11 November 2010
By Pritha Chatterjee
SIX months after the firstever medical group insurance policy for the HIV positive in Mumbai–Thane region was introduced, beneficiaries have started complaining of delay in reimbursements. The scheme, introduced in April for HIV patients in Mumbai–Thane, is supported by United States Agency for International Development (USAID).
A patient who sought treatment at a nursing home in Kurla (West) had a harrowing experience when he was discharged without proper records of his admission in July. A representative of Mumbai Network of Positive People, who was closely associated with the claimant, said the hospital discharged him without discharge certifications.
He was only given OPD papers.
At another nursing home in Mahim (West), a patient was not given specifications of the cost of the medicines. "The prescription only mentions the names of medicines without specifying the dosage or the time of intake.
The patient purchased the medicines from the hospital pharmacy, but the bill does not mention the total cost," said Rachna Naik, an insurance officer with Population Services International (PSI) in Mumbai, a nongovernmental organisation supporting the policy holders with their annual premium of Rs 1,511.
PSI representatives say these delays can be largely attributed to faulty medical information in the hospital records. According to Ravi Subbaiah, incharge of this project for PSI, "Inadequate proof of treatment in prescriptions largely leads to these problems. Insurance companies send back claims demanding confirmations, and policy holders have to run after doctors for additional written clarifications to get their due benefits."
When contacted, authorities at these two hospitals said details could not be shared without producing medical records of the patients. Experts say delays also happen due to a lack of understanding of the finer details of the policy among beneficia
ries. "One of the important exclusions of the policy is pre existing diseases, which is true for most medical insurances," said Subbaiah.
However, he says the organisation which is responsible for scrutinizing applications based on eligibility criteria, receives applications for claims on problems like hypertension. "The capacity building programme for HIV positive people that has started at Karnataka, needs to be replicated here. Patients have to be equipped in two areas –firstly, to demand proper treatment records from hospitals, and secondly to understand where they can avail of this scheme, and the conditions where it is not applicable,"added Dr Shekhar Waikar, the Mumbai in charge of PSI.
Experts also say that adding more hospitals to the cashless scheme will solve this problem.
"Currently hospitals are classified into two categoriesnetwork and non network ones.
Cashless benefits can be availed only in network hospitals," said Dr Waikar. Though 187 hospitals are on the list of network hospitals in Mumbai–Thane, only a single patient has applied for benefits under the scheme from Bhiwandi, since May, as per PSI records.
"We need to spread more awareness, and also see if these hospitals are accessible enough," said Rachna Naik.
These hospitals are evaluated and added to the list by insurance companies. The scheme introduced in April in the city, is available for HIV patients with a CD4 count of 300, and clients are eligible for a benefit of up to Rs 30,000.
The policy was running in Karnataka, Andhra Pradesh and ten districts of Maharashtra, before being introduced in Mumbai. For a cover of Rs 30,000, the claimant has to pay a premium of Rs 1,511 to the insurance company, of which Rs 750 has to be paid by the policy holder and the rest is contributed by PSI.
Half of this amount can be claimed at the onset of AIDS, and the other half for treatment of other problems, like co–infections associated with HIV.
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