Friday, July 9, 2010

Deception in Mediclaim

The headlines  in the Times of India dated today said  that many hospitals are off the Mediclaim radar as many are supposedly involved in false claims.There are related reports about increase in consumer cases because of rejected Mediclaims &Hospital  charges being too exorbitant.

The insurance companies have resorted to denial of cashless facility. All this has led to a lot of hardships for the patients .Obviously after the fleecing by hospitals & TPAs,insurance companies have become bereft of cash - so cashless has suddenly got a new meaning ,for the Insurance Industry that is !

It has been reported that Hospitals have indulged in putting up fraud claims in collusion with TPAs ( Third Party Administrators)  to whom processing of  health related claims has been outsourced by the Insurance Companies.Patients are also said to be  a party to the frauds.TPAs are a recent phenomena unlike hospitals which have been in existence much before.TPAs came in, when the Public Sector Insurance Companies announced the VRS ( Voluntary Retirement Scheme) some years back.The staff shortage due to VRS was tackled by outsourcing processing of health related claims to TPAs.

But the Insurance Companies seem to think that TPAs are doing a good job.Hence,the axe has fallen on the Hospitals. This is not to say that Hospitals are clean but to question this blacklisting of Hospitals.The TPAs ought to be taken to task .But instead of that, a TPA has investigated & based on that investigation ,Hospitals have been listed out.This is giving new meaning to the term " natural justice." Natural justice demands that no one should be a judge in his own case.In this instance,a TPA is the investigating agency & based on that ,so many are blacklisted.How can a TPA sit in judgement on other TPAs as also Hospitals ? The report omits to state if any TPAs have been blacklisted but still,this is all an eye wash.

What are the credentials of the TPA which investigated the fraud claims ? The said TPA is a later entrant compared to some  TPAs .As happens sooner than later,the said TPA may be involved in bigger frauds or maybe get involved later.Perhaps, it wants a clean slate to begin.After all,aren't we  too familiar with the brands which worked hard to get the  ISI marks & once,they got it,it has just been downhill ever since.

The report also says that many Hospitals are in the dark about their status & some Hospitals have themselves opted out of the list due to strict norms.The insurance industry will soon inform its decision to the listed Hospitals but " soon" in Public Sector parlance can range from days to months to years ! So ,the stage is set for disputes about Hospitalisation in blacklisted hospitals as neither the TPA,nor the patient or the Hospital knows the current status of the Hospital.

Related reports speak about the rising number of consumer disputes about Mediclaim.About two thirds of all Insurance claims end up in consumer forums.This is a very sorry state of affairs.Claims are rejected for flimsy reasons like pre-existing ailments,excluded diseases,etal.Moreover,in Public Sector,decisions ( if any ) to delay & reject claims are lauded .Such actions also keep the bosses in good books of the audit & vigilance departments.The executives are preventing the drain of wealth thereby protecting the funds.But when the judgement comes,generally interest payment is also a condition But such small things do keep happening in big Public Sector companies.So,no one gets wiser.

It has been stated in the  report that one can choose the TPA.But this is easier said than done.Many compnaies have only some TPAs on their rolls.So this may not be economical .Moreover,if I want a particular TPA,it may be taken to mean that I want to conspire with the TPA to defraud the Insurance Company.Moreover,how does one know if any TPA is good ,bad or ugly ? Many will tell you that all TPAs are chips of the same block.

Mediclaim is a drain & has been so for a long time.With the TPAs in it now,it has started burning huge holes in the pockets of the  Insurance Companies. So what is the way out ?

One way is to start in house TPA cells manned by the employees of the Insurance Companies .Some private sector companies have set up such cells for processing Mediclaims.The TPAs should be strictly monitored as well, as before the TPAs came in,there were no such blatant attempts at cheating.Unfortunately,the TOI report seems to suggest that TPAs or rather the investigator TPA is calling the shots ! The said TPA Manager has spoken to the press & the Insurance Companies have no spokesperson to tell about their version /s  ! One really wonders " Who is the boss -the TPA /s or the Insurance Companies ? The more things change,the more they remain the same or perhaps change for the worse.On second thoughts,we haven't yet hit the pits ,not yet !


octa8on said...

Wonderful perspective, written a way that only a person with deep understanding of the goings-on can write.

Maybe you can post links of the article you referred into the blog post. Indeed you may post a comment on the TOI site and link it back to your blog post. Many people do this a lot!

Bhavik said...

Yes, what octa8on told is perfectly write. You can also promote your blog by social bookmarking. You can also link back to, which is also a very popular site.

tina joy said...

I was searching for this headline in TOI website, but didnt got it.
Thank You for sharing this post.

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