The Insurance Regulatory and Development Authority (IRDA) came out with landmark draft health insurance guidelines on 31st May 2012. While it addressed numerous important issues like lifelong renewal, claims settlement within 30 days of receiving all documents, refund on pre-insurance medical check-ups, separate grievance cell for senior citizens and so on, there are several other issues which have vexed mediclaim policyholders.
On 16th May 2012, Moneylife Foundation had submitted a Health Insurance memorandum to IRDA chairman, J Hari Narayan, who was the chief guest at the event.
Here are some of the points from the Moneylife Foundation memorandum that are not taken up in the health insurance guidelines:
- Senior citizens disallowed increase in Sum Insured (SI) – Survivors of critical illness like cancer are also denied increase in SI by the insurance company. This is easily managed by the insurance company under the garb of Right to Underwrite.
- Action required – There should be mandatory allowance for inflation-linked increase in sum insured irrespective of past claims history.
- Need to cover prosthetics and artificial limbs for disabled The Challenging Ones NGO gave a memorandum to the IRDA chairman on 16th May 2012 requesting him to ensure that all insurance providers be mandated by regulations to offer mediclaim and accident cover policies to cover the cost of provision of prosthesis/artificial limbs to the insured person, up to the sum insured and without any artificial cap. At the moment, not all insurance companies cover the cost of prosthetics.
- Action required IRDA chairman had given positive feedback and immediately acknowledged the need for mediclaim to cover prosthesis. He was going to advice companies about it as there is increasing need for various types of implants. Unfortunately, even after reminders there is no action taken by IRDA.
- 24 hour hospitalisation used as an excuse to reject claims – Today technological advancement does not necessitate hospitals to keep the insured for more than 24 hours in many cases. Insurance companies are rejecting claims under the garb of 24 hours hospitalisation.
- Action required More day-care procedures need to be added to mediclaim. IRDA should make insurance companies needs realistic rather than mechanically rejecting claims just because the stay in hospital was less than 24 hours.
- Lack of infrastructure to receive hospitalisation intimation – Many insurers have a strict 24/48 hour intimation rule for hospitalisation intimation and seven days for claim submission. There are other issues too. For instance, TPAs deny having received hospitalisation intimation. Sometimes they do not have 24-hour helpline, are closed on public holidays and weekends, or are short-staffed leading to endless wait time to get connected to a person. This prevents genuine hospitalisation intimation and is often exploited to reject claims mechanically.
- Action required – IRDA should take tough stand on such frivolous claims rejection. All insurers should have a 24-hour toll-free phone number, fax, email and SMS facility for customers or agents to intimate hospitalisation. Technology makes this both inexpensive and easy to provide. Email/internet and SMS should have an auto confirmation facility. It is not acceptable that genuine intimation within the timelines end up rejected with TPAs denying receipt of intimation.
- Cashless facility is restricted to preferred-provider-network (PPN) which does not include majority of high-end hospitals for government insurers. This issue is only for retail and not for corporate mediclaim policies.
- Action required If cashless is offered for corporate mediclaim, the same insurance company cannot disallow retail mediclam policies from getting same benefit. Just because individuals have less bargaining power, insurance companies can get away with it. Cashless facility must be re-started for retail consumers, at all Quality Council of India (QCI) accredited hospitals and nursing homes.
At the Bombay High Court hearing (12 February 2013) of a public interest litigation filed by social activist Gaurang Damani, IRDA legal representative stated that health insurance draft regulations have been approved by its board and it is now pending approval of Parliament. It means that there is less scope of the above-mentioned issues to be considered even though IRDA should have been proactive about it.
In the next article we will discuss pending issues that IRDA needs to address to improve life insurance customer satisfaction.
http://www.moneylife.in/article/irdas-health-insurance-guidelines-key-consumer-ric-points-ignored/31257.html
