When a life altering moment occurs, people remember – Castle.
Having a baby is one such moment and you remember every thing around that event for the rest of your life. For many, the happenings around that moment are really happy ones. Everything except one for me was as well.
This post is about that one thing which wasn’t the happy one. And that thing is the way S.L.Raheja (A Fortis associate) Hospital dealt with providing cashless insurance for maternity.
To cut a long story short, they f***** up big time on the way they behaved with us on providing cashless insurance for maternity. And I guess they’d do the same with anyone looking to opt for one there. My strong recommendation is, don’t go to a Fortis Hospital if you are thinking of getting cashless facility for (some part) maternity expenses.
The rest of this post is going to chronicle my ridiculous interactions with Fortis TPA and administration in a chronological order.
| Day -9: A few days before the D-Day, we decide to go to the hospital to check and do all formalities needed for admission. Accordingly, we are directed to the counselling section to check about registration and costs. | |
| Counsellor1 |
The counsellor explains the standard maternity packages along with estimated additional charges. The package we decide on was Rs.100k for normal delivery and Rs.125k for Cesarean delivery. She then informs us that since my wife – ‘the patient’ (I have strong reservations on the use of this word for (expectant) moms) – was already registered, we can come and do all financial formalities at the time of admission.
We then mentioned that we had a corporate insurance policy that covered maternity and would like to use the cashless facility up to the extent it covered (it covered Rs.50k). The rest, we said, we’ll pay promptly and as asked. Immediately, the counsellor asked about the insurance company and when we mentioned it was National Insurance, she said, ‘we don’t accept GIPSA’ (note the sweeping nature of this statement) claims and that we’ll have to pay in full ourselves and claim later. Our questions on why fell on deaf ears so we decided to go to the person who was in charge (of administration?) of the maternity ward (referred to by our Doctor) to find out more. |
| Resident Doctor |
Near the ward, we bump into the Resident Doctor doing her rounds and who knew us well by now (a couple of rounds of consulting). On hearing about our query on insurance, she promptly calls up the Counsellor to ask, ‘what is the problem with insurance?’
She then directs us to go back and speak to the Counsellor. |
| Counsellor1 | We go back to the Counsellor who rolls her eyes on seeing us. After the conversation with her, we leave the place with the explicit understanding that cashless facility will be provided to us. |
| Day 0: It’s 00:00 hrs and the D-Day has officially started. Time to get admitted and we are all excited! | |
| Cashier1 | We go straight to the payments section, state the purpose for admission, mention the maternity package and insurance, fill the necessary forms, pay the demanded advance (Rs.10k), go to the ward and get admitted. |
| TPA assistant1 & Admin1 |
Just after the counter opens for the day, I ask for the necessary TPA/insurance forms and get them filled (take wife’s signature, Resident Doctors note and signature etc.,). While submitting, I specifically check if they take ‘GIPSA claims for maternity’ and they tell me they do.
I also notice Admin1 hanging around in the background listening to my questions on ‘GIPSA maternity claims’. This happened to be a coincidence and he didn’t raise any issue then. |
| Midday – Day 0: It apparently takes a few hours for the TPA assistance cell at the hospital to process a single page form! And while processing, the hospital TPA assistants ‘realise’ they cannot accept it. They then call me up asking me to visit the counselling section. | |
| TPA assistant1 |
I go to check on the problem.
The TPA assistant informs me that she wasn’t aware of the ‘hospital rule’ that they are not supposed to accept ‘GIPSA maternity claims’. I collect my TPA forms and storm to Counselling. |
| Counsellor2 |
Counsellor1 we met a few days ago isn’t around. So, I meet Counsellor2 who point blank tells me, ‘GIPSA claims for maternity are not accepted.’
When I ask for clarification, she directs me to Counsellor3. |
| Counsellor3 |
Counsellor3 explains to me that GIPSA is not accepted by the doctors because they ‘don’t make money’ due to the low claim limits.
I clarify a) that I am going to pay the maternity package amount not covered by insurance when asked, b) that I already paid Rs.10k as advance at the time of admission and c) that I expect the insurance to cover Rs.50k, the maximum payable for maternity. And I further added that if they have any concerns, I’ll pay an additional Rs.50k (the remaining cost for normal delivery; not including the advance) which should cover the full package cost right then. I also tell her that we’ve already informed the necessary corporate person in charge of insurance who’ll follow-up for prompt processing at the insurance agency end. She still asks me to pay full and claim insurance later to which I ask if it is a ‘hospital policy’ or a ‘doctor policy’ not to accept GIPSA claims. When she states it’s a ‘doctor problem’, I ask her to speak to the Doctor before me because, I think, the Doctor we go to will not have a problem. As expected, the busy Doctor doesn’t answer her calls. She tells me she’ll inform me post speaking to the Doctor. |
| Cashier2 | Not willing to take any risks, I promptly go to the cashier and pay a further Rs.50k. |
| An hour or so later, the Doctor comes for her visit to our room. | |
| Doctor |
I find an appropriate time and ask her about her unwillingness to accept GIPSA claims.
