Hospitals that refuse health insurance are eligible for cashless payments? What are your options?

With the number of coronavirus patients growing exponentially in the second wave of the pandemic, many policyholders are struggling to gain approval for cashless treatment at the network hospital. The insurance regulator IRDAI has taken note of the problem and said: “There are reports from certain network operators (hospitals) that charge high rates and insist on cash payments from policyholders to treat COVID-19 infected patients despite cashless agreements with insurers”.

This is the way for people to get health insurance so they don’t run into trouble during a health crisis. What are your options when you find yourself in a similar situation?

Contact your TPA to make them aware of this

The IRDA took this matter very seriously and asked hospitals to adhere to the established standards. The regulator has issued circulars on this issue twice within two days to ensure that insurance companies and network hospitals are complying with the service level agreement and are not harassing policyholders.

“The insurers ensure that when the policyholder is informed of the availability of a cashless facility at the independent network operator, the cashless facility at this network operator is made available to the policyholders in accordance with the provisions of the insurance contract and the provisions of the insurance contract in the service level Agreement (SLA) agreed terms, ”said IRDAI in the circular.

If you run into difficulties, you should make a formal application for cashless admission to the network hospital with your third-party administrator (TPA). If you are still being refused cashless admission, you can use this refusal to file your formal complaint against the hospital with your insurer.

Get the treatment primarily in reimbursement mode

The cashless facility removes many of the hurdles policyholders face with the repayment mode. If the situation permits, you can contact another network hospital for the cashless facility. This not only minimizes your expenses, but also ensures that the total costs do not skyrocket.

IRDA has warned insurers to ensure hospitals meet agreed prices. “When considering cashless inquiries, insurers are also advised to ensure that policyholders are charged according to the tariffs agreed by the network operators, if applicable. It is also recommended that insurers ensure that hospitals do not charge additional fees for the same treatment, other than the rates agreed with the insurers, ”the IRDA circular stated.

The deviations and additional costs that the hospital will cause can be corrected later through a complaint. “If a network operator refuses the cashless facility and deviates from the agreed conditions of the SLA, the insurance company will take appropriate measures against the network operators provided for in the SLA in addition to the appropriate measures,” recommends the IRDAI circular.

However, if the situation is critical and the network hospital offers entry on a payment basis, you can opt for it and have the money reimbursed later. “All insurers are instructed to ensure that the” reimbursement claims from health insurance are paid quickly in accordance with the provisions of the respective insurance contract. It is recommended that insurers issue guidelines to all TPAs, “the IRDAI circular said.

If this is refused, you can also be treated in a hospital without a network

It is the cashless facility that limits your choices to only stick to network hospitals that are affiliated with your insurer or the TPA. In the event of a rejection by a network hospital, you can also seek treatment in a non-network hospital as the priority is still to save the patient’s life. With the reimbursement method you can claim the costs after the treatment with your health insurance company.

While this process may introduce some delays in getting your refund and some additional issues, it will help you prioritize treatment and get your money back.

File a complaint against the hospital

The insurance supervisory authority has asked insurers to communicate with their network operators on a regular basis in order to guarantee policyholders a problem-free service. It has also asked insurers to report such cases to local authorities for appropriate prosecution.

“It is recommended that insurers set up an effective communication channel with all network operators in order to resolve complaints from policyholders immediately. It is recommended that insurers report the collection of additional costs or the refusal of the cashless facility to the respective state governments in order to take appropriate measures, ”it says.

While the insurance company is on its set course to complain against hospitals, you should register your own complaint in the event that medical use is poor.

How to refer your complaint to the Appeals Board

You should also be aware of how your complaint will be submitted and escalated until it is no longer resolved or you do not receive a satisfactory response. Follow these steps to resolve your complaint:

First, contact the insurer’s complaint mechanism described in the insurance policy document. In the event that the insurer does not fully process the complaint within 15 days of submitting it, you can use the IGMS (Integrated Grievance Management System) to forward the complaint to IRDAI.

IGMS makes it easy to register complaints from policyholders online and helps track their status. A policyholder can make the most of this system by providing accurate information about the complaint such as policy number, insurer name, complainant contact details, etc. It would be helpful to have the insurance document ready when registering the complaint online.

The complaint registration process consists of the following steps:

  • Step 1: Register by entering your login information (website: https://igms.irda.gov.in/).
  • Step 2: Use registered credentials to register complaints / view their status

Alternatively, you can also send the complaint by email to [email protected] or call the toll-free number 155255 or 1800 4254 732.

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