Arbitrary premium hikes and claim processing delays could soon be a
thing of past, with the Insurance Regulatory and Development Authority
(Irda) finalising norms on health Insurance to address these issues.
These directives, which will come into effect from October 1, are
expected to change many practices in the health insurance space.
Some of the guidelines, like mandatory lifetime renewal and minimum
entry age limit of 65 years, are already in place. However, a few new
ones like prohibiting insurers from hiking renewal premiums simply
because of a claim made in the previous year will definitely help many
policyholders. Claim-based loading — an industry practice where renewal
premiums are hiked when you make claims — is often a cause of heartburn
for policyholders.
After October 1, insurers will not be allowed
to load premiums arbitrarily — they will have to base it on preceding
three years’ claims experience as also expected claims experience. The
reasoning behind proposed pricing will have to be justified. "Loading
will apply only when individual claims experience for three consecutive
years is 500% of current year premium. So, the insurance company can
apply loading only, if say, the current year premium is . 15,000 and
claims for three consecutive years amount to over . 75,000," explains
Mahavir Chopra, head of personal lines and e-business with health
insurance consultancy firm medimanage.
Also, you will be
informed about any change in premium or renewal terms three months in
advance. "The ’Delayed claim settlement to attract interest’ clause will
have to be added to policy document. Also, insurers cannot reject
claims without a proper medical reason," says activist Gaurang Damani,
who had filed a petition in the Bombay High Court that led to Irda to
formulating health insurance guidelines. Policyholders exasperated with
third party administrators’ functioning can also expect some relief.
The
insurance company, and not the TPA, will now have to take on the
responsibility of settling or rejecting the claim. "TPA cannot settle
claims, but only process claim. This will have a great impact, as only
insurance companies can settle claims now. In cases where third-party
administrators (TPA) issued cheques for claims, often, payments used to
get delayed. Also, it was difficult to ascertain whether the TPA had
handed over the entire claim amount approved by the insurer to the
policyholder," says Damani.
This apart, the regulator has also
sought to standardise definitions of certain terms, critical illnesses
and exclusion among other things. "Policyholders will surely benefit due
to the reduction in ambiguity of the various terms used by the
different insurers leading to fewer disputes between them and the
insurers. It also educates customers and reduces chances of their being
taken for a ride by unscrupulous health care providers ," says Amarnath
Ananthanarayan , CEO & MD, Bharti-AXA General Insurance.
Standardisation of norms
Given
the voluminous policy documents and complicated language that
policyholders have to deal with, it is hardly surprising that very few
go through them. Besides, due to the ambiguity , clauses are open to
interpretation , resulting in disputes. Therefore , Irda has come up
with standard definitions for certain terms. "The standard definition
has been prescribed for the 45 most common terms used in health
insurance — such as day care treatment, hospital, inpatient care,
pre-existing disease etc — that will help in reducing different
interpretation by various stakeholders ," says Antony Jacob, CEO, Apollo
Munich.
Henceforth, all insurers will have to stick to these
definitions in their policy documents. Irda has also defined 11 critical
illnesses that are covered under various policies. "Defining critical
illnesses will reduce disappointment at the claims stage on the coverage
norms and exclusions under each critical illness. This should certainly
avoid confusion among consumers and industry," says Ramesh Ramani,
senior vice-president , consumer lines, Tata-AIG General.
Common list of exclusions
As
one of the chief causes for disputes is exclusions, the insurance
regulator has finalised a list of expenses the insurance companies need
not pay for. "The standardisation will reduce the disputes between the
customers and the industry companies with respect to what is covered
under an insurance policy, and therefore, payable as a claim," says
Ananthanarayan. Irda has put out a list of 199 items and has indicated
whether they are admissible or not. "The interpretation of the excluded
items has been different at every stage by every stakeholder .
Standardising the interpretation will ensure clarity. Policy coverage
hasn’t been defined and has been left to the insurers. If the insurers
wish to include these as part of the hospitalisation expenses in their
product design , they are free to do so," adds Ramani.
Uniform claim forms
Yet
another step towards eliminating confusion, this measure could come to
the aid of policyholders at the most critical stage — at the time of
making claims. "Standard pre-authorisation (for cashless claims) and
claim form will significantly streamline processes at every stage. By
implementing it in an optical character recognition (OCR) format, the
ability to transfer data from a handwritten paper-based form to IT
systems has been enhanced , thus reducing data entry issues for TPAs and
insurers. This will help in reducing the turnaround time and hence
result in swifter claim settlements," says Jacob.
source: ET