REMOTE SECOND MEDICAL OPINION is the subject, which is under consideration of Health Insurers in India and some of them have selectively included this aspect within the scope of Health Insurance Policies. What is the meaning of “REMOTE SECOND MEDICAL OPINION” and what relation it has with Health Insurance Policies? To understand the concept we need to look into the following aspects elaborately.
The need for a patient to go for second medical opinion can arise when he/she has a very serious or life threatening disease, where the diagnosis is not clear and where no established consensus on approved treatment, where the treatment is risky, where the patient is considering participation in a trail for a new drug or considering new experimental procedure involving use of experimental instruments or devices.
Invariably in the above situations the patient or his family members choose to go for second medical opinion before taking final decision for treatment or surgery. However in that case the vital question that comes in front of the patient is whether such second medical opinion should be obtained with the knowledge and involvement of their chosen physician or surgeon. This is a tricky situation. Often such situation may lead to creation of mistrust and may also create an apprehension in the mind of the patient that the treating doctor may feel insulted. However the advantage of going for second opinion by taking chosen physician or surgeon into the confidence is that all the medical records and pathological tests done by the patient’s doctor needs to be presented to the doctor giving second medical opinion. Also if two experts discuss the issue in an open way what the areas of agreement and disagreement are it will be beneficial for arriving at a conclusion. Therefore it is always advisable to go for second medical opinion by taking own doctor into confidence. At times even the treating doctor himself suggests for second medical opinion. However, the difference between own doctor suggesting for second opinion and patient seeking to go for second opinion is that the own doctor may prefer to go for such opinion from his choice of doctor or from his senior and in such case the confidence level between consulting doctors remain comfortable whereas in the case of patient selecting to go for second medical opinion such confidence level may not be there and possibility of disagreement on contrary views remains very much.
Another aspect pertaining to second medical opinion is that the patient himself requests the doctor to seek second medical opinion before proceeding with the suggested treatment or surgery. However, the immediate and possible consequence of such a proposal to the doctor is that he/she may feel lack of confidence of the patient on his judgment. Also if he/she has to arrange for the second medical opinion he/she may approach a doctor or institution which in all likely-hood will strengthen his line of approach. It will, therefore, be a better proposition to select doctor or institution by the patient keeping in mind the importance of seeking such opinion from an institution or doctor having different institutional culture or philosophy to consider and give their findings and suggestion for the case in an independent manner.
From the patient’s point of view the need for going to seek second medical opinion is to confirm and make it doubly sure that he/she is going to get the correct and appropriate medical treatment which will give him/her best possible result. However it may not always be the case where results of second medical opinion will put the patient in a comfortable position to take right decision. If the opinion confirms the diagnosis and line of treatment or surgery suggested by the first doctor, particularly when such confirmation comes from a doctor or institution independent of the first doctor’s choice, it becomes easier for the patient to take his/her decision quickly. It is when such second opinion grossly differs from the findings and suggestions of the first doctor, chances of which cannot be ruled out, the position of the patient becomes awkward. Also there are two aspects of the second medical opinion, one that the findings as to the diagnosis and second for the line of treatment or surgery. When the outcome as to the diagnosis matches with the original findings it confirms the medical problem faced by the patient. However, when findings as to the diagnosis grossly differ at two levels it puts the patient in a great dilemma. For the second aspect i.e. line of treatment or surgery, it is again the same case when it confirms with the suggestions of the original doctor the patient find himself in an assured position. However, it is a known fact that some doctors and institution believes and follow the conservative approach whereas others believe in aggressive and (tested / untested) new approaches. Any suggestions for the remedy of the patient’s problem based on these two beliefs may again result into different opinion for line of actions and patient will find himselfherself again in awkward position.
When patient finds himself in such awkward situations after obtaining second medical opinion he/she is left with choice of either to go for third or more medical opinions or take a difficult decision on the basis of two different findings. In today’s modern world the option of obtaining second medical opinion from the doctors and/or institutions of foreign countries is also available. Even the cases where finding as to the diagnosis or line of treatment / surgery grossly differs, particularly where the nature of disease is critical, can be referred to such foreign doctors or institutions.
