Does Insurance Helpdesk Help?

Insurance patients come to hospital completely unaware about their insurance benefits and restrictions.

- Anuj Jindal

Hospitals want insurance patients. That is why they invest years of effort to gain empanelment with insurers or third party administrators (TPA). They complain when an insurer doesn't empanel them. Hospitals are also willing to block their working capital and receive payments for cashless after a month or so. Such is the hunger for insurance or TPA business. So what happens when finally such a prized business comes to the hospital?

Current cashless process 

At the time of admission, patient or their representative is asked to make a choice for the treatment package and room category. Once the selection is made, they sign on a pre-authorisation form to be sent to insurance company for approval. The patient is assigned a bed, and depending on complexity of case, it may take 2-24 hours to get pre-auth approval. Patient takes the treatment and on the day of discharge, all medical records are sent to insurance company for final approval. Mostly the claim gets approved for a certain amount, but in a few cases, the cashless claim gets rejected. The IRDAI (Insurance Regulatory and Development Authority of India) data suggests one in 15 cashless claims is rejected. Even in case of approved claims, patients may end up paying substantial amounts out of-pocket because of several reasons, some of which are – 

Copayment clause 

Chosen room category is more expensive than the one allowed as per insurance policy 

Treatment-specific capping 

Sum insured limit exhausted

Patient experience