Cashless Mediclaim: A Second Person Narrative

Regular readers may recall that I described my experience with cashless mediclaim when I underwent a thymectomy last march.  A couple of Wednesdays ago my mother fell and broke her femur bone.  While mine was a planned hospitalization, this was an emergency hospitalization.

I am no stranger to emergency hospitalizations (unfortunately). This is the 5th such situation I have found myself in, in the last 8 years (plus 4 planned hospitalizations).

So I have a reasonable idea of the modus operandi

  • Stabilize the patient and minimize pain
  • Alert support system
  • Inform doctor and arrange for a bed-side X-ray (in case of falls)
  • Meanwhile get mediclaim policy documents along with ID proof. Note sum insured and sub-limits if any. We have individual policies from United India. My mom has a SI of 3.5L with a room rent limit of 1%, that is Rs. 3, 500 per day.
  • Liquidate emergency funds. At least a lakh to start with. This is in case
    • The doctor chooses a hospital where cashless is not accepted
    • Cashless is refused (can apply for reimbursement upon discharge)
    • Some cash is needed for daily expenses and charges that the insurer will not cover.
    • My mom has one 1 Lakh in an e-fd. This can be broken online and the credit to SB account is instantaneous. This e-fd is part of my families emergency reserves.
  • Once the bone-break was established-intertrochanteric fracture the doctor asked if my mother had insurance. Since I answered in the affirmative, he chose a hospital which allowed cashless stay, thankfully just a stones throw away from my house.
  • The next step is securing a hospital room within the insurance sub-limit.  At Rs. 3,500 a day I could have got a decent deluxe room, I however chose a single ac-room at Rs. 2,900 a day.  Not sure why I chose a less expensive room now! Guess I was not thinking straight! In hindsight, I as the sole attender would have been more comfortable with the deluxe room!

Anyway, soon I found myself staring at my mother in bed. I am a pretty competent attender, even if I say so myself. I once spent 3 weeks in hospital without once coming home as I nursed my father through orthopaedic surgery, radiation and chemotherapy, while preparing for my IITM, faculty interview.

This time though, I was scared. As I had Myasthenia Gravis, I would often feel tired and was worried about attending as it is a full-time job. Thankfully, by Gods grace I was able to handle the ordeal.

However, I did not anticipate what was in store for me.

First about emergency cashless admission. It is quite simple.

  • All one needs is the policy card/ policy copy along with ID proof of the patient.
  • When we submit these, the hospital gives the pre-authorisation form given by the insurer or TPA (TTK healthcare in my case. TTK is now called Vidal Health) to be filled.
  • Submit the form to the nurse and the hospital takes care of the rest.
  • The exchange of information between the TPA and the insurer was relied to me via SMS. Cashless hospitalization was approved up to Rs. 30,000 initially.
  • All set for the surgery and rehabilitation…. or so I thought!

My mothers surgery was scheduled 48 hours after hospitalization. About 5 hours before the surgery, I was told that the orthopaedic surgeon (lets call him Dr. Dogood) was down with severe fever and could not operate that day.

The surgery was postponed by another 48 hours. This time, just a couple of hours before the surgery, I was again told that Dr. Dogood’s fever had returned, and he could not operate that day either!

The surgery was postponed by another 48 hours. Thankfully my mothers leg was stabilized with a traction, and she was not in much of pain. However, I was worried about bed sores as she could not turn.

Dr. Dogood later told me that he had para-typhoid. He had delayed taking antibiotics by two days in hope that his fever was caused by a virus (instead of a bacteria).

In the midst of these postponements, I was worried if the hospital would pressurize us to choose another orthopaedic surgeon to mend the fracture as the insurer was paying for the stay. Although a person from the insurance dept. wanted to know the cause of the delay, there were no such problems.

The nurses however were curious as to why I was putting up with this delay and why I did not change the doctor. Dr. Dogood is not a stranger to me. He had operated thrice on my fathers legs when his bones broke because of multiple myeloma.

He had called on my father four times at home and not once asked for a fee! When I asked him, how much I owed him, he replied, ‘I have never made house visits before. So I don’t know how to ask for a fee! So I don’t want anything’!

About six months ago when my mother fell off her chair, Dr. Dogood again came home to confirm that it was not a fracture. Again no fee!

