Can Cashless be Painless too??

A couple in their mid-50s went for a regular annual health check-up, which was after a lapse of almost 18 months, due to Covid situation.?The lady is a diabetic for 10+ years, with not the best of diabetic control, although she has been regular on medicines.?The test results based on TMT reports suggested possible blockages in the arteries and the next course of action suggested was to go for an angiogram to confirm the same. ??All said and done angiogram, although is not a very painful process, it is still an invasive process.?So, the couple kept on dilly dallying their decision to go ahead with angiogram.?After consultation with a reliable and a renowned cardiologist, who also happened to be one of the good acquaintances of her husband, on LinkedIn, it was confirmed that she would certainly need to go for an angiogram.?

The couple has a long-standing health insurance cover with one of the private insurance companies.?As per insurance protocol, for a claim to be admissible, 24 hours hospitalisation is required, although the angiogram procedure per se may not require a stay in the hospital.?If one could reach the hospital early, with pre-booking at the Cath Lab (the place where angiogram/angioplasty procedures are carried out by the cardiologists), it is possible that by evening one could get back home and relax in the comforts of home.?So, why not cover the angiogram as an OPD procedure under the health cover?

The couple, to get insurance cover, therefore, planned to reach the hospital on a Friday morning, depending also on the availability of the consulting cardiologist in the hospital, so that if no further procedure is needed, they could return home on Saturday morning.?But, as it turned out, she had multiple blockages and was suggested to undergo angioplasty and placement of a stent in one of the arteries which had a major blockage.?The rest of the blockages were minor in nature and therefore, she was advised to medically manage them to ensure they don’t increase further.

It was almost an instantaneous decision by the couple to go ahead with angioplasty which was also supported by their only daughter who is also interning at the same hospital, after her MBBS.?That’s when the insurance claim process started.

The process involved submitting a form, which the hospital provided, with details of the policy, details of the patient, her medical history, as certified by the treating doctor, her identity proof, etc., along with the estimated cost of treatment and likely number of days of stay in the hospital.?These documents were submitted by around 3 pm on Friday.?It was only on Saturday the TPA (Third Party Administrator) concerned asked for some additional information about the patient.?Incidentally, there was not a single query on the medical history and/or on the treatment. ?The queries were more pertaining to the identity of the patient.?Not sure, if that is triggered by the suspicion around the current location of the patient, with address on the insurance policy and on the Aadhar card as Delhi, but the patient was in a hospital in Karnataka.?Btw, the health policies technically cover cost of medical treatment, subject to other terms and conditions, anywhere in India.?

The queries raised were responded to in the best possible manner.?Some of the requirements were also irrelevant.?The first requirement was for the PAN Card of the patient.?Under the Income Tax Law, it is not mandatory yet for everyone to possess a PAN Card.?The patient concerned, being a home maker throughout her life, doesn’t have a PAN card.?So, this was responded to accordingly.?The next funny requirement was for the Employee identity card.?The Health Policy of the couple were Personal Health Insurance Policies and they were not one of those policies issued by the Corporates.?Therefore, the requirement for the Employee identity card was a baseless query by the TPA. (It also reflects how mechanically these guys process claims, with least application of mind).?

After having sent a befitting response to both these requirements, the couple assumed that TPA should be accepting the logical arguments given and should therefore, send the approval.?However, there must have been at least 4 emails from the TPA, with the same request.?In the normal course, if they read and understand emails that are sent to them, they shouldn’t have raised the same query repeatedly.?At least, what they asked should have been some additional information to substantiate whatever explanation was given in the email.?Later there were also requests for a KYC form (Didn’t they know their customer, while collecting annual premium for 16 years???!!!), Form 60 under the Income Tax Act.?Finally the TPA communicated the full approval for the claim at around 8 pm on Monday, which was almost 77 hours after first intimation of the claim.?

It was indeed 77 hours of exhausting and painful wait for them, not necessarily from the point of view of affordability of the treatment, if in case it was declined by the insurance company, but from the kind of questions that were being asked and the need for running around for the claim approval, after having paid premium of 16 long years.?In absolute terms, the actual premium payment itself is much more than the claim and in terms of time value of money, it will be significantly very high.?It resulted in some unwarranted stress to the individuals concerned.?

Drawing lessons from the above experience, I have the following suggestions to make to the Insurance Companies/TPAs:

1.??????While you sell an Insurance product, don’t you foresee the possibility of a claim, howsoever insignificant the probability of such a claim be? If so, what stops you from collecting the documents necessary for a claim settlement, before hand??For example, if KYC is needed, it should be an annual process of getting KYC done along with the annual insurance payment. If identify proof is needed collect it in advance.?If PAN Card is a must, then why issue the policy to those who do not have a PAN Card?

2.??????If you guys can make 10 follow-up calls for renewal payment couple of months in advance from the time the insurance is due for renewal, what stops you guys to talk to the insured directly, while the claim process is on??This may perhaps speed up the process, instead of routing all communication through the hospitals.?Hospitals invariably are dealing with multiple TPAs and very many claims at any given point in time.?Therefore, they may not be able to prioritise to respond in time.?However, if you could reach-out to the insured directly, clarifications on matters other than medical issues, could be much faster.

3.??????Can you guys be more considerate with your expectations, when the patient is in the hospital bed and his/her relatives are busy attending to the patient??It was indeed an insensitive request that you need KYC document with passport size photograph, duly filed and signed by the patient.?

4.??????What stops you guys from?being a bit more transparent wrt your discussions with the hospital, regarding the claim process. ??It costs nothing for your guys to Cc all emails to the concerned individual.