Page 35 - Insurance Times May 2019

Incurred Claims Ratio(%) of Retail Health for Major Insurers (Net Earned)

Insurer 2013-14 2014-15 2015-16 2016-17 Service Provider
Bajaj Allianz 59 61 65 69 In-house
ICICI Lombard 70 62 61 50 TPA
Apollo Munich 56 56 60 51 In-house
Star Health 67 63 52 60 In-house
New India 83 80 81 79 TPA
National 98 103 92 98 TPA
Oriental 111 103 115 108 TPA
United India 103 101 99 96 TPA
**Source: IRDAI Hand Book
From the available data we find ICR of Public Sector Insurers 2) Whether the cost of procedure and number of days
(PSU) varies from 79% to 111% whereas for Private Sector staying in hospital for medical management case varies
Insurers varies from 51% to 70% for last four years ending with the payment schedule of the TPAs /IHAs to
FY 2016-17. Even recently published data of IRDAI for 2017- Hospital. (Earlier payment to hospital means lesser
18 exhibits Health ICR of Public Sector Insurers is 109.86% outgo on claims?)
whereas for Private Sector Insurers and Stand Alone Health 3) Whether the cost of procedure and number of days
Insurers are 71.32% and 59.58% respectively. staying in hospital for medical management case is less
if the customer pays upfront to the hospital and seeks
But it is difficult to get authentic information/data available claim on re-imbursement basis. (Cashless claim is
in the public domain on the following aspects:
costlier than Reimbursement claims?)
1) In case of cashless claim, whether the hospitals get time
4) Whether the TPAs provide service to the customers of
bound payment from the Insurers; there is no
the Insurer as per provisions (including Turn-around-
mismatch between final approved amount of claim
Time for different services) laid down under the Service
authorized by the TPA to hospital at the time of
discharge of patient and the actual amount paid to Level Agreement (SLA) between the TPA and the
hospital for the same claim. Insurer. ("Implementathons" of SLA from paper to
ground?)
5) Whether the TPAs get their service charges/fees timely
from their Insurers as per provisions of the SLA.

This information is available with the TPAs and Insurers. All
these factors have a strong bearing on the customer service
and Incurred Claims. This is the time when the concerned
stakeholders would critically analyze the data, discover
insights, find out why something is happening in addition
to what is happening and finally come out with solutions.
This will drive to smoothen the process and enhance
customer experience leading to the sustainable growth of
Retail Health Insurance in India. T

!! Hearty Congratulations !!

Thanks readers for excellent response for our Insurance Quiz published in our March 2019 issue. This month the lucky
winner of the Quiz is Siddharth Banerjee.
Who will be the next?????
Who will be the next?????
Who will be the next?????
Who will be the next?????
Who will be the next?????
The Insurance Times, May 2019 35