Gupta, nevertheless, sought a second opinion. One other physician quoted ₹50,000 for a similar therapy, with simply two days of hospitalization and common physiotherapy thereafter. Gupta went forward, paid the fees and filed for reimbursement. That’s when his struggles started. “Star Well being rejected my declare over a doc discrepancy. I had a street visitors accident, however the insurer assumed it was renal tubular acidosis, a kidney illness. I attempted reasoning with them, however to no avail. I’ve written to the insurance coverage ombudsman now,” stated Gupta.
Such rejections will not be unusual with some insurers. Shishir Bhatnagar, 42, of Noida is paralyzed and has been battling IFFCO-Tokio for the final 12 years over his declare. “I’ve been paralyzed ever since I fell in a swimming pool throughout a marriage. The insurance coverage firm, nevertheless, claimed that I used to be inebriated once I fell. That is completely preposterous and the physician’s assertion on the time of admission clearly guidelines out any alcohol or drug use,” stated Bhatnagar. He filed a case towards IFFCO-Tokio and it was upheld by district and state client boards in Uttar Pradesh. Nevertheless, the insurer has now moved the nationwide client discussion board.
View Full Picture
The promise of medical insurance is proving to be a mirage for policyholders like Gupta and Bhatnagar. Many pay excessive premiums and purchase these insurance policies believing that within the occasion they want healthcare, they are going to be absolutely coated. Nevertheless, that cowl is proving to be non-existent for some, with even pre-authorized cashless claims being rejected in sure circumstances. All of this has led to a rising notion that sure insurers at all times discover causes to disclaim or delay claims. Certainly, information from public disclosures reveals that Star Well being, the market chief, has poor claims settlement ratio—the ratio has fallen drastically for key merchandise (see chart).
In one other case, Vishal Bhardwaj, a New Delhi-based entrepreneur, acquired his daughter admitted within the emergency ward at Sir Ganga Ram Hospital, New Delhi, the place an emergency surgical procedure was carried out on her to repair an belly perforation. Bhardwaj, who had a coverage from Care Well being, utilized for pre-authorization of cashless therapy. Nevertheless, the insurer refused, declaring that it was a pre-existing illness. “They didn’t approve it even after the physician’s assertion in my favour,” Bhardwaj stated in a LinkedIn submit. It was solely after the case unfold on social media that Care Insurance coverage authorized the cashless declare.
An electronic mail despatched to Care Well being on its claims complaints information didn’t elicit any response. Emails despatched to IFFCO-Tokio on the paralyzed Bhatnagar’s case additionally didn’t elicit any response.
Mint reached out to Star Well being searching for particulars on why Pawan Gupta’s declare had been rejected. Responding to our queries through electronic mail, a spokesperson for the insurer stated, “Our medical officers who course of claims might typically ask further data on earlier therapy data and line of therapy, and many others., to reach at an acceptable resolution. The declare can also be adjudicated primarily based on system alerts, previous historical past and coverage circumstances.” The spokesperson added, “Within the case of Pawan Gupta, we acquired two variations of the medical doc. In a single set of paperwork it was talked about that this was a case the place Pawan fell from the steps at his residence. In one other set of paperwork, the case was attributed to a Highway Visitors Accident. Nevertheless, we raised considerations as there have been no data like police data, and many others. In view of this contradiction in medical paperwork, the declare was rejected.”
Earlier this month, a annoyed medical affiliation’s points with Star Well being made their method into the general public area. The Ahmedabad Hospitals and Nursing Houses Affiliation had written to the insurer searching for an pressing assembly to handle points, together with claims rejections and delisting of community hospitals. The letter was extensively circulated on social media, and noticed many irate customers sharing tales about their claims being rejected by Star Well being and different insurers.
“We take care of a number of insurers however my staff that handles claims tells me it is vitally tough to get cashless approvals from Star Well being and Care Well being, particularly for bariatric surgical procedures,” stated Dr Vikram Lotwala, who runs a nursing residence in Surat. Bariatric surgical procedures assist overweight individuals shed pounds and enhance their well being.
In response to the Ahmedabad affiliation’s allegations, a spokesperson for Star Well being stated, “We highlighted a number of deficiencies from some member hospitals in Ahmedabad, on account of which we needed to take away them from our cashless community. A follow-up assembly is tentatively scheduled for the primary week of October.”
To make sure, some hospitals are recognized to cost exorbitantly for cashless remedies because the insurer picks up the tab. This, nevertheless, finally impacts policyholders, as insurers turn out to be suspicious of even real claims. Certainly, when insurers and hospitals are at loggerheads, policyholders are those that suffer.
