Fear: 4. The spectre of healthcare

The modern version of the Hippocratic oath that the medical industry presumes to swear by also states that:

…I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick…I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm…

People in India have been only mildly curious at the tussle over healthcare plans in USA, or criticisms of healthcare creditors in UK. We understand that the organized nature of their society encourages a preoccupation with the physical and expensive medical treatment not always necessary.  

And anyway, all this happens only on the other side of the globe. The Indian public tends to give hospitals a wide berth. In a country of over a billion people with no universally institutionalized social security, the awareness about medical facilities is fear-based. People hope to get by with indigenous therapies of herbs and spells, ayurveda, yoga, homeopathy, and self-prescribed medications obtained over the counter.

The general hospitals in the country are heavily government subsidized, with the noble intent of reaching the masses. However, general bureaucratic negligence has led instead to general lack of responsibility, funds, technology, accommodation or caring to make them death traps, literally the last resort for the desperately ill.

Private institutions have come up to address this major issue of immediate healthcare. Big business houses have invested heavily in creating hospitals with a difference. Indeed they have raised the existing standards of sanitation and hygiene, technology and nursing care. Smaller nursing homes owned or supported by reputed medical practitioners have also mushroomed to drive home the point that they are alternative tiers for the same brand of healthcare at more economical prices.

However, being business after all, this medical service does not come cheap for the ordinary consumer. By itself the private healthcare industry is socially divisive. Access is restricted to members of the corporate world or individuals who are blessed with the affordability. For the remaining majority, intervention that should be associated with positive emotions of imminent physical, mental and emotional wellbeing, more often arouse abject fears of soon being out of pocket.

Privately owned insurance companies, quick to identify the financial need, corner the market as relief-givers. Their ‘health shield’ card opens hospital doors on the third-party network. Buy our health policy and forget hospitalization cost concerns, they seem to say. My investment brokers strongly encourage signing up for the general health insurance scheme. The utilitarian equation is reasonable to the rational mind. Intuitively, however, the feeling remained that the oasis promised could be a mirage.

Anyway, several years of inactivity on my policy raised my cover amount as bonus was added on. I finally decided on a long overdue health check. The specialist identified a common ailment that required surgery, and recommended a relatively painless procedure with modern technological. The hospital management welcomed my insurance cover.  Prior to surgery a battery of investigative tests was prescribed showing off the thoroughness of their caring.

I was somewhat uneasy with the accumulating costs, and my faith in the service providers needed bolstering! I revisited the Policy to calculate entitlement. The expenses they pledged to cover included:

1. Room, Boarding Expenses as provided by the Hospital/Nursing Home subject to a limit of 1.5% of the Sum Insured per day and for Intensive Care Unit 3% of the Sum Insured per day.
2. Nursing Expenses incurred during In-Patient hospitalization.
3. Surgeon, Anaesthetist, Medical Practitioner, Consultants & Specialist Fees are subject to a limit of 40% of the Sum Insured.
4. Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy Radiotherapy, Donors medical expenses towards Organ transplant, Cost of Pacemaker, Artificial Limbs, Cost of Organs.
5. Pre-Hospitalisation and Post-Hospitalisation expenses when the claim for hospitalization is admitted under the policy.
6. Hospital Cash Allowance, a lump sum of 2% of the Sum insured per claim, in case of continuous hospitalization for a period of more than 15 days.
7. Ambulance charges in an emergency, subject to a limit of Rs.1000/- per claim.

It sounds aboveboard. The company appears to be impressively altruistic in intent, and my suspicions unfounded. I asked the hospital for their estimate, just to be sure. Strangely they passed me on desk to desk, and eventually came up with a ‘verbal’ amount of 60K+. That was well within the insured amount of (now) 220K, so I opted for the intervention and the ‘cashless’ procedure, whereby the insurance provider picks up the tab. After forwarding the application, the hospital casually informed me that the amount actually quoted to the insurance provider was twice that estimated earlier – that is, 120K+. Reason? Junior executives apparently had erred in calculation, “sorry for that…”

I had the distinctly sick feeling of being low-balled. My suspicions reared up once more against what seemed a business tactic to constrain higher payments for the same service. The initial insurance amount sanctioned was 20K. What about the approximately 90 percent balances? My persistent inquiries were met with vague replies. Alarm bells rang in my mind that I might well be left holding the bag!

I re-revisited the Policy to read between the lines. Hidden in the fine print of item 8 of the terms and conditions is the reality check: common disease, illness, medical condition or injury like cataract, haemorrhoids, sinusitis, benign prostatic, hypertrophy, hernia, joint replacement, cancer, renal failure, appendicitis, gall bladder stones, gynae disorders and so on, are subject to pre-determined limits irrespective of the actual medical procedure. [What’s left, I wonder, and notice cosmetic surgery is not on this limits list!]

The company simply pays a first (and final) amount set arbitrarily to between 10-40 percent of the total billing, depending on the assumed gravity of the disease. In my case, effectively that 20K sanctioned initially was the total cover amount payable. Items 1-7 mentioned above are then broken up as 2K for room and board, 8K for the surgery and so on, although the surgeon assures me that these prices are archaic. The remaining amount of 100K is my problem; payback I suppose, for being on the common ailments list!

Now why? The insurance companies have latched on that all private medical institutions, tiered first, second or third, inflate expenses. The story is the same anywhere in the world today, especially when there is insurance cover and a third party network to hide within. The justification proffered is that the insurance companies generally delay payments by months, and they too need to survive. Television channel CNN recently revealed the extent of the billing scam in USA. The hospital they investigated billed a toothbrush at 1000 USD, and a single cotton swab at 43 USD. In India, among other things, a new technological instrument costing 20K in retail may be billed 80K for the patient.

Although comparatively lower key, the nursing homes in India also push the envelope, following practice of the leaders in the field.  I notice, for instance, that the amenities requiring daily changes, like sheets, towels and clothing are largely non-existent, worn-out and tattered material being served up instead. Patients here have to make do with faulty lights and plumbing even in the ‘exclusive’ single occupancy cabins. The check-in/out timings are rigid, so even a few minutes before or after the deadlines become additional in-patient days to be paid in full. Another common practice is to repeat pathological tests unnecessarily – e.g., in a biopsy test, three slides being used means three times the price for the same test result. 

Realization dawns that through the third-party network, we in India are as affected by the spectre of healthcare as are people in the West. Whether or not there is a nexus between the insurance companies and the private hospital managements, their common focus is keeping their businesses in the black, and patient welfare is definitely not priority. In tune with the present vampire craze, feeding off human resources becomes the norm in the modern healthcare business process. 

In the absence of adequate monitoring by watchdog agencies in India, profiteering from illness proceeds unchecked. Because the economic burden is simply passed on to the client, patients and their relatives have cruel choices to make when, despite the medical insurance, the health costs of their loved ones could financially skin them alive, and the cheaper alternative of public hospitals is also unthinkable. Notwithstanding Hippocrates, the general public is today as afraid to live, as they are to die. 

References for this post:

1. “Cashless mediclaim facility to be restored today” deccanherald.com. Deccan Herald. Aug 19, 2010 
2. “Definition of Hippocratic Oath” medterms.com. MedicineNet.com. MedicineNet Inc.  7/13/2002 
3. “Health Shield Online Policy” royalsundaram.in. Royal Sundaram General Insurance. Chennai, India. 

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