Cashless Health Insurance Claims | What is going on??

General Insurance companies have taken the battle to the hospitals. In a move that is aimed at reducing the exorbitant level of hospital claims and cost, the four public General Insurance companies (New India, National, Oriental and United India) have decided to stop/reduce the facility of cashless health insurance claims in the top hospitals of the country. About 100 of the preferred partner network hospitals (PPN) have been struck off the list from July 1, 2010. Most of the renowned, branded private hospitals have been removed from the list of hospitals where cashless health insurance claims are entertained.

What is a cashless claim: The cashless claim feature has been primarily designed for the benefit of the insured. Under this, whenever the insured person has a hospitalization claim, s/he does not have to pay the hospital bills but the bill is directly paid by the insurer to the hospital. Thus, there is no cash outflow from the patient. In theory, this is great as it eliminates the cash outflow from the patient.

But where is the problem: the problem has been that because the bill is directly settled by the health insurance company, the financial stakes of the patient has become nil under the cashless claim and s/he has stopped being bothered about how much the hospital is charging. This has been a boon to the hospital as they can charge as much as they want from a price indifferent patient. In this entire process, the fact that for a tripartite agreement to work , there has to be a stake for all the three parties has been violated. All the risk has been passed on to the insurer.

At the same time, reducing cashless will still prove to be a huge inconvenience for the genuine insured person who has cash flow issues in paying directly upfront for the exorbitant hospital costs. In this entire process of trying to do away with the cashless facility, are we throwing the baby out with the bathwater.

One good solution could be that for any cashless facility, there has to be a mandatory co-pay option. This would lead to the consumer (i.e the patient/insured) to have a financial stake as a part of the bill would need to be paid by him, and thus he would be conscious that the hospital is not overcharging.

There is another point to note here: why is it that the claims ratio (around 115%) of the public general insurance companies is far higher than that of the private general insurance companies. The basic fact is that the public companies have far lesser controls than the private players, which opens it up for potential misuse. An overall overhaul of their management practices might be more efficient in reducing the claims ratio rather than by stopping cashless claims. The danger in the path that the public health insurance companies is taking is that their customer base could move away to the private health insurance companies.

The latest noise that one is hearing is that the public health insurance companies will be extending the cashless facility on a case to case basis, whatever that means. There is also talk of a new grading system for hospitals. There has also been news that a 10.3% service tax on the cashless claim amount has to be paid by the TPA to the hospital. In effect this would mean that around 10% of the claim cost would get transferred to the insured. In the case of reimbursement (instead of cashless facility), this claim will not be there. The final word is yet to be written on this issue.