IRDA has come up with momentous regulations which will change the health insurance industry workings if the draft is implemented without watering it down. TPAs' role will get marginalized and hence they may try to scuttle the implementation in its current form
Insurance Regulatory and Development Authority (IRDA) has finally issued draft health insurance regulations addressing several areas of concern which were raised in a public interest litigation (PIL) by social activist Gaurang Damani. The draft covers product design, renewability, portability, file and use procedures, protection of policyholders' interest, servicing of health insurance policy, third party administrators (TPA), contract between insurer and hospitals and so on.
According to Mr Damani, "They have accepted 80%-90% of what I had demanded in the court. A few minor things remain, some of which are already there in their other circulars, but just need to be added to the policy document. I would mention the same in the next court hearing. One point that is missing in the draft guidelines is need for a doctor's signature in case of claims denial."
The important points in IRDA guidelines are related to following:
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An aspect to be taken up by Moneylife with IRDA, is to challenge the wide spread practice of hospitals to charge for surgery, doctors fee etc, basis the type of room one takes. If one takes a single room, the cost of surgery and cost of surgeon, anaesthesia etc, is charged much higher than if the patient takes a double room. The difference becomes even more, if one takes a ward, instead of a single room. This has no logic, as the same operation theatre, doctor and team is used and same pre operation preparation area and same post operation recovery area. For same service, the same charge should apply, irrespective of room type booked for use before and after an operation or for any treatment in the rooms. Only services that change due to room type e.g. nurse to patient ratio in shared rooms compared to single rooms, can have change in rates, basis the extra man hours allocated.
The current practice is just looting of people wanting some privacy in times of stress
Inquiry GIPSA and TPA role by Director of Vigilance declare it non constitutional, illegal against public interest. Transition and the way fraudulent business is being conducted by GIPSA and TPA in cashless medicalim service is questionable by Dept of Economic affairs.
1. General Insurance Public Sector Association (GIPSA), a group of 4 PSU decided to standardise rates for around 42 medical procedures across various categories of over 4000 hospitals for settling cashless claims, but is looting and cheating patient by GOOF-up with hospital and TPA. When 4 PSU come together to form GIPSA, they r creating monopoly in rates and r trying to exploiting the trapped patient who must have landed up in hospital for first time for surgery after paying hefty premium for years.. GIPSA common monopoly rates for 4 PSU is against the original policy because of which it was necessary to create 4 PSU for competition.
2. Rates as decided by GIPSA or TPA in package is almost 4 times the rate that any patient can do a procedure under cash payment in same hospital. This can be confirmed by calling the reception counter of any particular hospital. In open market hospital faces completion with other hospital so rates for cash payment r most competitive. Each hospital as of today has 3 rates, one for cash payment, 2nd for patients registered with private company insurers which is higher than cash payment most costly is GIPSA applicable to patients insured with 4 PSU. And all this is not make known to patient at the time of admission. There cannot be separate charges for insured and non insured patients again different rates for Pvt company insured patient GIPSA insured patient.
3. GIPSA or TPA different category packages has no transparency how a category is chosen rates fixed or negotiated for that category. The moment any authority is negotiating for fixing rates, in implies that there is every possibility of inviting bribe corruption. Patient does not know if he has been right placed in the right category for his surgery by hospital. Hospital arbitrarily decides this higher category to squeeze out maximum profit not only from patient by exhausting his mediclaim limits but also from PSU which is nothing but public money. Hospital refuses to explain his placement into any such category. Hospital has no display on wall or catalog or break up for such rates charged in any given category. Thus here also GIPSA or TPA offers corruption chance with conspiracy between Hospital, GIPSA, PSU and TPA.
4. Under what law / rule, 4 PSU have formed this association ? Like IRDA, should GIPSA or TPA also not get passed by both house of parliament before it start function arbitrarily.
5. What is Legal identity of GIPSA. Whether GIPSA is registered under any law of the land that is whether it is registered as a society or a trust or under Companies Act. ? In absence of any such legal identity it is a illegal association to expolit monopoly of common rates of 4 PSU to cheat and commit fraud on public for arbitrarily directing hospital to charge rates which are many times more than prevailing market rate charged by that particular hospital for cash services.
6. In absence of no governing body that keeps track on the working of GIPSA TPA, makes It venerable to corruption.
7. Is GIPSA role of TPA, formed under some conspiracy to promote business of private insurer who had negligible market share earlier but after coming of GIPSA this has reached to 50%.
8. Health service Regulator and Insurance act, no where mentions, that TPA as an intermediatory or otherwise can settle claims. Claim settlement can not be done outsourced to a TPA and must be done in-house by a qualified medical practitioner as per section 42D (5) (e) of the Insurance Act.
9. there is no mandate in the Insurance or IRDA Act which allows TPA's or GIPSA
to negotiate on behalf of insurer. This activity must be performed by
insurer only.
For ur reference below link of DNA newspaper
http://www.dnaindia.com/mumbai/report_th...
The big medical insurance loot - Mumbai - DNA
Can you please share information regarding inquiry of Director Vigilance vide which GISPA is declared unconstitutional.
Regards
Sagar Bhatia
9810262582
email: [email protected]
The four PSU insurers were pioneers in health coverage. Other collecting hefty premium they've done precious little by way of research, life style study, premium rate analysis.
In stead of seamless In House Claims Settlement Dept. they were forced by a lobby into going for outsourced TPA system which is made up of the worst of the goons - no proper infrastructure to respond, receive and record calls, staff exiting unable to bear the angry customers, un- and underqualified 'doctors' to evaluate and process the claims leading to rampant uncalled for deductions and rejections.
