New Delhi: On September 17, Omveer Singh from Kosma Hinood village in Zilla Mainpuri, Uttar Pradesh, was admitted to Indraprastha Apollo Hospital, Delhi. His medical reports suggest that he has had a history of inflammatory back pain for 8-10 years. He had to be hospitalised for a day. “All I had was a health insurance policy that I had signed up for four years ago on the doctor’s advice. I needed the hospital to confirm if that would cover my medical expenses,” he said.
Singh mustered up the courage for his treatment only after the hospital repeatedly assured him that the insurance would cover his expenses. Yet, his stay in the hospital eventually took a strange turn that made him not just another patient, but a hostage, with the hospital refusing to release him and holding him overnight until every last bill was cleared.
Elsewhere in India, on September 13, Parvathi Sabavat, a 29-year-old pregnant woman from Nagarkurnool in Andhra Pradesh, arrived at Aditya Hospital, Hyderabad, for her delivery. Her baby was born the next day and the treatment was satisfactory. But her baby suffered from a lung issue and since the treatment at Aditya Hospital was unaffordable, the family decided to move the baby to Owaisi hospital.
But Parvathi became a hostage to billing issues at Aditya Hospital, held by the hospital authorities for nine hours while the desperate members of her below poverty line family sought help to get her out.
Patient hostage cases have been taking place in India for years; they are not a novelty that arose during the pandemic alone. Court orders pertaining to such cases exist from years ago. In the Devesh Singh Chauhan v. State and Others case in 2016, the High Court of Delhi, with a bench consisting of Justices Vipin Sanghi and Deepa Sharma, passed an order clearly stating, “If bills are not paid, then release the patient. You cannot keep patients hostage. That cannot be the modus operandi.” The order further clarified, “Even if dues are outstanding, custody of patients cannot be withheld to extract money towards unpaid bills (of the hospital). We deprecate this practice.”
More recently, on October 23, in the Reeja v. SHO and Others case, the High Court of Kerala also ordered a government hospital to discharge an inpatient who had allegedly been detained at the hospital for failing to clear the hospital bills.
But as the cases of Omveer and Parvathi show, court orders appear to have little impact in a country where healthcare is perceived as a petty matter and not the subject it should be of political and government concern with an emphasis on patient rights.
Process and payment
At the time of his admission, Singh was provided an estimated bill of Rs 90,000 including room rent, the professional fees of the surgeons, medicines and consumables and other expenses. His treatment started after the hospital received a prompt approval of Rs 49,000 from Singh’s insurance provider.
By the next day, the bill had shot up to Rs 1.37 lakh. When the hospital sent this claim to the insurance provider, it was rejected. The insurance provider said: “The said procedure does not require 24 hour hospitalisation and is not listed under day care hospitalisation benefits.”
The billing department informed Singh about this exchange and demanded that he pay the remaining amount. “I did not have any money on me, let alone this unimaginable amount of Rs 90,000!” Singh told The Wire. He was confused and felt hopeless. “I felt like I was running around, knocking on the doors of empty rooms. There was no one to hear me out or explain what had happened,” he said.
When The Wire contacted Indraprastha Apollo’s billing department on November 2, an executive explained that differences between the estimate and the final bill are not uncommon. “The final bill can vary from the estimate due to the patient’s medical condition, complexity of treatment, changes in the patient’s medical condition and duration of stay in the hospital,” said the billing executive. “We make the estimate based on these factors given by the doctor.”
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Hospital charges are always explained to the patient, added the executive. He added, “We also offer timely counselling to keep the patient informed about changes in the bill. If the patient feels this is unaffordable, she is free to stop the treatment there and move out after requesting the doctor to release her.”
When a patient cannot pay after the treatment, the billing executive told The Wire, “You will have to request your doctor [for intervention]. The discharge will be initiated after you clear your balance payments.” He seemed to take no notice of possible hostage situations.
Singh, however, had not been aware of any such procedure when he was at the hospital. All he knew was that his discharge process was stalled and the hospital refused to let him leave. He recalled that a manager had even told him that poor people like him go for medical treatments and when they realise their true aukaat (status), they bring a bad name to reputable institutions like the Apollo hospital. He does not know the name or proper designation of this person. “Poor people like us hardly ever get answers, after all,” he told The Wire.
He tried to send a voice recording of the aukaat statement to his cousin, Man Singh, but stopped when the officials found out and threatened to call the security personnel.
Man Singh had heard of hostage patient cases from scattered local news reports and he grew more worried after a hurried conversation with Singh. So he did what most aggrieved patients in India do now: he checked online. He managed to get in touch with the Campaign for Dignified and Affordable Healthcare. With their help, he wrote a letter to Delhi chief minister Arvind Kejriwal and various state institutions, detailing the entire case and requesting urgent interventions to release his brother from the hospital and also initiate an FIR against the hospital for such mistreatment.