RELATION OF SECOND MEDICAL OPINION AND INSURANCE COVER
The question arises what relation the second medical opinion has with the provisions of health insurance plans. As is said at the beginning that the subject of this aspect is under consideration of the Insurers and some have included provisions for REMOTE SECOND MEDICAL OPINION selectively under some of their health insurance plans. As such what is the implication of this new provision for the insured?
The first and foremost question that arises is whether the cost incurred towards professional fee and investigations associated with second medical opinion are covered or not under the basic health insurance plans even if this new provision is not included under the policy? The answer is yes it is covered under the basic policy itself. However the difference is that under the basic cover the cost is covered under the provision of “Pre & Post Hospitalisation Expenses cover”, which provides a limited cover of normally 10% of the sum insured for all relevant pre and post hospitalization expenses including second medical opinion. Normally such opinion is obtained prior to the hospitalization as such the coverage for reimbursement the cost for second medical opinion is considered when such opinion is obtained within the time limit prescribed (normally 30 days) for pre-hospitalisation cover under the policy.
TERMS & CONDITIONS OF THE NEW PROVISION
The cover for REMOTE SECOND MEDICAL OPINION, which is provided by the insurers in their health plans now a day however has certain specific and limited provisions. The salient features of such cover are as under:
- The Insurer will arrange and pay for the selected qualified medical conditions only (normally for chronic diseases such as heart diseases, cancer, liver and kidney diseases etc which are specifically mentioned under the policy) for which the diagnosis is made and the course of treatment is recommended by the local physician;
- Such medical opinion can be obtained from only empanelled ‘World Leading Medical Centre (WLMC)’;
- The Insurer shall identify the names of three WLMCs, having expertise in concerned case, from which the patient or his family members must select one WLMC from which they would like to obtain second medical opinion based on inputs of his/her local Physician;
- The second opinion on the diagnosis and the recommended course of Treatment would be provided directly to the Insured Person;
- Only one time opinion can be obtained during policy period; and
- The Insurer will not be responsible for any legal liability due to any error or omission or representation or consequences of any action taken in reliance of the Remote Medical Second Opinion provided by the World Leading Medical Centre.
In most of health plans the terms & conditions of the cover are on above lines. However in some insurers have some additional features also.
IMPLICATION FOR THE INSURED
From the above provisions of the cover provided under the policy on this aspect one can very well understand that these provisions have certain limitations. The patient can choose to go far one such second medical opinion but not from the choice of his doctor or institution. The insurer will indicate three names of institutions from which patient or his family members has to select one and can obtain such second opinion and for which the insurer will bear the cost. The empanelled institution can be Indian or Foreign Institutions but such panel does not include independent individual doctors. The opinion can specifically be obtained only on the diagnosed medical conditions covered under the policy and on the course of treatment recommended by the local physician. The Insured will be provided with the second opinion directly by the chosen WLMC. Although the Insurer will be maintaining ‘World Leading Medical Centre’ and will select three WLMC from which the Insured has to select one for obtaining the opinion, the Insurer will neither be a party to this arrangement nor will be responsible for any legal liability due to any error or omission or representation or consequences of any action taken in reliance of the Remote Medical Second Opinion provided by the World Leading Medical Centre.
With the limited scope of such provision for the Insured, when such opinion only can be obtained on diagnosed disease and it’s recommended treatment, there is no scope for seeking such second opinion in various other situations like where the diagnosis is not clear and where no established consensus on approved treatment is available, where the patient is considering participation in a trail for a new drug or considering new experimental procedure involving use of experimental instruments or devices. Also permitted opinion can only be obtained from the Insurer’s choice of Institutions and the Insured cannot obtain opinion from his/her choice of doctor or institution. In majority of cases where the question of second opinion arises it is found that the patient prefers to obtain such opinion from a Doctor who is quite senior and having specialization in the concerned field.
