In the complex world of modern medicine, where hospitals bills are often paid by insurance companies, you need someone to negotiate on your behalf
Two days after surgery to replace both his knee joints, a social worker employed by a hospital informed the patient that the insurance company would not pay for his stay at the hospital any longer. However observing that the patient was barely able to get to the bathroom unaided, the patient-advocate, on her own accord, informed the insurance company that the patient was not ready for discharge and
insisted that he be given at least one more day’s stay in the hospital. The request was granted and the patient was grateful for the advocate’s timely intervention. Left to his own devices, he was in no shape to argue his case with the insurance company call center staff, whose primary goal is to save money for the company, and who do not care about a patient’s well-being.
In the complex world of modern medicine, where hospitals bills are often paid by insurance companies patients - especially those who are critically ill, need a patient-advocate -, someone to negotiate on their behalf with the insurance company, to ensure that they are receiving the care that they deserve.
Mahesh Sharma was stabbed in the neck by unknown miscreants and was seriously injured. He was rushed to a nearby trauma center, but the problem was that this centre was not affiliated to the health insurance company from which he had bought a health insurance policy. Cashless care was therefore ruled out. His wife settled the hospital bill and six days later Sharma was discharged from the hospital. Four weeks into his recovery, he received a letter from his insurance company informing him that his claim for reimbursement was denied because the trauma centre was not part of their service network!
He consulted a friend who informed him about a non-government patient-advocacy group that mediates with insurance companies on behalf of consumers like Sharma. Six months later, with the assistance of this advocacy group, who petitioned the IRDA (Insurance Regulatory and Development Authority), Sharma won his the case, and besides the cost of the treatment, he was also awarded damages for delay and needless harassment caused by the insurance company.
When you file a claim, you need to study the fine print in your insurance policy carefully. There are likely to be terms such as deductible, coinsurance, co-pay, out-of-pocket limit, definitions of out-of-network and emergency services; and details of the appeals process, that may not be immediately clear, because they are couched in dense legalese. A patient-advocate can help you make sense of these !
Literacy on insurance related issues is extremely low in India. You may think you deserve full reimbursement, whereas your policy may provide only for partial pay out. Sit with your advocate and understand your entitlement before you file a petition. Remember that besides resolving disagreements between patients and insurers, the main responsibility of a patient- advocate is to give more information to citizens about health insurance in an objective, professional and impartial manner.