Page 50 - Insurance Times September 2023

lower than 9,900 in the network of Star Health Insurance, and whether: (i) the PSU insurers managed the health insurance
10,000 hospitals of HDFC Ergo General Insurance Company. portfolio in a sustainable manner and the performance
parameters were optimal; (ii) the PSU insurers have laid down
a system for empanelment of Third Party Administrators
(TPAs), enrolment of hospitals and monitoring of services
rendered by TPAs; (iii) there existed a suitable system for
processing and settlement of claims in line with IRDAI
regulations, guidelines, rules, circulars, policies, and
agreements with various parties and; (iv) risk underwriting
of health insurance policies was done in a prudent manner
and appropriate internal control mechanisms were in place
to protect revenue.

To prevent incorrect processing of claims and excess payments
beyond the scope of cover, PSU insurers have to enforce
deterrents through levy and timely recovery of penalties.
PSU insurers need to design and implement a robust fraud
management policy to prevent fraud and should take
appropriate action regarding cancellation of policy and de-
empanelment of hospital in fraudulent cases.

Health insurance business is the second largest line of business References:
of the PSU insurers (the first being motor insurance) having 1. https://www.business-standard.com/article/economy-
gross direct premium of Rs.1,16,551 crore during the five- policy/four-psu-insurers-lacked
year period from 2016-17 to 2020-21. The performance of 2. https://theprobe.in/why-indias-public-sector-general-
PSU insurers in health insurance business is at present not insurance-companies-are-losing-out
profitable and they have suffered a revenue loss of Rs.26,364 3. https://www.livemint.com/Money/
crore during five years ended 31 March 2021. In health Degw7xq8PHo8xQU7LKIJ3M/best-health-insurance
insurance business, TPAs are engaged to have better 4. https://www.financialexpress.com/money/insurance/
expertise, specialization in provider interface, medical cag-report-psu-general-insurers
adjudication of claims and technologically driven customer 5. HEALTH INSURANCE FRAUD DETECTION Co-authored by
services. Jasmine Kaur Gill and Shaun Aghili
6. IRDAI Annual Report 2020-21
The Audit was taken up with objectives of ascertaining 7. Newspapers & Journals

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