[idea1979]

Mediclaim : Hospital Asking for 5% Extra. Is it Justified?


Need some info.

Recently my family member is admitted to ICU in a reputed hospital due to medical emergency. Hospital is in cashless facility of my mediclaim facility. It means i dont have to pay anything as long as my expenses are not beyond my sum insured.

However, hospital management is asking for 5% extra on total bill under head of service charges just because it is a Cashless Mediclaim !! If i dont use mediclaim cover, i dont have to pay these charges. This is totally new to me and i have never heard of it. I have used cashless mediclaim facility quite few times earlier and no hospital has asked me for such charges.

Seeking opinion. Would also appreciate legal perspective if possible.

PS: Its not about money or 5%, but i surely feel it is not legitimate to ask for this.
Patient is still in ICU

[Jaggu]

Inform your company and let them in turn work it out with insurance provider/vendor and the hospital. 5% additional charge, i have never come across.

Wishing your family member a speedy recovery.

[debugged]

Unless the insurance specifically says co-pay of 5%, you should report to the insurance company/Third party Administrator(TPA).

[jinojohnt]

I think in your case the hospital is fooling around. But it also depends on the mediclaim policy that you have.

For the first category (perfect cashless insurance), the premium would be high, but in-patient treatment would be fully free. This was given by my previous employer.
The mediclaim insurance policy that I have through my current employer is of the second category - my employer pays less premium, but I have to pay some percentage (10% I think, called co-pay) of the bill, plus medicine expenses.

Based on my experience, I think it's better to get treatment without mentioning anything about insurance, and then claim insurance later. This works out to be cheaper.

Here's my story:
I got treatment from a famous private hospital in Trivandrum, and they gave me a bill of Rs 4732.
I asked them why they are giving me a bill, as I had informed previously that I have 'cashless'.
Cash counter staff: "Oh sir, the insurance desk must have missed. Please give me back the bill, we would consolidate and give you."
Me: "Why do you need to consolidate again? It is already consolidated before giving to me".
Staff: "Ok sir, please pay the amount (Rs 4732) as advance payment. Later when we get the claim, you can come back here and we'll give you the amount back".
After 3 weeks, I get a mail from Mediclaim that my application (through hospital) for Rs 8000 has been approved. I insisted and got a full refund of Rs 4732 from the hospital this time (without co-pay), as I knew that they would not argue much.

Got the funda?
If I had not mentioned about insurance and paid the bill (Rs 4732), I could have later applied through my employer and got a Mediclaim refund of approx 4500 Rs (means I will lose only less than Rs 300).
If I tell upfront that I have insurance, the bill would be Rs. 8000 and I would be forced to pay around Rs. 2000 at the hospital.
(This is because if you mention about insurance, a big chunk of the bill would be non-claimable expenses such as service charges, admin charges, etc).

My personal experience is that whenever I mention about insurance upfront, I shell out 25% of the inflated bill.
But if I keep silent and claim later, I lose only around 10% of the small bill as co-pay.
(For my dad's hernia surgery, the actual bill was Rs 42000 and I got back Rs 37000 within one month when I applied through my office.)

[vivekiny2k]

Let me tell you guys something. Health insurance is a big scam. Indian entrepreneurs have learnt this business opportunity from USA and I won't be surprised if India falls into the same black hole that USA is in WRT health care.

[Gilead]

I have claimed cashless mediclaim twice at Apollo and there was no mention of an explicit 5% extra. If at all they are doing it, it's probably baked into the bill somewhere.

Originally Posted by jinojohnt

(This is because if you mention about insurance, a big chunk of the bill would be non-claimable expenses such as service charges, admin charges, etc).

This is a bit of an exaggeration. In my case, on a bill of ~45K, the only non-claimable items were admin charges of 400 bucks and nutrition/dietician charges of 800 bucks. Non-claimable charges are usually a small portion of the bill.

[RX135]

Are they asking that money from you as additional expenses or are they asking you to keep that 5% money as deposit?

In case of cashless, some hospitals keep 5% as security deposit till they get all expenses reimbursed from the Insurance company. (Insurance company can deny reimbursement for few items). You can get those 5% back later, after around 6-8 months.

[idea1979]

Mates, thanks a lot for all your best wishes and opinion. No doubt stress is enormous.


I feel i was not clear in my first post.

Here is example:

Suppose hospital bill is 50000/-

Hospital is syaing , mediclaim will pay all 50000/- but as per hospitals policy, i need to pay hospital over and above of this 50000/- and that amount is 5% (under name of service charge?) of total bill i'e 2500/-

So hospital will get 50000/- (Actual bill- will be given by mediclaim) + 2500 (from patient.): Total 52500/-


This is also shocking that total bill also covers medicines purchased at MRP so if they are taking 5% on that , they are actually selling medicines above MRP rates.

