Mumbai: In a move aimed at curbing “unnecessary hospitalisation” and rising health insurance claims, General Insurance Council (GI Council) has issued clinical guidelines advising hospitals and nursing homes on when patients with common fevers and infectious diseases should be admitted and considered eligible for cashless insurance.The advisory says admission should be based on “medical need rather than fever alone”. Patients with uncomplicated fever can usually be on an outpatient basis, it says, while prescribing admission criteria for viral fever, pneumonia and acute gastroenteritis.GI Council is an industry association.The move has alarmed doctors and nursing home owners, who fear insurers could use the advisory to deny cashless approvals and reject claims, particularly at smaller hospitals.However, Dr S Prakash, GIC’s CEO (Health Insurance Ecosystem), told TOI the document is only advisory. “We respect clinical judgement,” he said, “but we want to avoid scenarios where a patient is admitted on the first day of high fever when a confirmatory test can only be done on the third day.”He said, “Every monsoon, insurance companies receive hundreds of claims that appear to misuse the privilege of health insurance. This isn’t unique to India; it happens globally. There is hence a need for guidance on which patients genuinely require hospitalisation.” This is not a restrictive document but an effort to promote rational hospitalisations, he added.The advisory recommends admission only for patients with warning signs such as persistent high fever, breathing difficulty, dehydration, altered consciousness, organ dysfunction or other serious complications. It also covers elderly patients with significant comorbidities, children with seizures, lethargy, inability to feed, severe malnutrition or prolonged fever, and those with danger signs such as bleeding, repeated vomiting and severe abdominal pain.It cites recommendations of Indian Medical Association (IMA), Indian Council of Medical Research (ICMR), World Health Organization (WHO), National Health Mission (NHM) and Union health ministry.An industry executive said that the reduction of fraud, abuse and wastage was required to keep health insurance affordable since claims had to be paid out of premium collected.Dr Deepak Baid, who runs a hospital in Ghatkopar, said the advisory sets benchmarks for hospital admissions. “Medicine isn’t a pure science. If we don’t admit a patient today and the patient deteriorates tomorrow, it could further strain the doctor-patient relationship. We cannot blindly apply Western insurance standards here,” he said.Gautam Khanna, CEO of Hinduja Hospital and president of Association of Hospitals, described the document as advisory rather than mandatory. “We have discussed it with our members. It is up to individual hospitals whether to follow it,” he said.Dr Sudhir Naik, trustee of Association of Medical Consultants and a nursing home owner, said, “While GIC says clinical judgement remains supreme, the document could become a weapon in the hands of insurance companies to deny claims.” He added that the worst affected would be patients visiting smaller hospitals which may not have the negotiating power of corporate hospitals for “fever packages”.
