Bhavtosh Mishra from Delhi was charged Rs 750 per day in a private hospital as charges for infection control when he was hospitalised for Covid-19 treatment. Though he shared a room with another person (who was uninsured), only Mishra was charged this amount.
His insurer refused to bear the full cost and he had to pay an additional Rs 10,000 from his own pocket. Moneycontrol reviewed the bills and found that the other patient wasn't charged the same rate.
“I checked the bills of fellow patients and they were not charged the same amount. Just because I have a health insurance cover, why should I be made to pay?” said Mishra.
While close to 1,27,000 claims have been filed for Covid-19 related medical expenses by customers, hospitals and insurance companies continue to battle it out over which charges are covered by insurance.
Policyholders are the victims of this blame-game between the two sides.
Claims are only paid partly on the one hand, while hospitals continue to add newer charges such as temperature check fee, PPE kit fee and cleaning fee, on the other.
Insurers rue that hospitals are not following the standard rate cards that were issued in June 2020 by industry body General Insurance Council. Hospitals, on the other hand, have said that all patients cannot be put under capped rates.
Moneycontrol had reported earlier on how hospitals have increased treatment costs due to the infection-control measures adopted after the Covid-19 outbreak. This was passed on to customers resulting in higher bills.
But insurers are of the view that insured customers are being unfairly charged.
What insurers want
The government has capped rates for Covid-19 treatment in hospitals. But not all hospitals are following these rates and insurers want the pre-agreed terms to be followed.
The insurers want a legal mandate to ensure that all hospitals follow the rate chart provided earlier and stick to it for all Covid-19 treatment expenses for patients with health policies.
The General Insurance (GI) Council is filing an appeal to implead itself in an ongoing public interest litigation (PIL) case in the Supreme Court over charges incurred in hospitals for Coronavirus (Covid-19) treatment.
The GI Council wants to point out that insurers cannot compensate by paying high costs for infection-control measures in hospitals.
“When there is a ready reference rate provided to all hospitals, why can’t the medical establishments stick to the rate? Insured customers shouldn’t be overcompensating for the uninsured patients in a hospital,” said the head of claims at a mid-sized private general insurer.
Customers stuck in the middle
Meanwhile, customers have been suffering due to the back-and-forth between the hospitals and insurers.
Akshata Tiwari, an IT professional from Kolkata had to wait for almost three weeks before she received confirmation on what expenses would be payable for her father's Covid-19 hospitalisation.
“I have been informed that I will only be reimbursed 65 percent of the costs. In earlier instances of hospitalisation for my father, specialised medication was not excluded. But this time, it is. The insurer and hospitals must clearly decide and tell us what is covered and what isn't. That way we can plan the finances better," she added.
What hospitals want
Hospitals are of the view that insurance companies must be more flexible and ensure that customers don’t suffer.
Dr Ashutosh Raghuvanshi, Managing Director and CEO, Fortis Healthcare, told Moneycontrol that insurance companies can pitch in more actively to share the burden of Covid treatment with hospitals so that patients are not at the receiving end.
He added that they can also adopt a more flexible procedure for cashless services, processes, scrutiny of bills and evaluation.
The cap on rates for Covid-19 treatment is also not acceptable for many hospitals since they are of the view that the virus is unique in nature and exact costs vary from customer to customer.
Yogesh Sareen, Senior Director and CFO, Max Healthcare said that insurance companies can’t shy away from contracted rates and take shelter under capped rates.
“Capped rates should apply to 30-40 percent of the patients and not to all. The public good at private cost is bad economics for a sector where we direly need private investments to augment capacity,” he added.
When it comes to cashless treatment for insured patients, hospitals generally follow pre-agreed protocols and rates agreed with the partner insurance companies.
Hospitals are of the view that insurance companies are now suddenly shrugging off responsibility and don’t want to share the burden of increased treatment costs due to the nature of Covid-19.
Their view is that customers who have the ability to pay should pay and that they should not be put under capped rates.
Dr Nandakumar Jairam, CEO, Chairman and GMD, Columbia Asia Hospitals India, said that the capped treatment should be excluded for people who are insured and for people who can afford to pay for the treatment. This, he said, will help maintain the balance.
“It would not be fair to generalise. However, there are some insurance providers who are arbitrarily deducting our claims even if the claims are as per the signed contracts, which is unfair. We condemn this practice and expect that to stop immediately,” he added.
For health insurance customers, the worst is far from over. If there is a court decision legalising standard rates for Covid-19 treatment, it will be binding on both insurers and hospitals.