Hyderabad ophthalmologists move IRDAI, Health ministry over alleged Patient diversion, insurance misuse by healthcare aggregators

Hyderabad: Highlighting alleged unethical patient diversion and misuse of health insurance, a group of ophthalmologists from Hyderabad has written to the Insurance Regulatory and Development Authority of India (IRDAI) and the Ministry of Health and Family Welfare, seeking an investigation into the functioning of certain digital healthcare aggregators.

The doctors alleged that some healthcare aggregators are working in collusion with select Third Party Administrators (TPAs) and empanelled hospitals to redirect insured patients to hospitals with which they have financial arrangements.

According to the doctors, these practices compromise patient welfare, distort fair medical competition, and drive up insurance premiums for the wider insured public. At the heart of their concerns is the systematic redirection of patients.

They claimed that when insured patients contact these aggregators for medical consultation or hospital recommendations, they are not provided neutral guidance. Instead, patients are allegedly steered towards hospitals that financially benefit the aggregator rather than those chosen based on the doctor's clinical merit, competence, or affordability.

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According to them, these payments are often disguised as "service charges" or commissions included in hospital bills.

The ophthalmologists also raised concerns over the alleged misuse of health insurance for elective eye procedures, particularly LASIK surgery.

According to the doctors, insurance reimbursement for refractive correction is generally limited to patients with very high spectacle power, usually above 7.5 diopters. However, they alleged that some patients with significantly lower refractive errors, in certain cases as low as 1 diopter, are being coached to falsely declare higher spectacle power to qualify for insurance coverage.

This is said to involve coordinated collusion among aggregators, hospitals, and certain TPAs to secure fraudulent insurance approvals. The doctors argue that these practices collectively impose an unjust financial burden on the broader insured population through inflated premiums and unnecessary payouts, and they have urged both IRDAI and the Ministry to investigate and intervene.

The doctors also flagged concerns regarding insurance claims in cataract surgery. They explained that while cataract surgery with a standard monofocal intraocular lens is considered disease treatment, premium lenses chosen mainly to eliminate the need for glasses are cosmetic upgrades.

Unlike in the United States, where insurance generally covers only the basic monofocal lens, India's insurance coverage is limited by sum assured, which is unlimited in the USA, and can vary from Rs 1 lakh to Rs 1 crore, so the amount for cataract surgery can be restricted to a certain percentage of sum assured.

For instance, 5- 10% of the sum assured for each eye is subject to a ceiling of, say, about Rs 2 lakhs, irrespective of the type of lens they opt for. Once again, here it is prone to manipulations, which insurance companies can never monitor. In the process, ethical practitioners suffer.

Speaking to Deccan Herald, Hyderabad-based ophthalmologist Dr Puranik said, "More alarmingly, several reputed doctors who have not formally associated with these aggregators reportedly still have their profiles displayed on such platforms. This is done without the consent of those doctors or any meaningful disclosure to patients. When patients specifically seek appointments with these doctors, they are allegedly contacted telephonically and diverted toward aggregator-linked hospitals instead. Such conduct amounts to deceptive patient acquisition practices and deliberate manipulation of patient choice."

"Ultimately, these losses are not borne by insurance companies alone, but by the general public in the form of continuously rising insurance premiums, reduced claim sustainability, increased scrutiny of genuine claims, and eventual denial or dilution of coverage for deserving patients," she added.

She had also submitted audio recordings and supporting case material wherein customer care interactions appear to demonstrate directional steering toward particular hospitals.

Seeking urgent intervention, the ophthalmologists requested IRDAI and the Health Ministry to investigate the role of digital healthcare aggregators in influencing patient choice, examine financial arrangements between aggregators, hospitals and TPAs, and ensure compliance with IRDAI norms on neutrality, transparency and fair claims processing.

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