GROUND REALITIES -ROLE OF

INTERMEDIARIES

Introduction

Insurance intermediaries Insurance business has a peculiarity where

interface and interaction of a customer is more often with an Intermediary than with the Insurer.

Agents, Corporate Agents Brokers, TPA’S and Surveyors are recognized and licensed intermediaries.

ROLE OF SURVEYORS Surveyors and Loss assessors are

independent licensed professionals appointed by an insurance company to assess the loss or damage, when a claim is notified under a policy issued by them.

Legal status under S.64UM of the Insurance Act and Surveyor’s Regulations.

Surveyor’s role His duties include: investigate and confirm the cause of loss. advise the insured to take good care of salvage to

mitigate the loss. To ensure that insured has taken all necessary

steps to contain the loss. assess the quantum of loss. Determine the liability of the insurers within the

framework of the policy conditions. To act on behalf of the insurance company in

disposal of salvage to realize maximum value.

TOTAL LOSS

Loss admissible ? Total loss ? Emotional loss?

No records or evidence - best judgement method

Grievance situations Policy Holder refuses to co-operate or

agree or interact with a surveyor for various reasons

Grievances arise - Insurer is duty bound to intervene, mediate and sort out issues.

Grievance redressal Many times this does not happen as

Insurers are reluctant to overrule a surveyor’s findings on cause or quantum of loss for concern of audit or vigilance action.

This results in a large number of grievances moving to Adjudication or to IRDA.

TPA’S(HEALTH SERVICES) Legal Status– Licensed by IRDA under TPA

Regulations to act as support services in the health insurance sector.

In short, the job of the TPA's is to maintain databases of policyholders and issue them identity cards with unique identification numbers and handle all the post policy issues including claim settlements.

TPA’S ROLE In terms of infrastructure, TPA's run a 24-hour toll-

free number, which can be accessed from anywhere in the country.

They have full-time medical practitioners under

their employment who immediately take a view on whether the ailment is covered under the policy.

TPA’S ROLE All the records of medical insurance policies of an

insurer are transferred to the TPA.

In case of a claim, policyholder has to inform TPA on 24 hr toll free line provided by the TPA.

On informing the TPA, policy holder will be directed to a hospital where the TPA has a tied arrangement. However policyholder will have the option to join any other hospital of his choice, but in such case payment shall be on reimbursement basis.

TPA,S ROLE TPA issues an authorization letter to the hospital, for the

treatment.

TPA tracks the case of the insured at the hospital and at the point of discharge all the bills will be sent to TPA.

TPA makes the payment to the hospital.

TPA sends all the documents necessary for consideration of claims, along with bills to the insurer.

Insurer reimburses the TPA.

Grievance situations Delayed pre- authorization resulting in delayed

admission and treatment. Differences in interpretation of pre-existing

diseases and exclusion clauses. Delay in issuance of ID cards and issuance of

incorrect cards. Non submission of complete and correct

documents by insurance company to TPA resulting in deficient service.

Non accreditation of hospitals due to differences between hospitals and TPA’S.

Grievance Redressal Insurer must intervene and settle issue one

way or the other as TPA is only an extended service arm of the Insurer.

Failure to intervene results in grievances and petitions to grievance redressal authorities.

NEWS CLIPPINGS

Recently, Insurers and TPA’s have launched ‘The Package Deal Pricing’.

As per the move, healthcare institutes are graded and package charges for various medical services and procedures have been decided as per the grade of the healthcare institute.

The move aims to control the abnormal claims ratio in health insurance. Since package charges are pre-determined, they will act as a ceiling and prevent healthcare providers and hospitals to charge above a certain limit

News clippings Delhi healthcare providers have found the

charges abysmally low and allege that the TPAs have threatened to withdraw cashless service from those hospitals that do not agree to the package charges.

According to them, the scheme will force them to provide sub-standard treatment and they fear that incase they don’t sign the agreement, TPAs will divert their clientele to those hospitals which agree to carry out treatment at the package charges fixed by the TPAs.

Institutional voices Says Dr Vinay Aggarwal, honorary

secretary general of IMA,

“TPAs do not have the expertise to accreditate healthcare institutes. It’s the job of the government and rating agencies. But here, the TPA’s are acting as accrediting agencies. Besides they are determining rates for hospitals.”

Institutional voices Healthcare providers argue that the treatment for

two patients suffering from the same disease can be different.

For instance, if the patient is diabetic and has to undergo an appendicitis operation, a lot of care goes in management of diabetes before the surgery. Also the stay in such a case will be extended for more than two days, and so it won’t be possible for a hospital to provide treatment in the pre-determined package charge of Rs 10,000 in X hospital and the treatment will be out of pocket for the patient.

View from the other side The TPA’s on the other hand feel that the

cashless system has been abused to the hilt and so it is imperative to bring in standardization and regulation in the healthcare industry. An insured patient admitted to the hospital is made to undergo an array of unnecessary tests by the hospitals thereby increasing the bill.

TPA’S VIEW Says Dr Nayan Shah, managing director,

Paramount Health Services, “There has to be some kind of regulation in the healthcare industry. If arbitrary charging by healthcare providers is allowed, then consumers will end up paying higher premium. Can an airline charge 10 times higher because the client is wealthy? Then how can a healthcare provider/hospital charge more from the insured patient? We have decided customary and reasonable charges,”

Resolving the conflict THESIS >

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PERSPECTIVE Medical and insurance costs should come

down if meaningful medical coverage is to be provided to large sections of society.

THANK YOU