She informs me that she doesn’t have any problem as long as we pay any shortfall on the ‘full hospital package amount’ that the insurance will not cover. I inform her that I’ve already paid 50% of that amount and she tells me that cashless insurance claim is absolutely fine with her before leaving. |
| TPA assistant1 | Armed with this clarification, I go down to the TPA assistance desk to check on the status of my claim. She directs me to speak to Admin1. |
| Admin1 | He directs me to Admin2. |
| Admin2 |
Admin2 gives me the story of ‘Doctors not accepting GIPSA’. I clarify again that I’ll pay whatever the insurance doesn’t cover in the package and show her the 50% payment I already made (which should cover for any shortfall).
Having lost my patience, I now demand to speak to someone really senior at the hospital about this matter. She informs me that she’ll come back. |
| Post noon – Day0: Looks like things on this GIPSA front have settled now. My wife’s labour pains have started and just when we are looking forward to the next few hours, the TPA assistant calls and asks me to fill another form. | |
| TPA assistant1 |
The assistant hands me an additional form, asks me to fill and submit it.
This form was essentially a declaration letter to the hospital which stated that I have financial problems and hence cannot pay the bills (not the exact words but something to that effect)! |
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Admin1 & Admin2 |
Furious, I storm into the billing office and ask them about why I need to fill that ‘declaration’ when I already paid quite a bit.
They explain that it’s the only way out to accept ‘GIPSA claims’ at their end. I tell them that I’ll not sign such a ridiculous letter and demand to speak to that someone really senior at the hospital and leave the hospital to have lunch. |
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Sometime in the afternoon – Day0: The Doctor calls my wife (she doesn’t have my number) to tell that she’s been getting pestering calls from the counselling office and requests me to solve this issue.
A few minutes after that, CounsellorX (I don’t know who it was exactly as I wasn’t around) visits the room my wife was in and asks us to pay ourselves and not claim cashless insurance. My wife, half in labour, who was very well looped into the nonsense happening on this front (and on whose corporate policy, we wanted the claim done) asks her why? Hearing the ridiculous ‘doctor problem’ story the Counsellor tells her again, she loses it and shouts at her. The counsellor realises my wife’s condition and leaves noticing her trembling in anger. |
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Late afternoon – Day0: I come back and help calm my wife down. Not hearing anything more on the payment front, we settle into a routine of timing her contractions.
Unfortunately, the duty doctor realises that there is a slight complication and advises us to go for a Cesarean section delivery. We agree. The duty nurse hands over a form to me and asks me to get it signed by counselling and submit it to billing. The form is essentially a clearance of dues for Cesarean delivery. Once done, the doctor and patient can proceed to the operation theater she states. By now completely frustrated by the counselling, TPA and admin teams, I decide to pay the bills myself and claim the insurance later. |
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| Counsellor1 |
Me: You need to sign this. I don’t want to do cashless insurance. Let me know how much I need to pay. I’ll pay it immediately.
Counsellor1: How much did you pay already? Me: [in my mind – you are supposed to know this dammit!] 50k + 10k advance. Counsellor1: [opens the maternity package details, confused with the calculations] You don’t have to pay anything now. She then signs the form and hands it to me. Me: Thank you. |
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I then proceed to the cashier, hand over the form to him and ask him to expedite whatever he has to do on it.
A couple of hours later, I pay another Rs.5k as advance for the baby. |
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| Two days later, I pay another Rs.67.6k to settle all dues thus paying the full hospital charges myself and not claiming cashless insurance via the hospital. | |
Walking out of that hospital. I decide not to visit it another time.
GIPSA maternity packages are not made by Obstetricians.And it is the Obstetrician who is going to deliver the baby.So charges should be such as the on going rate charged by Obstetricians.Myself obgyn came to know about this recently. Patient told of Rs 30000 GIPSA maternity package but according to the hospital Only Rs 10500 they are getting so now tell me Dr gets only maybe Rs 2000. Which gynae is ready to do delivery for Rs 2000. Making maternity packages without consulting Obstetricians – high time drs put their foot down on such nonsense
I don’t think you got the gist of this post… It’s about charging what the insurance guys won’t pay as part of the package to the patient. Worse still, it’s not wanting to process insurance claims for the big 4 insurers in India.
Hi Ravi, may I know who was doctor and which corporate company the insurance was from? I also need to decide which hospital to go to for wife’s delivery. Fortis or Max. Not sure if any other good is there.
The insurance was from National. But check with either of the hospitals if they accept cashless from any of the big 4 government insurers. The doctor doesn’t matter. My gripe is with the way the hospital behaved in not accepting a cashless insurance claim. The other thing to check if you guys are keen on a natural delivery is the hospitals delivery stats. They should be able to give it else the local municipal office will have all the information.
Thanks for the post. I was planning to consider Fortis. But not anymore.