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Health Insurance Claims Settlement to be more Transparent

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Of late, increasing dependence of insurance companies on third party administrators (TPAs) has been reportedly causing quite a few glitches in cases of claims settlement. While some instances have been genuine, according to sources, there have been insurers who have made TPAs operate on a more business-like front. Thus, TPAs, whose sole function is to validate claims and get the final decision-making done by the insurer, have ended up having targets based on reducing hospital bills.

Getting admitted into and treated in a hospital that’s not included in the Preferred Provider Network (PPN) list of the insurer could seriously cost you a lot of time and money after the treatment is done. The hassle faced by many policyholders in such a situation is the near relentless follow-up with the TPAs and often, request for an extra payment in order to settle the claim completely. TPAs have either rejected claims outright owing to missing documents or some other discrepancy. A more common scenario is where they provide a list of deductions to bring down the claim amount.

As per activist Gaurang Damani, health insurers are as much to blame as the TPAs themselves. Producing documents that corroborated the fact that TPAs hand out targets based on lowest claim amount per day, he advocated that such targets are a result of the insurers offering incentives on lower claim settlement. With differing amounts sanctioned for the same illness at the same hospital, glaring instances of malpractice are quite evident. The Insurance Regulatory and Development Authority of India (IRDAI) has been quick to act on this. IRDAI has clearly mentioned in its draft health insurance regulations that TPAs cannot act on behalf of the insurer to reject any claim and that they can only administer cashless claims. It is hoped that wrongful decisions pertaining to rejection of claims will be reduced, now that the insuring agency will have to take official responsibility of its actions.

TPAs and health insurance companies generally have negotiations with hospitals to avail discounts for releasing the payment. This fact remains hidden to the policyholders and thus, the benefits of a possibly lower bill are completely lost to them. As per the new regulations by the IRDAI, such discounts will now be mandatorily reflected in the bills provided by the hospitals. A pivotal step as this will allow the policyholder to save on his insured sum and claim future settlements. In case of an entire insurance amount being claimed, the final payout would be lesser.

Adding on to the aforementioned grotesque state of affairs, many health insurance providers do not maintain proper records pertaining to either the TPAs they dealt with or the amount or number or claims the TPAs helped settle. TPAs have also been reported to ask for commissions from hospitals on every claim filed, in order for the latter to be enrolled in a Preferred Provider Network (PPN) list. Since insurers rely primarily on the PPN list to allow successful cashless settlements, often many hospitals fall for this lure. Bajaj Allianz General Insurance and many other private insurers have set up their own claims settlement departments just to get rid of this scenario.

Insurance providers are essentially the ones who should be in charge of deciding whether or not a claim should be accepted. But quite a few instances have proven that many TPAs were accepting and rejecting claims on their own. A secondary level of settlement also comes into play wherein TPAs negotiate with the hospitals and get to keep the reduction amount in the claim for themselves. Ethically, they are not supposed to solicit any business. Such kind of practices eventually lead the healthcare providers to amp up the fees of the services provided by them. Health insurance providers have also been reported to offer bonuses and rate TPAs according to the reduction that they made possible in the claim amount. Yet again, the policyholder gets to face a larger hole in his pocket due to these reasons. The recent regulations will help cut down on such malpractices and offer a breather to the policyholder.

As for the solution to the removal of some hospitals from the insurers’ PPN list, the ones that faced an issue of monetary reimbursement, which was sorted out rather quickly. But as for standardisation of rates for different medical procedures, all the partners involved in this reform are working together to find an entity that’s expert and credible enough to look into the issue.

It’s important to note that most private insurers now have in-house claims management and that the TPA market is majorly dependent on the public insurers in the market. With a change in the market share for public and private insurers, it can be expected that claims settlement by the insuring agencies themselves will be the trend that will gain the upper hand.

