A woman who was recently admitted to a private hospital off EM Bypass and had a health insurance policy with a cashless facility had to wait for more than six hours to go home after the doctor discharged her.
An elderly man who was admitted to a hospital for two days earlier this week for an eye problem had to wait for more than seven hours before his medical insurance police with cashless benefit got approved.
The long wait for the insurance company’s approval has returned for subscribers to health insurance policies with cashless facility, after the situation had improved briefly during the Covid pandemic, allege patients.
Private hospitals and insurance policy providers are blaming each other for the situation.
In the case of the woman, an official of the hospital said the document for discharge was sent to the insurance company at 3.28pm and a query was raised by the insurance provider at 4.50pm.
“Even after we replied to the query, the insurance company sent the same query again at 7.30pm. We sent another reply. Finally, a third query came at 8.40pm,” said the official.
The final approval was given by the insurance company at 9.37pm, the official said.
Sources in the health insurance sector and hospitals said some of the reasons for the long wait that discharged patients have to suffer are queries raised by the insurance provider going back and forth several times during the process of approval of claims, disputes over allegedly inflated bills, treatments cost exceeding the approved limit and shortage of personnel to process claims.
“During the Covid pandemic, the Insurance Regulatory and Development Authority of India had asked everyone to ensure that the turnaround time for cashless policies should not be more than an hour, which was mostly maintained. However, now the turnaround time is getting longer and mostly because some of the hospitals are delaying the process,” said a senior official of a government-run insurance company.
The official said hospitals often send incomplete documents and delay in replying to queries.
“Hospitals and insurance companies both have to bridge the gap of timeline for discharge for better services of patients. We have gone a long way in improving the services in this aspect and we request the insurance companies to work towards the same,” said R. Venkatesh, group COO, Narayana Health.
A doctor attached to the health insurance sector for several years said there were problems at both ends for which patients suffer.
“Now that the pandemic is over, the claims are no longer processed on a priority basis. The delay is on both ends. The hospitals delay in sending documents and replying to queries. In the case of insurance companies, there is delay in processing the claims and conducting field investigations. Shortage of manpower is one important reason for this,” said Dipayan Saha, a medical officer attached to the private health insurance sector.
One official of a private insurance company said a medical officer quit the company in June and his replacement has yet to be appointed. So, the workload of the remaining medical officers has increased.
Subhasish Datta, chief general manager of Ruby General Hospital, referred to shortcoming at both ends.
“The insurance companies should be more focused on the discharge process. Hospitals often don’t send documents relevant to the treatment beforehand. So, when the documents are sent during discharge, there are disputes, causing the delay,” said Datta.
“We are writing to the insurance companies if there is delay in discharge approval for more than two hours, asking for the actual cause.”
Jyotirmay Kundu, all-India network manager for Heritage Health Insurance TPA, a third-party administrator, said that in several cases the delay was because the reasons for a particular treatment are not mentioned.
“At times, bills justifying the amount are not received. If there are unnecessary investigations during the course of the treatment, we seek justifications from the hospital,” he said.
Pradip Tondon, CEO, Belle Vue Clinic, said: “If the documentation is correct and the bills are as per the agreement entered between the insurer and hospitals, there should
not be any major problem. But in many cases, this does not happen.”
