Page 40 - Insurance Times August New 2023
P. 40

Health Insurance


          Claims



          Mismanagement in



          PSU Insurers is an                                                                 Jagendra Kumar
                                                                                                       Ex. CEO,
                                                                                          Pearl Insurance Brokers
          eye opener                                                                                    JAIPUR







           The IRDAI has brought in multiple reforms in order to fix issues related to mismanagement of claims.
           For fixing the issue, IRDAI has notified a draft health insurance regulations statement where it
           has been stated that TPAs do not have the right to reject claims and this will exclusively be the
           right of the insurance company.



                   ut of the 32 general insurance companies which  multiple claim settlements, excess payment over sum insured,
         O         do health insurance business in India, there are  and breaching of capping limit for specific diseases are some
                                                              of  the lapses by  four public  sector insurers that the
                   only  four  public  sector  general  insurance
                                                              Comptroller and Auditor General of India (CAG) has flagged
                   companies: The New India Assurance Company
          Limited (NIACL), United India Insurance Company Limited  in its  report. The gross underperformance and multiple
          (UIICL), The Oriental Insurance Company Limited (OICL) and  irregularities have made India's four PSU general insurers
          National Insurance Company Limited (NICL). The Comptroller  lose out to private players. This is evident from the June
          and Auditor General (CAG), during its audit of the four PSU  quarter results of the companies. Even when the market
          insurance companies found  mismanagement of Health  share of the private companies rose to 51.82 per cent in June
          Insurance claims on various fronts which is an eye opener.  2022 from 47.63 per cent last year, PSU general insurers lost
          The CAG audit notes that the PSU insurers failed to carry out  the market share from 42.23 per cent to 37.85 per cent.
          a proper and timely investigation into the claims settled by
          various TPAs. The audit has found that all is not well with the  The IRDAI has brought in multiple reforms in order to fix
          functioning of the four PSU insurers because of which even  issues related to mismanagement of claims. For fixing the
          when the health insurance business is the second largest line  issue, IRDAI has notified a draft health insurance regulations
          of business, all the four PSU insurers have incurred losses.  statement where it has been stated that TPAs do not have
                                                              the right to reject claims and this will exclusively be the right
          The four companies had a gross direct premium of Rs 1,16,551  of the insurance company. TPAs, as recommended, should
          crores between 2016 and 2021, yet they incurred losses in  only handle cashless claims. Processing of health insurance
          the e-health insurance portfolio in all five years between 2016  claims is largely on digital platform both at PSU insurer level
          to 2021, with an aggregate loss of all the four PSU insurers  as well as TPA level warranting sound IT systems with built in
          being Rs 26,264 crores. The CAG report talks about the  validation controls, data integration and seamless flow of
          malpractices or the irregularities that were going on within  data. The IT systems in PSU insurers lacked appropriate
          the government companies. Inadequate checks leading to  validation checks and controls, undermining the smooth

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