Mediclaim Policyholders, Do you know the Definition of a Nursing Home?

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Since many years, the definition of Hospital / Nursing Home for Mediclaim Policies of various insurers has been similar & it evolved to add some more criterion but did not change the basic tenets of the qualifying criterion.
This is how it was worded:

'HOSPITAL/NURSING HOME’ means any institution in India established for indoor care and treatment of sickness and injuries and which either
a) Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner.
OR

b) In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognized in locality as Hospital / Nursing Home and should comply with minimum criteria as under:


i.      It should have at least 15 in‐patient medical beds in case of Metro cities, A Class cities & B class cities or 10 in‐ patient medical beds in case of   “C class” cities. Classification of cities shall be as per Govt of India Notifications issued in this respect from time to time.


ii.    Fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test and X‐ray, E.C.G. etc for the care and treatment of injured or sick persons as in‐patient.


iii.    Fully equipped operation theatre of its own, wherever surgical operations are carried out.


iv.    Fully qualified nursing staff under its employment round the clock.


v.    Fully qualifiedDoctor(s) should be physical in‐ charge round the clock.


The term ‘Hospital/Nursing Home’ shall not include an establishment, which is a place of rest, a place for the aged, a place for drug addicts or a place for alcoholics, a hotel or a similar place.

However, on February 20th, 2013, Insurance Regulatory & Development Authority, vide it’s circular (No. IRDA/HLT/CIR/036/02/2013) regarding Guidelines on Standardization in Health Insurance, changed this definition as follows:

A hospital means any institution established for in- patient care and day care treatment of sickness and / or injuries and which has been registered as a hospital with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under:
•    Has at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and 15 inpatient beds in all other places;
•    Has qualified nursing staff under its employment round the clock;
- has qualified medical practitioner (s) in charge round the clock;
- has a fully equipped operation theatre of its own where surgical procedures are carried out
- maintains daily records of patients and will make these accessible to the Insurance company’s authorized personnel.

If you observe the difference between both these definitions, the word “OR” was missing in the new definition & was replaced with AND. This simple change would have affected a population of at least 16 Crore Indians in roughly 53 Indian Cities (Census 2011) where population is more than 10,00,000. The difference in definition disqualified all those nursing homes with less than 15 beds in these 53 cities from treating the patient insured under Mediclaim policy. It did not matter whether they are registered with the Local Municipal Corporation or Licencing Authority. Any insured member undertaking In-patient treatment in these Nursing Homes would not have got reimbursement of expenses under Mediclaim policy & this would have led to rejection of claims worth many Crores. (Most of the small surgical procedures like Hernia, Hydrocele, Common ENT Surgeries and Eye Surgeries are undertaken in hospitals less than 15 beds. In Mumbai alone, 55% of registered nursing homes are with bed capacity less than 15 beds.)


These guidelines are already effective for all Group Policies from 1st July 2013 & it would be applicable for all Individual Insurance Policies from 1st October 2013.
Association of Medical Consultants, an apex body of small nursing homes in Mumbai challenged this circular in Mumbai High Court thru a writ petition in June 2013 & IRDA responded to this by making a change in the Definition of Hospital / Nursing Homes vide its circular No. IRDA/HLT/REG/CIR/125/07/2013 dated 3rd July 2013 wherein the AND was replaced with OR. The definition is now in line with original tenets & as long as the hospital is registered with local licencing authorities (even if its less than 15 beds), treatment taken would be payable under Mediclaim.

This one small change would have led to major furore among Mediclaim policyholders from Urban & Semi-urban parts of India & almost all policyholders were blissfully unaware of this change. We are happy that this issue was contained well before it would have ballooned into a major controversy. 

(This reminds me of popular Marathi legend wherein Raghobadada sent a message to hold (in Marathi Dhara) Narayanrao Peshwa in custody. This message was intercepted by his cunning wife Anandibai & she changed it to Kill (in Marathi Mara). This simple change from Dha to Ma got a young Peshwa killed. The OR & AND saga here would have created similar history.)

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About the Author:

Sudhir Sarnobat is one of the Founder-Directors of Medimanage.com, a specialist health insurance advisory service for Individuals, Families and Corporates. Know more about Medimanage's free advisory services here:
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