Govt med insurance only for general ward patients

Only patients admitted in a general ward will be eligible for the government sponsored cashless health insurance for inpatient treatment for primary and secondary illnesses in government and private hospitals in Goa. If a patient is admitted in the ICU, the "Swarnajayanti Aarogya Bima Yojana" card will not serve to pay for treatment.

The card has a ceiling of Rs60, 000. Admitting this, health minister Vishwajit Rane said, "The scheme is for primary and secondary illnesses and one doesn't need ICU admission for these illnesses." Doctors, however, differ with the health minister's view. "Treatments under the scheme include major surgeries such as nephrectomy (surgery to remove part or entire kidney), abdomino perineal resection (removal of anus, rectum, or colon), commando operation (surgery for first degree malignancy of the tongue) and other such treatments, in which patients in a majority of cases need to be admitted in the ICU. Also what about patients who come to the hospital for primary and secondary care but later develop complications and need to be shifted to the ICU?" Association of Private Nursing Homes spokesperson Dr Govind Kamat said. Dr Mithun Mahatme of Mahatme Nursing Home, Bicholim said, "The intent may be good but implementation is not practical. The insurance is for admission in a general ward.

What happens if an emergency patient comes and the general ward beds are full? Also, the rates quoted are low due to which we would be forced to cut corners which won't be in the patients' interest." Though private hospitals have shown discontent with the rates, ICICI Lombard, that will run the scheme, claims that Manipal, R G stone, Wockhardt and SMRC-Vivus hospitals (all corporate hospitals) have agreed to the terms and the company is in final talks with a several other hospitals as well.

Pvt hospitals roped in

FISG-ICICI Lombard GIC Vice-president Birendra Mohanty said, "The implementation of the scheme has already begun and we have roped in more than 10 private hospitals in the network, along with three public hospitals. We are in negotiations with other private hospitals." Kamat, however, said, "The hospitals named by the insurance company are not members of our association. As far as we know, except for one member, none of the others have entered into an agreement with the insurance company. We have also called a meeting of all the members on Sunday to decide the future course of action." Goa has about 110 private nursing homes.

Rane added, "We want the association of private nursing homes on board. They do have some apprehensions but that will be resolved by ICICI." ICICI Lombard's "scope of services" clause states that the package will include "bed charges (general ward), nursing and boarding charges, surgeons, anesthetists, medical practitioner, consultants fees, anesthesia, blood, oxygen, OT charges, cost of surgical appliances, medicines and drugs, cost of prosthetic devices, implants, X-ray and diagnostic tests, food for patient etc". It also includes expenses incurred for diagnostic tests and medicines one day before admission and up to five days after discharge from the hospital.

Transportation expense from the patient's residence to the hospital is also covered and would be reimbursed in cash by the hospital to the patient on providing proof of expenditure. The maximum amount payable to the patient for transportation would be `100.

Health cover doesn’t fit the ayurveda bill

Are you suffering from diabetes, arthritis or any other chronic disease and opting for ancient forms of medicine? The good news is insurance cover is available for such patients. After some insurance companies began recognizing ayurvedic treatment, many are going ahead with cashless transactions or 80% reimbursements for chronic diseases. Not just that, Karnataka has recognized 15 ayurvedic hospitals for its employees who can undergo treatment and even claim reimbursement.

The Ayush department is in the process of drafting specifications of ayurvedic treatments that can be reimbursed like any other mainstream one. "This can help employees get treated anywhere they like," said Ayush director G N Srikantaiah.

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It is also evolving standards for alternative medicine hospitals so that they can be covered by private insurance companies.

But ayurvedic hospitals feel private insurance companies are still restrictive in terms of coverage. At Soukya holistic health centre in Whitefield, 25 cases of 80% coverage have been made after some insurance companies began covering alternative medicine. "It was a little tough as the parameters of our treatment do not match that of mainstream medicine and diseases. Neither do we have standard pricing. But nowadays, people are coming to us for long-term chronic diseases that could cost up to Rs 1.5 lakh. These are comparable to surgeries in English medicine," said Dr Isaac Mathai, director of Soukya.

Soukya is in the process of getting a certificate from the National Accreditation Board for Hospitals and Healthcare Providers (NABH), so that the process of insurance coverage becomes smoother. At Soukya, the diseases mostly covered by insurance are chronic longterm conditions like arthritis , spondilytis, neurological diseases and even cancer. "Anything chronic should be covered by health insurance providers ,'' added Dr Mathai.

