Hyderabad: It is often a rude shock to families of patients when hospitals refuse to honour ‘cashless’ insurance policies. Unlike 10 years back, most insurance companies these days give insurance cards which are supposed to be used for cashless settlements at hospitals. Unfortunately, for many who have bought these policies, the experience has not lived up to the promise.

Rajeshwar Saha, who works with a private marketing company, had a bitter experience with his cashless settlement policy from National Insurance. Mr Saha had to undergo an operation and he duly informed the insurance company and the TPA (third party administrator).

Things, however, became complicated when, after the surgery, Mr Saha suffered a urinary blockage which meant spending more days in the hospital. The total cost came to Rs 40,000. The TPA, however, said it would reimburse only Rs 18,000.

He contacted his agent, who advised him to pay the full amount to the hospital and then claim from the TPA. He did this but it was only after three months of chasing that the TPA coughed up 80 per cent of the total amount. Despite repeated attempts, the TPA did not give its views on the issue.

Another policy holder, Chetan Kumar, who worked in a software company, had to be rushed to a network hospital when he met with an accident. Although his cashless card was produced, the hospital still asked his friends to pay Rs 15,000-20,000 up front and get it reimbursed from the TPA later.

An insurance broker had to intervene and ask the TPA to verify details and process his cashless policy soon. Mr Kumar’s brother, A. Vishwanath, said, “Buying a cashless settlement Mediclaim policy is of no use if the insured has to either pay the hospital himself or get it reimbursed later, or run from pillar to post for the ‘pre-paid’ facility.”

The hospital administrators say they generally admit and start treatment once a patient’s health card details are provided. However, they claim exceptions. A businessman who did not get a cashless treatment on admission at a hospital said, “The TPA refused to provide the cashless facility saying the illness could have been caused due to my pre-existing heart ailments and that it needed time to scrutinise the claim. However, if you ask medical professionals, they will tell you that my illness has nothing to do with any kind of cardiac ailment.”

P. Rama Rao, general manager, Credit Billing, Yashoda Hospital, said, “Once we get the card details we initiate the treatment. But, if we do not get the confirmation from the insurance companies or the TPA for the payment, we ask the patient to pay .” Hospital managements say that insurances are generally rejected when they come under the exclusions and terms and conditions of the insurance cover.