angioplasty. which would cost one to one and a half lakh. We cannot sanction the total amount in this case at once, since the hospital may take up the entire amount."
Explain officials at Wockhardt hospital, ?There are two types of part sanction. One is when the TPA agrees to sanction a part of the amount and the balance is to be borne by the Mediclaim policyholder, till such time that the final bill is produced by the hospital at the time of discharge of the patient. Once the final bill is produced the TPA in question pays up the balance amount to the hospital and the hospital in turn would pay it back to the patient. This happens in around 40% of the cases."
"The other type of part sanction is wherein the TPA sanctions only a part of the total estimated amount and the balance has to be paid by the policyholder. TPAs claim to reimburse the amount incurred in about 20 days."
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Says a senior official at Wockhardt, "It is a misconception that Mediclaim offers total cashless hospitalization. Individuals should be aware that it is a conditional cashless facility and several factors come into play. While many aspects are not put down in print there are many limitations on the kind of room you can opt for. Mediclaim policyholders cannot avail of a super deluxe room in the hospital. The limit is a single A/C room."
"Also many a times the hospital may not give a proper break-up of the various charges due to which the TPA sanctions a smaller amount. Get a clear break -up of the total cost before you approach the TPA. Also in case of follow-up do not expect the hospital authorities to do all your follow up. Take sufficient interest and try doing it yourself."
Officials at IRDA are clueless about how ?cashless hospitalization? has turned conditional cashless. Says a senior officer at IRDA, "In a situation where the TPA has sanctioned only part of the total estimated amount, it has to be brought to the notice of the insurance company and should be sorted out. Also the TPA and the hospital authorities have to negotiate and arrive at the right amount. But in no way, should the policyholder be made to pay up for all this."
"In the above case find out if there has been any previous claim in the same year and if it is subject to adequate sum assured. A TPA sanctions the amount on the basis of customary and reasonable charges. If the cost of a knee replacement in Mumbai is atleast Rs 1.75 lakh and the amount sanctioned by the TPA is only Rs 80,000 there is definitely cause for concern. Aggrieved policyholders should make it a point to bring up such instances."
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