Whenever you visit a hospital for treatment, the first thing you are asked is, do you have health insurance. The health insurance plan covers hospitalization expenses during a medical emergency. When you have health insurance, your hospitalization expenses are borne by the insurance company.
In health insurance, there are two types of claims:
In case of reimbursement, you will have to bear the medical expenses, and they are reimbursed when submitting the medical bills. On the other hand, in case of cashless claims, the insurance company settles the bills directly with the hospital.
A few years ago, private hospitals would inflate the medical bills, if the patient was covered under a cashless health insurance plan. This was done with the intention of looting insurers. In order to curb this practice, insurers have come up with standard rates for hospitals and medical procedures. If a hospital is found overcharging, they would be put on a negative list.
The insurance company will also reject the claim, if they believe a particular treatment or procedure, was not medically necessary. If the person is covered under health insurance, some hospitals perform medical procedures or treatment, which may not be necessary, just to inflate the medical bills.
Patients and their families are well relaxed, believing the hospitalization charges would be borne by the insurer. But, they get a nasty shock when they find they have to bear the medical expenses, themselves.
Even though insurance companies have come up with various initiatives to curb this practice, some hospitals still continue this, but to a much smaller extent. So, it is very important for patients to be cautious when hospitalized.
A person was suffering from serious body pain and was taken to a nearby clinic. After the check-up, the doctor asked him to undergo certain diagnostic tests. After the diagnostic tests, the patient and his family were informed that a surgery had to be performed. The doctor suggested a hospital for the surgery, where he was a consultant doctor.
The patient and his family went to the hospital and enquired on the charges for the surgery, without informing the hospital on the health insurance policy.
The hospital said that the charges would be Rs 40,000 which consists of the procedure, room rent, nursing charges and relevant diagnostic tests. The Patient and his family were fine with this and got admitted to the hospital.
Once the patient was admitted to the hospital, his family informed that he had a health insurance policy and provided all the necessary documents to avail the cashless claim.
After getting to know that the patient had a health insurance policy, the hospital sent a cashless request to the insurer for Rs 65,000 and the insurer made the initial approval of Rs 56,000. The patient’s family had no idea on the amount requested by the hospital and approved the amounts stated by the insurer.
With the intention of hiking the bill, the hospital repeated the diagnostic tests which were done prior to admission. To increase the hospital room rent, the patient was asked to stay back for 3 days.
See Also: Patient Rights In Hospital
Initially, the hospital had stated that the patient would be discharged the following day. The family somehow managed to get the patient discharged the next day. On the discharge day, the hospital sent the final approval to the insurance company with the medical bill amount of Rs 68,000. But, the insurance company set the final approval for Rs 35,000, stating that the policy had a sub-limit of Rs. 35,000 for that particular medical procedure. The insurer also informed that the initial approval was a mistake.
The patient was asked to pay the difference. But, the patient’s family did not pay the difference; instead, they spoke to the hospital administration as the quote was Rs 40,000, initially. At this stage, the hospital was forced to admit that the tests which were carried out initially; were not taken into consideration and as the patient had insurance, tests were carried out again.
In this particular case, the hospital tried to cheat both the insurer and the patient. The hospital bill was revised to Rs 40,000 and the family paid Rs 5,000 from their pocket.
To avoid this kind of fraud, you must get clear information from the hospital and be aware of all the medical procedures involved in the treatment.
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