This is the eventuality for which people purchase health insurance so that they do not face difficulties during a health crisis. So, what are your options if you find yourself in a similar situation?
Get in touch with your TPA to bring it to their notice
IRDA has taken this matter very seriously and asked hospitals to stick to the laid down norms. The regulator has released circulars on this issue twice in two days to make sure that insurance companies and network hospitals follow the service level agreement and do not put policyholder to inconvenience.
“The Insurers shall ensure that where the policyholder is notified about availability of cashless facility at the empanelled network provider, the cashless facility at such network provider shall be made available to the policyholders in accordance to the terms and conditions of the policy contract and as per the terms agreed in Service Level Agreement (SLA)” said IRDAI in the circular.
If you face any difficulty, you should make a formal request with your Third-Party Administrator (TPA) for the cashless admission in the network hospital. If you are still denied admission on cashless basis, you can use this denial to lodge your formal complain with your insurer against the hospital.
Get the treatment on priority even on re-imbursement mode
The cashless facility eliminates many hurdles which policyholders face with re-imbursement mode. So if the situation allows, you can go for another network hospital to get the cashless facility. This will not only minimize your out-of-pocket expenses but also make sure that overall expenses does not shoot up.
IRDA has cautioned the insurance providers to make sure that hospitals are following the agreed pricing. “While reviewing cashless requests the Insurers are also advised to ensure that the policyholders are charged as per the rates agreed to by network providers wherever applicable. Insurers are also advised to ensure that hospitals do not levy any additional charges for the same treatment other than those rates that are agreed with the insurers” says the IRDA circular.
The deviations and additional charges that the hospital will make can later be addressed by complaining. “Where any network provider denies cashless facility and deviates from agreed terms of the SLA, insurance company shall take an appropriate action against such network providers as provided in SLA in addition to taking up appropriate action,” recommends the IRDAI circular.
However, if the situation is critical and if the network hospital is offering admission on payment basis you can go for it and later get the money re-imbursed. “All Insurers are directed to ensure that the “reimbursement claims under a health insurance policy shall be settled as per the terms and conditions of the respective policy contract expeditiously. Insurers are advised to issue suitable guidelines on this to all TPAs” says the IRDAI circular.
If denied, get treatment even at non-network hospital
It is the cashless facility which limits your choices to stick to only network hospitals which are empaneled with your insurer or the TPA. In case of denial by network hospital you can also go for treatment at a non-network hospital as the priority remains to save the life of the patient. The re-imbursement method allows you to claim the expenses with your health insurance provider after the treatment.
Though this process may involve some delay in getting refund and also some additional running around but it will help you get the treatment on priority and getting the money back.
Make a complaint against the hospital
The insurance regulator has asked the insurers to regularly communicate to their network providers to ensure hassle free service to the policyholders. It has also asked insurers to report such cases to local authorities for appropriate penal action.
“Insurers are advised to put in place an effective communication channel with all the network providers for prompt resolution of grievances of policyholders. Insurers are advised to report levying of excess charges or denial of cashless facility to the respective State Governments for appropriate action,” it says.
While the insurance company will follow its set course to complain against hospitals, you should register your own complaint in case of any deficiency in availing medical services.
How to escalate your complain to the appellate authority
You should also be aware about the process lodging your complaint and escalating it till it is not resolve or till you don’t get a satisfactory response. Follow these steps to resolve your complaint:
First approach the insurer’s Grievance Redressal Mechanism as spelt out in the insurance policy document. In case the complaint is not fully attended to by the Insurer within 15 days of lodging it, you may use the Integrated Grievance Management System (IGMS) for escalating the complaint to IRDAI.
IGMS facilitates online registration of policyholders’ complaints and helps track their status. A policyholder can make optimum use of this system by giving accurate information about the complaint like the policy number, name of the insurer, complainant’s contact details etc. It would be useful to keep the policy document ready while registering the complaint online.
The Complaint Registration Process involves the following steps-
- Step 1 : Register yourself by entering your credentials (Website: https://igms.irda.gov.in/)
- Step 2 : Use Registered credentials to register complaints / view their status
Alternatively, you can also send the complaint through Email to complaints@irdai.gov.in or call Toll Free No. 155255 or 1800 4254 732.
