Capping in health insurance benefits the patient in the long run


Dr KK Aggarwal    25 July 2018

The rising health care costs are taking a toll on people, especially the poor as well as the middle class. This is because of the very high out-of-pocket expenditure on health care due to the dismal spending on health by the government. Having a health insurance plan is gradually becoming inevitable.

One can have two types of health insurance with limited coverage or unlimited coverage. For example, we may take an insurance of five lakhs for the full year with a small premium of Rs 500/- per month. We may not be able to afford a coverage of one crore. 

In limited coverage, the insurance may be through GIPSA or open. If through GIPSA provider, then there will be a capping, a limit up to which the insurance will meet the expenses of a particular procedure in a defined Hospital/Nursing Home. Any amount beyond this limit will be non payable by the insurance company. This arrangement will be cashless. 

Non GIPSA insurance provider, in their limited coverage, will not have a procedure based capping. With no capping, the patient or the hospital may be tempted to use a large amount of money in the first admission itself. As a result, he/she may run short for future admissions or other members’ claim, if it was a family floater.

General Insurance Public Sector Association (GIPSA) is the umbrella organization for the four public sector insurance companies (National Insurance Co Ltd, New India Assurance Company Ltd, Oriental Insurance Co Ltd & United India Insurance Co Ltd), which cover around 80% of the country’s cashless insurance market, which introduced the PPN (Preferred Provider Network) in July 2010 to cap the high costs of surgical procedures.

Non-GIPSA insurance companies are private sector insurance companies.

Capping of treatment in health insurance is good for the patient and ultimately benefits the patient and/or the family in long run.

What should the capping limit be? This is a matter of debate between hospitals, insurance companies and the government.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

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