Hospitalisation, health insurance and TPA woes: A first-hand experience

A couple of months back, my Appa (father) was unwell enough to require hospitalisation. It was a very stressful period for all us, but the stress factor came not so much from his illness or hospitalisation or treatment or care and recovery, but from an unexpected source—his health insurance’s Third Party Administrator (TPA), who created delays and blocks at every step, making the actual hospital stay seem almost like a vacation in comparison.

Both my parents are covered in the health insurance plan offered by the organisation I work in, and this was the first time I was availing of medical insurance, which is administered by a well-known TPA. The insurance plan I am covered under offers a “cashless” hospitalisation facility in most of the well-known hospitals in Mumbai. A reason to feel relaxed about and not have palpitations. Right? Wrong !

Appa had been having fever, which showed no signs of abating in spite of medication and care at home, as well as his doctor’s supervision. After a week of battling with the fever, his doctor advised hospitalisation for investigations and focussed treatment at a well-known hospital, close to our house. Once this decision was taken, my brothers and I got into action—while they would get him ready for the hospitalisation, I would get the insurance and TPA formalities sorted out.

Though I was aware that there would be some procedure and paperwork involved, I had no idea what it would entail. I first called up my colleague who is responsible for looking after medical insurance and TPA-related matters for our organisation to inform him about Appa’s hospitalisation. This colleague, lets call him Office Boy, immediately informed the TPA by email and phone about the impending hospitalisation, my health insurance details, as well as my contact details. Within 5 minutes, I got a call from the TPA liaison for my organisation. Impressed as I was with the quick response, I didn’t realise that this was just the beginning of the ordeal.

The TPA liaison, lets call her TPA Girl, came straight to the point—I should have informed the TPA about the hospitalisation in advance, especially if I was availing of the cashless facility. Huh??? I think I was speechless for some time. When I recovered I remarked sarcastically that, in future, even if my parents or I sneezed, I would call her up and inform her about imminent hospitalisation. Sadly, the sarcasm was lost over the phone line and TPA Girl went on to briskly outline the procedure for cashless hospitalisation—(i) collect the insurance form provided by the hospital, (ii) fill in details of the patient, the insured and the illness, (iii) have the form attested by the attending doctor, (iv) submit it to the hospital within 24 hours of admission, along with photocopies of Appa’s identification and my insurance card. The hospital would fax all these documents to my TPA for further processing. The TPA would respond to claim for cashless hospitalisation within 2 hours, (v) inform the TPA at least 2 hours in advance before discharge, so that all papers would be cleared. So simple, no? I actually believed TPA Girl.

TPA Girl “forgot” to mention one important procedure—that I would still have to pay a  deposit. Neglecting to tell me this meant that my brothers and I got into a foolish and rather unnecessary argument at the hospital’s admission desk. When I contacted TPA Girl for clarifications, her response was, “Ya. That is how it is. What is the need to explain this procedure? Everyone understands this.” When I reminded her that the operative word here was “CASHLESS”, this is what whe had to say:

It is cashless, Madam. After the deposit, you don’t have to pay anything. Besides, if you pay the deposit with your credit card or debit card, it will be truly cashless.

I am really sorry to say here, that I could not come up with an appropriate comeback for this. I paid the deposit, which the hospital assured me was fully refundable, admitted Appa, and completed the all the formalities for claiming cashless hospitalisation. That same evening, the hospital faxed the form to the TPA.

The next day, I got a call from TPA Girl saying that there was a problem. She said that forget cashless hospitalisation, I would not even be able to get the expenses reimbursed. This was because my name (and therefore my parents’ names) did not appear on the list of those insured by my organisation. What????????????

It took 2 days of frantic phone calls to Office Boy and TPA Girl and their bosses, as well as 2 days of headache and acidity to get to the root of the problem—TPA Girl was referring to the insured list of another organisation, which had a similar sounding name as the organisation I work in.

Appa was in hospital for a week and for me, each day began and ended not with monitoring his health and recovery, but with monitoring the TPA process and ensuring that they were doing their job. The evening before Appa was discharged, I informed TPA Girl and Office Boy (and their respective bosses), and even had the hospital fax them a preliminary bill so that they could get working on the discharge. The final bill was faxed to the TPA at 8.30 am the next day. In spite of all this, the approval from the TPA did not come through till 2.30 pm. Phone calls to TPA Girl only brought forth responses like, “You have to be patient, Madam. Procedure takes time.” By the time we got my stressed-out Appa home, it was nearly, 3.30 pm. That evening, Appa developed low-grade fever. Thankfully, he was okay next morning, though the same cannot be said for me. 😦

The entire episode had me fervently praying never to have the misfortune to go through this experience again. But about 10 days back, Appa had to be hospitalised again. This time though, I informed the TPA in advance, though it has not made any difference. The TPA circus with its delays and goof-ups remain. In fact, it has been compounded as there is a new TPA Girl, who made the same mistake of trying to locate my name in another organisation’s list of insured. I spent yesterday and most of today sorting out that issue. One response which will be different from my side is I will not be telling my father when he will be discharged till the TPA go-ahead has come through. I don’t want him to go through any more stress.

These last few weeks, I have been talking to many people who have TPAs for their health insurance and most have them have some or the other stressful story to share. I am trying to understand why this has to be so. Is it because the TPAs are innately suspicious or is it because of the paperwork and red tape involved? Is it because the insured is caught in the crossfire between hospitals and the TPAs? Or is it all of the above? Whatever the reason, the insured and their families could do without the stress that this generates.

What do you think?