Medical insurance: promoting unethical practices?

We appreciate the authors of your illustrative and interesting articles (1, 2, 3) on health care insurance in India for their lucid handling of issues in the medical insurance sector. While the health insurance sector in India is still at a nascent stage and has to meet enormous challenges, insurance policies must be transparent and standardized, and made clear to both patients and medical practitioners.

It is a distressing truth that the ethical values in medical practice are deteriorating day by day. But this is not always the case. There are plenty of complaints of denial of insurance claims on trivial grounds (patient not on parentral medications, flaws in documentation etc). This prompts the doctor to modify the treatment plan in favour of the patient. In order to reduce the risk of such denials, the physician is indirectly forced to treat the patient unethically. The patient may be put under unnecessary medication, which is not justifiable even though the intention is to facilitate the payment of a rightful insurance claim. Can we completely blame the physician for this? Doesn’t this unfortunate situation arise from the ambiguity regarding the requirements of insurance claims?

There is a definite lack of transparency in the health insurance sector and most physicians and consumers are uninformed regarding the ‘do’s and don’ts’ of these policies. Practitioners should, essentially, be trained in the proper documentation of the mandatory pre-authorisation form. The form carries details of current and past illnesses, the proposed line of management, the expected duration of hospital stay, and the approximate cost of treatment. Any flaw or mismatch in this documentation can result in delay or denial of a claim, adding to the patient’s suffering.The client should be fully aware of his rights as also of ethical responsibilities. There are cases of people who get admitted to hospital for minor illnesses just to receive insurance payments. On the other hand, there are cases where insurance has been rejected even in emergency admissions. The reason for denial of claims, is, most often, not even communicated to the patient. The insured person should be provided a comprehensible written explanation regarding the reasons for denial, preferably in the local language.

Community based insurance schemes are doing well and the number of subscribers is increasing particularly in rural areas. The majority are illiterate and poor. Marketing agents highlight the advantages of insurance schemes and consciously underplay the complexities in availing the claim. Many succumb to the lure of cashless private health care schemes, only to be frustrated when their insurance claims are denied and they are unable to pay the heavy medical bills. This highlights the urgent need for an efficient grievance redressal system.

Though medical insurance can be a boon to the consumer, it is promoting unethical practices among treating physicians. This trend is unacceptable and measures should be taken to curb it.. Health authorities, the insurance regulatory agency, the Indian Medical Association and the Medical Council of India should take the necessary steps to establish a transparent health insurance and a proper monitoring system to ensure good, evidence based clinical practice, doing no harm to the patient and protecting his rights as a consumer.