The doctor had discharged the patient at 8.30 am. The 63-year-old woman walked out of the hospital at 1 am the next day. In between, the hospital kept the patient waiting citing clarifications from the “insurance” side.
The West Bengal Clinical Establishment Regulatory Commission on Monday asked Fortis Hospital to pay Rs 1 lakh as penalty for keeping the patient in the hospital for over 16 hours after she was discharged.
Retired judge Ashim Banerjee, chairperson of the commission, said the commission had heard manycomplaints of delayed discharged, but the complaint against Fortis was far more serious.
The woman, who underwent two surgeries duringher stay at the hospital, was discharged at 8.30am on June 14, said Banerjee. Her daughter arrived at the hospital at 11am.
“The hospital told the family that they were awaiting nod from the TPA (third party administrator). Around 5.30pm, it became clear that the insurance company had approved Rs 3 lakh and the patient party have to pay the rest. The total bill was Rs 3,04,018,” Banerjee said at an online news conference on Monday.
Third party administrators are agencies that process insurance claims.
Around 7pm, when the family was about to make the payment, an official of the hospital said the patient could not be allowed to leave.
“The official said that about Rs 25,000 in the bill was for non-medical expenses and the insurance companies never pay for those. His point was that in this particular case, the insurance companyhad agreed to pay the non-medical expenses by mistake and would eventually refuse to pay the amount,” Banerjee said.
Non-medical expenses include those incurred by the hospital for sterilising equipment and maintaining medical records, and admission charges.
According to Banerjee, the official asked the family to pay Rs 25,000 or wait for the TPA to clarify the matter as the hospital had sought a clarification.
The patient’s family refused to pay saying there was no bill that showed they had to pay the amount.
Around 11pm, the distraught daughter dialed 100. Officers from Anandapur police station arrived at the hospital.
It was around 1am — more than 16 hours after thedoctor had discharged the patient — that the sexagenarian finally walked out of the hospital, almost forcibly, said Banerjee.
A senior official at Fortis Hospital said the entire episode was “unfortunate and undesirable”.
“But one must also understand that Fortis was not at fault in this case. There have been instances when insurance companies refused to pay part of a bill despite giving approval earlier. We asked the family to pay the non-medical expenses but they refused,” said the official.
“The woman (the patient’s daughter) said she would pay only what she was supposed to pay, according to the initial approval from the insurance company. Our staff, too, remained firm in his stand,” he said.
One TPA said there were primarily two factors that lead to delays: lack of clear communication from hospitals and a new system that requires TPAs to take clearance from doctors hired by insurance companies before approving a claim.
“Earlier, TPAs could approve a claim on their own. But now they have to take clearance from doctors of insurance companies. This can delay the approval,” said Shamita Paul, senior vice-president, east, Paramount Health Services & TPA Private Limited.
“During discharge, hospitals at times do not share all documents, including treatment sheets or papers justifying prolonged stay in hospital. The treating doctors are not always available to give proper response and back and forth... leads to delays in discharge,” she said.
“TPAs as service providers try to get all relevant documents in the interest of the insured, even if it takes time, since they are subject to various audits and penalties,” said Paul.
Commission chairman Banerjee said the panel had heard “many complaints of delayed discharge, but this is a very serious one”.
The family refused toaccept the penalty the commission ordered the hos-pital to pay. It was then that the commission askedFortis to pay the amountto a shelter for mentallychallenged children in New Town.