Insurer cannot arbitrarily refuse policy renewal

Healthcare is costlier than a stay in a five-star hotel. Clearly, it is beyond the means of the common man. One-time hospitalization can wipe out a lifetime's savings. So, mediclaim policy, as a welfare measure to bring the cost of decent healthcare within the reach of the average citizen, was introduced. Yet, insurance companies, which willingly accept premium year after year, are reluctant to settle legitimate claims. They look for excuses to reject these.

Often, insurers arbitrarily refuse to renew a policy, when it becomes evident that the claims ratio would go up. This, clearly, is not permissible, as held by the Supreme Court in the case of Biman Krishna Bose versus United India Insurance & Anr.

Biman Bose and his wife, Alka, had a mediclaim policy with United India Insurance. Alka fell ill, and was hospitalised. After discharge, a claim was made for reimbursement of expenses, amounting to Rs 8,243. Although all the necessary documents were submitted, yet even this meagre claim was not settled. This, despite repeated reminders.

So, the insured filed a complaint before the Kolkata district consumer forum. The ding-dong legal battle spanned four years and four tiers of courts till the Supreme Court finally intervened, directing the insurer to pay the claim, as also awarding Rs 20,000.

One would have expected the matter to have concluded here. But, unfortunately, when the policy became due for renewal, the insurer refused to renew in vengeance.

Once again, the insured felt compelled to take legal action. A writ petition was filed in the Calcutta high court, and the second round of battle ensued.

The High Court allowed the writ, set aside the insurer’s refusal, and directed the policy be renewed.

The insurer, however, contended the policy had lapsed, as, during litigation, the renewal premium had not been paid. So, the division bench, while agreeing with the view taken by the single judge, directed the insured to subscribe to a new policy, holding that renewal was not possible.

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This order defeated the very purpose of litigation, because, in case a fresh policy is taken, all pre-existing diseases are excluded. Also, claims in respect of certain diseases contracted within the first 30 days of the new policy are excluded. So, Bose appealed to the Supreme Court (SC).

The SC observed the insurer is bound to act fairly and reasonably. Renewal cannot be refused on irrelevant and extraneous considerations, or in an arbitrary manner. Refusal to renew merely because the insured had approached the courts against the rejection of the claim is not justified.

The SC further observed the initial renewal premium had been paid by the insured, but wasn’t acknowledged by the insurer. Even during the intervening years of litigation, there arose no occasion to deposit the premium.

Accordingly, it held the refusal to renew as unfair and arbitrary, and directed the policy be renewed from the date it fell due for renewal.

It also ordered to further renew the policies for the subsequent expired years, if the premium had been paid. The insured was also awarded costs of Rs 5,000.

Since then, the SC has now held that refusal to renew a policy amounts to victimisation, unfair practice, and high-handededness.

Health expo to unveil low-cost medical equipment

The Indian healthcare sector has emerged as one of the most progressive and largest service sectors in India. The public sector however is likely to contribute only around 15% to 20% of the required $ 86 billion investment.

"The corporate India is, therefore, leveraging on this business potential and various health care brands have started aggressive expansion in the country," said Dr EV Ramana Reddy, secretary to the department of Health and Family Welfare, at the inauguration of a three-day long exhibition, Healthex, on Friday.

“Various state governments are collaborating with the private sector through PPP to improve efficiency and decrease the inequity in the health system. Community health insurance initiatives have also been undertaken in terms of Yeshaswini Scheme in Karnataka,” said Dr Reddy.

The country's vision 2020 should include the delivery of affordable healthcare system even to the rural people. Preventive healthcare is another aspect that should be focused on and doctors should gear up to educate patients, he added.

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On the healthcare development in Karnataka, he revealed that the healthcare landscape is changing rapidly with corporate and foreign hospitals setting up centres to offer high quality healthcare. Moreover, the government is also promoting India as the global healthcare destination to offer holistic treatment. Now, private and public hospitals need to synergise their efforts to promote India as the healthcare destination worldwide, said Dr Reddy.

The Indian healthcare industry is undergoing a rapid expansion and in order to survive the healthcare market competition and growth, hospitals are continuously updating themselves on current issues, challenges, and the best methods to reach out to and serve their patients better, he said.With several innovations in the healthcare sector, there is a need for both private and public sector to work jointly.

"The rapid technical changes in the recent past and the commitment of the Army Medical Corps Services to provide a cradle-to-grave service have encouraged diversification in the unexplored fields in military medical services,” said Air Vice Marshal Pankaj Tyagi, principal medical officer, Headquarters Training Command, Indian Air Force.

