Page 21 - The Insurance Times September 2022

amount will be borne by myself or patient only. I have also The scope of cover under various health policies of PSU
been explained that when room service of a category better Companies provides for indemnity for 'Medically necessary,
than the eligible room rent is availed by the patient, not reasonable and customary medical expenses' incurred for
only the difference in room rent but also an equal proportion treatment, subject to terms, conditions which includes any
of all other charges associated with the treatment shall be capping, sub-limits etc. and subject to sum insured under
borne by me. the policy'. If one reads the policy carefully, there is no
definition of implant, there is no definition of category of
Signature :…………………… Signature :……………………". treatment. Yes, various capping and various sub-limits are
defined under the policies.
Causes of failure of this declaration
All the aspects of above mentioned declaration, if we
system
consider in the context of scope of cover provided under
From the above form of declaration, two things are deduced, various health insurance policies, such declaration appears
(1) Better Facility (i.e. Additional Facility or Provision, and to be meaningless. Moreover, in many hospitalisations bills
(2) better Procedure/Treatment for which Hospitals/NH can it is never found that charges are levied for "better
charge additional amount over and above the package rates procedure or treatments". Also, unlike room rent tariff,
and insured has to bear the same. If we look into the first which is published by the hospitals or shown in their
aspect of so-called better facility which is "additional facility websites, there is no differential rates shown for better or
or Provision" availed by insured, the question arises what normal procedure/treatment. Yes, differential rates are
kind of better facility during hospitalisation can be available made available normally for method of treatment, such as
for the patient? Immediate answer to this is better category laparoscope surgery etc. as also with regard to implants,
of room i.e., single room, double room or general ward, such as lenses for cataract etc. It is also pertinent to note
deluxe room or ordinary room etc. Now for this different that in the absence of any definition for covered category
category of rooms, hospital tariff is offered and whichever of treatment or selection of implants under the policy, can
kind of room, patient selects, hospital levies charges indemnity be denied for selection of better procedure for
accordingly. treatment or better implant? Such indemnity is to be
considered within the meaning of capping and sub-limits
For this aspect in most of the health policies of PSU room provided under the policy.
rent capping is provided and not only extra charges over and
above eligible limit of room rent but also proportionate One more important thing is that for similar type of
charge on various other heads of the hospital bill are to be treatment for any disease, even in conventional procedure,
borne by the insured. Besides the accommodation in room requirement of medical attention may differ from patient
what other "additional facility or provision" can be availed to patient. There may be different complications in different
by any patient. Normally, we have never seen that in cases and different quantity of medicines, more
hospitals, treatment in different types of Operation Theatres investigations and repeated treatment may have to be
(say, ordinary or deluxe) are given as a choice to the patient. given, which will certainly increase cost. Such costs, in terms
of scope of policy, are 'Medically necessary, reasonable and
Yes, for certain procedures some advanced instruments or customary medical expenses. As such, how can claims for
machines are used, but in normal circumstances decision to such cases be settled in uniform manner of PPN agreed rates.
use such type of instruments or machineries are taken by
the doctors. As such, it is not understood what this aspect However, it is one thing that additional charges are levied
of declaration means for the insured. in the bill for such defined reasons of the declaration, if any,
and it is a different thing that hospitals/nursing homes
Similarly, for the second aspect i.e., "better procedure/ charges extra amount over and above package rates
treatment" insured is called upon to bear extra charges. For "without giving any justification, whatsoever, in terms of
any patient, treatment at hospital is taken with sole aim of IRDA defined better facility". Invariably, in hospital bills
getting relief from medical situations from which he or she charges are levied over and above agreed package rates and
suffers. In some cases, even such treatment is required to no justification for that is provided under the bill document
be taken from lifesaving considerations. In both the by the hospitals and nursing homes.
situations any patient naturally would like to opt for best
procedure/treatment available. Such bills come in front of the TPA authorities, either at the

The Insurance Times, September 2022 21