​When an individual is taken to hospital for treatment, the first question posed by the hospital is whether the patient is covered under any insurance policy or not.

Also, insurers many times reject the claim saying a service or procedure was "not medically necessary". Private hospitals, in their quest to generate higher revenue, perform medical procedures, which may not be necessary on patient covered by a medical insurance policy. The patient and their families are generally relaxed about it as they mistakenly assume the money will be paid by the insurance company. The penny drops when the claim is rejected!
This is where, everyone needs to be cautious!!
 
On one such occasion, when a family enquired about the charges, to their surprise the charges for treatment availed on back of insurance policy were different from the charges availed without insurance.
 
Here’s what happened in a hospital recently:
 
An individual felt a terrible pain in one of the organs in his body. His family members took him to the nearest clinic. After examining the patient, the doctor suggested him to undergo some diagnostic tests. Post the test results, doctor advised the patient to undergo a surgery & referred to the hospital where he was a consultant doctor. Patient and his family members enquired with the hospital for the charges without disclosing about his corporate insurance policy. The hospital gave a “Package” of Rs. 40,000 which covers the procedure, room rent, nursing charges & relevant diagnostic tests. A date was decided and the patient was admitted as Inpatient in the hospital.
 
Following his admission in the hospital, the patient’s family members disclosed that he was covered under insurance policy & all relevant documentation was submitted for cashless approval. The hospital’s true colors were exhibited from here on. Hospital sent a cashless request to the insurance company for Rs. 65,000/- and the insurance company sent an approval of Rs. 56,000/- as initial approval. The patient or his family members were unaware of the requested amount and approved amount of the insurance company. Hospital just informed them that the request has been approved.
 
The diagnostic tests which were already done before his admission, were repeated again citing reasons of requirement of latest reports (which the family later came to know that it was not required). Also, the patient was subjected to mental trauma as he had to undergo all tests again.
 
The procedures finally came to end and doctors who initially said that patient can be discharged the next day, was now asked to stay back for 3 days (so that they can jack up the bill by room rent).  It was only after much discussion and arguments between the patient’s family and the hospital administration that doctors agreed to discharge the patient the next day. On the day of discharge, final approval was sent to the insurance company with the final bill amounting to Rs. 68000/-. It was surprising for the hospital, when the insurance company’s final approval was only Rs. 35000/- citing policy had a sub-limit of Rs. 35000/- for the said procedure & initial approval sent was by mistake.
 
The bill was then sent to the patient, to pay the difference. The patient‘s family members then confronted the hospital, as why did they quote only Rs. 40,000 initially & why final bill was given as Rs. 68,000.  The hospital authorities had to agree that the diagnostics & procedures which were carried out were initially not taken into consideration & as the patient had insurance, they thought it would be relevant for them to carry on the tests again.
 
The hospital tried to cheat the patient and the insurance company by jacking up their bills. They kept the information confidential of what was the amount approved by the insurance company. The mistake from the patient’s family members was not to seek clear information from the hospital assuming insurance company will take care. The unnecessary tests which were conducted on the patient, jacking up the price of the surgery, overstaying in the hospital was all created to jack up the bill. If the policy did not have sub-limit, the insurance company would have paid completely and the patient would have not known about the cheating.
 
Your health insurance premium is dependent on the sum insured chosen. while buying health insurance seek complete information, don’t feel shy to question the procedures / tests conducted on the patient, before signing the final bill. Check each component of the bill even if the insurance company has allowed the same.
 
In this case, final bill was revised to Rs. 40,000/- as the patient’s family members were adamant in paying the amount which was given in the quote. They paid Rs. 5000/- difference amount and got discharged.
 
Article by Srikanth Ghanathay