To wrap it all up, one should keep in mind that -

  1. Claim rejection and acceptance are now solely dependent on medical grounds
  2. Only the insuring agency has the authority to accept or reject a claim
  3. Insurance agencies or affiliated TPAs can request documentation only once
  4. All the information pertaining to the entitlement of the policyholder will be in a one-page document
  5. If the claim settlement moves beyond 30 days, the insurer is liable to pay interest on the amount to the policyholder
  6. TPAs can only recommend options for settling a claim

Health Insurance Claims Settlement to be more Transparent Reviews

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  • ICICI Lombard Health Insurance
    "Good service"
    0.5 4.0/5 "Great!"
    I have taken my health insurance with ICICI Lombard general insurance, there service is good, there agent had explain me about the policy which is covered in this insurance and they have tie up with many hospital and they have shared me there location , and the premium amount they have charged me was nominal,i use to pay on yearly basis.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 20, 2019
  • HDFC Ergo Health Insurance
    "Good service"
    0.5 4.0/5 "Great!"
    I took my medi claim with HDFC ERGO, they have tie up with many hospital,and they have shared me the location regarding this,they have mention the location on excel,and the premium amount they have charged me is nominal,they have charged me on yearly basis.overall service is good.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 20, 2019
  • Apollo Munich Health Insurance
    "Average Policy"
    0.5 3.0/5 "Satisfactory"
    My organization has given me a health insurance from Apollo Munich. I have not gone through about the documents and hospital list. My entire family has been covered in this policy. They have given me a satisfied coverage value. I have not contact the customer care so far.
    Was this review helpful? 0
    , gurgaon
    Reviewed on Jan 20, 2019
  • HDFC Ergo Health Insurance
    "Average Policy"
    0.5 3.0/5 "Satisfactory"
    I have purchased the health insurance from HDFC Ergo. For some enquiry, i have called the customer care service and they have resolved my query immediately. I have not made any claim experience so far. I pay the premium amount of Rs. 37000 and myself has been covered in this policy.
    Was this review helpful? 0
    , gurgaon
    Reviewed on Jan 20, 2019
  • Star Health Health Insurance
    "Less premium with Extra benefits"
    0.5 3.0/5 "Satisfactory"
    Taken my health insurance policy recently from Star. Till now i have not spoke with the customer care. Since my age is above 50, i made the premium amount of Rs. 17000. Myself, my wife and child has been covered in this policy. They have given me a coverage value of Rs. 4 lakhs. Almost major hospital has been covered in this list.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 20, 2019
  • Reliance General Health Insurance
    "Overall Experience is good"
    0.5 4.0/5 "Great!"
    I'm using the health insurance from Reliance last 5 years. Since I'm the in charge of corporate insurance the customer care service is really fine. I made many claim from Reliance for other employee. As per the policy, they are fulfilling the customer needs. They are providing good cashless treatment facility. They used to send a updation on a regular basis.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 20, 2019
  • Apollo Munich Health Insurance
    "Very Good Policy"
    0.5 5.0/5 "Blown Away!"
    I have a corporate covered health insurance policy from Apollo Munich. They have given me a coverage value of Rs. 4 lakhs. My entire family has been covered in this policy. This policy covers all the major hospitals in all over India. I have not made any claim so far.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 20, 2019
  • ICICI Lombard Health Insurance
    "Average Policy"
    0.5 3.0/5 "Satisfactory"
    My health insurance was purchased from ICICI Lombard. To apply the claim, its a lengthy process. I had a claim experience and they have given the claim upto 80%. I pay the premium amount of Rs. 12500 every year. My entire family has been covered in this policy.
    Was this review helpful? 0
    , indore
    Reviewed on Jan 20, 2019
  • HDFC Ergo Health Insurance
    "Excellent service"
    0.5 5.0/5 "Blown Away!"
    I experience my health insurance with HDFC Ergo,they have tie up many hospital ,i have not have claim experience yet,there is cashless treatment option available,the premium they have charged me on monthly basis,they have charged me up to 700 which is nominal , i pay premium through on line.
    Was this review helpful? 0
    , kolkata
    Reviewed on Jan 20, 2019
  • ICICI Lombard Health Insurance
    "Bad experience"
    0.5 1.0/5 "Really Bad"
