In a development that may impact health insurance policyholders in Ahmedabad, the Ahmedabad Hospital and Nursing Home Association (AHNA) has declared a suspension of cashless claim settlement for three big insurers: Tata AIG, Star Health, and CARE Health. Some of the hospitals under the AHNA umbrella have ceased to provide cashless facilities to policyholders of these insurers amid ongoing disagreements regarding old rates and suspected blacklisting.
AHNA has cautioned that if the insurers do not sort out the problem, the ban could be extended to the whole state of Gujarat, and this could add to the disruption.
Why are hospitals denying cashless claims?
AHNA President Dr. Bharat Gadhavi mentioned the arbitrary delisting of hospitals, non-revision of treatment rates, and discriminatory payment practices as the primary reasons for the suspension. They assert that numerous hospitals are being compelled to offer treatment at old rates determined 5-6 years ago - rates which do not take into account present medical inflation.
Adding to the woes, they complained that certain hospitals were blacklisted without prior notice and now insurers are offsetting money from already settled claims, financially pinching hospitals.
In the case of TATA AIG, they have explicitly mentioned that "expenses for treatment at any hospital, by any medical practitioner, or other providers that are specifically excluded by Tata AIG and listed on our website will not be covered."
Insurers Push Back: Fraudulent Claims
Insurers have countered the allegations by claiming that some hospitals were delisted for fraudulent reasons.
Tata AIG claimed the delisting was needed to safeguard policyholders from exorbitant costs, which in turn would hike premiums.
Star Health took the same line and threatened legal action against AHNA for what it termed "baseless and misleading claims".
Care Health has so far not said anything about the issue, though reports indicate it is also confronting the same challenges.
According to TATA AIG, “Some hospitals were found to be involved in malpractices; hence, they were delisted by TATA AIG. Such actions are necessary to protect policyholders from inflated costs that ultimately impact insurance premiums. Our priority is to ensure that our customers face no inconvenience and continue to receive uninterrupted healthcare services at an affordable price."
Based on the Insurance Regulatory and Development Authority of India (IRDAI) 2023-24 data:
Star Health got 16,603 complaints, the most by all health insurers.
Care Health got 6,492 complaints.
Tata AIG had 3,792 complaints.
What does this mean for contractual holders/policyholders?
Contractual holders/policyholders may make claims as usual, but cashless facilities would not be available at some of the top hospitals in Ahmedabad. Tata AIG has explained that procedures at hospitals specified on its site will not be covered by cashless settlements.
Even though insurers are reporting uninterrupted services in other urban centers such as Surat and Vadodara, Ahmedabad policyholders will have to endure extra paperwork and financial burden during emergencies.
Low cashless coverage and fewer network hospitals in Gujarat
IRDAI statistics present a dismal picture for Gujarat policyholders:
Out of 6.75 lakh claims, cashless mode settlements were made only in 29.43 per cent of cases, much less than the national average of 60.60 per cent.
In Ahmedabad, there are few network hospitals, resulting in a high ratio of patients to hospitals:
Tata AIG: 1 network hospital for every 23,271 individuals.
Care Health: 1 for every 41,461 individuals.
Star Health: 1 for every 30,311 individuals.
This deficiency forces insured patients to run around for reimbursement claims, particularly when cashless facilities are withdrawn.
Who is paying the price? The policyholder
Without the issue being resolved, individuals receiving care might end up paying out of pocket and navigating a cumbersome payment process. With AHNA poised to roll out the moratorium statewide, things are only going to get worse.
As per a Star Health spokesperson, “Despite our responses to AHNA’s earlier claims, the association has made no effort to engage with us directly. AHNA’s repeated attempts to mislead the public are irresponsible and unwarranted. Few hospitals were investigated for fraud, waste, and abuse as a routine process, and after a thorough review process, they have been designated as excluded providers or have been de-empanelled or suspended for a cashless facility.
Whether IRDAI intervenes to resolve the dispute is yet to be seen, but in the meantime, Ahmedabad insureds should double-check their hospital affiliation and prepare for possible claim obstacles.
(Input from various sources)
(Rehash/Muhammad Faisal Arshad/MSM)
