Health Insurance – How to Facilitate Free Treatment

Health insurance companies in the country have started providing 100 percent cashless treatment on the instructions of IRDAI, the insurance regulatory authority.

This decision to implement a cash-free treatment system is beneficial to the policyholders. It is also a means of managing claims for insurance companies.

To avail of free treatment through hospitals, the criteria approved by the Insurance Council have to be met. Once the authorization letter is approved by the hospital for cashless treatment, an agreement should be signed with the insurance company. The benefit here is for insurance companies, consumers and hospitals.

Role of Hospitals: Such schemes can be run smoothly only if the insurance department of the hospitals is impeccable. All hospitals shall provide the rates approved by the General Insurance Council for treatment and medical expenses. At the same time, policyholders should have the facility to know the details of this information in time. They should know about the coverage amounts, excluded diseases, other terms of the policy, the coverage available to the hospitalized patient, the risks not covered and the amount to be paid under various health insurance policies in India.

Conditions should be made for treatment in hospitals at reasonable rates. The health insurance departments in hospitals should be more equipped. Should be able to gain knowledge about the policies of various insurance companies in India and be able to convince the customer about it. Hospitals should also take the initiative to educate the general public about health insurance.

Insurance companies: First and foremost, a clear treatment package should be prepared and the insurance settlement department will settle the charges directly by the companies should be crystal clear. The services of specially skilled people and doctors should be ensured. Claims should be settled promptly in time with skilled persons, albeit third-party administrators. The claim amount must be paid to the hospitals within 30 days after receipt of all the supporting documents. New types of health policies should be issued in certain new situations accordingly. Awareness about health insurance should be spread among people. Strong measures should be taken against wrong/bad marketing practices.

Claim Procedures: In case of a claim, the information should be reported to the insurance company/TPA company immediately. Free treatment is available only on acceptance of rates approved by the Insurance Company/TPA Company. Free treatment is available only subject to the terms of the policy. Such treatments can only be obtained from institutions that fall within the definition of a ‘Hospital’. (i.e, 15 beds, local body’s license, authorized doctors/staff, operation theatre etc.) and also their address, email and contact number should be provided.

At least 24 hours’ notice should be given in case of emergencies and accidents. A pre- authorized report prepared by the insurance company/TPA from the hospital, understanding what the illness is and how much the treatment costs are sent to the company. The treatment costs given in it will be compared with the rates available to them and after that the insurance company will send the rates approved to the hospital. The existing rate is compared with the available rate, and approved by the insurance company is sent to the hospital.

Certainly, health insurance’s importance will increase further when free treatment is available through hospitals. Together, the hospitals, insurance companies, etc related to this sector should educate the public about its importance. In the future, hospitals’ income source will be mostly via health insurance. So the health insurance department of each hospitals should acquire more knowledge, skills and experience. Then the patients can return from the hospital smoothly, disease-free and without any hurdles.

A regulatory authority should be established to regulate the health insurance sector. There should be facilities to pay health insurance premium in monthly instalments.

A portal that contains all the information related to the health sector should be shared with the general public.

In the future, there should be a portal that contains the health information of every citizen of India.

Hospitals also should have access to disease information, insurance information, etc. from this portal as per requirements.

Viswanathan Odatt Managing Director,

AIMS Insurance Broking Co., Phone: 9895768333


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