Medical insurance in India for the elderly – II

(This is a follow up to my earlier post dated 31-3-2013 dealing with a government sponsored insurance scheme for the central government employees and pensioners)

In India medical insurance policies are currently being offered to public by several Public Sector Undertaking (PSU) insurance companies like National, New India, United India or Oriental, etc or by a host of private companies like Bajaj Allianz, Max Bupa, Religare, etc). Collectively these can be grouped as MEDICLAIM type insurance wherein an insured customer is covered mainly for claims arising out of the expenditure incurred by him/her as an in-patient in a ‘network’ of private and government hospitals recognized by the insurance company. Most of these companies either have policies specifically configured for the senior citizens or are extended to age-bands that include the elderly. This is a welcome development.

The customer may choose either a post-hospitalization reimbursement of the expenditure claimed or, more assiduously marketed by the insurance companies, a system of ‘cashless’ direct payment of the incurred expenses by the insurer to the hospital. Many companies, especially those in the public sector, actually outsource the claims management (initiation/intimation, authorization and final settlement) to an interface organization, euphemistically called ‘Third Party Administrator (TPA)’ that is supposed to have the requisite technical and medical expertise to settle the claims. Others declare that they have efficient in-house teams to take care of the claims.

In terms of the sum insured amounts, range of coverage and the corresponding premium, clearly, the policies offered by the public sector companies are much cheaper than the ‘products’ (yes, the policies are offered or being sold as insurance products !) brought to the market by the private players. But premium should probably not be the only criterion to select a health insurance policy. In any case these types of policies target and cover middle and preferably higher income group people usually not eligible or not opting for insurance cover offered by the central and some state governments. Together the total coverage may not be more than about a few percent of the population of the country. 

Be that as it may, here is a checklist for anybody looking for a useful medical insurance in India today to carefully consider (looking beyond the advertisement blurbs, glossy brochures and persuasive agents) before making a proposal to an insurance company. One may not have much of a choice as regards many of the terms and conditions governing a policy. But at least one should be fully aware of them and make a more informed choice among the various policies available in the market.

The issues are important for everybody. For the elderly, the general importance stems from the usually limited funds available to them. But there are many issues specially relevant to them, like the limit of indemnity, maximum age of entry, premium loading and the co-pay requirement with progressing age, the waiting period for the pre-existing illness that are more typical of the old age and the permanent exclusion for what the companies (i.e. their panel of doctors) judge as the congenital disorders.

Moreover, it should be emphasized that these policies do not, usually, cover expenditure for visits either to hospital OPD or to dispensaries of neighborhood general practitioners or consulting offices of specialist doctors for regular treatment of chronic diseases like diabetes or hypertension or osteoporosis, etc, some or all of which could be of major concern to the senior citizens. 

