A LITANY of grievances keeps flooding the social media handles of insurance companies. Each complaint demonstrates a sense of frustration, extreme anger and helplessness of a policyholder seeking end to the ordeal of claim approval. Despite the rapid strides in technology, despite initiation of new schemes in healthcare programmes, many frustrating difficulties still persist in getting insurance claims processed in the country. The insured are always on the toes in case of an emergency, dealing with a double whammy of ill health and uncertainty over claim approvals. The process of insurance claim is a two-way traffic between hospitals and health insurance companies. It entails a constant flow of communications between the two about health details of the patient admitted, details of the policy chosen and benefits entitled. The to-and-fro is to ascertain the cause and need for hospitalisation. This remains the biggest catch in the process as ambiguity in contracts often leaves a lot of scope for interpretation and also suspicion.

 

Caught between the two is the policyholder, waiting for hours to get a clarity on his/her claim which often leads to inordinate delay in discharge from the hospital. A recent survey by LocalCircles found out that 6 in 10 health insurance policy owners who filed a claim in the last three years took between 6 and 48 hours for their claim to be approved and for them to be discharged. Similarly, over 5 in 10 policy owners had a claim rejected or partially approved for invalid reasons. This indicates that the process of claiming health insurance is extremely time consuming with many policyholders and their family members spending the last day of their hospital admission running around trying to get their claim processed. The time-frame set by the Insurance Regulatory and Development Authority of India (IRDAI) is not respected in most cases leading to harassment of policyholders who keep facing a constant fear of escalation in hospital charges.

 

What is extremely annoying is the lack of participation of the actual policyholder in the entire process. Unsure of the status of their claim, the insured are always on the tenterhooks as the third-party assistance (TPA) desk continues communication with the insurance provider through dedicated portals. The time taken to acknowledge a query at both ends becomes a wait for eternity as despite the framed rules the process is mostly not completed within the window of three-four hours. This area of communication and the time taken to reach a settlement is totally grey and urgently requires a more dedicated approach by the IRDAI. What becomes absolutely glaring in insurance claims is the lack of trust between the two parties involved. The team of doctors at the treating hospitals often complains about the questions raised about their diagnosis of the patient and need for hospitalisation. Though a review of the medical process initiated by the doctors by the panel of the health insurance company is perfectly valid, it often becomes a clash of opinion over the treatment initiated. Removing this difference needs a robust mechanism and dollops of faith as ultimately it affects the patient and his family members.

 

hen there is the matter of commerce involved in the medical business which leads to perceptions of exploitation of the facilities. This adds further cloak to the distrust factor, leading to further queries and responses via on-line systems which culminates into delays in claim approvals. The issue here, thus, is having a system which eradicates the distrust factor. A team of senior medical practitioners appointed by IRDAI in collaboration with all health insurance companies in network hospitals can be a solution. It will expedite the claims process as the queries can be solved at the local level itself instead of the lengthy series of mails with company headquarters. It will also make the policyholders or their family part of the process giving them clear understanding of the situation and expenses likely to be incurred. Not that the solution has not been tried but there seems some hesitation over acceptance of authority which is not helping the cause. Health insurance has become a necessity for every family in the age of rising cost of healthcare. Though the government has introduced healthcare schemes like Ayushman Bharat and affordable generic medicines through Jan Aushadhi Kendras, a large section of Indians is still far away from the benefits. Under Ayushman Bharat, the underprivileged get treated at minimum cost. It is indeed high time that taxpayers were considered for the benefits because of rising healthcare costs in the country.

 

A big number of taxpayers has to bank upon private insurance which also is a tedious process to choose due to lack of full disclosure about exclusions and eligibility of claims in policies. Heavy use of technical jargon and complex words further add to the policyholder’s confusion. A policy is ultimately chosen traversing through this maze with help of the company intermediary. And even after this, when it comes to claiming the benefits of high premiums paid, the system rigmarole ends up in mental harassment for the holder. The IRDAI has to make it mandatory for insurance companies to be extra transparent in disclosing details of the cases under review within deadline. It will help the policyholder search for other alternatives including financial provisions to effect discharge. There is also a need for a uniform rulebook for insurance companies for claim settlements apart from a dedicated system which ensures expeditious processing in a set time-frame. For, health insurance is an earned right, not a freebie. n