Economic Fraud
MUMBAI: The recent leak of actor Saif Ali Khan’s health insurance claim document on the microblogging platform X has triggered widespread debate on the inequities in how insurance companies handle claims for celebrities compared to the average citizen.
The controversy has brought to light the significant challenges faced by the middle class in navigating health insurance claims, particularly during emergencies.
According to the leaked document, Khan filed a claim of RS 35.95 lakh for his treatment, of which his insurer, Niva Bupa Health Insurance, approved RS 25 lakh. The final hospital bill amounted to RS26 lakh, sources revealed.
The revelation sparked discussions on social media, with users questioning the discrepancies in claim approvals. Dr. Prashant Mishra, a cardiac surgeon at Tunga Hospital, Malad, shared his perspective on X, stating,
“For smaller hospitals and the common man, Niva Bupa typically sanctions no more than ₹5 lakh for similar treatments. Five-star hospitals charge exorbitant fees, and insurance companies pay them, leading to rising premiums that burden the middle class.”
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Expert Insights
Speaking to Hindustan Times, Dr. Mishra elaborated that insurers often dictate the amount they approve for treatments, regardless of actual costs incurred. He expressed concern over the inflated fees charged by high-end hospitals, which insurers reimburse, driving up premiums for all policyholders.
Dr. Mishra also highlighted how insurance companies appear more lenient with high-profile patients or luxury hospitals, creating an uneven playing field. “This system disproportionately affects the middle class, making mediclaim policies less affordable as premiums continue to rise,” he said.
Real-Life Struggles
Several individuals shared their experiences, shedding light on the challenges faced by ordinary policyholders:
- Kiran Karkera : After undergoing spine surgery earlier this month, Karkera had to deposit RS 1.8 lakh at admission, as his urgent surgery was not classified as an emergency. Despite having a top-up policy, he found the claims process tedious and complicated, with minor errors potentially leading to rejection.
- Mahesh Seth: Following his wife’s hip replacement and knee surgery after a major accident, Seth paid Rs 4 lakh upfront as the hospital was not in his insurer’s network. Although he was reimbursed Rs 3.88 lakh, exclusions such as consumables left him bearing part of the cost.
- Anonymous Goregaon Resident : After paying Rs 15,000 for an endoscopy, her claim was rejected because the procedure was classified as outpatient (OPD) rather than a day-care procedure. She questioned why technicalities like day-care admission should affect claim approvals when the procedure is the same.
Mahavir Chopra, an insurance consultant, emphasized the limitations of cashless insurance policies, particularly during emergencies. He shared an incident where a child required immediate treatment at night, costing Rs 20,000. The claim was denied as it did not meet the 24-hour hospitalization requirement.
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Insurer’s Response
A Niva Bupa spokesperson clarified that treatment costs depend on various factors, including the illness, severity, procedure, location, and type of hospital. “Even within the same hospital, costs vary depending on the room type selected by the customer,” the spokesperson said.
The spokesperson added that claims are processed per the policy’s terms and conditions. Insurers work with most hospitals on mutually agreed tariffs, periodically revised for medical inflation. However, some hospitals operate on open billing without fixed tariffs.
For cashless claims, customers must submit a pre-authorization request 48 hours before planned hospitalizations or as early as possible during emergencies. For reimbursement claims, customers must settle hospital bills themselves and file for reimbursement within 30 days of discharge, which is processed within 15 days of submission.
Conclusion
The leaked document has reignited discussions about the disparity in health insurance claims, with many urging insurers to adopt fairer practices to alleviate the financial strain on middle-class families. The debate underscores the need for greater transparency and equitable policies in the health insurance sector.