• Sub-limit/ceiling of expenditure (as a % of the sum insured, SI, or the limit of indemnity per illness, defined as a specified period of continuous treatment as an in-patient in a hospital) under any head – accommodation, ICU stay, medicine/drugs, nursing, pathological/laboratory tests, radiological tests (X-ray, etc), scans, CAT lab diagnostic procedures, surgical procedure, operation theatre, anaesthesia, surgical materials/gases used for anaesthesia/drugs used in OT, any procedure to put a prosthetic on or inside the body as a part of the treatment, etc.
• Limit of expenditure on or exclusion of any drug (generic or branded), vitamins, supplements, etc.
• Limit of expenditure on or exclusion of any prosthetic (type, material) put on or inside the body as a part of the treatment.
• List or schedule of day care (less than 24 hrs) procedures (such as dialysis, chemotherapy, radiotherapy, etc) covered. Can these be taken in the OPD of a recognized hospital or only as an in-patient ?
• Co-pay (% of the actual expenditure OR % of the admissible claim) due to any reason – treatment in a non-network hospital, claims arising in cases of pre-existing illness.
• Of especial importance for the senior citizens, (a) is there an entry age limit (70 or 75 or 80 years ?) for joining a plan beyond which insurance coverage will be refused; (b) will the premium be progressively enhanced with aging of the insured (sometimes there are pre-defined premium loading on renewal after a specified age limit is crossed, say, 65 years) or will the % co-payment increase ?
• One should find out the overall/ultimate limit of indemnity (usually a small multiple of the SI) even for a policy that is continuously renewed and no further coverage beyond that limit would be provided for the particular insured [It should be noted that this milepost of denial of cover by one insurance company may eventually be (like a credit rating a credit card user develops with one card company) freely shared by others in deciding to provide or deny the cover in future. This also means that the promised automatic lifetime renewal may be just that – a promise.]
• Senior citizens joining a policy should be especially aware that most companies disallow coverage for some very common disorders (like kidney or gall stones, hernia, piles, benign prostatic hypertrophy, any condition requiring hysterectomy, etc) for at least 12 months after joining, some 24 months (called specific waiting periods)
• What is a pre-existing illness ? Complete list of pre-existing illnesses and the mandatory waiting period before each of these are covered (say, a continuous claim-free period of 24 to 48 months) should be scrutinized before joining the plan. It may mean, for instance, that a diabetic entering the plan at the age 61, with an waiting period of 48 months, will have to keep paying the premium for up to 4 years but can not make any claim against any hospitalization related to any and every disease or health issues (say, peripheral vascular disease) that can be shown to arise due to diabetes. By the time one becomes eligible for cover, higher co-pay might kick in due to one’s reaching an age band of 65 years and above ! Some plans may cover pre-existing illness after a lower waiting period (say, 12 months) but with a co-pay requirement of say, 20% or coverage limited to 50% of the sum insured.
• Can an independently happening diseased condition be deduced or connected to a pre-existing condition (e.g. a cardiac problem happening to a diabetic patient – if such an eventuality occurs within the waiting period will the claim be denied ?). It may be advisable to clarify such issues with the panel of doctors of the insurer before buying the policy. 
• If a pre-existing illness is covered after a waiting period, it should be clarified whether the coverage is for any and every disease or illness that may be associated with the defined pre-existing disease ?
• Congenital disorder/illness and any related treatment are usually permanently excluded. It should be clarified if a correctional treatment or one arising out of such a disorder be considered as a pre-existing illness after a specified waiting period or excluded ?
• What happens when the insured gets hospitalized for some emergency medical condition and on final diagnosis this turns out (based on the medical diagnosis) as a result of a pre-existing or congenital disorder genuinely unknown to the insured? Will his claim be denied outright ?
• While most companies allow a small percentage of SI as expenditure for both pre- and post-hospitalization treatment, further tests etc, if these treatments and tests are not taken at the OPD of the same hospital (in which case the TPA or insurance department of the hospital may help) the claim form sections/documentation required to be filled by the attending doctor or his private clinic may pose practical difficulties (without satisfactory filling of the forms the claim may be denied or settlement delayed).
• In many emergency room (ER)/casualty ward scenarios (before formal admission to the hospital) the patient’s relatives are often not provided with the complete and official prescriptions for medicines to be urgently procured for administering to the patient or the detailed heads (like a blood test/ECG/MRI or ER bed charges, consumables, etc.) not specified under which bills are raised and expected by the hospital to be paid immediately (cash/CC). In absence of a proper prescription consistent with the bills and the amounts paid, claims for reimbursement may be denied or settlement delayed. The relatives either may not be knowledgeable enough or in a stable metal state to insist on such details. Check with the company and the hospital, whether the expenditure incurred in the ER is covered as pre-hospitalization expense or as an integral part of the hospitalization claim.
• Is the ambulance charges part of the hospitalization or the pre-hospitalization claims (is there any medical authorization required ?)
• Is there a provision of annual health check up within the scheme and how is it paid for ? Is it subjected to continuous renewal of the policy for a specified number of claim-free years ?
• Is there a renewal bonus and if so how does the benefit accrue to the insured ?
• Finally, one should be aware of the reality of the cashless claim settlement in a hospital scenario vis-à-vis reimbursement of claim made post-discharge (documentation required in the latter case should be clearly understood and diligently procured to avoid harassment).

Despite assurances by the insurance company officials, their agents and the customer care staff of the third party administrator (TPA) agencies actually administering the medical claims, the so-called cash-less procedure is anything but painless. Prior to (or on the day of hospitalization) the insured patient has to get an authorization from the TPA for the hospital treatment, which requires filling up a prescribed pre-authorization form. Help of the hospital (one would be lucky if the hospital has a dedicated TPA department) is required to fill this form and send it to the TPA for their approval.

