A Recent Experience with a TPA

health-insuranceA few days ago a colleague mentioned to me that his wife has developed a painful swelling on the underside of her wrist. Knowing that I have worked in hospitals in Delhi, he wanted me to guide him to the right doctor.

An MRI was duly done and the problem was identified as a cavernous haemangioma. Cavernous hemangiomas are wild, jumbled growths of blood vessels fed by numerous tributary arteries. They are probably all present at birth, but start to enlarge rapidly after delivery.

My colleague fixed an appointment with Dr. Atul Peters a laparoscopic and general surgeon at Max Healthcare in New Delhi. Dr. Peters recommended surgical removal of the growth indicating that the patient will need to stay in the hospital overnight.  

My colleague, like all of us, is covered by an insurance policy provided by our employer and sourced through a nationalised health insurance company. We submitted our pre authorisation for a cashless service to the third party administrator (TPA), expecting a quick approval.

That is exactly where the trouble began. The TPA turned down the request citing a clause in our policy, which excludes ‘congenital’ diseases. We were quite befuddled as we thought ‘congenital’ meant ‘from birth’. The patient in question is a 25 year old lady, a mother and a wife and this problem was not more than 3 weeks old. At this stage I decided to accompany my colleague to Max Hospital and meet Dr. Peters and check with him. We discovered that these haemangiomas can be congenital in origin, but in this particular case, it seemed unlikely. We got Dr. Peters to write this down and sent the document for reconsideration to the insurance company. We also used the services of a company, which acts as a go between the corporates and TPA’s to sort out issues like these. Sure enough the TPA agreed to do a cashless transaction and my colleague’s wife is now scheduled for surgery next week.

This is what bothered me in all this.

I was quite amazed at the alacrity with which the TPA declined cashless service, and how we had to fight this out to get what one would assume was our due. How can a TPA doctor sitting in his office decide, whether the problem is congenital or not? Why did he not bother to check with the surgeon, who has access to all medical reports as well as the benefit of examining the patient?

The moment somebody with the knowledge of the industry started intervening, the TPA found a quick solution and agreed to do a cashless transaction. How is it that a problem, which the TPA previously thought was congenital in nature suddenly resolve itself into something, which has developed over last couple of weeks only and was payable by the insurance company.

The simple answer to this question is that the TPA is obliged to keep the ‘claim ratio’ (Claims Paid/Premium Collected) low, so that the insurance company makes a profit. It is least bothered about the customer and the trouble he has to undergo, in getting his due. If somebody challenges the TPA, they are quick to go back on their earlier stance. It is pretty much like saying that let us first try and browbeat the customer and if he pushes right back, we will pay.

This callous system needs to change.




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