Insurers plan action against hospitals for fraudulent claims, overcharging

GI Council moves to penalise hospitals that inflate bills

Hospitals overcharging patients possessing health insurance cover and filing bogus claims will have to face the music soon.

General Insurance Council, the industry association, has decided to collectively identify and initiate penal action against hospitals engaging in misconduct.

“We are trying to identify patterns and will initiate disciplinary action against such hospitals. Action will depend on the intensity of the incident,” S Prakash, Managing Director of Star Health and Allied Insurance and executive member of the General Insurance Council.

Pain points identified by the industry range from overcharging by hospitals to fraudulent claims.

In terms of action, it could be limited to reaching out to such hospitals to “sensitise” them on the need to give fair treatment to patients and insurance companies or could be sterner in the form of suspension of cashless facilities or blacklisting.

“We also want to recognise the good players. So, step one is to identify the ethical players and promote them,” he said.

In cases of fraud, however, the entire industry could completely exclude the hospital. That is, neither cashless nor reimbursement claims will be paid except in case of emergencies.

The Council plans to set up a committee with representatives from the insurance companies, hospitals, and medical and legal experts.

“We want to address some of the pain points (of policyholders). We want to increase insurance penetration, but can only do so through word of mouth… this is possible only when hospitals provide good service,” Prakash said.

“The objective is to boost policyholder confidence in the system by eliminating negative perceptions. The committee will make hospitals part of the solution. We want to create an escalation matrix so that hospitals can reach out to us. If insurers have erred, they can escalate the matter,” Prakash said.

The General Insurance Council will also initiate a common empanelment mechanism across the industry for hospitals.

“There will be a single form for empanelment across insurance companies, besides uniform forms for cashless authorisation and claims. A policyholder who visits any hospital need not run from pillar to post for documentation,” he said.

The Council has also proposed a Health Exchange, a digital platform for settling health insurance claims across the industry. It will be monitored by the National Health Authority (NHA) and the Insurance Regulatory and Development Authority of India (IRDAI).