Page 30 - Insurance Times January 2023

policies of PSU insurers stipulated that the room rent/ boarding pharmacy, and implants). Audit observed in 29 claims out of
charges per day should be restricted to one per cent of the 69 claims of NIACL and OICL that hospitals have depicted
sum insured per day and two per cent of sum insured per day incorrect/ lesser discount and TPAs failed to take notice of
for admission in ICU/ ICCU rooms. Audit observed that in 13 this while processing and recommending the claim
claims (Normal room rent/ boarding: 12 claims 30 and room settlement. This has resulted in excess settlement of Rs. 22.71
rent/ boarding for ICU: 1 claim 31) the settlement was not lakh, as per details given below:
restricted invoking the terms and conditions of the policies
resulting in excess settlement of Rs. 1.14 lakh (NIACL: 7 claims Discounts not given/less than agreed
involving Rs. 0.24 lakh and UIICL: 6 claims involving Rs. 0.90
rates given by network provider
lakh) ii) Proportionate deduction not applied Sub-limit clause
in terms and conditions of policies specified that in case of
admission to a room/ ICU/ ICCU at rates exceeding the limits
32, the reimbursement/ payment of all other expenses incurred
at the hospital, with the exception of cost of medicines, shall
be effected in the same proportion as the admissible rate per
day bears to the actual rate per day of room rent/ ICU/ ICCU
charges. Audit observed in NIACL that in five claims out of
1,154 claims, though policyholder availed room rent higher
than the entitlement, TPA failed to restrict the claim by applying
sub limit clause regarding proportional deduction as per terms
and condition of policy.

9. Discount on other than PPN agreed
10 Irregular payments on implants
procedures
Implants are medical devices such as cardiac stents, heart
PPN provides for cashless access to the policyholders. As on
valves, orthopedic implants, dental implants, etc. Cost of such
31 March 2020, PPN cover was available in 12 cities 33 through
implants are fixed by National Pharmaceutical Pricing
a network of 2,552 hospitals 34. PPN agreement provides
Authority (NPPA)35 and hospitals. List of documents to be
that PPN agreed rates are 'walk-in walk-out' package for
submitted at the time of claim includes invoice for implant
policyholders, unless specified otherwise. PPN agreements
and sticker details for implants as a proof. Test check of 1,912
provide that for other than agreed packages, the network
claims revealed that in 26 claims amounting to `34.98 lakh,
provider would provide a discount from the Schedule of
implants cost allowed by TPA was not supported by separate
Charges (SOCs) in line with package rate which varied from 8
bills/ invoices and stickers. OICL accepted (January/ October
to 18 per cent on the hospitals bills (excluding medicines,
2021) the Audit observation and stated that they have
initiated recovery process in three cases.
Claims where sticker/bills for implants
were not available

26 January 2023 The Insurance Times