health insurance: Improvement in tech, backend processes & team strength needed to achieve IRDA objective: Shweta Rajani

“Honestly the infrastructure would need to be improved, the backend technology would have to be improved for them and the timeline for them is I would say two months, within two months they have to get all this sorted,” says Shweta Rajani, Anand Rathi Wealth.

In my personal experience, I was hospitalised once and I got to discharge in the morning but the entire thing got settled only post 5 pm or 6 pm in the evening so almost seven to eight hours of waiting period and at that time you being a patient, you being discharged are in touch with the health insurance company, their customer call requesting them to give the authorization and just let me go home but now it seems this will be all stopping and not more than three hours you will be allowed to wait?
Absolutely. What you said is your experience is something that most family members or patients would have experienced even though they would have applied for cashless insurance, but at the time of discharge you are right it could end up taking easily seven to eight hours while during this time period the hospital is submitting all the bills, the required documents, then there is a wait time because the insurance company has to approve of all the claims, give the authorization and then only you are allowed to get discharged, not only that in a lot of cases it does not end there because you would have given still some amount of a deposit right because your entire claim process is still going to take a few days and that deposit money to come back to you could be a few days away. It is welcoming move what IRDA has done because it now means that one within three hours in a normal case the insurance company has to authorize the entire documentation and the claim approval has to go through, not only that they are also emphasising that there should be a 100% claim and any claim rejection by the insurance company would internally need internal explanations and approvals.

It is reducing your time of the discharge process, making it much smoother which is very much a welcome move as well as getting. But along with that there are also special or emergency cases where the timing should not be going more than one hour is that right?
You are absolutely right. So, in case while the treatment was going on, the patient passes away so in case of instances like death they are saying that within an hour’s time the claim process has to be completed and the body should be handed over to the family members so that is the special situation that they have mentioned, so that is the thing.One thing that really comes on anyone’s mind because alright we do have a cashless insurance policy and now since we have this notification or a mandate or a master circular coming up from the regulator, insurance companies would be working on having that kind of a setup and infrastructure to get this under process, but then what is the timeline for them to do it and also do they really have the infra right now to process all of this within that stipulated time frame?
Honestly the infrastructure would need to be improved, the backend technology would have to be improved for them and the timeline for them is I would say two months, within two months they have to get all this sorted.Even today you have some insurance companies which are able to do it, some are not. So, definitely improvement in technology, improvement in backend processes, team strength, all of it would be required to improve from the insurance company to achieve this objective that has been laid out by the IRDA today so that is some effort required in the next two months.
55 previous circulars were repealed, definitely this discharge one has taken away all the headlines but then there are few more which are very important as far as your health insurance policies are concerned. So, a few others that you might just want to highlight especially with regards to the policy holders and their benefit.
Just coming to the claim itself, one thing is that even while the time of application, when you are getting hospitalised it would we be a random amount that would be approved so that again they are saying within three hours you have to approve the application so that your entry also becomes smoother.

Second, and I would say again a very important point that is mentioned, is you get a lot of policy benefits if you have not utilised the claim for a few years.

So, what IRDA is saying is that as the policyholder you can either look at an option of getting a discount on your premium for the next few years or what you can do is have a higher sum insured to your policy so that is another benefit that they have spoken about which is very good because beyond a certain age the premium that you may have to pay for getting a higher insurance cover is something that not everyone will be able to afford it.

So, with this saying that if you have not utilised your claim for the last five years, then you getting this advantage is again a very important and welcome move because more number of higher claim amount in a future date when required can be used as well as the premium cost can come down for a lot of people, so affordability goes up.

And given the way health inflation is going, hospitalisation can easily take away a significant amount of your savings, so again getting a higher claim amount or a higher insurance cover is something which is most welcoming.
So, I would say overall the three-four points that they have, which are critical, I think getting it done combining those 55 different circulars notifications and reworking on this is something that works in favour of policyholders and little more effort from the insurance companies.