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Can health insurers settle Covid claims in 1 hr?

There is need to show urgency on the part of the insurers and the hospitals so that the cashless claim can be settled within the stipulated one hour

Can health insurers settle Covid claims in 1 hr?
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Can health insurers settle Covid claims in 1 hr?

New Delhi WITH health insurance claims and settlements piling up amid ongoing second wave of the pandemic, insurance experts have raised concern on the express insurance methodology saying that the responsibility to ensure speedier settlement of claims lies not only with the insurer/Third Party Administrator (TPA) but also with the hospitals. The experts have suggested that more proactive cooperation among the hospitals, clinics, insurers, TPAs, technology providers, emergency responders such as, ambulances is the need of the hour.

On April 29, Insurance Regulatory and Development Authority of India (IRDAI) specified the norms on Covid-19 insurance clearance on the directions of the Delhi High Court stating that all the health and general insurance companies should settle the claims for Covid-19 patients within 60 minutes. This was conveyed after the High Court had observed that insurance companies can't take 6-7 hours for approving bills of Covid-19 patients as delaying discharge make those in need of beds wait longer.

Joydeep Roy, Global Health Insurance Leader, Pricewaterhouse Coopers (PwC), told Bizz Buzz, "the claims in the second wave are rising and the standalone health insurance companies are worried since this may hit their solvency. The general insurance companies are relatively protected through the motor vehicle insurance claims." On April 28, it was reported that the General Insurance Council (GIC) shared data with the Finance Ministry stating there were 1.1 million Covid-19 health claims worth Rs 15,568 crore filed with insurers out of which only 9,30,729 claims worth Rs 8,918.57 crore were settled.

Insurance experts said that the IRDAI can direct the insurers on one-hour clearance, but it can only urge the hospitals since the health institutions don't come under the ambit of the insurance regulator. On cashless insurance, Roy further explains, "the time taken to approve a cashless claim is equally dependent on the hospital and the insurance company. Typically, the patient approaches the hospital and they complete the cashless entry registration process, and if that takes more than one hour, the insurer is powerless as they may not even know of the claim. Hence, a completely well-coordinated action is required and for that the hospitals, which are not governed by IRDA, have to act proactively first and with a sense of urgency, as they are at the first point of contact. After that, it is the duty of the TPA/insurer to make sure that the patient gets the speedy resolution of their situation."

Dr Abhitabh Gupta, CEO, Good Health Insurance TPA, said that the role of all the concerned parties is crucial in settlement of claims for Covid-19 patients. "Hospitals have to ensure that they have adequate manpower at insurance desk to cater to the workload. Also, they need to send all the relevant documents in one go. TPAs have to ensure that there are no unnecessary queries at the last moment and they process it within the time limit," Dr Gupta said.

The IRDAI circular issued on April 29 states that "decision on authorisation for cashless treatment for Covid-19 claims shall be communicated to the network provider (hospital) within a period of 60 minutes from the time of receipt of authorisation request along with all necessary requirements from the hospital."

Archana Rao
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