Claims and counterclaims
Most policyholders desire hassle-free, cashless therapy. However insurers have been sniffing a rip-off within the hefty payments generated by hospitals. Vivek Rege, founder and CEO, VR Wealth Advisors, stated claims are being rejected even in pre-authorized cashless circumstances, as occurred along with his worker, an workplace assistant, whose 24-year-old son had been hospitalized. The insurer on this case, too, was Star Well being.
“Star Well being had authorized the declare on the time of admission however rejected it when the ultimate invoice was introduced. The insurer stated the affected person was not a dependent although the coverage clearly said that kids as much as the age of 30 years may very well be coated as dependents, offered they weren’t employed,” stated Rege. The declare had been rejected on the premise that the affected person was employed, he added, noting that Star Well being had arrived at this resolution primarily based on the admission type, which Rege claims had been wrongly stuffed by somebody on the hospital.
After the declare was rejected, the hospital refused to discharge the affected person until its dues have been cleared. With every passing day, the invoice saved capturing up. “Lastly, my firm needed to foot the hospital invoice. I’ve contested the rejection with the grievance staff,” stated Rege.
In its response, Star Well being stated, “Within the case of Vivek Rege, there was a mismatch within the insured identify talked about within the coverage doc and the affected person’s identify. The policyholder additionally didn’t disclose the identify of his employer. The Hospital data indicated that he was employed on the time of admission.” It added, “After due investigation, once we approached the corporate to confirm if the affected person was a dependent coated beneath the corporate insurance coverage, the employer denied it. Requests to Vivek Rege for added data went unanswered. Because of this, it was not potential to course of the declare.”
The claims ratio
A method to take a look at an insurer’s file on clearing policyholders’ bills is to look at its claims settlement ratio. This metric can be utilized to examine the variety of claims settled in a given interval. The decrease the ratio, the more serious it’s from a buyer’s perspective, and the higher it’s from the insurer’s viewpoint, due to the decrease payout.
Nevertheless, precise claims settlement information just isn’t available in public disclosures, stated Aayush Dubey, co-founder and head of Analysis, Beshak.org, an impartial insurance coverage analysis platform. Furthermore, the ratio solely elements within the variety of claims, not the claimed quantity. “It doesn’t reveal something about how good the insurer is at dealing with claims or the velocity at which it processes them,” stated Dubey.
Star Well being has disclosed the claims settlement information for every of its merchandise individually in its public disclosures. The ratio has fallen drastically for merchandise corresponding to Household Well being Optima Insurance coverage Plan, Star Complete Insurance coverage Coverage and Younger Star Insurance coverage Coverage between 2021-22 and 2022-23.
The variety of complaints about claims is one other metric to analyse the file of insurers. Knowledge compiled by Beshak.org reveals that Star Well being registered the best quantity (49) of complaints for each 10,000 claims registered amongst standalone well being insurers in 2022-23, adopted by Niva Bupa (46), Care Well being (40), Manipal Cigna (19) and Aditya Birla Capital (18). Amongst normal insurers, Navi Normal Insurance coverage (99), SBI Normal Insurance coverage (24) and Shriram Normal Insurance coverage (23) topped within the variety of complaints acquired final fiscal yr.
Nevertheless, a like-to-like comparability between standalone well being insurers and normal insurers just isn’t potential, provided that the latter don’t publish medical insurance information individually (their information additionally contains, motor insurance coverage, theft, fireplace, flood claims, and many others). Usually, nevertheless, the well being enterprise receives extra complaints than different merchandise corresponding to motor insurance coverage.
Market chief
Whereas Star Well being tops within the variety of complaints, it ought to be famous that the corporate can also be the largest standalone well being insurer within the retail section, by way of enterprise. Knowledge from Nuvama Institutional Equities, a broking agency, reveals that the corporate’s market share surged 21 share factors to 33.7% between 2014-15 and 2022-23. The market share is greater than thrice that of the second-largest participant, HDFC Ergo (9.7%).
After incurring losses of about ₹1,000 crore in 2020-21 and 2021-22, the corporate reported a internet revenue of ₹619 crore in final fiscal yr, in keeping with its annual report.
Star Well being has outpaced business development by way of gross sales, backed by a robust agent community (most LIC brokers promote Star insurance policies) and aggressive premium pricing.
Based in 2006 by V. Jagannathan, Star Well being is India’s first standalone medical insurance supplier. The Rakesh Jhunjhunwala household owns a 17.31% stake within the firm. Jagannathan resigned from the Board in June, a month after he relinquished his place because the chief govt officer (CEO). Anand Roy, the corporate’s managing director, has changed him as CEO.
