Many patients admitted to private hospitals in the city said their health insurance claims are being denied after they were hospitalised for ailments that were later diagnosed as viral infections.
Hospitals and insurers also reported that final clearances are taking longer than usual, amid a surge in admissions.
Private hospitals across Calcutta are running near full capacity due to a sharp rise in viral infections. Patients are arriving with symptoms ranging from chest discomfort and fever to severe stomach infections. Despite years of paying health insurance premiums, many are being forced to pay out of their pockets as insurers reject cashless facility claims.
Mounting rejections
A man in his early 40s was admitted to Peerless Hospital with severe abdominal pain, vomiting, fever, and dehydration. Doctors treated him with intravenous fluids and medication and diagnosed a viral infection. He stayed for four days, and the hospital submitted a cashless claim of ₹82,000 to his private insurer — which was denied on the grounds that hospitalisation was not necessary.
The same insurance company on Thursday rejected a ₹50,000 cashless claim at RN Tagore International Institute of Cardiac Sciences for a 13-year-old girl with similar symptoms. Doctors confirmed a viral infection.
Another insurance company denied a cashless claim on Thursday for a 51-year-old man admitted to RN Tagore’s critical care unit with a lower respiratory tract infection.
“The patient has high blood sugar and hypertension. The insurance company asked for documents from years ago, which he couldn’t produce. The claim was rejected, even though he was admitted through emergency due to his condition,” said an official of Narayana Health, which runs the RN Tagore hospital.
“About 30 per cent of cashless insurance claims are now being denied daily at our hospital. There were denials earlier, too, but the rate has gone up in the past few weeks,” said Sudipta Mitra, CEO of Peerless Hospital. “Most denials involve patients with viral infections.”
He added that many such patients develop complications affecting the respiratory or gastrointestinal systems.
Package care push
“There is constant pressure from insurance companies to convert treatments into fixed packages — but that’s not practical for non-surgical, conservative treatments,” said Prashant Sharma, chairman of the Indian Chamber of Commerce’s national healthcare committee and managing director of Charnock Hospitals. “This is causing major inconvenience to patients.”
Insurance companies counter that hospitals often admit patients who could be treated in the OPD.
“When we see a patient receiving only oral medication, it’s clear they could have been treated as an outpatient. After a detailed review, we reject such claims,” said an official from a national health insurance company.
Talks on cards
Hospitals said they plan to meet with insurers to address the problem. “There are both denials and delays in claim approvals,” said Rupak Barua, president of the Association of Hospitals of Eastern India and CEO & MD of Woodlands Multispeciality Hospital. “Sometimes documentation from hospitals may be an issue. But many rejections from insurers are abrupt.”
Barua added: “Hospitals currently negotiate individually with insurers, but we are planning a joint meeting to discuss these issues.”