Page 47 - Insurance Times September 2023

Continued from last issue

Health Insurance

Claims

Mismanagement in

PSU Insurers is an Jagendra Kumar

Ex. CEO,
eye opener Pearl Insurance Brokers
JAIPUR

The insurance companies while releasing/ making payment to hospitals for settlement of medical/
insurance claims are liable to deduct tax at source under section 194J36 of Income Tax Act. During
data analysis in UIICL, Audit observed that in 42,847 claims out of 65,46,129 claims, TDS amounting
to Rs. 14.01 crore was not deducted from payments made to hospitals.

8. Incorrect assessment of admissible claim charges. Audit observed in NIACL that in five claims out of

amount by TPAs 1,154 claims, though policyholder availed room rent higher
than the entitlement, TPA failed to restrict the claim by applying
TPAs have failed to exercise appropriate checks which were sub limit clause regarding proportional deduction as per terms
required to be carried out while processing the claims and and condition of policy.
assessing the admissible amount, which resulted in excess
settlement in the following cases: i) Excess room rent/boarding
charges allowed in claim assessment Terms and conditions of 9. Discount on other than PPN agreed
policies of PSU insurers stipulated that the room rent/ boarding procedures
charges per day should be restricted to one per cent of the PPN provides for cashless access to the policyholders. As on
sum insured per day and two per cent of sum insured per day 31 March 2020, PPN cover was available in 12 cities through
for admission in ICU/ ICCU rooms. Audit observed that in 13 a network of 2,552 hospitals. PPN agreement provides that
claims (Normal room rent/ boarding: 12 claims30 and room PPN agreed rates are 'walk-in walk-out' package for
rent/ boarding for ICU: 1 claim31) the settlement was not policyholders, unless specified otherwise. PPN agreements
restricted invoking the terms and conditions of the policies provide that for other than agreed packages, the network
resulting in excess settlement of Rs. 1.14 lakh (NIACL: 7 claims provider would provide a discount from the Schedule of
involving Rs. 0.24 lakh and UIICL: 6 claims involving Rs. 0.90 Charges (SOCs) in linewith package rate which varied from 8
lakh) ii) Proportionate deduction not applied Sub-limit clause to 18 per cent on the hospitals bills (excluding medicines,
in terms and conditions of policies specified that in case of pharmacy, and implants). Audit observed in 29 claims out of
admission to a room/ ICU/ ICCU at rates exceeding the limits, 69 claims of NIACL and OICL that hospitals have depicted
the reimbursement/ payment of all other expenses incurred incorrect/ lesser discount and TPAs failed to take notice of
at the hospital, with the exception of cost of medicines, shall this while processing and recommending the claim
be effected in the same proportion as the admissible rate per settlement. This has resulted in excess settlement of Rs. 22.71
day bears to the actual rate per day of room rent/ ICU/ ICCU lakh, as per details given in the table below:

42 September 2023 The Insurance Times