How can an insurer question the doctor/ line of management?

By,
Dr. Salma Rayani Khan BHMS, LLB, FLMI. FAALU (US), PGDIA
AVP-Audit and Consulting - INCHES Healthcare Pvt. Ltd
&
Dr. C H Asrani DNB (Family Medicine), MBBS
Founder & CEO – INCHES Healthcare Pvt. Ltd

As per IRDAI report (2016-17), the death claims space was burdened with over 6000 pending cases and health insurance burdened with the stigma of 3,10,904 pending cases.

Most of these pending cases are courtesy right information not forthcoming. Further, industry is reeling under high claim ratios and paying crores of rupees just because doctor(s) won’t answer the query raised or won’t share the requisite document!

Faced with these challenges, insurance sector still lives with an assumption, “An insurer cannot question the treating doctor and the line of treatment given. That is treating doctor’s prerogative”.

This assumption cannot be more WRONG!

What is not known is that when a (any) doctor gets registered with state/ national medical council, she/ he has to abide by code of medical ethics drafted by National Medical Council of the country. Each country also has several legal provisions that a registered doctor has to comply with – commonest being ‘informing the police/ judiciary about some foul play in a given death’.  

Another reason for not questioning is lack of enough credible resources to frame the query. The treating doctor asking, when being questioned “What are your qualifications? Are you equally qualified to ask me about the treatment given?”

The query has to be very specific and worded crisply; else the doctor may give a roundabout answer not meaning much.

There have been instances, when doctors have asked insurance officials, to get a court order if they need some records - this despite an authorization from patient in possession!

Some examples of not adhering to the medical code of conduct can be:

  • Instances of issuing a death certificate for an unnatural death.
  • Cases of Malaria, Dengue treated with high-end antibiotics; without any clinical evidence of infection.
  • Cases of Acute pancreatitis, but history of alcohol consumption (either positive or negative) not mentioned; it is not possible any doctor treating Ac Pancreatitis will not enquire into h/o alcohol consumption.
  • Hospitalised in emergency for Accelerated Hypertension with no immediate management done for hypertension.
  • Patient hospitalized for evaluation/ observation / bed rest – all three could have been managed at home.

The list is endless.

Since the insurer is an important stakeholder in that hospitalization (being the payer of the hospitalization benefits), it has all the right to question the treating doctor with regards to a patient’s treatment, in case any clarification is needed.

When such a query is raised, one should take care that the purpose of the letter is purely for clarification of the doubt and one should specify the medico-legal provision for doctor’s understanding of the legalities behind it.

It is very important to frame the questions right. The art of asking the right questions can only come from in-depth disease specific clinical knowledge (Standard Treatment Guidelines) to pose medically exact questions; plus having sound knowledge of the region’s medico legal systems to understand the medico legal implications.

It’s time to get out of the box of assumptions that  you cannot question the treating doctor and raise questions in the right manner in case of doubt.

INCHES Healthcare Pvt. Ltd helps solve this issue wherein we not only help in rendering deep medical insights and opinions but also help in raising medically and legally compliant queries to the treating doctor. The medico legal query letter is created by two teams – clinical and legal to provide sound application of prevailing treatment guidelines as well as Medico Legal Systems.

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