On paper, the Cashless Everywhere scheme launched by the General Insurance Council in January means that any medical insurance policyholder can now access cashless facilities for treatment in any hospital, even if that institution is not in the network of their insurance company.
On the ground, however, the scheme’s uptake has been slow, marred by low consumer awareness about cashless hospital facilities, no standardisation of rates for treatment and medical procedures in hospitals across India, and the inability of medical institutes to quickly implement the new initiative. When hospitals and insurers fail to agree on treatment costs, cashless services cannot be offered.
“The initiative accommodates even hospitals in remote locations with limited access to technology. This flexibility ensures that policyholders have a wide range of hospitals in emergency medical condition, promoting accessibility and convenience in healthcare services. The key advantage is the freedom to choose any hospital, regardless of its network status subject to cashless approvals,” said Hilal Ahmad, medical superintendent of the Asian Institute of Medical Sciences.
‘Not enough clarity’
However, he also noted that, since no single hospital has the same rates, the tariffs under the scheme are still being worked out by the GIC. “This will be a challenge,” he said.
In an advisory to its members, the Indian Medical Association’s Hospital Board of India (IMA-HBI) said that the scheme has been launched without sufficient clarity on the process. It also warned its members that the sustainability of a hospital will be at stake if it accepts the scheme in its current format.
“Let the cashless be for actuals and don’t sign MOU with packages, discounts, freebies, etc, and don’t compromise on quality healthcare for patients,” said IMA-HBI chairman A.K. Ravikumar.
Awareness for patients, hospitals
Education is crucial on both sides, said Aakash Healthcare managing director Aashish Chaudhry, noting that patients need to be aware that they can now opt for treatment in any hospital, even outside their insurance company’s network list.
“From the hospital perspective, proactive steps are essential to educate patients about utilising this new initiative for treatment near their homes or in a trusted hospital, even if the specific disease or insurance isn’t covered there. This mutual understanding is vital for the successful implementation of the initiative,” he said. “For specialised procedures like liver or bone marrow transplants or certain cardiac devices, proactive steps, such as contacting insurance, discussing with doctors, and inviting insurance auditors, can help secure specialised approvals even for elective, expensive procedures. This process involves informed decision-making based on meetings with doctors and patients,” he added.
For elective procedures under the Cashless Everywhere scheme, policyholders are required to intimate their insurance company at least 48 hours prior to admission; for emergency treatment, the insurance company must be alerted within 48 hours of admission. Additionally, the claim should be admissible as per the terms of the policy and the cashless facility should be admissible as per the operating guidelines of the insurance company.
Expanding health coverage
Kaushalendra Singh, deputy general manager of operations at PSRI Hospital said that most hospitals are generally favourable towards the GIC’s new initiative. “The move is significant since it relieves patients of the financial burden of upfront costs and the number of patients choosing cashless services would rise significantly from the present 63% to possibly reach 90%,” he said.
In its report titled, “Health Insurance for India’s Missing Middle”, the NITI Aayog explained that expanding health insurance coverage is a necessary step, and a pathway towards India’s effort to achieve universal health coverage. It noted that India’s population is vulnerable to catastrophic spending, and impoverishment from expensive trips to hospitals and other health facilities, adding that the catastrophic effect of healthcare spending is not limited to the poor, but impacts all segments of the population.
“At least 30% of the population, or 40 crore individuals – called the missing middle in this report – are devoid of any financial protection for health,” it said. The Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) launched in September 2018, along with State governments’ extension schemes, provides comprehensive hospitalisation cover to the bottom 50% of the population, it said.
Suman Pal, chief claims officer, Onsurity, an employee healthcare platform that provides a monthly healthcare membership with group health insurance to businesses, noted that one of the key challenges is the probable reluctance of hospitals to align with insurer terms, potentially leading to instances where patients opt for reimbursement instead of cashless treatment which could defeat the purpose entirely.
“Central to this initiative is the consolidation of insurer hospital networks, encompassing approximately 40,000 hospitals under a unified umbrella. This unified approach will ensure that insurers honour claims from non-network hospitals promptly, effectively expanding healthcare access for policyholders,” he added.
