Cashless Mediclaim: A Second Person Narrative

Published: February 13, 2014 at 2:07 pm

Last Updated on

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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