Several measures in the health insurance standardisation programme, set to be implemented from July 1, are customer-friendly. However, the clause pertaining to the size of hospitals may prove to be a hindrance to many, especially pregnant women. Though the step may be aimed at ensuring customers don't go to unauthorised and unregulated hospitals, the clause could affect patients choosing smaller hospitals.
According to the Insurance Regulatory and Development Authority's (Irda) guidelines, the criteria for a hospital includes at least 10 inpatient beds in towns with a population of less than 10,00,000, and 15 inpatient beds in others. In addition, the hospital should have qualified nursing staff and medical practitioners round the clock and a fully-equipped operation theatre. It should also maintain daily records of patients.
Most insurance companies have their individual network of hospitals that meet these criteria. For one to claim reimbursement from a company after being admitted to a non-network hospital, the hospital would have to meet Irda guidelines.
This is even more pertinent for maternity hospitals, many of which are small in size. A senior Mumbai-based gynecologist says several small nursing homes meet all the other criteria laid down by Irda, except the one on the number of beds. "There are many recognised delivery centres that have less than 10 beds, especially in Mumbai's suburbs," she says.
Vivek Desai, managing director of Hosmac (a healthcare consulting firm) and a practising doctor, says due to high population density in big cities, the number of small hospitals there is more than in small towns. He, however, adds while the clause related to the number of beds may lead to hurdles in the short term, it would eventually help customers.
"Smaller hospitals are already facing woes because patients prefer to go to bigger hospitals, especially those which have health insurance. Also, treatment for critical care would be an issue in smaller hospitals," he says.
Of the 20-odd general insurance companies in India, only six offer maternity cover under individual and family floater policies. The waiting period after which one can claim insurance is two to six years.
The remaining companies offer these policies only under group policies, whose terms and conditions aren't known beforehand.
Divya Gandhi, head (general insurance & principal officer) at Emkay Insurance Brokers, says the restriction on the size of the hospital is aimed at addressing fudged bills, a factor common to many small hospitals.
"Not all third-party administrators have the manpower to physically check all bills. So, if there is a limit on the bed size, it is similar to an assurance that the hospital would be audited and forged claims would be few," she says, adding that the large number of small maternity hospitals in metros could be a hurdle.