Page 49 - Insurance Times March 2017 Sample

The PSU companies do have set up the systems of monitor- accordingly settle the claim. If the hospitals/NH is habitual
ing loopholes and complaints arising under the PPN system offender of charging without any rhyme and reason beyond
at Head Office level region-wise for all four companies i.e. agreed package rate and refuse to refund excess amount
each Head Office takes care of cases arising in any of the TPA can take up the matter with insurer for withdrawal of
four companies in their respective regions. However despite providing cashless benefit through such hospital/NH. By and
such mechanism the complaints are many and grievances large no hospital/NH would like to forego such empanelment
in insuring public are rising. Wherever such HO level set-up for providing cashless benefit as this facility is in their ad-
monitor the situation seriously in effective manner the con- vantage for volume of business.
trol is good but by and large there are no effective mea-
sures against such complaints in general. In the absence of such checks and balances insured will con-
tinue to suffer, which is not desirable. For the insured op-
In practice the PPN system has not worked in the interest tion of taking up the matter with grievance authorities or
of the policy holders. To achieve the goal set at the time of with ombudsman are always open but why they should be
implementation the PSU insurers must review the entire forced to go that route for seeking justice. When such ex-
working and introduce methods of checks and balances in tra charging by the hospitals/NH is gross injustice now
effective manner in all places at the stage of settlement of known to all concerned it becomes moral and legal respon-
claim at TPA's office. TPA officials are in best situation to sibility of PSU companies to make PPN system meaningful.
control such injustices since they get detailed bills of the
This system is definitely advantageous for all concerned pro-
hospital along with medical papers.
vided unjustified loopholes are plugged and the insured is
Before settlement of the claim they must arrive at conclu- not deprived of his right to avail full indemnity under the
sion and see whether extra charges beyond agreed pack- policy. Also the PSU insurer will do well to review the dis-
age rates are based on genuine medical necessity or not and criminatory aspect of the scheme as narrated above. 

The Insurance Times, March 2017 49

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