[Gilead]

idea, if the bill is 50K, no mediclaim company will pay the full 50K. Admin charges, bill charges, dietician charges are always excluded. Mediclaim will typically pay 48K and you pay 2K. It looks to me like your hospital is doing thing in a different way, but the end result is still the same. You will end up paying something or the other.

[abhinav.s]

Originally Posted by Gilead

idea, if the bill is 50K, no mediclaim company will pay the full 50K. Admin charges, bill charges, dietician charges are always excluded. Mediclaim will typically pay 48K and you pay 2K. It looks to me like your hospital is doing thing in a different way, but the end result is still the same. You will end up paying something or the other.

+1

This is how it works - Normally when the hospital sends your mediclaim id after admission, they also include a tentative bill amount. If for ex. the amount is 50k, then mediclaim will approve 30k in the beginning. After the treatment, once they get the final bill, they will settle it to the hospital.

Now mediclaim will not pay admin charges, bill charges, sometimes the sur charges etc. That would be around 2-5k depending on the total bill amount. This amount which the hospital cannot recover from the insurance agency will be taken from you as payment.

You can wait till the end to confirm how much of the bill amount was paid by mediclaim to the hospital before you pay the 5% of the bill amount.

[rohan_iitr]

Our honourable Finance Minister Pranab Mukherjee has made a proposal in the budget of imposing a service tax on hospitals where the payment has been made to them by insurance company / third party agent.

Service tax on cashless mediclaim: Will you suffer?: Rediff Getahead

I am not sure whether this has been implemented.

But if this has been implemented, then the hospital is not to be blamed.

Governments is collecting double service tax from the people, one at the time of buying insurance policy and another at the time of making claim.

Rohan

[idea1979]

Originally Posted by Gilead

idea, if the bill is 50K, no mediclaim company will pay the full 50K. Admin charges, bill charges, dietician charges are always excluded. Mediclaim will typically pay 48K and you pay 2K. It looks to me like your hospital is doing thing in a different way, but the end result is still the same. You will end up paying something or the other.

You are right. Not all things like diet, tonics,vitamins etc are not covered and this is explicitely mentioned in policy.

While 50000/- actually i was referring to bill of all covered items just to simplify example.

Originally Posted by abhinav.s

+1

This is how it works - Normally when the hospital sends your mediclaim id after admission, they also include a tentative bill amount. If for ex. the amount is 50k, then mediclaim will approve 30k in the beginning. After the treatment, once they get the final bill, they will settle it to the hospital.

You are right. This is called as Pre Authorisation.

Now mediclaim will not pay admin charges, bill charges, sometimes the sur charges etc. That would be around 2-5k depending on the total bill amount. This amount which the hospital cannot recover from the insurance agency will be taken from you as payment.

You can wait till the end to confirm how much of the bill amount was paid by mediclaim to the hospital before you pay the 5% of the bill amount.

Good suggestion. But any how 5% is still there right? and our question is Why?

[nitrous]

Originally Posted by vivekiny2k

Let me tell you guys something. Health insurance is a big scam. Indian entrepreneurs have learnt this business opportunity from USA and I won't be surprised if India falls into the same black hole that USA is in WRT health care.

+1
This is just a money making scam.
Every politician has money invested in this "healthcare" industry and so no one's questioning this in the parliament as well.

[abhinav.s]

Originally Posted by idea1979

Good suggestion. But any how 5% is still there right? and our question is Why?

In my experience it has not always been 5%. Guess its dependant on the hospital

One of my friends relative was admitted in columbia asia in Blore. His total bill was 1.5L.. After the insurance company took care of the amount covered, he had to shell out about 4.5k from his pocket which would work out to about 3%. He was told that this covers the amount not approved by the insurance company for the service charges on room rent, ICU etc.

Is this the case with you as well. If its not then the hospital is being extra careful to collect excess amount from you before hand. Normally this % of money what ever it is will be settled only after final billing has been done.

[idea1979]

Originally Posted by rohan_iitr

Our honourable Finance Minister Pranab Mukherjee has made a proposal in the budget of imposing a service tax on hospitals where the payment has been made to them by insurance company / third party agent.

Service tax on cashless mediclaim: Will you suffer?: Rediff Getahead

I am not sure whether this has been implemented.

But if this has been implemented, then the hospital is not to be blamed.

Governments is collecting double service tax from the people, one at the time of buying insurance policy and another at the time of making claim.

Rohan

Hospital is calling it service charge and not service tax.