    I hold health insurance with ICICI lombard,they have tie up with many hospital , and even they have shared me the location in pdf form, and i pay previously premium on yearly basis, but now it is flexible pay option is available, and i use to pay on monthly basis, up to 878 rupees ,it is bit high compare to market value,there is cashless treatment available.
    Was this review helpful? 0
    , ahmedabad
    Reviewed on Jan 19, 2019
  • Max Bupa Health Insurance
    "Good Policy"
    0.5 4.0/5 "Great!"
    I have chosen this MAX BUPA insurance mainly because of convincing premium benefits . This policy covers Cashless hospitalization. , pre diseases coverage . Overall am satisfied with customer care and service. Am getting income tax benefits and the premium amount which am paying is satisfied , Am making the payment through online .
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 19, 2019
  • Star Health Health Insurance
    "Excellent service"
    0.5 5.0/5 "Blown Away!"
    I have been using health insurance with Star health insurance, the agent had clearly explain me amount the claim policy, and they have tie up with my hospital, and they have charged me location regarding to hospital location, there premium amount is on yearly basis, and it use to get auto debited from my account.
    Was this review helpful? 0
    , thane
    Reviewed on Jan 19, 2019
  • HDFC Ergo Health Insurance
    "Best Policy"
    0.5 5.0/5 "Blown Away!"
    I have taken Health insurance from Hdfc ergo insurance . Am satisfied with the premium amount which am making the payment for every 2 years . This policy gives good coverage with cashless hospitalization and pre disease cover . Even they have given network list of hospitals . While taking the policy they have explained very well about policy and claim .
    Was this review helpful? 0
    , bhubaneshwar
    Reviewed on Jan 19, 2019
  • United India Health Insurance
    "Good service"
    0.5 4.0/5 "Great!"
    I have been using my mediclaim insurance with United state of India,the premium i use to pay on yearly basis,i need to pay through on line,they have tie up with many hospital , i no doing much important is that they have share the location,i have no claim experience yet,till now no issue ,any changes they use to notify and use to send hard copy.
    Was this review helpful? 0
    , bangalore
    Reviewed on Jan 19, 2019
  • United India Health Insurance
    "Good Claim Experience"
    0.5 5.0/5 "Blown Away!"
    I have mediclaim policy with United India Insurance, My wife got surgery, it was there in the listed hospitals. I paid only for the medical , remaining all taken care by the insurer gave me the cash less treatment. My total coverage value is Rs. 3.5 lakhs including my family its good.
    Was this review helpful? 0
    , chennai
    Reviewed on Jan 19, 2019
  • United India Health Insurance
    "Good Claim Experience"
    0.5 5.0/5 "Blown Away!"
    I got group insurance from company, on time I got policy. My father was not good at the time I have used the policy. I got the reimbursement around Rs. 23,000 the total value is Rs. 33,000. I went to shobha hospital they don't have tie up with United India, hence I got the reimbursement.
    Was this review helpful? 0
    , bangalore
    Reviewed on Jan 18, 2019
  • Max Bupa Health Insurance
    "Good Claim Experience"
    0.5 5.0/5 "Blown Away!"
    I have medical cover with Max bupa, they gave me the coverage value of Rs. 5 lakhs its covers for entire family. One time I claimed for my mother for the eye surgery, I got the reimbursed within 30 days with 90% of amount, the total experience was good.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 18, 2019
  • New India Health Insurance
    "Yet to experience the policy"
    0.5 5.0/5 "Blown Away!"
    My company has provided me a health insurance policy from new India. As per company norms, they have given me a coverage value of Rs. 5 lakhs. My entire family has been covered in this policy. They are offering a cashless treatment facility.
    Was this review helpful? 0
    , bangalore
    Reviewed on Jan 18, 2019
  • United India Health Insurance
    "Very Good Service"
    0.5 4.0/5 "Great!"
    I had taken this insurance policy in the year of 2018 and the the premium has been deducting from my salary. The premium amount has not been too high and there has been many hospitals collaborated within my locality. There has also been some cashless treatment available with this policy as well.
    Was this review helpful? 0
    , chennai
    Reviewed on Jan 17, 2019
  • Star Health Health Insurance
    "Good service"
    0.5 4.0/5 "Great!"
    I have my health insurance with Star health insurance, i had claim experience with it, my experience was good, they have good tie up with my hospital and they have mailed me about the location of it, and i am happy with there service, they have charged me premium amount on yearly basis, and the premium amount is nominal for me, and i use to pay through on line mode.
    Was this review helpful? 2
    , chennai
    Reviewed on Jan 17, 2019
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