One of the major setbacks of the health insurance industry is the time-taking claim settlement procedure. Ideally, a patient should not be held hostages while the insurance provider and the hospital is settling the claim.
It is difficult to get a discharge from a hospital in India. Without exaggerating, patients have to wait for 3 to 6 hours merely to approval from the Third party administrator. At times, patients give up, end up paying from their own pocket and leave the hospital to avoid the cumbersome claim settlement procedure. On the other hand, in the US when the patient is given a green signal by the doctor then he/she is free to go without waiting for a discharge summary from the TPA desk.
We need to bridge the gap between the insured, the hospital care receiver, and caregiver. We need to see how industry fares will help in serving the bridge between patients and insurers.
There are Two Viewpoints-
Cashless Claims as a Breakthrough
There are unique challenges in the Indian market as it is aspiring to seek international healthcare services. Cashless claim settlement allows the insurers to save cost by availing discounted packages from the hospitals. One can easily compare health insurance online and choose a plan that offers cashless services.
Patients don’t need to pay out-of-pocket expenses and it is a win-win for the network hospital in the form of a loyal patient base. It is felt that health insurance penetration would increase if the government would be more supportive.
The Second-point of View
Only 44% of people have health insurance in India and the figures are startlingly low as compared to the US where the insurance penetration is 99%.
Most of the current health insurance market is either corporate insurance or government funded. The percentage is quite low for voluntary private health insurance. And the cashless claim process has brought up only a little change in the last decade. And the communication between the hospital and the TPA is still slow. And there are many incidences of unnecessary charging the patients.
Reimbursement Claims
The experience of customers is even worse while filing a claim for reimbursement of health insurance. Deductions, delays, and rejections are common. The uncertainty of patients leads to extra scrutiny by the insurer and this leads to more frustration in the genuine claimants. If we are able to provide a positive claim experience to the customers it will increase the insurance penetration. The good news is that there are several ideas that are being discussed to improve the patient’s experience considerably.
What Should Be Done?
Launching of fixed benefit health insurance products can reduce the friction areas of a medical health insurance claim. In a fixed benefit product, the clam is payable and the amounts are pre-fixed in case of diagnosis of a specified disease or hospitalization. It eliminates the deductions and ambiguity and claim settlement is instantaneous. Hospital cash is also a fixed type of product and it is currently available. But the major drawback is the low cash payout. Most of the health insurance policies provide a daily hospital cash benefit between Rs. 2,000 and 4,000 per day and this amount are inadequate to cover healthcare expenses in metro cities. A minimum of 10,000 rupees is required to cover direct medical expenses in the metro cities.
Digitization
The existing health insurance claims process can be digitized. Considering the cost of surgeries these days a heart surgery can easily cost around 3 lakhs and a minor appendix surgery can cost around 20,000 rupees. For most health insurance companies, the process of cashless claims and reimbursement is similar. To simplify the process, especially for small claims, auto settlement of health claims should happen. The policyholder can get the original documents scanned instead of providing them in original. Insurance providers should initiate the claim procedure based on the scanned copies. It will save time, money and effort of the patients. Random investigations can happen and then the claim can be settled. A person who is lodging a claim is in the need to money and requires timely claim settlement and should be saved from going through so much before getting a claim against the premium that he pays every year. It’s his right to get the claim amount.
There are more than 10 million health claims every year, which itself is a great opportunity for the health insurance industry. The risk of discontinuity and policy cancellation is substantive constraints to filing fake small value claims. A few insurance companies have issued controlled measures in this direction.
Lastly, there has to be a deeper integration between the hospitals and the insurance providers in India. The current health insurance schemes should make it easier for a patient to immediately walk out of the hospital after treatment. It’s time to settle the claims between the hospitals and the insurers without troubling the patient. This can be done by a combination of virtual and physical intermediaries reserved for a limited number of hospitals only. A trial model on these lines is in progress with a closed hospital-network.
In a Nutshell
Apart from the physical suffering for the patients, hospitalization can be mentally exhausting for both the patient and their families. It can be unpleasant to be in a hospital, surrounded by patients and doctors. It’s time that the health insurance providers show empathy towards the insured patients and work to simplify the claim settlement procedure. Timely payout and a quick discharge can help mitigate this stress for the insured patients and their families. The insurers shall focus on offering peace of mind to their customers instead of adding more stress during such adversities.
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