Doctors allege collusion between healthcare aggregators, TPAs and hospitals leading to unethical patient referrals and fraudulent insurance claims
A group of ophthalmologists from Hyderabad has urged the Insurance Regulatory and Development Authority of India (IRDAI) and the Ministry of Health and Family Welfare (MoHFW) to investigate the functioning of certain digital healthcare aggregators over allegations of unethical patient diversion, misuse of health insurance, and non-transparent financial arrangements with hospitals.
In a representation submitted to the regulators, the doctors alleged that some healthcare aggregators are working in collusion with select Third Party Administrators (TPAs) and empanelled hospitals to redirect insured patients toward healthcare facilities that have financial arrangements with the aggregators rather than those best suited for the patient’s medical needs.
According to the ophthalmologists, insured patients approaching these digital platforms for consultations or hospital recommendations are allegedly not receiving neutral guidance. Instead, they are reportedly being directed to hospitals that provide financial incentives to the aggregators, compromising patient choice, fair competition among healthcare providers, and the overall integrity of the healthcare system.
The doctors further alleged that these financial transactions are often disguised as “service charges” or commissions incorporated into hospital bills, increasing healthcare costs and ultimately contributing to higher insurance premiums for policyholders.
Concerns over alleged misuse of insurance for LASIK procedures
The ophthalmologists also raised concerns regarding the alleged misuse of health insurance for elective eye procedures, particularly LASIK surgery.
According to the doctors, insurance reimbursement for refractive correction is generally restricted to patients with very high spectacle power, typically 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 become eligible for insurance reimbursement.
They claimed that such practices involve coordinated collusion among healthcare aggregators, certain hospitals, and TPAs to obtain fraudulent insurance approvals, resulting in unnecessary payouts and financial losses that are ultimately borne by insured individuals through rising premium costs.
Cataract surgery claims also vulnerable to manipulation, doctors say
The representation also highlighted concerns regarding insurance claims in cataract surgery.
The doctors explained that while cataract surgery involving a standard monofocal intraocular lens qualifies as medically necessary treatment, premium intraocular lenses selected primarily to reduce dependence on spectacles are considered elective upgrades.
Unlike countries such as the United States, where insurance generally covers only the cost of the standard monofocal lens, India’s insurance policies typically provide coverage based on a percentage of the insured sum, often subject to predefined ceilings. According to the doctors, this structure leaves room for billing manipulations that insurers may find difficult to monitor, placing ethical practitioners at a disadvantage.
Doctors allege unauthorized use of profiles and patient redirection
Speaking to Deccan Herald, Hyderabad-based ophthalmologist Dr. Puranik alleged that several reputed doctors who have not formally partnered with healthcare aggregators continue to have their profiles displayed on these digital platforms without consent.
She claimed that when patients specifically request appointments with such doctors, they are allegedly contacted by aggregator representatives and redirected to hospitals associated with the platforms instead.
According to Dr. Puranik, such practices amount to deceptive patient acquisition and deliberate interference with patient choice.
She further stated that the financial impact of these practices extends beyond insurers, eventually affecting the general public through rising insurance premiums, stricter scrutiny of genuine claims, and reduced sustainability of health insurance coverage.
Dr. Puranik also stated that audio recordings and supporting case materials had been submitted to the authorities, allegedly demonstrating customer care interactions in which patients were directed toward specific hospitals.
Doctors seek regulatory intervention
Seeking urgent regulatory action, the ophthalmologists have requested IRDAI and the Ministry of Health and Family Welfare to conduct a detailed investigation into the role of digital healthcare aggregators in influencing patient choice.
They have also urged authorities to examine the financial relationships between aggregators, hospitals, and TPAs, while ensuring strict compliance with IRDAI regulations governing transparency, neutrality, and fair insurance claim processing.
The doctors maintain that stronger oversight is necessary to protect patient interests, uphold ethical medical practices, and prevent unnecessary financial burdens on India’s health insurance system.