However this new provision for REMOTE SECOND MEDICAL OPINION under the health plan is certainly useful to the extent that the insured gets the opportunity to ascertain whether the diagnosis made and the course of treatment recommended by the local physician is correct or
not. But it also leaves the insured in awkward situation if the second opinion from the WLMC is contrary to the findings of the local physician. The patient in such a situation in all likelihood will have to go for more such opinions on his own.
The difference between the cover for second medical opinion under the ‘Pre-hospitalisation Expenses’ provision of the basic policy and the cover under the new provision of REMOTE SECOND MEDICAL OPINION is that as against the limited amount of cover within fixed timeframe (normally 30 days prior to hospitalization) under the ‘Pre-hospitalisation Expenses’ cover of the basic policy the entire cost for such second opinion irrespective of time limitation prior to hospitalization is covered under the new provision.
IMPLICATION FOR THE INSURER
Now the question arises why the Insurer has included this new provision whereby they bear the cost for such second medical opinion without charging additional premium? It is true that the scope of such second opinion is limited to the specific area and the terms & conditions of the new provision has made enough safeguard for the Insurer against resultant consequences and the legal liabilities, if any, the intention behind inclusion of the new provision is not only to give additional benefit to the insured but to contain loss ratio of health insurance port-folio.
It is a well known fact that there are reports that have established misuse of health insurance plans by the some of the medical fraternity. A report published in Times of India on 4th January, 2015 has revealed that almost 44% of 12500 patients for whom surgery was recommended were advised against it by their second opinion consultants. Therefore from the Insurers point of view the system of REMOTE SECOND MEDICAL OPINION is perhaps beneficial on the aspect of loss minimization.
However since the inclusion of this new provision in health insurance plans is a new one and is in selective manner in real sense at this stage it is difficult to judge how much it is beneficial for the insurers? The selective use of the provision in insurance plans itself indicates that the insurers are experimenting on this aspect.
It is also a fact that the most of the insured appear to be unsure how far this new provision is going to be helpful for them in view of its limitations? Also that the insurer sponsored second medical opinion when results into a finding which suggest no need of treatment or surgery as against the recommendation of the local doctor and in such situation when insured decides to go with the recommendation of his local doctor an apprehension generates in the mind of the insured that the insurer will deny the claim based on the findings of such second opinion.
COMMERCIALISATION OF THE SYSTEM
It is undoubtedly clear that the second medical opinion per se is integral part of the medical support system and invariably the patient has to go for such second or more opinions before arriving at a conclusion. However, such exercise of going for opinions is done by the insured from his/her choice of doctors or institutions. This kind of new benefit provided under the health insurance plans is altogether different in the sense that it provides limited option for obtaining second opinion. Moreover, this new system has linkage with the commercial aspects of medical services. Internet searches reveal that large number of institutes all over the world including in India have mushroomed claiming expertise in various medical fields for second opinion. Some of the institutes have been formed by renowned doctors having experience in their respective fields but in most of the cases it is difficult to judge the quality of doctors in the institute who are going to give opinion.
As is the case with health insurance benefits becoming a source for misuse in hospital treatment and medical services in substantial number of cases, the system of REMOTE SECOND MEDICAL OPINION from WLMCs when the same is provided as benefit under health plans, in the similar manner can be exploited for misuse. The report in the Times of India findings that 44% cases were found to be wrongly advised for surgeries only confirms that a section of medical fraternity is unscrupulously mislead the patients for self gains. In the similar manner a section of medical fraternity can unscrupulously exploit this new provision for personal gains by ganging up with the second opinion provider institutions.
CONCLUSION
The important question at present is that from Insurer and Insured’s point of view how much this new cover as benefit provided under health insurance plans will be beneficial? The limited aspect of the cover has not generated confidence of the insured and the insurer is not sure how much it will be helpful in containing losses. As far as the second medical opinion aspect is to be provided as benefit for the insured it will be benefitted only when the cover with the scope of obtaining genuine medical opinion, second or more, at his/her choice of doctor or institution for various contingencies is provided in full-proof manner. Such full-proof scope of cover, even by charging additional premium, shall be meaningful for the insured.
