L - Insurance Intermediares

7/28/2019 L - Insurance Intermediares

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ROLE OF INSURANCEINTERMEDIARIES

Manoj VermaFaculty, MAIMS

[email protected]


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Insurance intermediaries

Insurance business has a peculiarity whereinterface and interaction of a customer ismore often with an Intermediary than with

the Insurer.

Agents, Corporate Agents Brokers, TPAS and

Surveyors are recognized and licensedintermediaries.


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ROLE OF SURVEYORS

Surveyors and Loss assessors areindependent licensed professionalsappointed by an insurance company to assess

the loss or damage, when a claim is notifiedunder a policy issued by them.

Legal status under S.64UM of the InsuranceAct and Surveyors Regulations.


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Surveyors role

His duties include:

investigate and confirm the cause of loss.

advise the insured to take good care of salvage

to mitigate the loss. To ensure that insured has taken all necessary

steps to contain the loss.

assess the quantum of loss.

Determine the liability of the insurers within theframework of the policy conditions.

To act on behalf of the insurance company indisposal of salvage to realize maximum value.


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TOTAL LOSS


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oss a m ss e o a oss? Emotional loss?


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No records or evidence - best

judgement method


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Grievance situations

Policy Holder refuses to co-operate or agreeor interact with a surveyor for various reasons

Grievances arise - Insurer is duty bound to

intervene, mediate and sort out issues.


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Grievance redressal

Many times this does not happen as Insurersare reluctant to overrule a surveyors findingson cause or quantum of loss for concern of

audit or vigilance action.

This results in a large number of grievances

moving to Adjudication or to IRDA.


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TPAS(HEALTH SERVICES)

Legal Status Licensed by IRDA under TPARegulations to act as support services in thehealth insurance sector.

In short, the job of the TPA's is to maintaindatabases of policyholders and issue themidentity cards with unique identification numbersand handle all the post policy issues includingclaim settlements.


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TPAS ROLE

In terms of infrastructure, TPA's run a 24-hourtoll-free number, which can be accessed from

anywhere in the country.

They have full-time medical practitioners under

their employment who immediately take a view

on whether the ailment is covered under thepolicy.


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TPAS ROLE

All the records of medical insurance policies of aninsurer are transferred to the TPA.

In case of a claim, policyholder has to inform TPA on24 hr toll free line provided by the TPA.

On informing the TPA, policy holder will be directed

to a hospital where the TPA has a tied arrangement.However policyholder will have the option to join anyother hospital of his choice, but in such case paymentshall be on reimbursement basis.


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TPA,S ROLE

TPA issues an authorization letter to the hospital, forthe treatment.

TPA tracks the case of the insured at the hospital andat the point of discharge all the bills will be sent to TPA.

TPA makes the payment to the hospital.

TPA sends all the documents necessary forconsideration of claims, along with bills to the insurer.

Insurer reimburses the TPA.


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Grievance situations

Delayed pre- authorization resulting in delayedadmission and treatment.

Differences in interpretation of pre-existing

diseases and exclusion clauses. Delay in issuance of ID cards and issuance of

incorrect cards.

Non submission of complete and correctdocuments by insurance company to TPAresulting in deficient service.

Non accreditation of hospitals due to differencesbetween hospitals and TPAS.


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Grievance Redressal

Insurer must intervene and settle issue oneway or the other as TPA is only an extendedservice arm of the Insurer.

Failure to intervene results in grievances andpetitions to grievance redressal authorities.


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NEWS CLIPPINGS

Recently, Insurers and TPAs have launched ThePackage Deal Pricing.

As per the move, healthcare institutes are gradedand package charges for various medical servicesand procedures have been decided as per the gradeof the healthcare institute.

The move aims to control the abnormal claims ratioin health insurance. Since package charges are pre-determined, they will act as a ceiling and preventhealthcare providers and hospitals to charge abovea certain limit


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News clippings

Delhi healthcare providers have found the chargesabysmally low and allege that the TPAs havethreatened to withdraw cashless service from thosehospitals that do not agree to the package charges.

According to them, the scheme will force them toprovide sub-standard treatment and they fear thatincase they dont sign the agreement, TPAs will

divert their clientele to those hospitals which agreeto carry out treatment at the package charges fixedby the TPAs.


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Institutional voices

Says Dr Vinay Aggarwal, honorary secretarygeneral of IMA,

TPAs do not have the expertise to accreditatehealthcare institutes. Its the job of thegovernment and rating agencies. But here,the TPAs are acting as accrediting agencies.

Besides they are determining rates forhospitals.


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Institutional voices

Healthcare providers argue that the treatment fortwo patients suffering from the same disease canbe different.

For instance, if the patient is diabetic and has toundergo an appendicitis operation, a lot of caregoes in management of diabetes before thesurgery. Also the stay in such a case will beextended for more than two days, and so it wontbe possible for a hospital to provide treatment in

the pre-determined package charge of Rs 10,000 inX hospital and the treatment will be out of pocketfor the patient.


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View from the other side

The TPAs on the other hand feel that thecashless system has been abused to the hiltand so it is imperative to bring instandardization and regulation in thehealthcare industry. An insured patientadmitted to the hospital is made to undergo

an array of unnecessary tests by the hospitalsthereby increasing the bill.


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TPAS VIEW

Says Dr Nayan Shah, managing director,Paramount Health Services, There has to besome kind of regulation in the healthcare

industry. If arbitrary charging by healthcareproviders is allowed, then consumers will end uppaying higher premium. Can an airline charge 10times higher because the client is wealthy? Then

how can a healthcare provider/hospital chargemore from the insured patient? We have decidedcustomary and reasonable charges,


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PERSPECTIVE

Medical and insurance costs should comedown if meaningful medical coverage is to beprovided to large sections of society.

THANK YOU

L - Insurance Intermediares

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