Readers for Part-1, of this article, please refer : https://sharmajeeblog.wordpress.com/2017/05/21/how-indian-health-and-vehicle-insurance-companies-and-service-providers-cheat-their-customers-part-1/
Part-2: Modus Operandi and Possible Solutions
Insurance company and SP’s donot share openly with their clients or put in public domain on (insurance website, hospital website) their pre negotiated and agreed terms of services, schedule of rates of treatment/ repairs, surgery with their essential components like implants/ spares, duration of stay etc. etc. This facade increases scope of corruption and malpractices.
Insurance company in connivance with SP, keep blind eye on the treatment process, which is essentially their duty and responsibility to check if SP is performing and charging what is authorized, using implants what insurance is paying for (or substandard one) etc. etc. This can tackled by speaking phone to insured on be (whenever any pre authorization request is approved), informing him his entitlements details and contact number to reach Insurer in case of any difficulty or query.
Insurance companies are now started asking to submit proof of purchase and proof of implanting authorised implants used by SPs, but they are not verifying the same from their clients or by conducting surprise checks at SPs premises. Here maximum corruption and malpractices happens.
Insurance companies donot insist on SP’s, to give a copy of all communications between them and SP’s on pre authorization request, authorization letter, schedule and terms of treatment, repairs, job sheet, investigations, implants (every item of hospitalization bill to both customers for their reference). Many audacious SP’s get the signature of insured on plain papers and other lots of papers without giving any time to insured to verify, which they use in case insured go for litigation.
Both insurance companies and SPs have morale and ethical duty and responsibility to carrying awareness programs for insured to educate them about their rights and responsibilities as insured (like demanding copy of complete treatment records, bills, proof of implant/ spare implanted), entitlements/ limitations of service availed, possible methods of frauds / cheating by SP’s and precautions compulsorily, transparently.
No claim of SP should be accepted by insurance company, unless SPs bill is accompanied by a certificate of (both) insured certifying above list of documents have been handed over to insured.
Insurance company must put burdon of proof, in case of billing disputes on SP, not on poor insured, who has no say in whole process and has to run like pendulum between insurance company and SP, in the event of dispute .
No awareness programs are taken by insurer or SP’s to educate insured on what is not permissible/ payable to trim their ingenuine demands
Irony is big Private / Corporate hospitals, vehicle service centres, are encouraging these malpractices. Fact that almost all private/ corporate hospitals and Vehicle service centres have separate teams/ counters, to deal with insurance clients confirms that it’s a big business deal for them. I will not be exaggerating if I say many SPs today, are surviving on insurance clients chiefly. If any accident emergency patient / vehicle is rushed in hospital/ authorized service centre, than they are more interested to know if customer has Insurance (than his medical Emergency) or not. Rest of things are decided after ascertaining this moot question.
Corporate/ private hospitals or company service centres (SPs), own rates of services are exorbitant but in the greed of customer base they agree on lower negotiated rates of insurance company and become a panel SP. Insured also approach them as their infrastructure attracts them and than exploitation starts.
Lets see how this dirty game happens by two examples:
Let’s assume, Pre negotiated agreed package rate for hip replacement is Rs XXXX [while hospital’s own tariff may be (XXXX ) x 2]. This package rate includes stipulated duration of stay in single occupancy ward, nursing and OT charges, doctors visit fee during hospitalization, surgeon fee, medical investigations required for surgery, anesthesia fee, cost of implant, OT Medicines and consumables, Post operative medicines and all other relevant charges. (Hospital hide this fact and extorts money from patients for half of the these heads saying these are not included in insurance package).
Here they also play foul, when an accident patient reaches hospital in emergency, SP will say single occupancy ward is not available, so they will admit him in deluxe private ward (without giving option to patient to go to other hospital, nor would emergency allow). There is a surprising trend in corporate hospitals that all facility charges go exorbitantly high (nursing and OT charges, doctors visit fee during hospitalization, surgeon fee, medical investigations etc etc… ) for patients if admitted in private/ deluxe ward though same doctor, OT, staff, consumables, machines will do the job. As patient is admitted in private/ deluxe ward, he exceeds his entitlement(which nobody makes him aware), thus becomes liable to pay high hospital charges which are much higher than his/ her entitlement. Insurance companies keep a blind eye on this for unknown reasons……….
Here Insurance company people for obvious reasons, donot intervene or question why SP has denied services on their agreed terms? Patient/ relatives also donot exercise their right to go to other hospital as they know other places are they will meet same fate and secondly they are more concerned to treat the medical emergency first. After emergency when they complain to Insurance, their skeptical silence, further becomes a tool and chain of harassment……
Its now an open fact that many hospitals perform many irrational investigations, surgeries, fix implants more for commercial gains than for medical rationale. They charge indiscriminately for these implants and most patients carry a doubt post surgery that was this surgery or implant a real medical need? Or is implants implanted is same what their hospital or doctor charged for. Insurance companies are lawfully better equipped with their panel of experts to intervene here and clear this façade and restore confidence of insured.
Our government, Insurance and health authorities, political system are very well aware of these prevailing malpractices. Our Insurance Regulatory Authorities are totally apathetic towards safeguarding their own and their client’s interests being watch dog, instead they work like sleeping paper tiger, they hardly intervene or investigate thus encouraging these malpractices.
You are owner of a new brand bike (6 months old). Some car hits you from back and escapes…… God saves you and bike has following damage:
- Leg guard and handle has a minor bend
- Head light broken
- Clutch lever and wire loosened
- Wheel cover has minor bend, which seemingly can be repaired
- Side view mirror broken
- Slight bend on exhaust
- Indicator hanging
- Plus some general troubles as smooth running not there.
SP’s engineers/ technicians will ask you to leave the vehicle and go as vehicle shall be inspected at the sweet will and time of insurance co. surveyor. (No SP wants client to be present during survey).
Insurance company submits him a fat list of replacement of all the parts with labour cost. Suppose surveyor allows only handle and headlight replacement, and rest to be repaired(Labour cost allowed). (No discussion happens of surveyor with client nor client is given any authorization report of surveyor).
Now when poor insured enquires from SP about his claim, they are told: “The insurance company has allowed only handle and headlight replacement” (without showing survey report) and rest new parts and labour you will need to pay……. Than whole extortion process starts……… client is cheated……
In our country banking and insurance litigations form a major chunk of pendency in courts and it is still increasing. This vast number of increasing insurance disputes are a proof how a majority of customers are cheated, how inefficient and incompetent is regulator and also how insurance and SPs companies use litigation to harass its clients.
By not practicing transparency and colluding with SP, insurance company in a way works against their own aims and objectives, thus increasing claims value v/s premium value ratio, which than lead to losses to insurance and unlawful gains to SP. The poor insured becomes looser who pays premium to company for the odd times and feels cheated when he/ she has to over pay for his/ her hospitalisation as hospital/ service station bills reimbursements are rejected by insurance companies on technical ground or being not adhering to their tariff.
Insurance companies are trustees of their clients funds and have responsibility to safe guard their client’s interests. They also have to serve as watch dog so that no SP, is over charging, giving raw deal to their clients by overruling their agreed rates and terms of treatment and also that only genuine procedures, medicines, spare parts/ implants are carried out by SP. They must conduct frequent surprise checks through their authorized investigators where insured is availing services.
Insurance companies, have legitimate right and ethical responsibility and necessary expertise to seek justification/ rationale from SPs, of any repair/ surgery or treatment or procedure and its components like cost, drugs, duration of stay, charges for procedures, implants etc etc…… so that pool of money is not used on malicious fraudulent procedures/ consumables, which ultimately affects financial sustainability of insurer.