Collusion between the TPA & Hospital relating to charges not covered – India Consumer Forum

Collusion between the TPA & Hospital relating to charges not covered

I was recently admitted to the hospital for treatment and after a brief stay for 2 days was discharged on 17th April ’16. I an provide the details for treatment if required later.

During the discharge process I received a credit note from the TPA, stating the approved amount and the dues hospital needed to collect from me. This amount was around Rs. 4,500 (Exact details & documents are with me and can be provided when needed). However, this LOC contained a vague statement and asked the hospital to adjust for charges not covered in the policy. Please note that the room rent limit was mentioned in this LOC as Rs. 3,000, but in the note they also mentioned separately, the adjustments against room rent limit.

The hospital thus prepared a list of charges not covered- including the excess room rent, the charges they listed amounted to around Rs. 10,500. Thus a clear difference of almost Rs. 6,000 (Rs. 10,500 – 4,500) was evident based on the Letter of Credit from the TPA & the bill prepared by the Hospital.

Upon noticing the discrepancy I immediately reached out to the central customer care helpline of the TPA and they assured me that the amount they had mentioned in the LOC was correct and I had to only pay that amount to the Hospital (~Rs. 4,500). But even when I made them talk to the hospital’s billing desk (I am not sure what was discussed between them during the call), the hospital clearly refused to revise the bill amount.

After, the initial discussions between the TPA & billing at the hospital, the TPA sent a revised LOC, wherein the room rent limit was now mentioned as Rs. 4,500. Rest of the details including adjusted amount etc. remained same.

Now, I believe that IF there was some misunderstanding between the TPA & the hospital, based on this revised LOC, the hospital would have reviewed the bill and talk to the TPA again and made necessary adjustments to the final bill. However, the hospital flat out refused to do so and asked for the full amount they had calculated. Which I finally had to pay in order to get discharged.

I also noticed another similar case (relating to non-covered charges) in the hospital at the same time as I was going through all this- That patient had a total bill of around Rs. 2,00,000. I also casually inquired about such cases with the hospital staff and they confirmed that this is a regular feature for most of the insured customers and hospitals & TPA go on arguing for hours- ultimately leading to harassment of the patient who has already gone through painful treatment.

In my particular case, I was officially discharged by the hospital’s medical staff at 10 a.m. but this whole argument with the TPA & the hospital meant that I could leave the hospital only by 4 p.m. and even then with no resolution in sight.

The hospital’s & TPA’s tactics seem to be of creating pressure on the patient and using stress to make them overpay for services and products being offered. Patients who are too busy or just want to avoid any inconvenience can actually end up paying double of what they are due.

In my case the total bill amount is Rs. 20,000, but the disputed amount is almost Rs. 6,000. i.e. more than 25% of the bill!!!!

As mentioned earlier this seems to be a regular practice between the TPA & hospital, they bury the patients in paperwork and when asked questions they review some documents (like the LOC in my case) but still make the patients pay more than what they are due.

I personally believe for a person willing to dig into this issue, the potential for resolution for such cases could be huge!

Though mine is a humble case of only Rs. 6,000 I would like to be resolved as soon as possible so that I can know what the correct recourse is, if I face similar issue in the future. I feel for the people inconvenienced like this even though they pay hefty insurance premiums and still end-up paying their medical bills themselves.

Please feel free to contact me for any additional details or any suggestions on how to proceed with this.

Vibhor Singhal
New Delhi 110068
Email: / 01/05/2016 / 9:05 am

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