Page 28 - Insurance Times March 2017 Sample

reimbursement more than the package rates invariably Annexure "C" - Implication
complete reimbursement. By providing the cashless facility
In practice it has been observed that in many cases the PPN
the insurer cannot create such discriminatory situation for
system hospitals/NH are charging extra amount much more
the policy holders which defeats the very purpose of the
than the agreed package rates and insured invariably does
principle of indemnity.
not get reimbursement for the same under the policy nor
the refund for unjustified charges is arranged by the TPA .
Sum insured-wise package rates and categorisation is un-
The patient, when undertakes treatment is asked to give
justified. The higher sum insured Policy holders say having consent on form known as Annexure "C" for any extra
sum insured up to 50 lacs or basic 5 lac + higher Super Top charges.
Up are provided the same package rates as that for the
policyholder having sum insured of Rs. 3Lacs. Also the hos- As the scheme provides that the agreed package rates are
pitals/NH which is of different standards/categories it is
for standard, non-complicated cases as mentioned in the
observed that within agreed package rates such hospitals/
approved procedure list the hospitals have right to obtain
NH provides deferential standard of rooms than the entitled
undertaking from the patient for any extra charges arising
category as defined in the PPN scheme.
out of insured availing higher facility than the standard fa-
cilities as also for cost escalation on valid medical ground.
The provision under scheme that in the case of multiple
procedures under PPN the 2nd surgery shall be paid at 50%
However wordings of such undertaking must be appropri-
of the package rate is unjustified. This provision again cre-
ately stating that "the treatment being provided is at the
ates discrimination for the policy holders. For the treatment
agreed package rates and by doing so there will be no com-
in NON-PPN hospital such restriction of 50% for second sur- promise in terms of medical services for the relevant treat-
gery is not applicable.
ment. However extra cost, if any, arising on account of com-
plicated medical conditions, patient availing higher facilities
In some of the insurance policies differentiating terms and than the standard facilities and any other valid reasons on
conditions are applied for treatment taken in PPN system medical grounds shall be borne by the patient."
and NON-PPN system hospitals. For example if the treat-
ment is taken in NON-PPN hospitals 10% of co-pay is applied
for claims whereas there is no such co-pay is applicable for If the hospital is charging any amount beyond the package
rates they must give full details of the charges in their bill
treatment taken at PPN system hospitals.
stating the reason for the extra charges. As in the scheme
there is a provision that 'No break-up is required to be given
For certain specified procedures doctors/hospitals have their for agreed package rates' specific reasons given by the hos-
different approach of treatment as a result of which cost pital/NH for any extra charges must automatically be ac-
variation also occur. Standardisation under agreed package ceptable at TPA office if such extra charges are justifiably
under PPN system for such particular procedure deprives relate to valid medical ground and the insured must auto-
the patient to go for treatment of his choice which he feels matically get reimbursement for the same.
is best for him.
If the TPA after examining details given by the hospital/NH
For cataract surgeries main cost relates to the quality of lens
and if required after making further enquiry from them ar-
which is selected by the patient. Under many health poli-
rives at the conclusion that such extra charges are collected
cies there is already a capping for cataract surgeries and
by hospital/NH in unjustified manner they must ensure re-
further lower capping under PPN system deprives the pa- fund of the same from the hospital to the insured.
tient to select better lens for his treatment.
Since the TPA gets the bills and other claim documents for
Such differential treatment is discriminatory under the PPN settlement of claim they have the opportunity to verify the
system and is totally unjustified when at the same premium charges under the hospital bill and find out that any over-
cost insured persons availing treatment in NON-PPN hospi-
charging beyond the package rate has been charged for
tals are compensated in different manner for similar treat-
valid medical ground or not. This procedure must be made
ment. It is not desirable that by providing cashless benefit
obligatory on the part of the Insurer and TPA should be made
PSU companies create such discriminatory situation.
Continued in page 48

28 The Insurance Times, March 2017

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