How hospitals, insurers are cashing in on cashless cover

Mumbai-based septuagenarian PN Ojha was seeking treatment at the Asian Heart Institute. But as soon as he told them he had an insurance cover to get cashless treatment, he started getting disappointing responses.

“We told them our details and the lady there said, ‘Sir, but we don’t offer cashless facility to individuals for Raksha TPA’,” recalled Ojha. TPAs, or third party administrators, manage health insurance claims for insurance companies.

This was not a one-off. “My son was to be taken to Lilavati; there, we were told they cannot service clients for a Pune TPA called MD India,” he said, adding this was specific to individual patients. They accepted corporate clients.

What annoys Ojha is that you cannot choose your TPA. “There is no facility to change the TPA if your hospital is not servicing the clients,” he said.

Then, DNA checked with experts on why hospitals were denying treatment to patients serviced by certain TPAs. “Usually this is a temporary thing, when, say, the amount pending to be cleared by a TPA exceeds a limit set by each hospital. So until that outstanding amount comes down, the TPA is banned by the hospital,” said Rahul Aggarwal, who heads Optima Insurance Brokers.

While this is one way, other hospitals have been using other means to make sure insurers are kept on their toes. “Hospitals have started taking deposits from those who want a cashless treatment,” a doctor told DNA.

But how will taking deposits help? “When the customers’ money is stuck, they will follow up with the insurance company to free their money. It is a way to solve the problem,” says the cardiologist on the condition of anonymity.

To check if this indeed was the case, DNA visited hospitals in Mumbai and Navi Mumbai. The accounts counter of these hospitals — Lakshadweep Hospital, MGM and Bombay Hospital — where the bills are to be settled displayed a list of TPAs and the deposit that the customer has to pay to avail the cashless facility. This ranges between 20-25% in most cases.

When asked at the counter as to how long has this been on, the attendant replied, “Bahut dinno se hain... (This has been on for a while now).” What is worse, this deposit is not returned in full even after the claim is settled, citing ‘handling charges’.

But insurers that DNA checked with said, they had not heard of such a thing. Customers are still suffering the brunt of non-payments and the difference in the rates of deposits is evidence that the problem is on the payments front and the risk that hospitals associate with the TPA.

Some of the major hospitals denied demanding a “deposit,” specifically for patients with health insurance. “No such questions are asked to the patient, at the time of admission,” said a senior doctor at Hinduja Hospital.

However, the fact remains that a “deposit” is de rigeur in most hospitals as well as nursing homes, large and small, across the city.