Leave it to docs

Should an insurance industry association tell hospitals and nursing homes when to admit patients? It’s a clear conflict of interest because insurers profit by denying claims. The more premium they can collect, and the fewer claims they have to pay out, the happier they are. That’s why General Insurance Council’s “clinical guidelines” on hospital admissions are problematic, and Irdai, health ministry and medical bodies like IMA, should tell it to lay off.

The council has cleverly couched its guidance in medical best practices. It says they are meant to curb unnecessary hospitalisation and rising healthcare claims. But who is it to decide what’s unnecessary? It says people with common fevers and infections should be treated as outpatients ordinarily. Yes, but aren’t doctors the best judges of a fever’s severity? If a patient they didn’t admit – against their better judgment – develops complications, who’s liable?

While needless hospitalisation and bogus claims are facts of life, wilful denial of claims is no less a problem. Irdai’s latest report shows 1 in every 12 health claims is denied. This tendency has actually hurt consumer confidence, and become a hurdle for private insurance’s take-up. As a result, roughly 85% of healthcare costs in India are still borne directly by patients and govt. Meanwhile, private insurers, catering to the well-off, have market power over private hospitals and nursing homes.

Now the fear is insurers will use these guidelines to arbitrarily deny even more claims. While bigger hospital chains can fight back, small nursing homes can’t. Where does it leave patients? Getting admitted on their doctor’s advice could saddle them with a huge bill. Not doing so could cause serious bodily harm. So, the authorities should step in quickly in the interests of doctors, patients and hospitals, and tell GIC to mind its own business.

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