409. Hospital and Medical Insurance Travails!

I started working from 1991 and all through, the medical insurance was being taken care of by the various companies I worked in. In 1999, I was in between jobs and that is the time when I got into a trouble and had to be hospitalized.  There was no medical insurance for me and I had to pay around 40K from my pocket for the hospital visit.  Within a week of discharge, I called an insurance company and went for a private medical insurance for me and my family.  After getting another job, I got insured by the company. But I still continued paying the premium for my private medical insurance.  After some years, I changed my insurer to a different company and maintained paying the insurance premiums.

Continuing from the previous blog, by 1230pm I was told by the duty nurse that all the files have been sent to the Billing team and now the ball was in their court.  I was told that the insurance would take some 3-4 hours. Just to be sure, I called up the billing person at the hospital and asked if he had received all the documents.  He confirmed it and said he will require half an hour to go through and confirm everything was in order. Then he would forward the documents to my medical insurance company for approval.

I then had my lunch. I started reading another novel and also began seeing India getting demolished by South Africa in the cricket test match!  About 3pm or so, I got a mail from my insurance company stating that they have received the claim from the hospital and they would revert back in the next 2 hours on the approval. They had mentioned a figure of Rs 5.34 lakhs for the stay😊!  Seeing the figure, I got a real shock. Just a couple of days back I had a stent inserted into my body and here I was getting a shock to test the stent’s durability😊! 

I asked my wife to go to the billing department in the hospital and get a copy of the bill sent to the insurance company for approval.  She got a summarised bill stating the procedures done and the amount charged for the same.  I didn’t have any breakup regarding doctor visits or room rents or food and other stuff.  Just procedures.  We were told that insurance patients only get summarised bill and the insurance company only gets the detailed bill.  I had no issues on the amount as my limit was much more than the claimed amount. But I was aghast at the charges for the whole stay.

The bill just had 3 items stating figures for Surgical procedures (angiogram and angioplasty, the stent implant and one other procedure).  Maybe there was some arranged agreement between the hospital and the insurer regarding these charges. 

At 4pm or so, I got the approval letter, by email, from the insurer stating that only 53% of the total amount had been approved.  They had reduced some charges from surgical procedures and some from implant. They had mentioned “unjustified” as the reason for deduction from the implant total.  For the other procedure, they did not approve a single amount😊!

I called up the billing department and told him that the insurer has replied and approved only some of the amount.  He said he will check and get back to me.  After about half an hour he said he has replied to them and we should be getting another approval from them.  By 530 pm also nothing had happened.  I called the billing person again and said we still have to wait.  I asked my wife to go the billing department to sort this out.  She was told by the person that we would have to pay the balance and then only we will be able to get discharged. 

I changed from the hospital gown to normal dress and my wife and I went to see the main doctor who did the operation.  I told the doctor that I cannot pay the balance as neither am I working and nor is my wife. So, there is no way I am going to pay the balance.  He said usually the insurer does this thing so that they can get away from non-payment. He said he would send them a letter justifying the procedure. He said that before doing the procedure also they had sent a letter to the insurer mentioning why this was required.

I was worried that by the time this correspondence between them came to a conclusion, I will be forced to spend the night in the hospital itself😊! 

The doctor told the billing guy as to why I was not in the hospital gown.  I told him that since I was coming to meet him, I changed and the billing guy did not know. 

After coming back to the room, I had a mind to just skip out of the hospital😊!  Better sense prevailed and I stayed put.  Had dinner there and my wife too went out to have her dinner.  By 8pm, I got another mail from the insurer where they had added 10K more to the final amount, which came to only about 55% of the total amount claimed.  Again, phone calls with billing department started to and fro, with them saying that we have to wait for the final approval. 

At around 9pm or so I called my insurance company and asked them to escalate the matter as the hospital was not letting me get discharged.  After speaking to the higher official, I was told that based on their internal team, the amount sanctioned was justified and they can’t do anything about that.  At 1015pm, the insurer sent me an official mail stating the same mentioning, their concerned department had gone through the bill thoroughly and with due diligence and their decision stays unchanged as per the policy terms and condition.  My wife then went to trace the main doctor to know what the next step would be.  The doctor was in an operation theatre doing some procedure and there was no way she could speak to him.

The billing guy stopped picking my call and went home.  We had come to a conclusion that we have to stay the night in the hospital and then look for the next day to sort out this issue.   At 1030pm, I asked my wife to go and check for the doctor again to enquire about this.  She found that the doctor was still in the operation theatre.  While coming back to the room, she was told by the floor nurse that the discharge has been approved and I can now leave the hospital😊!!  We completed the formalities and came back home by around 11pm that night!

I have not gone back to the hospital again and have now referred to another doctor.  He has given some medicines and has asked to me visit again after 3 months.  The earlier hospital has also not called me to pay the remaining amount and I am sure they would be in correspondence with my insurer for the charges.  I have come to a conclusion that if you have an insurance, go the reputed and specialized hospitals instead of nearby hospitals😊!  At least they would have proper understanding with the different insurers and maybe nobody has to suffer like me for discharge!  At least I hope so😊!!

Cheers till next time😊!!