Times of India
10 July 2010
By Pushpa Narayan
Chennai, India

Who decides if a patient should be managed medically or undergo a surgery? Who decides whether a patient requires an open surgery or the less invasive keyhole surgery? Doctors. "But that’s in an ideal world. We now see insurance companies often making noises and questioning the doctor’s decisions," says Sanjay Rai, director (marketing and consumer management) Max Healthcare, New Delhi. "We seem to be going the US way. It’s time we learnt our lessons. Insurance companies must advocate good medical practices instead of controlling hospitals," he says. The six centres of the hospital have had over 60 rejections in the last ten days.

Several doctors in leading hospitals complain that they are now forced to spend time explaining to insurances companies about their decisions and why they think it is best for their patients.

"Sometimes, the price they offer for some complicated procedure is ridiculous. They compare the rates of a corporate hospital with those in a nursing home. What they fail to see are the results in the corporate hospital," says Chennai–based cardiac surgeon Dr K R Balakrishnan. "Take for instance, the cost offered under the Tamil Nadu state health insurance scheme. It’s impossible to do a coronary artery by–pass at Rs 70,000 without compromising on quality. There has to be a compromise on nursing, sterility and even quality of antibiotics. It’s important to know that there is cost attached to safety," he said.

Insurance firms, both private and public sectors ones, say they had taken the regulatory role due to increasing fraudulent claims. Star Health Insurance had said that even in the state employee health scheme, hospitals had carried out needless surgeries, including hysterectomy on young women.

"Most hospitals push up treatment costs by around 20–25% when a patient walks in with a policy. The pricing policy for a patient with health insurance cover is different from others who pay from their pockets. They hand over packages for every procedure," said a senior official of Bajaj Alliance Health Insurance.

Most hospitals admit that they have comprehensive tariffs for at least 40 standard medical procedures such as deliveries, heart surgeries, hip and knee replacement and abdominal surgeries. "But it’s not different for non–insurance holders," says Shivakumar Pattabiraman, vice–president of Apollo Hospitals.

"Our pricing is different for different kinds of facilities. For instance, the charges for procedure in the general ward is lower than for those who choose twin sharing or single occupancy. The difference in billing is not just the room rent but every other component as well," he said.

While hospitals and insurance companies argue over their rights, it’s the patient who get caught in the battle. "A private hospital sends a mail to the insurance company to approves money for an elective heart surgery. I have been told to pay upfront. I thought I was doing myself a favour by paying the premium. But I was wrong," says S Santharaman, 45, a private firm employee.

Since July 1, a wide range of hospitals in metros have been knocked off the empanelled list without prior information to the policy holder or the hospital. Many leading institutions like Apollo, Fortis, Gangarams and Max Healthcare have written to the Insurance Regulatory and Development Authority, the monitoring authority, to intervene. "The decision can’t be unilateral. They should at least discuss it with hospitals before taking any such decisions," said Sunil Kapur, head of marketing, Fortis Group of Hospitals.