Dr. Purvish Parikh writes on a common situation doctors face- denial of legitimate health insurance claims for their patients, and the steps they can take to help them reverse a rejection.

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We doctors are sometimes faced with unpleasant situations. One of them is when our patients covered by health insurance, receive communication from TPA or insurance companies denying their legitimate claims for reimbursement of medical expenses or cashless processing.

Most often we don't know how to deal with this situation, even if we want to help our patients. This article will give tips on how doctors can take proactive measures to help their patients.

We have previously published the results of a nationwide survey by Medic LAWgic (Indian Journal of Medical Science, 2019). This consisted of 8 simple MCQs that to less than three minutes to answer online. Being the collective experience of 377 practicing doctors, it represents a wealth of information, the results of which may astound some of us.

1. More than half (55%) of the responding doctors had knowledge of significant number their patients (more than 10%) experiencing problems with medical insurance claims. This included outright rejection of the claims (48%) as well as cut in the claim amounts (70%).
2. Some reasons were related to the insurance policy terms, the most common one being failure to disclose a pre-existing medical condition (62%).
3. The other group of issues, relating to treatment specifics, included use of oral medication (53%), treatment without indoor admission (41%), and use of with new modalities of therapy (40%).
4. The good news is that 80% of the doctors had written to the insurance companies in support of their patients’ claim. And even better news is that in 57% of instances, such support by doctors forced the insurance companies to reverse their denial.

This is a very important lesson for all of us. The problem of mediclaim insurance denial is real and growing exponentially. And it is hitting the people who need such financial assistance the most. No wonder, globally 100 million families are pushed into extreme poverty every year due to their healthcare bills.

In the United States, medical insurance claim denial rates were up to 45% in 2017. Sadly, people gave up their rights very easily and <0.5% of patients appealed against the denial.

In our country, the insurance regulatory and development authority of India (IRDA) has taken many proactive steps in the interest of genuine patients. IRDA is supported by consumer dispute resolution commissions as well as judicial courts in following a patient-centric approach.

1. "Bad" habits: Tobacco and alcohol consumption cannot be used by insurance companies for automatically rejecting claims, stating that the illness (lung cancer, pancreatitis) was due to such indiscretions. This is supported by a consumer court judgment from Chandigarh.
2. Pre-existing conditions: Pre-existing medical conditions need to be disclosed at the time of purchasing the policy. But once this is disclosed, at the time of renewal, the new policy can't exclude such conditions. This is not known to many patients. We can spread awareness about the same among our patients.
3. Genetic conditions: This term was incorporated in insurance policies to exclude hereditary conditions in the newborn. However, insurance companies and TPA are wrongly interpreting this term to also reject claims for diseases like cancer that are associated with genetic changes in the tumor cells- alterations are clearly not hereditary in nature. IRDA has issued official communications that insurance companies cannot do this.
4. Timelines:

• For informing insurence companies- When a person becomes sick, the priority is to seek medical help and not inform the insurance company. This is well recognised. Hence, IRDA has issued clarifications that delays in informing the insurance companies due to genuine trains must be condoned. It cannot be the sole reason for rejection of claims.
• For claims settlement- Remember the IRDA guidelines that claims are required to be settled by 30 days. It is the legally bound duty of insurance companies to fulfill their obligation for genuine claims without harrassing the insured patient.

5. New therapy: Medicine is a constantly evolving field. This is why there is a legal requirement of updating ourselves with CME credit points for renewal of our license to prescribe medicine. It also reflects the development of new modalities of treatment. Such novel therapies are likely to be expensive, not widely available and take time to be incorporated into standard treatment guidelines. This last point is often used by insurance companies to reject claims, especially when the medical intervention is expensive. The way to support such use is by using scientific rationale, highlighting unmet needs and why this modality was used instead of other means in our specific patient. Such efforts often force the insurance company to reverse their denial.

In Conclusion, us doctors are the pillars of strength for our patients in more ways than one. By helping them support genuine medical insurance claims, we have one more avenue for strengthening doctor-patient relationships and earning their blessings.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The authir, Dr. Purvish M. Parikh is the Group Oncology Director & Professor of Medical Oncology at Shalby Cancer & Research Institutes and Precision & Medical Oncologist at Asian Institute of Oncology, Somaiya Hospital, Mumbai.