Hospitals versus insurers
Whereas their claims settlement ratio is a trigger for concern, insurers have been fast to level out that they’ve been victims of insurance coverage fraud, which has shot up in latest instances. Whereas there isn’t any publicly out there consolidated information, business specialists say fraud claims may simply make up 10-15% of total claims paid in a yr. If that’s true, the full quantity paid out by India’s 5 standalone well being insurers and 24 normal well being insurers to settle such claims can be within the area of ₹7,000-10,000 crore. That’s kind of a billion {dollars} a yr misplaced to fraudulent claims.
Insurers have even recognized clusters from the place fraud claims ceaselessly originate—Surat and Ahmedabad in Gujarat; Faridabad, Gurugram and Palwal in Haryana; Meerut, Kanpur, Lucknow and Unnao in Uttar Pradesh; Pune, Nashik, and Ahmednagar in Maharashtra; and Bengaluru in Karnataka.
The surge in scamming has pushed insurers to leverage synthetic intelligence instruments, which difficulty an alert on discovering a sample in probably fraudulent claims. Nevertheless, real circumstances additionally get caught up on this internet.
Vikas Mittal, a pharma gross sales supervisor primarily based in Meerut, stated his declare was rejected by Star Well being, which accused him of conniving with the hospital to file a fraudulent declare. “The corporate didn’t take any motion on my repeated mails and in-person visits for 3 months. Thereafter, a surveyor visited my residence and the hospital the place I used to be handled and located advantage in my declare,” he stated. Regardless of this, the corporate continued to reject his declare. “The employees additionally misbehaved with me each time I visited the department. Lastly, I approached Insurance coverage Samadhan and acquired my declare settled,” stated Mittal.
Insurance coverage Samadhan is a grievance redressal platform that helps aggrieved policyholders battle their circumstances with insurers, for a price.
In response to queries about this case, Star Well being stated, “Within the case of Vikas Mittal, there have been a number of claims raised and we authorized ₹2.5 lakh in cashless claims. A number of claims of the policyholder have been flagged on account of considerations like non-submission of discharge abstract. Hospital invoices for each insured (husband and spouse) have been an identical and (there have been) critical discrepancies in numbering of the receipts, which pointed to potential claims fraud. We had additionally acquired suspicious claims from the treating hospital prior to now and our fraud detection techniques had suggested warning.”
Individually, insurers are annoyed by what they time period ‘tender fraud’ within the type of inflated medical payments. They declare that such rip-offs by hospitals contain undesirable medical procedures. However that’s no purpose for them to reject real claims, stated Mumbai-based cardiac surgeon Dr Prashant Mishra. “I don’t deny that such frauds exist, however insurance coverage firms, particularly Star Well being, are taking excessive measures. Whereas renewing their contract, they pester smaller hospitals and nursing houses to simply accept even decrease prices regardless that medical inflation itself has risen to 14%,” he stated. “These hospitals don’t need to lose out to the competitors, in order that they settle for it, however it isn’t sustainable. Skilled docs at these hospitals at the moment are refusing to deal with sufferers coated beneath Star Well being and Care Insurance coverage insurance policies.”
Dr Lotwala from Surat stated insurance coverage firms demand therapy packages which are on par with the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PMJAY), which has very low charges. “Not many personal hospitals have opted for it (AB PMJAY). Satirically, for comparable procedures, insurers settle massive claims from huge hospitals regardless of the extra prices however refuse a lot smaller claims from hospitals situated in tier II and tier III cities,” he stated.
The best way ahead
Business specialists say that the necessity of the hour is for all of the stakeholders to have a constructive dialogue for justified, pre-negotiated tariff packages consistent with what the Normal Insurance coverage Public Sector Affiliation, a bunch of 4 state-owned normal insurers, affords community hospitals.
Consultants additionally level out that policyholders can not await the business to discover a resolution. Policyholders must make a full disclosure whereas shopping for a coverage and must be cautious whereas submitting claims, and insurers, too, must match that by turning into clear of their dealings, they stated.
From the policyholder’s perspective, some specialists consider it’s higher to decide on a dependable middleman who may also help with claims settlement. “When prospects strategy insurers straight, they speak emotionally or aggressively,” stated Sanjay Aggarwal, co-founder and authorized head of Insurance coverage Samadhan. “Insurers don’t entertain feelings. You could converse to them in authorized language to make your level.”
