Page 30 - The Insurance Times August 2024

mode at the hospital to deal and assist with the cashless pitfalls in the system. Some of the measures which could
requests. make the services of these intermediaries worth are:

d. Insurers are also required to provide pre-authorization
to the policyholder through Digital mode. a) Cashless claims service at no extra cost to the
e. To grant final authorization within three hours of the customers.
receipt of discharge authorization request from the Claims management is an important aspect of post sale
hospital. In no case, the policyholder shall be made to service which helps the Insurers to build up their brand
wait to be discharged from the Hospital. In case of any image. Insurers who manage their claims through TPAs,
delay beyond three hours, the additional amount if any charge higher premium from the customers. Claims
charged by the hospital is to be borne by the insurer management expense is a component of pricing health
from shareholder's fund. insurance premium , hence charging a separate cost for the
same to the customers is highly unethical.
f. In the event of the death of the policyholder during the
treatment, the insurer is required to immediately
process the request for claim settlement and get the b) Effective monitoring of the services of TPA
mortal remains (dead body) released from the hospital The insurers lack of monitoring and auditing of the TPA
immediately. result in claim cost escalation. Concurrent auditing by TPA
staff and verifying the facts at the time of hospitalisation if
g. No claim can be repudiated without the approval of the
Claims Review Committee. done effectively will prevent the providers from inflating the
bills by over treatment. Insurers need to evaluate the
h. Performance Monitoring of TPAs- Insurers to have a customer service parameters- average cost of common
board approved policy not only for performance
procedures ,delays, grievance reddressal and accuracy of
monitoring and obtaining feedback from customers but claim processing frequently.
also to have criteria for claw back of remuneration/
charges paid to TPA based on the customer feedback.
The Regulator by means of more stringent regulations needs
The clawed back amounts will be passed to the to specify the scope of services to be provided by the TPAs
customer.
to the Insurance companies. Further, the services should be
monitored and objectively reviewed by the Regulator so as
The norms set by the Regulator are meant to strengthen
to control unethical practices. The new health insurance
the services and better customer experience but the crux
rules by the regulator are a step forward in this direction,
of the issue is, are these norms achievable considering the to have clawback policy for the remuneration paid to the
current claims services and impediments associated with the
TPA based on customer feedback.
functioning of the Insurers/ TPAs. As per IRDA report 2022-
23, considering both settlement through TPAs and In-house
claim settlement only 56 per cent of total number of claims c) Qualification/Training of TPAs and Hospital
were settled through cashless mode and 42 per cent were Desk staff
settled through reimbursement mode. 100% cashless claim There is complete lack of dedicated customer support
settlement seems to be a big challenge for Insurers/TPA and services to assist policyholders with queries related to
needs a complete Revamping and Restructuring of the cashless treatment by many TPAs. Major reason for the
current servicing practices. inadequate service is due to lack of management
competencies and capabilities by the personal at TPAs
Some measures for better functioning of office. Untrained and incompetent personal cannot handle
the latent intricacies associated with health insurance
TPAs contract . TPAs should engage people who understand the

Although the expansion of TPA services during the last work and functioning of hospitals. There is a need to
decade has reduced financial barriers for seeking healthcare emphasize on the selection of adequately qualified
for the customers opting cashless hospitalisation services but personnel and training regime of the person in interface
has contributed in escalating healthcare cost. The system with the customers on helpline.
of TPAs can work effectively and efficiently in the Indian
market only if strict measures are taken to control the TPAs can only ensure quality services at network providers

28 August 2024 The Insurance Times