Dr. Dogood also treats me from time to time and I can freely discuss my condition with him.

Therefore, the thought of changing the doctor never occurred to me.

Finally, a week after admission my mom was successfully operated. I am glad that I did not change the doctor. When I saw the X-ray with the screws and plates fitted in, I realised that the fracture was rather severe.

Dr. Dogood told me that for such fractures four month bed rest is mandatory. However since my mother has Parkinson’s (reason why she fell), he has added an additional implant to make her walk asap. This is what the implant looks like.

Cashless Mediclaim
Dynamic Hip Screw. Source: Wikipedia. In my mothers case, there are three additional screws to hold the bones together.

The physiotherapists in the hospital made her take a few steps three days after the surgery.

A week after the surgery, she was ready for discharge.  She is still in bed, still on a catheter but gaining muscle strength day by day. I hope with a physiotherapists help, she will be able to walk again in a couple of months.

Upon discharge, I learned that the hospital bill was Rs. 1.9 Lakhs out of which I had to pay for ‘non-medical expenses’ ~ Rs. 18,000.

Out of this 18K, Rs. 600 is the patient registration fee, Rs. 2900 the room rent when I used the room while my mom was in the ICU.

The remaining 14K is from

“External and or durable Medical / Non-medical equipment of any kind used for diagnosis and/or treatment and/or monitoring and/or maintenance and/or support including CPAP, CAPD, Infusion pump, Oxygen concentrator etc., Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, elastocrepe bandages, external orthopaedic pads, sub cutaneous insulin pump, Diabetic foot wear, Glucometer/Thermometer, alpha/water bed and similar related items etc. and also any medical equipment

and

“telephone, television, ayah, private nursing/barber or beauty services, diet charges, baby food, cosmetic, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses”

Source: United India - Gold Policy Wordings

According to the TPA, “Non Medical expenses are: Admission fees, Registration fees, gloves, blade, water bed, food & beverages, extra bed etc.,”

Here is a more complete list of ‘non-medical’ expenses from TATA AIGs mediprime policy

Do you really think many of the items in this list are non-medicinal in nature?

Many of these items depend on the room-rent. So higher the room-rent, higher the non-medical expenses bill.  Therefore higher should be the cash-in-hand during ‘cashless’ hospitalization!

ps. Someone told me that there is about 30% difference in cost between cashless hospitalization and paid hospitalization! When I look the surgeons fee, I am beginning to think that it is quite true!

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44 thoughts on “Cashless Mediclaim: A Second Person Narrative

  1. bemoneyaware

    OMG It was scary reading the article. Thanks for sharing. the part about emergency fund (e-fd_ was good.
    Hats off to you for taking care of your mother

    Some questions I have:
    30,000 was approved initially? When did the remaining amount get approved? Was it difficult getting approval?
    Your mother had 3.5L with a room rent limit of 1%, and bill was 1.9 lakh (-18,000) the rest was paid cashless. How does it affect future medical expenses!

    Reply
    1. pattu

      Once the doctor announces the discharge, the insurer is notified and the final settlement is made. typically it is not difficult but it will take a full business day to get it approved. Since I had trouble with this delay for my own hospitalization, I asked the doctor to time the discharge 36 hrs away.

      That is he announced the dischared on Wed morning by Mon night. So the paperwork was completed on Tue itself.

      You are right about the number. 1.9L -18K was paid via cashless.

      "How does it affect future medical expenses!" Great question. Subject of my next post!

      Reply
  2. bemoneyaware

    OMG It was scary reading the article. Thanks for sharing. the part about emergency fund (e-fd_ was good.
    Hats off to you for taking care of your mother

    Some questions I have:
    30,000 was approved initially? When did the remaining amount get approved? Was it difficult getting approval?
    Your mother had 3.5L with a room rent limit of 1%, and bill was 1.9 lakh (-18,000) the rest was paid cashless. How does it affect future medical expenses!

    Reply
    1. pattu

      Once the doctor announces the discharge, the insurer is notified and the final settlement is made. typically it is not difficult but it will take a full business day to get it approved. Since I had trouble with this delay for my own hospitalization, I asked the doctor to time the discharge 36 hrs away.

