Does Health Insurance give Us an Assurance? A Study on the Extent of Coverage of Health Insurance at a Tertiary Care Hospital in North India

Abstract

ABSTRACT Introduction Health insurance is emerging fast as an important mechanism to finance health care needs of the people. Complexity of the health insurance industry has been much talked about and less understood in the Indian scenario. Hence, it is imperative to assess the level of awareness that the population has with respect to health insurance policies. Materials and methods Cross-sectional prospective study conducted over a period of 6 months, at the third-party administrator (TPA) desk of the hospital. The data was collected using a preformed close-ended questionnaire after obtaining consent from all the participants. Only patients admitted in the hospital availing cashless hospitalization were included in the study. The study was undertaken with the objective to determine the level of awareness about insurance policies and procedures among those insured and identify the problems faced by those insured when availing cashless treatment. Responses to the variables in the questionnaire were compiled and tabulated using Excel 2010. Results Response rate of 76% was observed. 56% of the study population were planned admissions and 44% were admitted through emergency department. The study showed that about 56% of the principal policy holders were between 30 and 50 years of age. The awareness regarding the terms and conditions of the health care insurance policy and the servicing TPA was found to be 70%. However, on interacting with patients it came to light that despite being appraised by their insurance agent, they faced challenges while availing health care benefits under health care insurance and were ignorant about the procedure involved. For the current admission, in 78% of the cases, the TPA responded within 24 hours of intimation; however, in 22% cases there were delays in response from the TPA mostly attributed to communication gap between the Insurance Company and the TPA. Preexisting disease was not covered in 14% cases. 82% cases had to wait for more than 2 hours for the final clearance from the TPA. Over the years, as ascertained in 2016 also, the scenario of insurance has not undergone significant change. Conclusion Strategies to optimize claims by bringing about a uniformity in the rates being charged by the hospitals for different procedures are needed to increase coverage. How to cite this article Jain K, Sinha SK, Jain D, Kumar R. Does Health Insurance give Us an Assurance? A Study on the Extent of Coverage of Health Insurance at a Tertiary Care Hospital in North India. Int J Res Foundation Hospc Health Adm 2016;4(1):25-30.