Rs.150-cr for new insurance scheme

A sum of Rs.150 crore has been allotted initially against newly-formulated Chief Minister's Comprehensive Health Insurance Scheme, Finance Minister O. Panneerselvam announced in the Assembly on Thursday.

The old insurance scheme of the DMK regime was terminated, but to benefit patients in the bridge period between suspending the old scheme and launching the new one, a sum of Rs.100 crore was separately allocated, Finance Secretary K. Shanmugam said in his post budget briefing.

The government will focus on improvement of primary health care facilities in urban areas. The 60 centres already sanctioned under the National Rural Health Mission, will be shifted under the administrative and technical control of the Directorate of Public Health. Further, the Finance Minister announced that Urban Primary Health Care centres will be set up in 75 more small urban towns. A super-speciality centre, at a cost of Rs.100 crore, would be set up in Annal Gandhi Government Hospital, Tiruchi.

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Additionally, infrastructure and equipment upgradation has been planned for district hospitals and poison treatment centres at a cost of Rs.55 crore, under the Tamil Nadu Health Systems Project. Also, under public-private partnership agreements, diagnostic facilities at the major hospitals will be improved, and state-of-the-art computer aided laboratories established in all districts in a phased manner. A ‘Hospital on Wheels' scheme will be launched to provide door-to-door health care services far-flung areas to begin with. Sanitary napkins will be provided free of cost to rural girls through the ICDS network and village health nurses. A sum of Rs.46 crore has been provided for this.

Emergency transportation provided through the 108 ambulance service will further be extended to offering inter-facility transfer for all emergencies. Additionally, special vehicles will be put into service in tribal and hilly areas, and one vehicle will be provided per district for transporting new born babies.

Choose your health cover with care

Check for renewal ceasing age, co-pay norm and sub-limits before opting.

A health insurance policy is a ‘must-have’ according to financial planners. Yet, picking up the right health insurance is not an easy task, given that there are 23 health insurance companies. Consider the six to eight life insurers offering health benefits and customers can be spoilt for choice.

While cost is certainly a deciding factor when choosing a plan, here’s a checklist of what else to consider.

Renewal ceasing age: Customers buying insurance rarely look at the age of policy renewal. The renewal ceasing age is the one when the insurer, no matter how long you have been with it, will refuse to renew your policy. For instance, health policies from ICICI Lombard cease at age 70.

Obviously, the higher the renewal ceasing age, the better. Most companies now offer higher or even lifetime renewal policies to customers.

Co-pay options: Typically, as health risks rise with age, companies ask customers to chip in. Besides higher premiums, customers may also have to co-pay for the policy. Companies follow different parameters to decide when they will convert the policy to a co-pay scheme.

For instance, Star Health Insurance begins co-pay once the renewal ceasing age sets in. So, customers could extend their period of coverage by changing their existing plan to a co-pay scheme. Bajaj Allianz General Insurance asks to co-pay if the customer goes to a non-network hospital.

Exclusions and PEDs: These two factors are the most painful ones. An exclusion is a statement in an insurance policy which describes a condition or type of loss not covered under it. Like, hospital cash plans do not cover dental treatment or surgery, pregnancy-related treatment, childbirth and so on.

KG Krishnamoorthy Rao, MD & CEO, Future Generali General Insurance, says, “Check for the coverage in terms of the inclusions and exclusions. These are mentioned in the policy brochure. And, if it does not cover something, you can either opt for other plans or take a rider.”

Another important feature, pre-existing disease (PED), may or may not be covered in health policies. PED is an illness or medical condition diagnosed prior to buying the policy. Nowadays, most companies cover PED with a lag of two to four years.

Sometimes complications arising from already existing diseases may also not be covered for the first four years of the policy. Senior citizen health plans exclude many ailments and, in many cases, need to be topped up with a rider.

Sub-limits: Check, Krishnamoorthy warns, to check for the limit on payments against the health plan. Health insurers reimburse those expenses that have been incurred reasonably. This is one way for insurers to restrict payments, especially when they think there is overcharging by hospitals. Typically, policies have a cap on the hospital room rent, operation theatre, ambulance charges and so on. For instance, ambulance charges on Bajaj Allianz Health Guard are only up to Rs 1,000.

All other charges, too, are reduced in proportion to the room rent cap. This is primarily because the charge structures levied by hospitals varies by the type of room chosen by you. But insurers are trying to do away with it. ICICI Lombard Family Protect Premier does not have sub-limits or a cap on room charges.

Policy issuer: According to health insurance experts, there isn’t much to debate here. “A traditional plan from health insurers should be the first medical policy that you buy, as these are exhaustive. Those from a life insurer can be an additional buy,” says Mahavir Chopra, head of e-business and retail, Medimange.com.

