In its most recent budget in February 2018, the Indian government attempted to create an ambitious health insurance plan for almost half of the Indian population. Known as Ayushman Bharat, the effort underlines the importance of having health insurance for every individual. Tune into any business channel on TV and you will see financial experts espousing the cause of the having health insurance as a part of financial planning. Theoretically speaking, even though having a health insurance is advantageous, no one really talks about its implementation from the perspective of a patient In this post, I attempt to bridge the gap by talking about my learnings after dealing with health insurance several times during the course of my chronic pain illness. Specifically, I discuss the factors one should keep in mind while purchasing health insurance and also how to deal with hospitalization and claim processing.
Purchasing health insurance
Instead of looking at the features that are offered by the health insurance, – coverage of alternative therapies, diagnostic tests and availability of wellness related discounts, consider looking for the insurance with a branch office to which you can commute easily. When it comes to claim processing, chances are that you will become commuting is several times back-and-forth from your home to the branch office. Often, this may happen immediately after discharge from hospital while you’re still recovering and therefore, it is imperative that you don’t end up losing your claim because of the inability to commute. Moreover, in my experience, the so-called wellness discounts look to be mere marketing gimmicks. One of the insurance companies that I had got my friends insurance from sent him a lot of coupons for services at wellness organizations. However, none of them was honoured by the merchants. The customer service of the insurance company insisted that they would work. The merchants said that they would not honour them. After several emails and phone calls back-and-forth, my friend ultimately threw in the towel and coughed up the charges at normal rates.
Go over your medical history carefully. Mention all the medical conditions that you have had earlier. Make sure that you give a precise summary of your past medical conditions. For example, if you have had a minor surgery of anal fissure, do not specify it as an anorectal disorder. If you ever developed any other anorectal condition like an anal fistula, your claim will be treated as pre-existing medical condition
Notify insurance in advance: If you’re having a planned procedure, check with your insurance first to see how much they would reimburse. Also, check if there is cashless claim facility for your insurance available at the hospital. If the admission to the hospital happens unexpectedly, do let the insurance know about it at the first possible opportunity. Even if there is no clear diagnosis, you can just let them know that the patient has been admitted to the hospital.
Preserve hospital documentation Carry a folder, a pen and a stack of paperclips to organize all the prescriptions and pharmacy receipts. Insist on a receipt for every financial transaction, however small it may seem. For example, you may be asked to purchase a single tablet and the pharmacy may be unwilling to give you a receipt for it. Try to get it nevertheless. The issue here is that the single tablet may be very important to the treatment and can help in convincing the insurance that you were really sick. For example, in my case, they kept on saying that there was no need of hospital admission for me as the medications prescribed to me could have been taken at home also. It was only after I showed them pharmacy receipts for purchase of intravenous injection that they were convinced that I did need a hospital admission.
Ensure that the duration of hospital stay is more than 24 hours At the time of discharge , be cognizant of the fact that in most cases, the difference between the admission and discharge time has to be more than 24 hours for it to be eligible for reimbursement by insurance. Sometimes, a formal admission receipt may be generated hours after the patient has been admitted. This may lead to a case where the duration of admission in the hospital documentation may be much less than the actual duration. For example, in one of my hospital stays, the timestamp on the discharge receipt was 10:30 AM while the timestamp on the admission document was 11 AM of the previous day. The reality was that I was at the hospital at 9 AM but got the admission formalities done only at 11 AM because I was doing a litany of medical tests. Needless to say, the insurance flatly rejected my claim.
Backup Medical Records. Typically the insurance will ask for originals of all prescriptions and medical receipts. If they ‘lose’ the paperwork (as it happened in my case where they claimed that did not receive any paperwork only to mysteriously ‘find’ it after threats of escalation to ombudsman/IREDA), you need to have a photocopy of records. Make sure that the photocopies are legible. Sometimes the photocopy vendors may not have good paper/ink. The insurance, of course, is looking for opportunities to reject the claim and your task is to reduce that possibility to your best extent. If possible, scan everything with your mobile phone also and upload to any cloud drives, for example, Google Drive. On Andriod, I have found CamScanner to be very useful for this.
Record all the calls. There are various applications for recording mobile phone calls available in the market. While recording, be sure to tell the customer service that they are being recorded. Privacy is increasingly (and rightly so ) a big issue. So it is always best to let the other party know that they are being recorded.
Dealing with customer service: In my experience, the first level of customer service is usually only good for basic queries – like confirming whether papers have been received or your claim has been registered etc. Mostly, they will either request for more information or tell you that your claim is under processing and that you should call back after a few days. If your case is not progressing to your satisfaction, register a complaint with the grievance department of the health insurance company. For this, you may need to get contact information. The customer service will try their best not to give you that information saying that you should wait and often, giving you (empty) reassurances that your claim will get processed. Insist on getting the contact information. You can also dig up this information from your insurance documentation or with a web search. Once you initiate contact with the grievance department, try to get the connect to the doctor who is reviewing your case. That is, of course, easier said than done. You can persist in your efforts to get access to the doctor by requesting for it in every written communication. In my case, it was only after six months that I was able to get access to the doctor. But once I was able to talk to the doctor, the case was resolved within a month after that.
Escalation of grievance
if your case is not being resolved even after repeated communications with the grievance department of the company, you can escalate it to the government of India insurance regulator – IREDA. Note that before escalating the matter, they require that you show clear evidence that you have tried to settle the issue with the insurance company.
You can also consider contacting online customer grievance forums and television channels like CNBC. CNBC has a show called Pehredaar that will contact the company’s on your behalf in an attempt to resolve the problem.
In my case, I started tweeting to the people who had invested in Apollo Munich. I don’t know if it worked or not but I did hear the next day after one of my tweets from the grievance department who offer to put me in touch with the Dr reviewing my case. With that said, health insurance claim processing disputes are a David versus Goliath kind of situation where the whole system is set up to work against you. There are no laws or regulation that penalise the health insurance company for slow claim processing. On the face of it, you do have consumer protection laws but for everything, you need to put in a lot of effort presumably while you are still recovering from your sickness.
At the end, we are still at a stage of limited consumer awareness about health insurance in India. Increasing awareness will perhaps help set up pressure groups that will make the functioning of health insurance companies more transparent and more responsive to consumer needs.
For now, health insurance consumers need to network and learn from each other as much as possible. Do share with us if you have had any experience with health insurance if you have any suggestions on how others can help avoid any pitfalls of claim processing.