After conversations with the Director of Medical Services, on September 19, the hospital finally received an approval for an insurance claim of about Rs 1.37 lakh. By then, the bill had changed further and Singh was expected to pay Rs 3,700 more as ‘additional charges’.
These were not the only bills he had to take care of. A battery of medical tests exhausted the Rs 10,000 he had carried with him to Delhi. His COVID-19 test had had to be done twice. “The first time was at a government facility and Apollo refused to accept the report because my name had been misspelled. The next time, I paid Rs 2,000 at a private diagnostic laboratory for the test,” he explained. Thankfully, he had tested negative on both occasions. To pay for all this, he had had to borrow money.
When Singh spoke to his doctor about the costs of the medical tests, he was told they just had to be done and this was only a small amount. “People like me know that this amount could last for an entire year. Yet there I was, spending it all in a few days,” he said.
No country for healthcare
Singh’s experience with the travesty that is healthcare in India was not a recent affair. It had started all the way back in 2016, when he travelled over 100 km to a hospital in Agra for help with his back pain. The doctors there suggested that he try the All India Institute of Medical Science (AIIMS) in Delhi instead. But AIIMS set the appointment for his treatment a year later. “I could not have possibly waited that long, so I asked for more options. That is how I ended up with Apollo Hospital,” Singh said.
At Apollo, he had to get injections costing about Rs 25,000 each. Singh sold his small photo shop in Kosma Hinood and took loans to meet these costs. But he was told that this was a prolonged treatment and he would need to be better prepared. His doctor then suggested health insurance as the most viable solution. Singh dared to continue his treatment this year only because of that insurance cover.
Singh was finally discharged from Apollo on the evening of September 19. He had to borrow again for his bus ticket home. He has no clue how he will begin to repay the loans he had taken. Unsurprisingly, the lockdown did not help his financial situation. He continues his photography work from home without a proper shop and hopes to make ends meet with “mehnaat and mazdoori (effort and labour)”.
In Hyderabad, Parvathi Sabavat had first gone to Amma Hospital, a private hospital in Nagarkurnool, but was told that hers was a critical case that could be best handled at Aditya Hospital in Hyderabad. Her in-laws are beneficiaries of the Aarogyashree health insurance cover, a state-sponsored mechanism for people who fall below the poverty line, but they knew these medical costs would not be covered. So they arranged most of the money through a loan against the family gold.
The lung issue Parvathi’s baby suffered could be treated at Aditya Hospital for Rs 30,000 per day for a week. But they couldn’t afford treatment at that price, so they had the baby discharged from Aditya and then admitted at Owaisi hospital which promised to do the treatment for Rs 10,000 per day.
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Bunny Kethavath, Parvathi’s brother, recalls an estimated bill of Rs 1.2 lakh for Parvathi’s delivery at the time of her admission to Aditya Hospital. Yet, on September 18, when Parvathi was supposed to be discharged, the bill had scaled up to Rs 1.6 lakh. “What is the point of an estimated bill then? And as this is not a government hospital, it is almost as if there is no accountability at all!” Kethavath said. There was no one around to offer an explanation. According to Kethavath, the manager of the billing department even switched off his phone and left for the day.
Parvathi was supposed to be discharged by 9 am, but she could leave only after 6 pm. The family pleaded with the officials to let her leave on the basis of some kind of memorandum of understanding or a different arrangement. “We were basically just exploring any other options available. Anything apart from just holding her back like this. Not only did no one pay heed to us, but also it seemed as though there was no clarity on even who was taking these decisions,” said Kethavath.
So, like Singh, Kethavath looked online for help. He got in touch with a few local journalists as well as Malini Aisola, the co-convenor of the All India Drug Action Network (AIDAN). They finally managed to get a discount of Rs 35,000 from Aditya Hospital. “My brother-in-law gets daily wages and these costs are a huge setback for the family,” Kethavath lamented.
Paper guardians
For Aisola and other health rights advocates who have been helping patients and their families navigate the perils of our healthcare systems, hostage cases have become a painfully regular affair. Not very long ago, Aisola dealt with a particularly distressing case of a grieving son wanting help just to get Apollo hospital, Vizag, to release his father’s dead body. Hospitals have not hesitated to hold even dead bodies as hostage over payment issues, she told The Wire.
In another case, a young woman had to fight the billing department at Maharaja Agrasen hospital, Delhi, to release her mother who had been admitted there for over a week. To meet the costs, the family sold their cattle, tractor, and the mother’s jewellery, mortgaged their land, took a loan from relatives and also sold what the father had arranged in anticipation of the young woman’s wedding initially scheduled for early next year. They still could not meet the costs and went through another harrowing ordeal just to get the mother back home.
Such gross violations have seldom been addressed by political action, but that is not what Jasmine Shah, vice-chairperson of the Dialogue and Development Commission, Delhi government, believes.
