Insurer and not TPA to settle health insurance claims

At a high court hearing of a public interest litigation filed by Gaurang Damani, IRDA member (non-life) stated that health insurance draft guidelines accept that the insurer and not TPA will settle or reject health insurance claims

 An Insurance Regulatory and Development Authority (IRDA) member (non-life) confirmed that health insurance draft guidelines limit the TPA’s (third party administrator) role to claims processing and not settlement. The insurance company will make direct payments to the hospital and policyholder (not through the TPA). Cheques will have to be written by the insurance company and sent to the hospital (for cashless) and to the policyholder (for reimbursement). It means that cheques cannot be held by TPAs as a float.
 

 According to Gaurang Damani, a social activist, who has filed the public interest litigation (PIL), “TPAs are supposed to process claims, instead they’re settling claims. There are no standard guidelines to settle claims and it is left to the whims and fancies of the TPAs who are in fact not entitled to settle claims but are found to be doing so in several cases.”
 

 Interestingly, at the hearing IRDA member (non-life) M Ramaprasad admitted that even veterinarians are appointed by the TPAs in addition to ayurvedics and homeopaths to assess cases. There have been cases where specialist doctors were not able to convince the need of specific procedure to TPA doctors, who may be well qualified in their respective field but not in the specialised allopathic stream.
 

 Another point which was agreed by IRDA at the hearing was to make the TPA send scanned claims electronically to the insurance company to speed up the process. This is followed by LIC and hence it may well be implemented by TPAs working for general insurance companies.
 

Moneylife had reported that United India and New India Assurance have an incentive clause in the TPA agreement to keep claims ratio within a certain range. This is completely detrimental to the interest of the policyholder whose genuine claims can also be partially paid or rejected just so that the TPA is able to get incentives from the insurance company.
 
 Read - United India Insurance doles out incentives to TPAs to reduce claims ratio!
 
 At the hearing, Mr Ramaprasad said it was logically not correct for TPAs to be paid incentives. “If we find such instances, we shall take such companies to task.'” He will be taking the issue to the General Insurance Council to decide further steps.
 Gaurang Damani's petition says that in addition to the incentive clause, there is discrimination in settling insurance claims of individuals and that of corporate clients. Group claims have better negotiation power with insurance companies due to the volume of business.
 
 According to Mr Damani, “If mediclaim policies indicated the amount an insured was eligible for specific ailments, it will ensure that they have clarity on which hospitals to go; the hospitals too would know how much they would get.” The advocate for Association of Medical Consultants (AMC) agreed to indicate the amounts for 42 standard ailments. HC has directed the petitioner to send a notice to Association of Hospitals (AOH) and Bombay Nursing Homes Association to get the range of package rates for the 42 standard ailments.

 The next hearing would be on 12th February. It is understood that the IRDA chairman wants to finalize the health insurance guidelines before he demits the office in mid-February.
 

vinay mohanty