Traditional policies from health insurers or indemnity plans settle claims on a cashless basis or they may reimburse your bills. Life insurers who offer benefit plans or Hospital Cash Benefit Plans pay a fixed amount as soon as the illness is diagnosed.

Policies from life insurers offer restrictive covereage. They also have limits on the amount paid per day and the number of days the benefit can be availed. Say, you are supposed to be paid Rs 25,000 for a surgery; you will get it. But if the actual expense rises to Rs 40,000, you will bear the extra Rs 15,000.

ICICI Lombard associates with Air India Express

ICICI Lombard is collaborating with Air India Express to provide travel insurance solutions to overseas and domestic travellers. This would enable customers to take advantage of Group Travel Insurance (Overseas) for a period as short as 15 days or their return to India, whichever is earlier.

The policy covers customers travelling abroad against possible risks and situations such as medical expenses caused by hospitalisation arising out of accidents, loss from trip delay, loss or delay of checked-in baggage, loss of passport, etc. Talking about the tie up, Neelesh Garg, executive director, ICICI Lombard General Insurance said, “Our partnership with Air India Express brings together a comprehensive, cost effective travel insurance cover at the time of ticket purchase along with the ease of instant online policy issuance. The product coverage has been carefully designed to meet the needs of Air India Express’ guests and has a convenient claims settlement process.“ The company has also tied up with Europ Assistance, a leading global assistance provider to provide hassle free claim settlement.

BPL insurance plan hit by payment delays

The government’s flagship health insurance scheme for below poverty line (BPL) people, Rash­triya Swasthya Bima Yojana, is in trouble as about Rs 250 crore premiums due to insurers is pending with state governments. In turn, claims worth Rs 96 crore made by hospitals have to be settled by insurers as of April 15, 2011. RSBY is subsidised by state and central governments in the ratio 25:75.

Insurers and their third party administrators have complained to the centre about delay in premium receipts. The centre, in turn, has pointed to the longer time taken by them to settle claims.

The government has held discussions with chai­rmen and managing directors of insurance companies and TPAs in Raipur during May 2-5 to resolve outstanding issues. Labour ministry has also begun one-to-one meetings with chiefs of insurance companies and TPAs beginning last Friday, said Anil Swar­up, joint secretary in labour and employment ministry.

“Delay in payments to insurers is a problem. It happens as the payment has to be made in advance and also since RSBY has expanded very fast. The bu­dgetary requirements have increased and processes take time. However, in so­me cases, 100 per cent premium has been received by insurance companies yet the claims are not settled to hospitals,” Swarup said.

“We have raised the issue at national and state-level workshops emphasising the need for state governments to expedite payment to insurance companies. There has been quite a lot of improvement in states like Punjab, Kerala and West Bengal that have set up mechanisms thr­ough which money is housed with a state nodal agency and is paid to the insurer,” said Swarup.

“The central government has just recently cleared all pending bills of insurance companies. It is now only the dues from the state governments that are pending,” added Swarup.

G Srinivasan, chairman and managing director of government-owned United India Insurance, said, “Rs 50 crore to Rs 60 crore is outstanding with the governments in the last four to eight months. We are talking to the governments to get timely payment and are not contemplating withdrawing from the scheme.”

A senior official of Oriental Insurance said, “The premium booked by us last year was Rs 150 crore of which Rs 40 crore is still outstanding.”

ICICI Lombard has to receive Rs 27 crore premiums from the central government while Cholamandalam MS General has Rs 50 crore pending.

Alok Agarwal, executive director at ICICI Lombard, said, “We are talking to RSBY coordinators in expediting the payment. We are not considering withdrawal from the scheme.”

Even though RSBY requires that insurance companies settle claims in 21 days, government-owned insurers have not been able to settle even 50 per cent of the claims in the past three years.

Data with Financial Chronicle show that four government-owned insurers — New India Assurance, Oriental Insurance, National Insurance and United India Insurance — have yet to settle more than 50 per cent of the claims on April 15, 2011. Among private insurance companies, ICICI Lombard has 35.31 per cent claims pending while Tata-AIG General has 28 per cent. However, companies like Star Health and Allied Insurance, Apollo Munich and Iffco-Tokio have no pending claims.

“The inertia in government companies is more. Private players, on the contrary, are more innovative and have evolved systems for faster claims settlement,” said Swarup.

State insurers and private insurers have a market share of 50 per cent each in RSBY. Overall, the scheme has been profitable for insurance companies. There are 11 insurance companies that have insured RSBY beneficiaries.

