Jan 21, 2008 05:29 PM
27146 Views
(Updated Jan 21, 2008 08:34 PM)
Health insurance is one of the weakest links in the insurance chain - of course the government had no major say in its change so far and often overlooked it through macroscopic eyes.
Thyagarajan walks into Manipal hospital after being recommended for an operation by a trusted doctor. The most FAQ while being admitted to a hospital -'Do you have health insurance?' or are you paying by yourself? You are not worried if the fee is exorbitant if you have medical insurance for the networked hospital. But if you have noticed the fee when you pay by cash is at least 25% lesser than what it is otherwise with insurance.
Naveena recently had a baby. Her husband, being a techie had a valid medical insurance. But they admitted her in one of the smaller nursing homes near her place. The entire cost of maternity including 3 days of stay at a nursing home nearby cost them 8800/- At the same time, one of her neighbors who delivered a kid earlier the same month wanted it to be a cashless transaction cost around 17900/- Naveena's husband submitted the bill for 8800 and got back the entire expenses(except the baby blankets) used for the new born baby.
One of the less lucky persons is Kantaraj. He had an ear operation done to enhance his hearing.(Bone tissue growth was blocking his hearing due to sinuous problems and his hearing was affected in both ears) The specialist mentioned that the cost would be 17K at his clinic since Oriental insurance didn’t support his clinic. The company based insurer didn't provided cashless transactions for a nursing home which had fewer than 20 beds. When Kantaraj approached a big hospital, he was informed that the cashless transactions would be available at a whopping 46K including medication, operation and the stay at the hospital. The only reason Kantaraj preferred the specialist was since he trusted the specialist more than the doctors at the big hospital. This was due to - His initial meeting in which the doctor accurately explained the symptoms since birth and also gave an accurate analysis of his current problems with a clear explanation. Even though he needn't have paid a single penny, it was his ears and he decided to give the specialist a try at his own cost. He raised the issue with the insurance company before and after the operation, but in the end had to shell out his money independently. Thankfully, he has no regrets. The operation(stapedectomy) concerning the middle ear was a huge success and he doesn't have to get a second operation done for the other ear. However, he cannot get a refund since the clinic was a 5 bed clinic.
All the above situations are true and no names have been changed. Medical insurance increasingly offers scope for such frauds. While watching a recent news item on TV about insurance and risk mitigation(Sunday), it got me interested enough. The expert had stated that the determining factor of your insurance policies is
a. 25-30% of your targeted income in medical insurance. While it is good to have a failover policy, why should a policy, even cashless jack up the costs of the operation?
b. The government thankfully has noticed this, but is yet to determine the price of each operation independently. If it does, I hope there is more uniformity in the pricing of operations.
The amount you spend on medical insurance should not be determined by your income, but by the number of dependents. Suppose a working couple has dependents, they can increase the limit of the insurance by decreasing the number of dependents each individual can support. Suppose Mr. Paul had himself(compulsory) and his parents on insurance, Mrs Paul can add the children on her side. This reduces your costs involved in medical insurance while increasing the limit each head is liable for. In such a case, taking an additional medical policy is unnecessary and unwarranted as all dependents are covered.
Taking an additional medical insurance policy is unnecessary if insurers work towards providing services better. For ex., if you have a workplace issued insurance, then the insurers can provide additional services which enhance his margins while reducing my costs. I would prefer a single point of contact who offer me and my family all the health benefits instead of contacting different insurers for different claims. That might turn out a headache. Besides multiple insurers are not going to refund you for the same operation, so what exactly is the point of holding multiple ones?
What to look for in a medical policy
a. A medical policy should typically reimburse doctor visits and diagnostic services. Does your policy offer this?
b. If the hospital is not in the list of networked hospitals, does it refund the costs even if it is a small clinic offering diagnostic services?
c. Can you change your dependents every year depending on your requirements?
d. How fast is their service? Can you contact them by phone?(no, not the automated machines, but a living person)
e. Cost of the package decreases if there is a decrease in the claims amount.
f. How fast is the amount refunded if it is a cashless transaction.
g. The cost of the operation should be determined according to location and hospital and paid accordingly. However there should also be a mechanism to check rampant overpricing for people with insurance.
h. Senior citizen ailments must be diagnosed free of cost anywhere in India. This can be done as they already have a huge senior citizen cost component.
i. Why opt for additional policies when you have company sponsored insurance? We can pay additional charges for additional leverages which work a cheaper cost to us and at the same time increasing the insurer's margins. I believe they should begin to work in this direction and provide add ons for workplace sponsored insurance.
Unfortunately, I am yet to find any which provides all the above requirements.