Usually it is expected that the insured waits (may be for 3-4 hours or more), may be at the hospital reception or some other convenient place till this approval comes and is admitted only after the financial commitment by the insurer is available to the hospital formally. In case the insured gets admitted pending the approval (which may be needed in emergency cases or where the insured requires to undergo urgent diagnostic tests, procedures as per medical advice) he/she may have to either opt for the reimbursement of the claims post hospitalization or give an undertaking to pay the difference in the hospitalization charges between the actual and the amount to be approved by the TPA in due course.

Post-discharge all the medical and billing information will have to be sent to the TPA (usually  this is done by the hospital) for their perusal, evaluation against the insurer profile with them (most notably about the exclusions due to pre-existing and congenital diseases, if any) and according to their norms regarding what charges mentioned within the hospital bills  (especially some overheads like documentation and office work or some consumables and excluded items included in the bills) are or are not be payable. This processing may take, together with the hospital bill and document preparation, upwards of six hours, as per common experience). Only after the final approved settlement from the TPA, as the authorized representative of the insurance company, is received by the hospital, the insured patient may get his/her discharge, if necessary, by paying any shortfall in payment as required by the hospital.  

Atrophy of ethical common sense - Your wrong doing versus mine

Everybody knows that two wrongs do not make it right. In other words the wrong things, say, of similar nature done by somebody else in the past cannot justify wrongs inflicted by you or me at the present time. This is an ethical common sense hard to escape for anybody. Yet in most conversations between the political adversaries in India this value is conveniently given the go by. At times it does look like a fight between children or silly ego clashes between temperamental adults. But we are talking about serious matters often involving death, destruction and destitution of a large number of poor and helpless people who are anyway living at the edge and mark their time at the mercy of the nature and some powerful men.

Whenever one side criticizes the other of some wrongdoing as of today, rest assured that swift riposte from the other side mentioning similar or related misdeeds of the critic would be invited. If my party is accused of post-Godhra state-sponsored Gujarat pogrom killing two thousand Muslims in 2002, be sure that I will put you on the mat about your party’s active role in organizing and conducting butchering and burning of three thousand Sikhs in 1984 and the government machinery, most notably the police, being complicit in allowing the carnage to happen and sabotaging the dispensation of justice over the next 30 years. If you are going to discuss Gulberg or Naroda Patiya massacre and be silent on the burning of the Sabarmati Express near Godhra that will be an one-sided talk and an indication of your lack of fairness and balanced outlook. If there are a flurry of corruption scandals, during our regime, and losses of public money due to the acts of omission and commission of some of our ministers and bureaucrats working under them, how can we let anybody (including our interlocutors) forget similar misappropriation of funds and cases of financial misdemeanor and sweetheart deals, tailor made policies to suit your crony industrialists and businessmen under your watch in different parts of the country. And so does unspool the blame game.

The amazing thing is that each party feels vindicated by the wrong doing of the other. And once the other party could be maligned with sufficiently strong coat of accusations one could feel relieved and live with one’s own share of the charge sheet. One also has to admire the elephantine memory on both sides of the political divide, helped as they are by technology and perhaps some professional support. Except that such skills are not used to accumulate statistics of hunger, malnutrition and stunted growth with equal perspicacity when the affected population live and die under our political dispensation. All our analytical acuity and statistical prowess would rather be used to prune the number of people taking their lives in our villages from the category of ‘real farmers’ having proper land deeds in their names (and not in the name of their old and infirm fathers), and not just anybody and everybody connected to agricultural activities because they have no other employment, the target being ‘zero farmer suicide’ as reported by some states.

Certain amount of self-righteousness is perhaps at the heart of any political action. But aren’t we overdoing it on all sides ? Moreover, being right should also entail not being wrong on all or most counts that we accuse our opponents about. Sadly, that happens rarely, if at all. As a result no one can occupy the moral high ground any more. If the energy expended and ingenuity marshalled in fault finding exercise directed to others, for a change, would have been redirected towards ourselves and our own decisions and actions, that in turn would have motivated us to take the corrective actions, hopefully, the initiation of the chain of blame would have been much more muted or even stalled from growing by inviting and adding to a similar chain of reverse polarity.