      That is he announced the dischared on Wed morning by Mon night. So the paperwork was completed on Tue itself.

      You are right about the number. 1.9L -18K was paid via cashless.

      "How does it affect future medical expenses!" Great question. Subject of my next post!

      Reply
  3. NATARAJAN

    Dear Pattu , thanks for sharing the real time event of your mother hospitalization and the insurance workout. I pray the almighty for her speedy recovery. The concluding part is not clear to me. Do you mean to say, Cashless is better option to reduce the cost of expenses or the hospitals charges more when you pay cash. Please amplify.

    Reply
    1. pattu

      Thank you. Hospitals charge more when it is cashless. If one does not have enough resources then it is best to go via cashless. Perhaps latter in life when has a decent emergency corpus, one can pay for bills and get it reimbursed.

      Reply
  4. NATARAJAN

    Dear Pattu , thanks for sharing the real time event of your mother hospitalization and the insurance workout. I pray the almighty for her speedy recovery. The concluding part is not clear to me. Do you mean to say, Cashless is better option to reduce the cost of expenses or the hospitals charges more when you pay cash. Please amplify.

    Reply
    1. pattu

      Thank you. Hospitals charge more when it is cashless. If one does not have enough resources then it is best to go via cashless. Perhaps latter in life when has a decent emergency corpus, one can pay for bills and get it reimbursed.

      Reply
  5. Mohit

    I also had similar kind of experience 2 months ago when my father was hospitalized. TPA raised some questions about the details given by hospital. I called TTK and by learning that I am calling from out of India, with in 2 hrs they approved everything.
    In my case also TTK approved 30 k initially but they approved full amount at the time of discharge.

    Reply
  6. Mohit

    I also had similar kind of experience 2 months ago when my father was hospitalized. TPA raised some questions about the details given by hospital. I called TTK and by learning that I am calling from out of India, with in 2 hrs they approved everything.
    In my case also TTK approved 30 k initially but they approved full amount at the time of discharge.

    Reply
  7. ashalanshu

    Dear Pattu, thanks for a detailed write up. Please check with your insurer that by paying the proportionate prem. is it possible to restore the original sum assured back to 3.5L Rs?

    Thanks

    Ashal

    Reply
  8. rakesh

    Wonderful write-up, Thanks for sharing. I had a similar experience with cashless mediclaim with National Insurance when the hospital charged exorbitant rates when they came to know I had a mediclaim. That was 5 years back, seems like things have not changed.

    Reply
    1. Dr. Nilesh

      Rakesh,
      At the outset, let me clarify, I'm an practising Family Physician.So that extent, admittingly i may be defensive for my fellow bretherens.
      Having said that " Doctor bashing is a national sport "-is the new mantra.
      Any Forum,Platform,social /religious meet , a doctor is hounded for allegedly, professional malpractices.
      Coming to the oft-repeated "MediClaim skyrockets your medical bills.!! ".Yes and No !!.
      Yes, because " you " are not paying.
      No ,because -
      Typically,Hospital is re-imbursedby the TPA / Insurer your bill ( after you have smilingly left the Hospital without paying the Doctor ( Cashless ), after 3 to 6 months.
      There are instances,when the Doctors / Hospitals have not received the " promised Authorised (pre-sanctioned ) Amount " and you will find Hospital owners/ Doctors fighting for the same at almost everyTPA Office.
      Further ,say, a Nursing Home offers Cashless Facilty and has 20 Beds and all patients opt for Cashless facility,How dose the Hospital takes care of its day-to-day Operational Expenditure ?.
      I too had parents. I also have a family. Bechara Bhala Dactur !!

      Reply
    2. Dr. Nilesh

      Natrajan /Pattarabiraman,
      In Cashless, Hospital is reimbursed as the per agreed terms (Contract between TPA's and Hospital Owner's Asstn.-called as GIPSA.This is irrespective of your bill
      For example,If you have a opted for package of Rs 40,000/- for say( Removal of Appendix ).Hospital will be reimbursed as per terms of contract (GIPSA )-always more than Rs.40000/-.
      Hence it is always prudent to check " Loading Terms on Renewal of MediClaim Policy "(separate Topic by itself ) of any Health Insurer, in event of Claim / adverse Medical History.

