Cashless treatment standoff: AHPI demands higher rates, Bajaj Allianz resists blanket hike, proposes negotiations with individual hospitals

“Hospitals have already raised their treatment rates steeply and arbitrarily post-COVID-19. While we are open to considering revision in rates, it cannot be a blanket hike across hospitals but will be based on negotiations with individual entities. We hope that the association will revoke its advisory to its member hospitals on suspension of cashless facilities,” an insurance official familiar with the discussions said.

Also read: Healthcare regulator, common empanelment for hospitals must for pricing transparency: Bajaj Allianz CEO

The dispute

AHPI says its decision follows repeated complaints by member hospitals that the insurer refused to revise reimbursement rates in line with rising medical costs and instead pressured healthcare providers to cut tariffs agreed upon years ago under now-expired contracts.

Hospitals also alleged unilateral deductions, delays in payments and excessive time taken for pre-authorisation and pre-discharge approvals, which they claim have further strained operations.

On August 26, insurers’ industry lobby the General Insurance Council hit back at the hospitals, terming the move arbitrary and against the interest of patient-policyholders.

"This sudden unilateral action on part of AHPI has created unnecessary confusion and concerns amongst citizens, impacting the trust in the health insurance ecosystem. Instead of enabling dialogue and resolution, a press statement was abruptly issued, prejudicing the interests of policyholders across the country," the council said.

Also read: General Insurance Council says AHPI's action against Bajaj Allianz is 'arbitrary, lacking clarity'

Reimbursement route in the interim

If your hospital is not part of your insurer’s cashless network or does not offer cashless facilities, you can opt for reimbursement – a process where you pay the treatment costs out of your pocket, with the insurer transferring the approved claim amount to your bank account later.

“You must submit all the necessary documents and original bills to your insurer for a smooth claim processing/reimbursement of your medical expenses during hospitalisation. Once your insurers approve all the necessary documents, your money will be reimbursed in your bank account. Reimbursement claims are typically processed within 15 days since all the required/original documents has been submitted to your insurer,” said Bhaskar Nerurkar, head, health administration team, Bajaj Allianz General Insurance.

The only condition is that the treatment should be eligible for the claim and the hospital not blacklisted – typically for fraud or over billing – by your insurer.

“One must also be aware that there may be an investigation to cross-verify the bills. Insurers generally conduct investigations in nearly 5 percent of the cases,” he added.

Recourse for policyholders

If yours is a planned treatment procedure, you can consider informing the insurer before hospitalisation. “Insurer will provide a checklist of documents required for filing the claim and even guide you through the hospitalisation processes. In fact, many insurers reimburse claims based on soft copies of discharge summary and bills. Depending on the insurer, treatment, hospital and so on, reimbursement is instant in many cases,” said Dr Bhabatosh Mishra, director and COO, Niva Bupa Health Insurance.

The policyholder should go through policy documents to ascertain the illnesses and treatment expenses that are covered as also the exclusions.

“You generally have 30 days to file a health insurance reimbursement claim after your hospital discharge or treatment, although this period can vary by policy and provider. Remember that you should intimate about hospitalisation for planned treatment and within 24 hours of admission for emergency treatment. It is important to file the claim within your insurer’s timeline to avoid rejection,” Nerurkar said.

Also read: Health insurance claim rejected? Approach the insurance ombudsman for complaint resolution

Preserve the original bills and documents. Should your claim be rejected, understand the reasons and the discrepancies highlighted. If you feel the insurer has rejected the claim unfairly, raise the matter with the firm’s grievance redressal officer. If you are dissatisfied, approach the insurance ombudsman. If all else fails, you can move consumers courts.