Consumers often face problems in cashless mediclaim

In 2001 when the Insurance Regulatory and Development Authority (IRDA) paved way for the entry of Third Party Administrators (TPAs) as intermediaries in health insurance sector, they were expected to bring substantial qualitative changes in the health insurance service delivery,

particularly  in the area of 'cashless mediclaim' or  cashless system of claim settlement.

But a decade hence, policyholders continue to be victims of inefficiency, insensitivity, and lack of standardisation in the sector, particularly in the processing and settlement of claims. A 'cashless health insurance' policy, for example, must ensure that the policy-holder is free of worry over payment of medical bills in case of any treatment or hospitalisation. However, consumers often complain about long waits involved in getting approvals for cashless treatment from TPAs/insurers.

For example, a reader SM Sarin writes about how despite a health insurance policy for cashless treatment, he had to pay a security deposit of R55,000 to a hospital because the required authorisation did not come in time from the TPA. Even though the pre-authorisation form with all the relevant details was submitted three days prior to the surgery, the authorisation did not come for five days, despite repeated phone calls and reminders, he says. 

Eventually, even though he was discharged from the hospital at 10am, he had to wait till 3pm for the approval of the medical bill, as the hospital would not let him go without it.  "I wish the insurers would become more sensitive to the suffering of those who are sick and are already nervous about their health and not impose further anxieties on them," said Sarin.

In 2009, a committee constituted by the IRDA to evaluate the performance of TPAs, had recommended steps to improve customer service, including formulation of strict service standards with specific timelines for all services and penalty for their non-adherence. The committee, after detailed consultations with TPAs, insurers, hospitals and policy-holders, had also recommended standardisation of all claim-related procedures, including hospital billing and discharge protocols, so as to bring uniformity in the processes and facilitate faster and efficient pre-authorisation and claim settlement.

Another recommendation was the creation of a health insurance industry body — Health Insurance Development Council with representation from all stakeholders — to spearhead standardisation and quality improvement, besides collection and maintenance of data for efficient delivery of services.

Now that IRDA has issued an order (on Feb 2) constituting such a body — Health Insurance Forum — to create standard processes and definitions in the insurance industry as well as the health sector, hopefully, consumers can look forward to better quality of service.

Ramesh Sharma: I have a mediclaim policy (family fluter) from a public sector insurance company purchased on March 12, 2011. I lodged a claim in April 11. The company rejected it, but settled it after my application to the grievance cell of the TPA. Again, I lodged a claim for the same illness in August, but the company is not making payment. What should I do?

Answer: Without details, it is difficult to answer this question. But I would suggest that you file a complaint with the insurance company and if you don't get a satisfactory response, lodge a complaint with the insurance ombudsman. You can also register your complaint on IRDA portal: the integrated grievance management system www.igms.irda.gov.in. It provides for online registration of policyholders' complaints and helps in tracking the progress of the complaint. The portal also gives you a link to the grievance redress system of insurance companies.

You can get details of the ombudsman scheme and the addresses of the ombudsmen fromwww.irda.gov.in.