“Any concerned person can bring their case to the notice of the Delhi Health Department. Then there is an investigation to determine the truth of the matter. It is all depends on a case-to-case basis. When there is a violation, the government will take suitable action,” Shah told The Wire. On being asked if there is any definition of such a “suitable action”, he reiterated, “It depends on a case-to-case basis.” He gave an example of overcharging in private hospitals and said that the health department ensures “corrective action” that involves a “reimbursement or a concession”.
In her many experiences with the Delhi government, Aisola has had every reason to disagree with Shah’s sentiment. “There has been complete inaction when families are facing medical hostage situations,” she said.
Dr R.N. Das, the Delhi government official supposedly designated to handle patient grievances against private hospitals, too, has not been of any help. On October 27, when Rajesh Gupta, the son of Omvati Devi, whose discharge was being stalled by Saroj Hospital over billing issues, finally reached out to Das for help, Das told him he was ‘busy’, though he did, however, email the hospital, asking for a resolution of the matter.
“Das simply forwards complaints to the hospital in question and asks them to submit an explanation which, if it arrives, he forwards to the patient,” said Aisola. “In many instances, the hospitals do not even bother to respond to his query as even they know it is a farce. In spite of numerous complaints and piles of evidence, no action has ever been taken against any hospital.”
Amresh Kumar, a member of the ruling Aam Aadmi Party (AAP) in Delhi, who earlier had intervened to help patients navigate crises in the healthcare systems, refused to make a “media statement” this time. In a previous case, it was found that his role had remained limited to putting the patient in touch with higher officials in the hospital so as to “try and negotiate” for a discount.
When The Wire asked Shah particularly about the government policy for patients who cannot pay after treatments, he said, “If any hospital is holding a patient ‘captive’, these are very specific scenarios. I think it is very unfortunate when the hospital is resorting to such behaviour.” However, he quickly added a disclaimer that he could only talk about government policies in these cases and not comment on how these “very specific scenarios” are handled by the health department.
Ashok Agarwal, an advocate in the Supreme Court, attributes the hostage problem to “the failing public healthcare system”. “A lot of these hostage cases arise when patients are made to believe that their insurance schemes will cover the bills in private hospitals, but then there are these shocking discrepancies at the time of final billing,” he said. He noted that the relationship between the patient and the healthcare institution is already an unequal one and it is immensely difficult to fight for patient rights while the treatment continues. For him, these are “unfair and unjust practices” that result from an “unconscionable contract” taken from the patient under duress.
“These are all cases of a violation of the patient’s right to informed consent. And hospitals getting away with such practices has become an unfortunate routine affair,” Agarwal said.
Poverty of public health
The problem is at least twofold. One, this is not merely about hospitals fleecing patients, but of our ideas of ethics in healthcare. A patient is, after all, not like a restaurant consumer, and the false analogy of eating out at a restaurant holds no merit here at all. Healthcare is a political subject, where the patients are entitled to their rights and must be treated with respect.
“Besides being a morally repugnant position to take, hospital managements have to realise that unlawful acts can never be justified as business practices,” said Aisola, who condemns the manner in which healthcare is being belittled as a petty commodity even during the pandemic.
In the case of medical bills, it gets even more complicated with opaque systems. “Bill estimates generally exclude many things, and there is no one to explain the billing process. How will the patients know that investigations, consumables, and a variety of ‘other charges’ will not be included? Or how will they deal with clashes between the hospital and insurance providers? There has to be transparency in the billing process and there must be correct counselling regarding the charges at the time of admission. Hospitals can’t arbitrarily punish patients for not having correctly interpreted the fine print,” Aisola added.
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Two, we continue to suffer with an increasingly unaffordable and inaccessible healthcare system that demands huge out-of-pocket expenses from patients. The immense effects of India’s low expenditure on public health that remains at a bare 1.29% of the GDP (in 2019-20) cannot be emphasised enough. And, with the crippling public healthcare system and the zealous push towards privatisation of healthcare, it is unfortunately inevitable that patients end up in large private hospitals that bleed their resources.
Contrary to what hospitals might want us to believe, these aggrieved patients and their families did not invite this fate onto themselves. None of them wanted to ‘bring a bad name’ to these reputed hospitals. It was the absolute lack of options available that led them there. But, irrespective of their trajectory of arrival at these hospitals, nothing justifies the hostage situation and the callousness they suffer.
In the meantime, Omveer Singh has to continue his treatment in Apollo after a few months. “My treatment did go well and I am grateful to have found a good doctor in the time of my distress. But what followed was brutal torture,” he said. He had initially had apprehensions about going public with the story, but later he wrote to me that he ‘wants’ this story to be public. He remains hopeful that someday no other hospital will ever mistreat patients like this anymore.
Sweta Dash is an independent researcher and journalist. She tweets @SwetaDash93.
