How to Make Health Insurance Healthy

A health care regulator on the lines of the Real Estate Regulatory Authority could standardise hospital pricing and treatment protocols, and reduce frauds

- TAMAL BANDYOPADHYAY

On July 16 last year, a private hospital at Patran in Patiala, Punjab, sought authorisation from a large health insurance company for cashless treatment of a patient admitted for dengue fever with thrombocytopenia, a condition that occurs when the platelet count in one's blood is too low. The amount involved was ₹1.28 lakh.

The third-party administrator (TPA)—an intermediary that helps insurance companies manage claims and policies on behalf of policyholders—confirmed the admission. The discharge was still pending due to the patient's illness.

A follow-up verification by the insurance company the next day let the cat out of the bag—the patient had never been admitted to the hospital!

Investigation exposed that the patient registration form was "signed" by his "deceased" father. The doctor treating him was not available for any consultation or verification; the hospital's resident medical officer (RMO) was unaware of the patient's admission; and the treating nurse never showed up for verification.

In another case, a 50-bed hospital in Hyderabad claimed ₹45,130 for treating a 34-year-old woman suffering from viral hyperpyrexia—severe fever with vomiting, cough and cold.

A tele-verification process revealed that the insured had actually undergone maternity-related treatment, which was not covered by her policy. The hospital fabricated medical documents to file the insurance claim.

In another instance, the hospital itself had ceased to exist before the claim was made! A cashless claim intimation was received from a hospital in Gorakhpur, Uttar Pradesh, under the "anywhere cashless" scheme for an insured patient. The hospital submitted pre-authorisation documents and other papers to support the claim.