Planning to buy health insurance plan? The devil is in details

Settling your hospital bills against your insurance claim can give you headaches for many days. Most of the health insurance policy holders are not fully aware about the terms and conditions of the insurance companies and later feel cheated.

So it’s critical to get your doubts fully answered before you lay your hands on a particular policy. In addition, according to experts, medical costs are increasing because of insurance.

“Hospitals tend to charge more when they get to know that the patients have medical insurance. So, many entities like the Health Ministry, insurance regulator, Indian Medical Association (IMA) need to pitch in to streamline the whole insurance settlement process,” one of the experts who didn’t want to be quoted told TNIE.

During Covid pandemic, even basic medicine prices were raised. So, the fair practices are not followed by the healthcare industry and then the whole blame on the insurance industry is put, according to the experts.

The Competition Commission of India (CCI) has ordered an investigation into allegations that some big hospital chains are abusing their dominance and overcharging patients for the rooms and medical equipment.

Limits of health insurance plans
Buying a health insurance plan does not mean all your healthcare expenses would be taken care of. There are different limits and caps under a health policy, and people would do well to know about them in advance.

“In most cases, people are not aware about the different components of the medical expenses covered in their policy. They randomly choose a policy thinking that all their medical expenses will be taken care of,” said one of the experts.

“Lack of standardisation, be it in treatment protocols or application of standard industry coding, results in a fair degree of arbitrary line of treatment to maximise profits. Payers scrutinise these health claims for wastage and other anomalies, thus denying or adjusting claims,” he added.

Also, people should be aware that just having a policy with higher sum assured doesn’t mean that their bills will be settled up to that limit. They must know the cap on the room rent that is one of the most important deciding factors in the final settlement of their hospital bills.

“Choosing health insurance plans that suit the specific requirements of an individual/family is of prime importance. There are various product offerings that a consumer can opt for based on parameters ranging from PED waiting period, specific benefits like unlimited automatic recharge of sum insured,  annual health check-ups, air ambulance cover, maternity cover, OPD cover, among many more,” Ajay Shah, Director- Head of Retail Business, Care Health Insurance said.

All this, in addition to getting cashless treatment in case of  hospitalisation and coverage for pre and post hospitalisation expenses,” Shah added. One insurance expert says that people should opt for that policy which does not have any limit on room rent. 

“It’s always better to pay a higher premium for a policy with no such limits than going for one that comes cheaper with a sub-limit,” one of the insurance experts said.

Know your healthcare expenses
Experts say that consumers should question as their health and life are at stake. They have the full right to know what and why their doctors recommend. High cost does not mean better treatment or doctor, they argue. “Doctors recommend expensive stents, drugs etc. because they are incentivised. Consumers should be aware of all riders and the fine print of their health policy, if insured,” an expert stated.

Experts give examples of introduction of a few drugs – very high doses of antibiotics, etc -- for treatment of diseases, which have not been proved based on evidence that they cure the disease more effectively than a lower dose of the same drug. Industry insiders also cite examples of robotics surgeries which cost three times more than the laparoscopic surgery without offering additional clinical advantage for cancerous fibroid removal of the uterus.

Unlike India, in countries like the UK, there are independent bodies which evaluate every new test, every new procedure, etc from a health economic perspective. Here, no one knows whether the new equipment is as good as the existing one.

Experts also point to a new practice of hospitals adding new line items in hospital bills. “I have certain bills from some hospitals where I observed that patients who underwent angioplasty for stenting, these hospitals started charging a separate line item called stent implanting charges. But stenting itself means putting the stent to the coronary artery, then why this additional charge,” one of the experts questioned.
“Such innovative practices by hospitals lead to higher scrutiny of health insurance claims, which if not done would become a practice,” he said.

 If you do not want to get a shock at the time of getting discharged from hospital, it is very necessary for you to understand both the limits of your health policy and the cost of health expenses.

Settling your hospital bills against your insurance claim can give you headaches for many days. Most of the health insurance policy holders are not fully aware about the terms and conditions of the insurance companies and later feel cheated. So it’s critical to get your doubts fully answered before you lay your hands on a particular policy. In addition, according to experts, medical costs are increasing because of insurance. “Hospitals tend to charge more when they get to know that the patients have medical insurance. So, many entities like the Health Ministry, insurance regulator, Indian Medical Association (IMA) need to pitch in to streamline the whole insurance settlement process,” one of the experts who didn’t want to be quoted told TNIE. During Covid pandemic, even basic medicine prices were raised. So, the fair practices are not followed by the healthcare industry and then the whole blame on the insurance industry is put, according to the experts. The Competition Commission of India (CCI) has ordered an investigation into allegations that some big hospital chains are abusing their dominance and overcharging patients for the rooms and medical equipment. Limits of health insurance plans Buying a health insurance plan does not mean all your healthcare expenses would be taken care of. There are different limits and caps under a health policy, and people would do well to know about them in advance. “In most cases, people are not aware about the different components of the medical expenses covered in their policy. They randomly choose a policy thinking that all their medical expenses will be taken care of,” said one of the experts. “Lack of standardisation, be it in treatment protocols or application of standard industry coding, results in a fair degree of arbitrary line of treatment to maximise profits. Payers scrutinise these health claims for wastage and other anomalies, thus denying or adjusting claims,” he added. Also, people should be aware that just having a policy with higher sum assured doesn’t mean that their bills will be settled up to that limit. They must know the cap on the room rent that is one of the most important deciding factors in the final settlement of their hospital bills. “Choosing health insurance plans that suit the specific requirements of an individual/family is of prime importance. There are various product offerings that a consumer can opt for based on parameters ranging from PED waiting period, specific benefits like unlimited automatic recharge of sum insured,  annual health check-ups, air ambulance cover, maternity cover, OPD cover, among many more,” Ajay Shah, Director- Head of Retail Business, Care Health Insurance said. All this, in addition to getting cashless treatment in case of  hospitalisation and coverage for pre and post hospitalisation expenses,” Shah added. One insurance expert says that people should opt for that policy which does not have any limit on room rent.  “It’s always better to pay a higher premium for a policy with no such limits than going for one that comes cheaper with a sub-limit,” one of the insurance experts said. Know your healthcare expenses Experts say that consumers should question as their health and life are at stake. They have the full right to know what and why their doctors recommend. High cost does not mean better treatment or doctor, they argue. “Doctors recommend expensive stents, drugs etc. because they are incentivised. Consumers should be aware of all riders and the fine print of their health policy, if insured,” an expert stated. Experts give examples of introduction of a few drugs – very high doses of antibiotics, etc -- for treatment of diseases, which have not been proved based on evidence that they cure the disease more effectively than a lower dose of the same drug. Industry insiders also cite examples of robotics surgeries which cost three times more than the laparoscopic surgery without offering additional clinical advantage for cancerous fibroid removal of the uterus. Unlike India, in countries like the UK, there are independent bodies which evaluate every new test, every new procedure, etc from a health economic perspective. Here, no one knows whether the new equipment is as good as the existing one. Experts also point to a new practice of hospitals adding new line items in hospital bills. “I have certain bills from some hospitals where I observed that patients who underwent angioplasty for stenting, these hospitals started charging a separate line item called stent implanting charges. But stenting itself means putting the stent to the coronary artery, then why this additional charge,” one of the experts questioned. “Such innovative practices by hospitals lead to higher scrutiny of health insurance claims, which if not done would become a practice,” he said.  If you do not want to get a shock at the time of getting discharged from hospital, it is very necessary for you to understand both the limits of your health policy and the cost of health expenses.