Gopabandhu Mohapatra
“Health is wealth” is a common phrase. Yet we understand the true meaning of the expression only when we fall sick or get hospitalized, resulting in medical expenses, physical pain, emotional distress, and financial strain. Surveys have shown that ill health and its related costs are the biggest causes of indebtedness in rural India, with one fourth of the rural population in the poorest groups falling into a debt trap to pay for healthcare.
In India the public healthcare facilities are never adequate to meet the healthcare requirement. Generally, patients have to rely on the more expensive private healthcare services. Lifestyle related ailments are common these days. Healthcare is becoming increasingly expensive. It is difficult for a family to quickly arrange for huge amounts of money required for treatment. Most of the savings of a family are in the form of fixed assets, which cannot be liquidated quickly. Moreover, in certain critical illnesses, the cost of treatment can be exorbitant, causing a severe strain to the family’s finances and their savings are rarely sufficient to meet such healthcare expenses.
Due to liberalization of economy and general awareness, the health insurance industry which was launched in the year 1986, has brought tremendous improvements in the quality of life at the cost of affordable healthcare for many, and it is popularly known as Mediclaim. The purpose behind buying health insurance is that if you or a family member needs medical treatment, at least the need for immediate finances is met through medical insurance. Usually, the minimum age for entry is 5 years and maximum is capped at 60 years, whereas the proposer must be over 18 years. One can avail the facility up to old age by renewing the policy every year.
It is advisable to take a single policy for all members of the family. It gives the entire family a total cover, which could be utilized by one or more members failing sick. Please note that Pre-Existing Diseases are not covered for certain period depending on the terms of the policy. Usually, medical cover of Rs.3 lakhs to 10 lakhs will keep you free from financial anxiety on the medical front. There is no need to carry cash to the hospital because one can avail of the cashless treatments. Mediclaim usually has features like reimbursement of expenses or cashless treatment by paying directly to the hospital towards charges for doctors & nurses, OT charges, medicines, blood, donors expenses towards organ transplant, oxygen, diagnostic materials and x-ray and so on for 30 days or so and certain pre hospitalization and post hospitalization charges are also reimbursed, but you cannot make a financial income from the process. While claiming the expenses, please remember to submit every document that is relevant and do not miss to collect the discharge certificate and all medical documents with doctor’s seal and signature.
The basic requirement is reimbursement for treatments that requires hospitalization for a day or more, for disease or accidents. It covers all expenses even before and after the actual hospitalization period. Ideally, with cashless settlement you should be able to walk into a network hospital, give them your card number and get the treatment without paying a paisa. In case of pre-planned hospitalisation, you should get the pre-authorised from third-party administrators (TPA). A TPA is an important intermediary between the insurance company and the hospital. It verifies your policy details, on behalf of the insurer, and gives clearance for the cashless services to be processed.The insurance company will examine the claim and will settle the claim as per eligibility and will settle the claim with the hospital directly.
In case of an emergency, you can have the cashless treatment through network hospital by showing your health card. Buying a cashless settlement mediclaim policy would be of no use if the insured has to either pay the hospital himself and get it reimbursed later, or run from pillar to post for the ‘pre-paid’ facility.
Under the Income Tax Act, (Section 80D), the insured person who takes out the policy can claim for tax benefit of Rs.25,000 for self, spouse and dependent children and Rs. 50,000/- for parents, who are senior citizen.
With so many features, the demand for health insurance has grown at a rate of 25 % per year, driven by rapidly increasing awareness, and is going to develop even more rapidly in the future.
But, there are reports of fraud and manipulation by clients and providers, which have implications for the growth and development of this sector. Monitoring systems are weak and there are chances that if the doctor and patient collude, they can do more harm to the system.
In the present day hospitalization treatment, the first question the patients face at the time of admission in a hospital is not about their illness, but whether they have insurance. The price for a patient without insurance is usually less than for a person with insurance. Hospitals in their defence say that the differential pricing is done as insurance companies take up to six months to clear bills.
The Insurance Regulatory and Development Authority will need to evolve mechanisms by which it puts some kind of statute in place to ensure that private insurance companies do not pollute the market.
Informative article, health insurance assumes very important in one’s life, Govt has covered BPLfamilies under govt schemes.this improves quality of life and makes every life as precious and every life is an agent of economic growth with his labour,savings ,capitalist entrepreneurs hip.Loosing a life entails loss of value addition ,similar is also live stock wealth.
But the overbilling ,exploitation by clinical institutes Hospital nursing home etc. needs to be regulated for their prices .Regulators like IRDA,RBI,SEBI,IMA,Drug Controller,CCI etc.
Our parents never had a chance to cover them or their children under any mediclaim policy. The facilities available at present needs more refinement. Like all service providers donot reimburse 100% claim by hospitals. A child above 25 years is not listed within family norm. Sometimes hospitals join hand and blacklist a specific service provider in case of disputes. There is no uniform charges for various tests, treatments, operations. Health insurance is much welcome in present context but as the author says disceplinary authorities need to be much vigilant and insurers and hospitals should not exploit the gaullible patients.
The author has elaborately mentioned the pros and cons of health insurance out of his own experience.
No doubt , cashless transaction is having advantage of both patients & the hospital but many a short comings are observed although
initially the health insurance has done tremendous good work.
– Exorbitant increase of insurance premium.
– Ins Cos have negative mind towards senior citizen & they indirectly discourage.
– Unethical Drs/Corp hospital owners put exorbitant claim on the patient on different pleas. Many a time they retain the patient till their ins limit is over.
– Similarly when hospital & patients collided, it is easy to put burden on ins co.
– Preplanned hospitalisation is having advantage as pilferage is less & settlement of claim is easy.
It is requested that the IRDA/Govt authorities to evolve a policy as regards to have effective control over the Ins Cos on premium, pilferage in hospital and unnecessary detention of patients etc.
Thanks to the author having brought out his views for the awareness of the public in general.
Concerted efforts are required in bridging the shortfalls in the availability of health infrastructure and it’s delivery for better health outcomes.really this article brings an awareness among people to must have a health insurance as all we know this health can never be taken for granted in todays life styles.
Article written by Sri Mohapatra is quite lucid and explanatory.Of late,everybody in the society is almost aware about health insurance .He tried to explain the need for health insurance.No doubt people talk about the pitfalls of the system and the hospital authorities sometime knowingly or unknowingly resort to different deterrent practices to bloat the bill.Insurance company as committed pays the bill and the hospital gets the payment-but alas,neither the doctor nor the patient- derive any benefit out of the transaction.Hand in glove or so,hence,Government authorities should probably find a way out to weed this corrupt practice.When we learn so many good practices from other Countries in the world ,we may find a way out may it be IRDAI or some other Govt. body.However, the author has picked up a good thread about our societal needs od modern day living.Kudos to Sri Mohapatra for his maiden attempt to highlight the Health Insurance.