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Medical insurance challenges

open page Radhika Sagar

open page Radhika Sagar  


The hurdles to a smooth closure of claims are innumerable during an illness

There is a raging debate over health insurance and its impact and coverage. These insurance plans cover a finite list of diseases, which are tapered to the convenience of the insurance companies, given the limitations.

Since the time when the physician or general practitioner would carry his big shiny brown bag, the épitomé of bourgeois respectability, to do a home visit for the sick, to the present day of insurance first, treatment later, things have truly evolved on the medical care front.

A long night

My first-hand experience with the health insurance started one such day when a loved one needed emergency surgery and was admitted to hospital. As he was insured, we had assumed it would be a smooth and a hassle-free ride.

No sooner had the thought crossed our mind than reality hit. While the initial process was a quick one, faster than I could procure my belongings, the final proceedings were extremely long and laborious.

During the course of the hospital stay, news of the progression of the disease from hopelessness to relief turned out to be the biggest discovery that cleared our doubts.

Amidst all this, to our amusement, we were periodically visited by a member of the insurance team with an ironic ‘get-well-soon’ card, like a intelligently cloaked insult.

On the day of discharge after a long and emotional stay, as we packed our bags and waited for what should have been a few hours, got dragged into an entire night.

As we were flummoxed by the unusual behaviour, we were duly informed by the insurance team that there was some confusion in regard to a change from the initial assessment of conservative treatment to surgical although all documentary evidence was in favour of the latter. Some of the questions put forth were, was Mr X first diagnosed with the disease, was he diagnosed with early-stage or late-stage disease? Why was it planned as a conservative procedure at the earlier stage?

Voice of reason

Now, as the health condition looks different with regard to each person, one cannot predict the nature or course of a disease or condition. As a surgeon, I can comprehend the reasons behind these decisions, while the insurance company only showed ambivalence with regard to the second decision. What matters to them is how the disease correlates to their insurance status and so their treatment varies.

As the night crawled away, while Mr X awaited his discharge after what had been a long week of emotional and physical upheavals, the rest were skirting across the floors to get a response from the insurance team. Oblivious to the mental stress caused, the team seemed to be moving at a snail’s pace and after an extended clarification cleared the discharge. There are countless stories such as this affecting people on a daily basis where the complicated interaction with the insurance company comes to the fore.


Not all health insurance is created equal. In India it is broadly divided between the rich and the poor. The government-sponsored health insurance programmes were designed to protect those who were vulnerable to impoverishment as a result of expensive hospital care. And so various schemes such as Pradhan Mantri Swasthya Suraksha Yojana, the Employees’ State Insurance and Yashaswini were created.

With the liberalisation of the Indian economy, various private insurance companies made a push to tap into the large Indian market. Numerous plans were being dished out, and the options, as well as the premium rates kept rising.

Although we have the luxury to choose a plan, the process when one needs to use it is truly cumbersome.

Age waits for no one. Truly the one who needs the services most are the aged. Yet with a disease cap it is curtailing the basic care needed for them and causing discomfort to the family as a whole.

The next day, just as I sat musing among a stack of bills and trying to resettle into my daily routine, I received a call from an insurance sales agent of the same group, spelling out excitedly the various benefits and uses for me of a policy. I grinned and informed him that he was knocking on the wrong age group.

The author is a senior resident in vascular surgery at a medical college in Bengaluru.

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Printable version | Jan 26, 2020 8:02:51 PM |

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