Companies say clients not aware of rules

Though 90 per cent of public sector insurance companies offering mediclaim policies promise cashless medical cover, policy-holders in the city claim they get only partial reimbursement or are dismissed as ineligible for the service. While most customers expect the cashless medical cover to meet all expenses at the hospital, insurance company officials claim that clients are not aware of the policy rules which specify the payable clauses.

A senior official of a public sector insurance company said there were specific conditions for cashless service and reimbursement. Insurance agents need to explain these conditions to their clients. However, poor customer service has resulted in only a few cashless claims coming up for settlement against the number of policies actually sold. Third Party Agents (TPAs), service providers on behalf of insurance companies, get 5.5 per cent of the premium as commission.

Hospital authorities’ failure to submit necessary documents on time resulted in cashless facility being rejected to clients, said an insurance agent. Some hospitals send all documents at the time of discharge, creating problems, he said.

If a client who is eligible for a room worth Rs. 1,000 a day takes up a room that costs Rs. 1,500, the extra charges and proportionate medical expenses are not reimbursed, said the agent.

A person, whose wife underwent treatment at a leading hospital in the city, said he was under the impression that cashless cover took care of all expenses. Not only did he not get cashless service, but his expenses were only partially reimbursed.

Hospitals in the city usually demand that the patients make deposits at the time of admission that are refunded on discharge. Despite being eligible for cashless treatment, he was told that no payments would be made for the injections required in his wife’s treatment. Trouble also cropped up when hospital authorities told him that he had not submitted receipts proving he had paid the premium for the scheme.

Later, it was only at the intervention of the insurance agent that he managed to get at least a partial reimbursement from the insurance company. The process of getting the reimbursement was more agonizing than getting rid of his wife’s disease, he said. In another instance, when 75-year-old Raja Raja Varma, who held cashless cover policy, met with an accident he got neither cashless treatment nor any reimbursement. When he demanded reimbursement, he was asked to produce medical documents certifying that he was not under the influence of alcohol at the time of the accident.