Tackling Malpractices

Tackling Malpractices

Insurance company officials however feel that they are unable to curb malpractices by unscrupulous elements teaming up with doctors and putting up false claims.

It is also claimed that false certificates are issued to fake patients by some medical institutes for a handsome bribe and this has resulted in heavy losses to the insurance companies who are forced to increase premium rates.


The problem also is not mentioning pre-existing illness when taking out an insurance policy. Some of the chronic ailments like diabetes and heart disease are on the rise. If a person takes out a policy with pre-existing problem, the premium paid is lot less than if they had declared. Once a policy is taken out the person enters the hospital for a procedure for the pre-existing disease and makes a claim. This is not uncommon and can result in loss for the company.

Due to the low numbers of people who take out a health insurance policy the companies at present work on low margins and every claim is scrutinized very carefully before being passed. This also results in genuine claims being rejected.

To some extent the fault perhaps is on both sides. There are many instances where a procedure would cost less to the insurance company if done as an outpatient but insurance companies insist on admission for payments. Again in a routine situation (Where there is no medical emergency) investigations can be done as outpatients but insurance company only makes payments if a patient is admitted. The worst sufferers are where a prior definitive diagnosis cannot be established and the patient is admitted for surgery. In this situation the insurance company raises all the possible objections during the claim process making the doctors feel like criminals. Talking on this issue one of the leading Urologist - Dr.Sumit (name changed) felt that the doctors who are on the panel of these TPAs and insurance company are not necessarily the most capable to understand the intricacies of a case. He also felt that sometimes the paper work took actually longer than the surgical procedure itself!

Sometimes when a case is taken up, the diagnosis procedures may result in unnecessary wastage of resources. The health insurance sector market in India is yetto mature.

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