Getting bored in a hospital! Not to worry much as I am not admitted but took my mother for an outpatient consultation as part of her routine screening. I took a leave for a couple of days to complete this job as this does not take less than 2 days. Yesterday was a little busy with lot of activity as she underwent all the routine investigations. Today, it is time to meet the consultants with the investigative reports gathered. Since everything is pretty normal with her reports, it can be called as a formal check-up and needs no tense moments. I hope I could explain the reason for my boredom. I grabbed a coffee for both of us and started sipping to munch away the half an hour in between a consultation as the doctor was busy in a surgery. My ears stood up with yelling sounds besides me and a man picked up an argument with billing executive in the reception. Since, I had nothing to do, I followed the argument to understand the case. The man was ranting over the executive and she was trying her best to calm him down. The Person outside the counter was accusing the hospital authorities of fraudulence as they were not considering his insurance policy and charging him for the bills while his wife was admitted. I wondered what would have been the case to reject an insurance policy despite paying premiums for it.
The executive was explaining that their hospital was not in the network of hospitals the patient’s insurer was covering. I was puzzled and so was the arguing man. How come an insurance policy is not covered by any hospital? Is there such a thing? I too was in an assumption that my parents’ health insurance policies would cover them for any ailment across hospitals. I immediately took my phone and contacted the insurance agent who has sold the policy. I got relieved with his answer. Let me put things in an order to make the policy holders understand the difference between network and non-network hospitals!
Insurance companies realize that private hospitals usually charge more from the patients who have insurance policies than the patients who do not have insurance coverage. This practice can shut the insurance companies down due to huge losses. In an attempt to stop losses and avoid expending unnecessary costs, insurers teamed up with some hospitals of their choice by including them as a part of their ‘network’.
Considering the reputation of a hospital in preferred localities, the health insurance companies negotiate with these hospitals to balance the costs in an attempt to prevent the hospital bills from surging. The insurance companies request these hospitals to be part of their broad network with a mutual benefit and are therefore known as the network hospitals. Rest of the hospitals across India and are outside this mutual network are considered as non-network hospitals.
Let’s compare few cases as examples for a better understanding of the difference between network and non-network hospitals.
Mr. Ram has an insurance policy with cashless benefit. He had to be admitted to a network hospital owing to a medical condition. He gets complete treatment in the hospital. However, despite having an insurance policy, he pays the entire bill from his own pocket. Mr. Ram submits a claim with his insurance company with the necessary original documents. The insurer analyzes the documents and gets the claim application processed and approves the submitted claim as per the terms and conditions mentioned in their mutual agreement of the policy.
In the second case, Mr. Sham has a cashless insurance benefit as per his policy. A visiting hospital which is part of his insurer’s network diagnoses him with an ailment and prescribes to get admitted to the hospital. As Mr. Sham has a cashless hospitalization benefit, his family members arrive at the Third party administrator (TPA) for a cashless hospitalization benefit as they are entitled to it as per their policy. Hence, Mr. Sham gets admitted and avails the best treatment from that hospital and the hospital confirms them that they don’t have to pay anything from their wallet and that the hospital will retrieve the bill from their insurance company. After Mr. Sham gets discharged, his family members approach the insurance company with the required original documents for record purpose. In this scenario, Mr. Sham’s family members only need to pay for the expenses which are not covered in their policy that are clearly mentioned and explained to the policy buyer at the time of the purchase.
In the third Scenario, Mr. Bhim has a health insurance plan too and on the diagnosis of an ailment, he gets admitted to a non-network hospital on the advice of the doctor in that hospital just as the person’s wife who was arguing with the billing executive in my case. It makes no difference whether Mr. Bhim has a cashless benefit or not in this case as he got admitted to a non-network hospital and the insurance company cannot offer him the cashless benefit. He had to bear the entire expenditure and later files a claim for reimbursement. After a proper evaluation, the insurer only approves the charges feasible as per their policy. In such cases, the claim can be fully or partially approved as per the conditions of the policy.
As we can compare the three examples quoted above, it is crystal clear to understand that it is better to get admitted to a network hospital unless it is a health emergency. Even if the policy holder does not have a need to get admitted to a hospital, it is suggested to have a list of the network hospitals to make the best use of the insurance policy. Hope this article gets all the insights to understand the difference between network and non-network hospitals.