Page 29 - Insurance Times October 2020

At the end of July 31, insurers had received 81,000 claims. the notice of National Health Authority (NHA), the nodal
So, the number of reported claims has doubled in a months' agency responsible for implementing the AB-PMJAY. The
time. Among states Maharashtra still leads in the number testing and treatment for covid-19 was made available free
of reported and settled claims, followed by Tamil Nadu, of cost for Ayushman Bharat beneficiaries at private
Karnataka, Gujarat, and Delhi. laboratories and empanelled hospitals in May.

A positive that has come out of this crisis is the fact that One of the hospitals was found with more than 100
consumers are more willing to buy health covers to protect admissions for covid-19 alone. There's no way to verify the
them from the uncertainties that the current pandemic admission or presence of patients in the hospital as no one
might throw up. Within a month of launching standardized is allowed to visit dedicated covid-19 hospitals for audits.
Covid-19 specific products, as many as 1.5 million lives have That being a testing centre also, positive cases can be
been covered. The regulator last month had launched two created, and admissions, too, can be created. There have
Covid-19 specific policies - Corona Kavach and Corona been instances where hospitals claim higher cost packages
Rakshak. wrongly, such as using 2 stents and claiming for 3 in cardiac
procedures; claiming expensive packages under paediatric
Furthermore, the industry is seeing, for the first time, the NICU (neonatal intensive care unit) treatment etc.
health segment overtaking motor as the largest business in
the general insurance space. the average ticket size for a It is also noticed that expired medicines are being used by
novel Coronavirus claim is around Rs 1.5 lakh in urban areas hospitals. Insurance company appoints TPAs where the
and around Rs 50,000-75,000 in semi-urban or rural areas. scheme is run on the insurance model such as Gujarat and
Where the condition of patient is serious, and she/he has Punjab. Primary services that FHPL provides in any state are
been admitted to the intensive care unit, claims are in the cashless and claims management subset of these services
range of Rs 6-8 lakh. are creating awareness among hospitals on using PMJAY
software, fraud and abuse control, hospital and beneficiary
The reasons for higher claims were also because of increased audits and feedback, verification of beneficiary and
expenses on overheads in the treatment of the virus where confirming the identification in Beneficiary Identification
the risk of contagion is rather high. When it started out in System (BIS) for registration of beneficiaries in PMJAY
March and April, the PPE kits were high due to the demand, software and contact centre management to address
the treatment protocols and cost patterns were not clear beneficiary queries and grievances.
which took a few weeks to settle down. From a hospital
perspective, there is also a pressure to improve capacity The coronavirus pandemic has prompted India's health
utilization. insurance industry to flag, for the first time in a court,
concerns about arbitrary overcharging of patients by private
General insurers have registered 1.92 lakh claims worth Rs. hospitals and to caution that such practices could increase
3,013 crore as on September 8, 2020. This is the monthly annual premiums. Excessive profiteering by private hospitals
claims data monitored and compiled by the General for treatment of COVID-19 patients has forced the statutory
Insurance Council. Of this, about 1.2 lakh claims were settled body of insurance companies to seek Supreme Court's
by industry amounting to Rs. 1,165 crore, the data further intervention. It said that this unchecked practice will raise
showed. Maharashtra led the country with 78,000 claims, the medical premium cost in India. It cited instances from
followed by Tamil Nadu, Karnataka, Gujarat, and Delhi. different cities where hospitals had initially sought payments
two to five times the amounts they accepted after
Frauds in Health Insurance: objections by insurance companies.
After attempts of fraud in the name of covid-19 treatment
by hospitals empanelled under Ayushman Bharat-Pradhan The Council found, one private hospital had billed a patient
Mantri Jan Arogya Yojna (AB-PMJAY) came to light, the Rs 282,782 for a 10-day stay of which Rs 200,000 was
government has warned of action against the erring charged under the head "PPE (personal protection
hospitals. The third-party administrators (TPA) servicing equipment) kit ward. The insurance company objected and
PMJAY have brought some incidents of fraud attempts to asked the patient to ask for a revised bill as an uninsured
The Insurance Times, October 2020