Budget allocation for RSBY in 2011-12 was Rs 279.94 crore. This is significantly lower than the actual spending of Rs 445.89 crore in 2010-11. The fall comes despite extending the coverage of the scheme to include unorganized workers in hazardous mining and associated industries.

RSBY was formally launched on October 1, 2007 and became operational on April 1, 2008. So far, more than 2.34 crore smart cards have been issued and nine crore people have been covered. The scheme is running in 25 states. It provides a cover for hospitalization charges of Rs 30,000 for a family of five.

What makes National Insurance third best?

In the HT-MaRS survey, customer satisfaction on customer servicing and interaction was measured using six parameters — product enquiry stage, purchase transaction, policy issuance, hospital network, renewal, and transparency. And the public sector National Insurance Company (NIC) ranked third, coming after private sector Tata AIG and ICICI Lombard.

There was also that little matter about it being the only state-owned company to feature at all among the top five in terms of customer satisfaction. The survey was carried out among 2074 medical insurance policy holders in eight major cities of India — Delhi, Lucknow, Kolkata, Mumbai, Ahmedabad, Chennai, Bangalore and Hyderabad.

While industry analysts said that the insurer had resorted to reasonable pricing, which went in its favour, insurance sector experts pointed out that claims settlement takes longer in NIC compared to its competitors, which might explain the third position.

“It takes about one to one-and-a-half months for settlement of claims in NIC,” said a leading third party administrator (TPA), on conditions of anonymity.

So what can public sector insurers do to get better in the area of customer satisfaction?

The four PSU insurers — National Insurance Company, New India Assurance, Oriental Insurance and United India Insurance — which together manage about R6,000 crore of health insurance business, complain about being saddled with a commercially unviable claims settlement ratio of 115%. They have to say that the way TPAs function also has a major bearing on customer satisfaction, and forming a common TPA is one way of cutting down on costs.

“The four state-owned general insurance companies are looking to engage a third party administrator to ensure that customers are not put through any major trouble especially when we have no health regulator, the process is on track and we hope to have one soon,” said NIC chairman and managing director NSR Chandra Prasad.

TPAs are intermediaries between patients and insurance firms. Typically stationed at hospitals, TPAs take care of the administrative process of mediclaim policies. “This arrangement will provide economies of scale to the four insurers,” said Prasad. NIC has set a claim settlement target for 2010-11 at 90%. And as Prasad lets in, “We are focused on customer service more than profits and business models.”

As Amit Mitra, secretary general of industry body Federation of Indian Chambers of Commerce and Industry puts it, “The emphasis has to be on consumer awareness and satisfaction, provision of quality health care, improved insurance services and greater collaboration and trust between insurers and healthcare providers.”

Is it possible to switch my health insurance provider

Yes. Health insurance portability facilitates one to switch your service provider if you are not happy with their services without compromising on policy terms. This will increase competition thus help you well-priced and more quality services. In fact it is going to be possible from the 1st of July 2011, just 4 months away!
Sanjay Datta, the head of health at ICICI Lombard General Insurance said, "It is more like mobile number portability. Waiting period of customers will be removed".
This is going to bring immense relief to unsatisfied health insurance customers. And, portability is going to make the health insurers very competitive thus making them serve their customers better.
Bharti AXA General Insurance CEO and Managing Director Amarnath Ananthanarayanan said, "There will be increased competition in the sector and better quality of service. Overcharging and variation in rates of premium would be reduced".
The Insurance Regulatory and Development Authority or IRDA – the sectoral regulator has issued guidelines has made it compulsory that pre-existing diseases (PED), which are covered by the existing insurers, would also be covered by the new insurer. Also the insurance companies will have to provide all records and claims history of the customer to the new insurance company.
To quote IRDA - "It is essential to protect the policyholders against discontinuity and consequential loss of PED cover by making the health insurance plans portable across the insurance companies".
Datta said, "Customers can now choose to shift their insurers in a hassle free way as there would be lot of choice of them and would also ensure better quality of service from the insurance companies by increasing competition".
Max Bupa Health Insurance CFO Neeraj Basur said, "This will bring in more transparency and will also allow insurers to assess the risk and provide underwriting at the point of sales".
Insurers say that though group insurance policies would be easily portable, individual policies could take some time; as, group policies offered by different insurers are mostly similar in nature but individual policies work out differently according to individual customers. Also, it will take time to ensure satisfaction after portability of individual health insurance due to dissimilar benefits and features of individual plans. The long and short of it is at least there is a chance to change your health insurer and get better service.