One of the worst
suspicions of insurance buyers has been confirmed.
Hard data presented to
the court following a petition filed by an activist reveals that claim payouts
are far higher for cashless health covers than the conventional reimbursement
facility where a patent's family has to fork out cash before recovering the
money from insurer.
Indeed, the average
cashless claim disbursal is nearly double that of reimbursement claim payouts
in case of many ailments, according to numbers disclosed by the insurance
watchdog Insurance Regulatory and Development Authority (IRDAI) to the Bombay
High Court.
For instance, the
average claim payout during 2013-14 for diseases of the circulatory system
(including cardiac ailments) was Rs. 81,384 through the cashless facility, but
was just Rs. 38,048 under the reimbursement mode.
Likewise, for diseases
involving blood and blood-forming organs and immune disorders, the average
claim paid out through the cashless mode was Rs, 35,958 while that through the
reimbursement route was just Rs. 17,726.
Activists believe that
reimbursement claims get partially settled as individual policyholders do not
have the bargaining power at that stage, while hospitals can get claims fully
settled due to their relationship with insurers.
“The general perception
amongst policyholders has always been that insurers tend to pay out a
relatively lower amount in case of reimbursement claims. Now, there is data to
back this view,“ said consumer activist Gaurang Damani who in 2012 had filed a
petition before the High Court, following which, the IRDAI framed health
insurance regulations in 2013.
The disclosure on
reimbursement & cashless claims is an outcome of the ongoing court
proceedings concerning the same case. It was found that out of the 22 diseases,
reimbursement amount is lower in all cases except mental disorder.
Insurers, however,
insist that this does not qualify as an apple-to-apple comparison.
“Even within the same
ailment categories, the variations could be due to several reasons. Unless the
classification is done on the basis of treatment procedures, you can not come to
a conclusion that insurers discriminate between cashless and reimbursement
modes,“ said a senior executive of a leading general insurance company who did
not wish to be named.
Policyholders also tend
to opt for `cashless' where expenses are higher and use the reimbursement route
in case of low ticket expenses, say insurers.
Src: Preeti Kulkarni,
ET0
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