‘Cashless & mediclaim arrangements non-transparent’

Amit Rohera has a Rs3 lakh medical insurance policy for the last 10 years and has religiously paid the premiums. However, in his hour of need, when his wife Mona, 30, was advised URS stone removal procedure, he was denied cashless facility by a hospital which is categorised as 'A' grade hospital for cashless facility on his insurance company's list. 

Rohera is now fighting with his insurance company to reimburse the money guided by Vinod Rajani, a risk management consultant having 28 years of experience in the insurance sector.

"It did not help Rohera to shell out hefty premiums for 10 years. And tomorrow it can be your turn to be in the same situation," Rajani said. He was briefing policyholders and doctors on developments in the issue on Thursday.

Rajani has joined hands with many like-minded victims in the city and is forming Policyholders' Association to fight against insurance companies and doctors.

Rajani and his group has begun a mass movement against the logjam and has sent about 400 copies of a letter to Insurance Regulatory and Development Authority (IRDA) that lists the prime concerns of  policyholders. Most hospitals in the city, including those on the preferred partner network (PPN) list of the insurance companies are not offering cashless facility due to their disagreement with third party administrators (TPAs) on price list.

The letter notes that the policyholder gets benefit according to sum insured and the premium rises with  age. How logical is the price list of TPAs mentioning the same charges for medical procedures for patients of all age groups?

Meanwhile, a petition challenging the new rates insurance companies imposed from May 16 has reached the court.
Dr Pragnesh Vachchrajani, vice-president of Ahmedabad Medical Association, which is in a dialogue with TPAs since over a month said, "There is no solution in sight to the problem. The doctors have to treat each age group differently. Having fixed rates for treating various ailments is illogical. It is a known fact that no insured person usually gets the fully claimed amount. However, the new rates forced by TPAs have irrational cuts."  

"After detailed study AMA members have found that the entire process of new cashless and mediclaim arrangements is non-transparent," he added.