      Reply
      1. pattu

        Thank you for mentioning about GIPSA. I was not aware of this. As per new IRDA rules (Oc. 2013) loading has been abolished. However insurers can refuse to increase Sum insured after a claim depending on the nature of hospitalization.

        Reply
    3. Dr. Nilesh

      Good question, " When did the remaining amount get approved ? ".
      Yes! ,it is, at times ,extremely difficult to get the TPA's (approving Authority ) for the same
      Phone call /Email goes unanswered.Agent goes undercover.
      Policy Holders have not read /have not been explained the " Exclusions /Pre-Existing Diseases (PED's ) "in the Policy etc.etc.

      Caveat Exemptor !!

      E-FD is good idea.
      A Credit Card with a good Credit limit should be left exclusively as " Emergency Medical Fund " or a similar Medical Fund,in cash, should be provided with.

      Corporate Hospitals do not admit patients without prior Deposits (ranging from Rs 20,000/-to Lakhs ),irrespective whether you have MediClaim or not.

      Reply
      1. pattu

        from my experience, the hospital sent the final medical records only after the doctor had announced the discharge. In any case on must be ready to pay any amount not initially sanctioned (can apply for reimbursement).

        Credit cards will work well for emergencies in which time is crucial. In my case I have a couple of hours before admission. So I would prefer to use an e-fd instead of a card. If at the time of discharge I need to pay I will use a card.

        As regards hospital deposits, I would prefer to stay away from them, if I can. Having a family physician who is in contact with a network of specialists helps in this regard. In any case from what I have learnt, South India is way, way cheaper than the north

        Reply
    4. Dr. Nilesh

      Do a " Recce " of nearby Hospitals-preferably-Multi-Speciality Hospitals.
      Don't worry.There will be no Snowden / Barrack .
      Get a feel.Smell the air.You have seen in the movies ,now sense it.
      Look for the packages offered.
      Almost all hospitals have Insurance Counter-to deal with Mediclaim Issues.
      Adios for now.
      LazyDoc !!

      Reply
  9. radhe

    Every Parents must have Child like you. While reading my eyes became wet (little bit) . I felt that you wrote the article from the (in your case READ Corei7 processor ) core of your heart.

    It desrves to get print in the 1st page of National News Paper.
    Hats of to you.

    Reply
  10. bharat shah

    thank you very much for most narrative, informative and guiding post on the subject. just like to know whether one has to pay the difference of the estimated a/m of hospitalization and initial a/m sanctioned by the TPA to the hospital, or it is normal to get sanctioned the difference before discharge.

    Reply
    1. pattu

      Thank you very much. Payment (the difference between total bill and sanctioned amt) has to be paid only at the time of discharge.

      Reply
  11. Prasanna

    Dear Pattu - I hope your mother makes a full recovery soon. She is very lucky to have a son like you. Thanks for sharing your experience via this blog post. The posting as well as the comments including additional insights from Dr. Nilesh are definitely worth reading. regards Prasanna

    Reply
  12. Shailesh Pai

    Rs. 1.9 lakhs for intertrochanteric fracture surgery??? That's atleast 3-4 times the charge for such surgery. I wonder how the insurance company accepted to pay such a huge bill..

    Reply
    1. pattu

      1.9L is not the cost of the surgery. It incl. hosp. stay for two weeks, ICU stay, medicines, X-ray, doctors fees, other diagnostic fee etc. From what I learn from my FB friends, it would cost much more if this had occurred in Mumbai or Delhi.

      Reply
  13. Rajiv Bajaj

    I recently underwent surgery for a very painful fissure. I assumed my mediclaim of Rs. 10 lac from Tata Aig would cover it but it did not. They rejected the hospital expenses of Rs. 66,000 saying that this procedure is only covered after two years and I have only been with them for a year. One would think they would treat someone who has taken a 10 lac policy better. I wanted to ask your opinion on whether I should continue with Tata AIG or possibly go for another company? I have lost faith in Tata AIG after this.

    Reply
    1. pattu

      Unfortunately, they are right if the fissure had developed before the start of the policy. It would then be a 'pre-existing' condition and will be covered only after 2 years! Such rejections are quite common and will occur irrespective of the insurer. So I suggest that you continue your cover with Tata AIG.

      Reply

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