Arjun, a software professional, underwent heart bypass surgery and was billed Rs 2.60 lakh. When he approached the insurance company for reimbursement, the hospital was made to refund Rs 35,000 while the insurer paid Rs 2.25 lakh, the rate fixed for the procedure.

Until last year, several hospitals had a dual billing structure where patients who were covered under insurance paid higher tariffs. What the insurance industry did was, they introduced their own rate card and created a panel of approved hospitals for cashless treatment which it termed as the preferred provider network (PPN). Thus patients are benefiting from the standardized cost structure introduced for common medical procedures. Now increasingly, insured patients do not have to bear any part of the hospitalization cost.

In cases of inflated billing, insurers are getting hospitals to refund the overcharged amount to patients.Another positive outcome is that the claims bill has come down reducing pressure on health insurance rates and keep them in check.

It can be pointed out that the effort by insurance companies have brought hospitals in line. Thus, benefiting the consumer. It does, however, point to an important gap in our regulatory framework. We have regulators for setting tariffs in power, telecom, financial services sector, whereas there is no such regulator body for the healthcare sector which directly affect life of people. We think that it’s time we had one such authority to balance the interest of the people and that of the healthcare industry.

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