Page 43 - Insurance Times August 2023

lakh was paid within 30 days from the date of the hysterectomy expenses, cancer benefit, etc., as per the terms
commencement of the policy, though terms and conditions and conditions of the respective policies was carried out. It
of the policy (New India Floater Mediclaim Policy) stated that was found that there was excess settlement of Rs. 1.65 crore
no claim will be payable for any illness contracted during the (729 claims for Rs. 1.24 crore - M/s Tata Consultancy Services
first 30 days of the commencement date of the policy. Limited and 275 claims for Rs. 40.98 lakhM/s Cognizant
Technology Services Ltd.) by NIACL to the beneficiaries under
4. Excess payments due to non-recovery of Co- the two group health insurance policies. In OICL, Audit
noticed that in 86 out of 378 claims settled in two policies
payment
towards treatment for cataract, the capping limit was not
Co-payment is a cost sharing requirement under a health
applied which resulted in excess settlement of Rs. 5.04 lakh.
insurance policy which provides that the policyholder/ insured
will bear a specified percentage of the admissible claims
6. Claim settlements under domiciliary hospital-
amount. Audit noticed that in NIACL the terms and conditions
ization
of group policy of one major group client (M/s. Cognizant
IRDAI vide its circular regarding guidelines on standardization
Technology Services Limited) contained the 'Co-payment'
of Health Insurance defines domiciliary hospitalization as
clause as per which the amount to be deducted from the
medical treatment for an illness/ injury in the normal course
admissible claim amount was 10 per cent in excess of Rs. 1
which would require care and treatment at a hospital but is
lakh for self or employee and 20 per cent for dependents on
actually taken while confined at home, provided where the
the entire admissible amount. Data analysis revealed that in
condition of the patient is such that he/ she is not in a condition
275 claims co-payment was not deducted and excess
to be moved to a hospital, or the patient takes treatment at
payment of Rs. 84.36 lakh was made. This was confirmed
home on account of non-availability of room in a hospital.
during test check of 5 sample cases out of 275 such claims. In
The said circular defines OPD treatment as the one in which
respect of retail claims, Audit carried out data analysis of
the insured visit a clinic/ hospital or associated facility like a
claims settled in respect of Senior Citizen Mediclaim Policy
consultation room for diagnosis and treatment is taken based
and New India Sixty Plus Mediclaim Policy and also test
on the advice of medical practitioner.
checked 700 claims out of 12,621 claims from the website of
10 TPAs28 and claim links provided to Audit. Out of 700 claims,
The insured is not admitted as a day care or in-patient. Test
in 117 claims (53 Senior Citizen Mediclaim Policy claims and
check of domiciliary claims in NIACL revealed that 242 claims
64 New India Sixty Plus Mediclaim Policy claims) TPAs did not
29 out of 1,154 claims were for OPD treatment but these
deduct the applicable co-payment amount leading to excess
were settled by showing them as domiciliary claims. The
payment of Rs. 7.71 lakh. This indicated that IT system
claims were of group policy issued to M/s TATA Consultancy
validation to verify application of co-payment clause was not
Services Ltd. (TCS) and M/s. HPCL Mittal Energy Ltd (HMEL)
prevalent in the TPA's end as well as NIACL's end.
under which OPD treatment was not covered.
5. Breach of capping on specific diseases
7. Non-adherence to network agreed rates
As per terms and conditions of policy, claim amount for specific
Regulatory clause 20(1) to (5) of IRDAI (TPA - Health Services)
diseases/ procedures would be capped at rates mentioned in
Regulations, 2016 provide for agreements between a TPA,
the policy. Data analysis was carried out to verify application
an insurer and a Network Provider. Accordingly, PSU insurers/
of the capping for a common disease viz. cataract, for which
TPA have negotiated and entered into agreements with
the capping amount ranging from Rs. 10,000 to Rs. 50,000
certain network hospitals for various medical/surgical
was fixed in 13 out of 19 individual products of NIACL. It was
procedures at agreed rates. In this regard, Audit observed
found that the capping of claim amount for cataract was not
that in respect of 19 claims out of 2,176 claims, there were
applied in 1,389 retail claims (pertaining to 12 individual
variation between the rate allowed by the TPAs and agreed
products) and there was excess payment of Rs. 2.33 crore
rate. Further, it was observed that certain items which were
due to breach of the ceiling amount. This was confirmed
part of the package rate such as doctor's fee, room charges
during test check of 43 claim records. Data analysis of group
and investigation charges, etc., were charged additionally
health insurance policies of two major group policy clients of
thereby resulting in excess payment. Charging higher rates
NIACL viz. M/s Tata Consultancy Services Limited and M/s
and additional charges resulted in excess settlement of claims
Cognizant Technology Services Ltd. with specific reference
amounting to Rs. 12.60 lakh.
to capping for certain diseases such as maternity and infertility
treatment, cataract expenses, joint replacements,
The Insurance Times August 2023 37