Forefront of rejecting valid claims by Indian health insurance companies

Payment of claims from the private sector health insurance companies in the country is not less than any scraps for the consumer. These companies are making the most of the policy flaws in this case. It is revealed in the Fair Play study of the National Institute of Public Finance and Policy (NIPFP) on Indian Health Insurance.

According to the studyer Shefali Malhotra, the government is going to start health insurance scheme Ayushman India for 100 million poor families. It has full cashless arrangement and the responsibility of payment will be on the company or trust. Whereas the biggest problem comes to those who take insurance for personal or family, when people are treated in unlisted hospitals, because in such cases, health insurance companies are reluctant to pay them.

forefront of rejecting valid claims by Indian health insurance companies

According to Shefali, the study and policy of health insurance sector in many countries of the world was examined. The rates of complaints in the health insurance sector are highest among claims in India compared to the state of California, Canada, Australia, UK and US. It is about poor quality of product and services.

Shefali says that the companies claim to provide the best services during the sale of insurance, but later reject them by taking flaws in claims and reject them. The study concluded that the level of consumer protection in health insurance is very poor. According to Shefali, the penalty imposed by the Consumer Forum on payment of claims against private companies is also not suitable. In such a case, in the health insurance sector, the government should prepare a strict policy regarding settlement of claims and delays.

Study of settlement of health insurance companies insurance claim

According to the study, the percentage of the settlement of claims is constantly falling as compared to the proportion of health insurance claims or total premiums. Considering Consumer Protection, it is a matter of concern that private health insurance companies are using the tactics to avoid settlement of claims. This is the reason why the claims settlement between 2013 and 2016 has reached 67 to 58 percent.

Globally, it is compulsory to pay claims for private companies in the US. If the ratio of claims is less than the minimum level, there is no such provision in India. The minimum claim ratio expansion in many U.S. states is 65 to 80 percent. In case of claims settlement, insurance companies have to pay the premiums of the consumer.

The studyer Shefali said that we also found that the claim ratio of government-backed insurance companies has increased steadily. This was 106 percent in 2013-14, which increased to 117 percent in 2015-16. The companies that fulfill these companies with their other business, otherwise many are on the brink of bankruptcy.

It was found in the study that private insurers spent a large portion (10 to 12 percent in 2013-14) of premium paid by the consumers to pay the agent commission, while public sector companies had only 6.8 percent in 2013 Used.

The health insurance provided for the protection of the workers is covered by 4 percent of the country’s population, while more than 2 percent of the cover has been provided at the individual level. In comparison, government funded health insurance scheme GFHIS covered 12 percent in 2013-14 and more than 20 percent of population in 2015-16. Ayushman India is a big form that will enable the poor to use health insurance in private hospitals.

In the study that it is better to deal with state-funded personal insurance claims compared to private companies. It was also seen that private companies failed to remove consumer complaints. In such a situation, there is a need to pay attention to the quality and services of these companies present in the country.

Compare health insurance in other countries

In many countries, health insurance not only involves hospitalization but also other welfare care including clinical visits, medication. In these situations, the possibilities of customer dissatisfaction are high. Despite this, the rate of complaint against health insurance companies in the country is very high. Due to the lack of rules, there is no proper conspiracy in this area. It has been noted in the study that consumer pain relief is not due to faulty institutional form and weak enforcement.

Insurance companies reject valid claims unless the dispute settlement mechanism, such as the Ombudsman and the consumer forum, will not be lost. There is no provision for penalties in the current rules for rejecting legitimate claims, even if the claims are being violated by denying the claims.

There are several such cases in which the insurers have compensated the sum insured and the amount spent in the dispute and harassment one year after the settlement process. Generally, the claims made by the consumer and fines less than the price of the time seems to be on the companies. Apart from this, there is no easy way to get the claim rejected by the insurance companies.

Ministry will explain only after detailed information

Director General of the Ministry of Finance DS Malik said that detailed information on this study on health insurance is being sought. After this the situation will be clear what is reality. Irda, on the other hand, refuses to give any reply in this matter.

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