Page 27 - Insurance Times March 2017 Sample

introduced by January 2012 the highlights of the scheme  PPN is applicable to all retail customers to begin with
were circulated to the policyholders and relevant provision and shall exclude emergency cases and group clients.
was incorporated in the policy documents. As per the circu-
 In case of PPN package rates no break-up is required to
lated highlights following main points of the system
be submitted by the PPN hospitals/NH.
emerges:
 CASHLESS benefit is provided for agreed package rates While introducing the system the PSU companies declared
and all other cases outside the package procedure only that the purpose of working out such package rates and sta-
in the PPN hospitals/NH. bilizing the hospitalisation costs will benefit the insured in
 For TRAUMA & EMERGENCY cases the cashless benefits many ways. Lower cost of every hospitalisation will leave a
may be provided by the TPA in Non-PPN hospitals/NH. larger balance in the sum insured in the policy for future
hospitalisation within the policy period. Lower cost will also
 Jurisdiction for PPN network hospitals/NH has been
specified (mainly within the municipal limits of major reduce loading on policy premium at the time of renewal.
cities) and for hospitals/NH outside such specified limits This step is in the interest of all health insurance policy hold-
the TPA will provide cashless benefits in all cases, pro- ers.
vided the such hospital/NH is network hospital of the
TPA. The un-stated reason for introducing PPN system was also
to minimise the loss ratio for health port-folio of the insur-
 Agreed PPN rates are all inclusive rates and only exclude ers, which, in almost all the PSU companies, has been in the
implant cost. red for many years.
 Rates agreed by the PPN hospital/NH for specified pro-
cedure, are the rates to be charged by them for both Although the idea of PPN system when first introduced
CASHLESS AND REIMBURSEMENT cases for looked very good and out of box thinking for the benefit of
hospitalisation period and shall be settled based on all stakeholders, particularly the insuring public. There is no
entitled category in the PPN hospitals/NH. doubt that the intention behind introduction of the scheme
was to streamline the health services cost and smooth work-
 Claims shall be payable as per the entitled category for ing of cashless system. However If we look at the above
their respective sum insured under the policy. Such en- aspects of the scheme and analyse how successfully the PPN
titled categories are General ward for Sum insured upto system has worked in practice we find that the most suf-
Rs.100000/-, Semi Private Room for Sum insured more ferer is the main stakeholder i.e. policyholders in the indus-
than Rs.100000/- and not exceeding Rs.300000/- and try. How the insuring public has been adversely affected on
Private Room for Sum Insured exceeding Rs.300000/-.
account of working of the PPN system over the five years
 Similarly the limits for Cataract Surgery based on sum can be analysed as under.
insured under the policy are also specified.
In case insured opts for higher room category than the Discriminatory aspect of the scheme

entitled category, he needs to bear the difference of For the specified procedures In the PPN Hospitals/NH irre-
two package charges. spective of whether cashless benefit is availed or not claim
 In case of multiple procedures under PPN the 2nd sur- settlements are made on the basis of agreed package rates
gery shall be paid 50% of package charges. only. In contrast to this if the policy holder takes treatment
in NON PPN Hospitals/NH claim settlements are made on
 For treatment other than specified procedures, the
actual basis as per the policy provisions. The premium cost
cashless facility is available in all the empanelled PPN for the policy holder irrespective of whether he avails treat-
hospitals/NH also.
ment in PPN System or NON-PPN system hospital is same.
 The agreed package rates are for Standard, non-com- If for availing treatment in PPN hospital the insured is not
plicated cases as mentioned in the procedure list. required to pay extra amount beyond the agreed package
 Sub-limits/disease capping under the policy shall not be rates than there is no discrimination but as in many cases
applicable for the PPN specified procedures. the hospital charges more than the package rates the in-
sured has to bear the same and does not get reimburse-
 For all reimbursement cases apart from those availed ment for such extra charges under the policy it becomes
in the PPN Hospitals/NH, the same will be payable as
per terms and conditions of the policy issued to the in- discriminatory.
sured.
The one who gets treatment at NON-PPN hospital will get
The Insurance Times, March 2017 27

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