Cashless claim settlement is a key benefit in health insurance, especially when one is afflicted with a cost-prohibitive critical illness, or there is a situation warranting huge medical expenditure. The least an insurer and network provider or hospital can do is to ensure that patients and families are not burdened with financial worries when they are entitled to protection through their health insurance cover.
There may be individual situations where cashless claims are denied. For eg., when a hospital has payments pending from an insurer, or when a particular insurer and hospital are sorting out their pre-agreed tariff rates. However, the recent trend of industry bodies and hospitals facing off under the veil of collective bargaining is distressing for policyholders.
Health insurance covers don’t come cheap, and when one cannot get cashless benefit, it further dilutes the trust factor, something that insurance as a financial protection mechanism is already struggling to overcome.
The regulatory framework for health insurance has been evolving to ensure that policyholders’ interests are always protected. Thanks to a regulatory push, the insurance industry is moving towards 100% cashless settlements. There are initiatives such as ‘Cashless Anywhere’ where the service is provided even where a hospital is not a network hospital that offers such services.
All such initiatives get overshadowed when hospital-insurer disputes take the limelight. The Insurance Regulatory and Development Authority of India (Irdai) is always quick to step in to advise the parties concerned to sort out issues. The regulator, however, does not get into the facts of the case, as that is not what it is expected to do. The parties involved have the prime responsibility to ensure that the policyholder is not inconvenienced.
Meanwhile, rising healthcare costs get built into health insurance, invariably burdening the policyholder. This is why insurers try to ensure a hard check on what they pay out. Having said that, insurers too could do better by keeping management expenses low, thereby reducing the cost for the policyholder.
We all agree that there should be no compromise on care and cure. The moot point is, how much cost is justified? This is where we miss having a regulator for the healthcare industry. Then again, how can the healthcare industry be compensated for increasing costs? Has any analysis been carried out of the costing for various diagnostic and treatment procedures? Do we know why hospitals in different geographies charge differently, or hospitals even within the same geography charge differently for similar quality of care?
There needs to be some methodology and standardization which will balance out the issues for both the industries—healthcare and insurance. The Common Provider Network that the insurance industry is working on will definitely help in this direction to some extent.
By offering financial protection to individuals, families and groups for health expenditure, the insurance industry makes it affordable for many to go to hospital for care and cure. An analysis will clearly show that people can afford treatment because they are insured, and that hospitals are able to offer their services to a larger section of the population.
There is a need to put the patient and policyholder before everything else. It is indeed laudable that the parties do try to get together and ensure that there are no scenarios where cashless service is denied en masse. But it is equally important that they ensure there is no panic created among policyholders due to uncertainties.
All industry stakeholders—and there are many of them in the health insurance value chain—have the responsibility to conduct themselves in a manner where they earn the trust of the policyholder. If instances of unnecessary claim delays or denials on the part of insurers are true, insurers must indeed pull up their socks. ‘Insurance For All by 2047’ will fructify only if all stakeholders focus on claims servicing. An oft-repeated phrase—‘A claim is the moment of truth in insurance’—can never become cliché.
Irdai’s framework is very facilitative, be it protecting the policyholder or enabling the insurer. The objective is clear—offer insurance protection and live up to the promises you make.
Yegnapriya Bharath is former chief general manager, health insurance, Insurance Regulatory and Development Authority of India.