The unilateral, without notice withdrawal of cash less is the greteat blow to the hapless insureds.
1. General Insurance Public Sector Association (GIPSA), a group of 4 PSU decided to standardise rates for around 42 medical procedures across various categories of over 4000 hospitals for settling cashless claims, but is looting and cheating patient by GOOF-up with hospital and TPA. When 4 PSU come together to form GIPSA, they r creating monopoly in rates and r trying to exploiting the trapped patient who must have landed up in hospital for first time for surgery after paying hefty premium for years.. GIPSA common monopoly rates for 4 PSU is against the original policy because of which it was necessary to create 4 PSU for competition.
2. Rates as decided by GIPSA or TPA in package is almost 4 times the rate that any patient can do a procedure under cash payment in same hospital. This can be confirmed by calling the reception counter of any particular hospital. In open market hospital faces completion with other hospital so rates for cash payment r most competitive. Each hospital as of today has 3 rates, one for cash payment, 2nd for patients registered with private company insurers which is higher than cash payment most costly is GIPSA applicable to patients insured with 4 PSU. And all this is not make known to patient at the time of admission. There cannot be separate charges for insured and non insured patients again different rates for Pvt company insured patient GIPSA insured patient.
3. GIPSA or TPA different category packages has no transparency how a category is chosen rates fixed or negotiated for that category. The moment any authority is negotiating for fixing rates, in implies that there is every possibility of inviting bribe corruption. Patient does not know if he has been right placed in the right category for his surgery by hospital. Hospital arbitrarily decides this higher category to squeeze out maximum profit not only from patient by exhausting his mediclaim limits but also from PSU which is nothing but public money. Hospital refuses to explain his placement into any such category. Hospital has no display on wall or catalog or break up for such rates charged in any given category. Thus here also GIPSA or TPA offers corruption chance with conspiracy between Hospital, GIPSA, PSU and TPA.
4. Under what law / rule, 4 PSU have formed this association ? Like IRDA, should GIPSA or TPA also not get passed by both house of parliament before it start function arbitrarily.
5. What is Legal identity of GIPSA. Whether GIPSA is registered under any law of the land that is whether it is registered as a society or a trust or under Companies Act. ? In absence of any such legal identity it is a illegal association to expolit monopoly of common rates of 4 PSU to cheat and commit fraud on public for arbitrarily directing hospital to charge rates which are many times more than prevailing market rate charged by that particular hospital for cash services.
6. In absence of no governing body that keeps track on the working of GIPSA TPA, makes It venerable to corruption.
7. Is GIPSA role of TPA, formed under some conspiracy to promote business of private insurer who had negligible market share earlier but after coming of GIPSA this has reached to 50%.
8. Health service Regulator and Insurance act, no where mentions, that TPA as an intermediatory or otherwise can settle claims. Claim settlement can not be done outsourced to a TPA and must be done in-house by a qualified medical practitioner as per section 42D (5) (e) of the Insurance Act.
9. there is no mandate in the Insurance or IRDA Act which allows TPA's or GIPSA
to negotiate on behalf of insurer. This activity must be performed by
insurer only.
For ur reference below link of DNA newspaper
http://www.dnaindia.com/mumbai/report_th...
The big medical insurance loot - Mumbai - DNA
With this system, Deficiency Memo system will be outdated.
Hope it will be implemented before 30th June 2012.
The intimation of claim period should be same under all Health insurane policies.
In case, the claim is under dispute and insured approach insurer, the details of discussions need to be recorded and insured to sign it.
Kudos to the Moneylife team, carry on the extraordinary good work and we shall support you in your efforts to make the average Indian's voice to be heard.
FOR LAST 5 YRS. IN A ROW, UNLESS I WRITE TO CMD, I NEVER GET REMINDER TO RENEW, I HAVE TO CAJOLE THEM TO RENEW, THE POLICY ALMOST NEVER COMES, THE CARD COMES ANYWHERE FROM 10 MONTHS TO AT LEAST 4 MONTHS INTO THE INSURED PERIOD.
WILL IRDA BOTHER TO ENSURE BASIC CUSTOMER RESPONSIBILITIES ARE MET BY ALL & SUNDRY WHO COLLECT PREMIUM (LET IT BE CHEAPER/EVEN FREE!!!), IF NOT SO-CALLED CUSOTMER SERVICE THAT JUST ABOUT DOES NOT EXIST IN THIS COUNTRY ACROSS ALL SPECTRUMS OF GOODS & SERVICES THOUGH WE PAY THROUGH THE NOSE, SO-CALLED MONEY-MAKING MACHINE CREATED BY CHIDAMBARAM CALLED """""""""""SERVICE TAX""""""""""IN A COUNTRY WHERE WE PAY A HEFTY, FAT, LEECHY 13% (DIS) SERVICE TAX TO A GOVT. WHICH JUST DOESNT BOTHER ABOUT ANYTHING EXCEPT SPENDING MONEY ONLY ON PHONY/FAKE/TEETHLESS CREATURES LIKE "JAGO GRAHAK JAGO"....!
saarey jahna se achha, hindustan hamara.....JO BILKUL HI NAHI HAI!
Deny Mediclaim to the Newborn till he / she gets 3 month old is unjustified. When parents of newborn has a valid mediclaim policy, the infant also must be covered under mediclaim immediately once born. Premium for the newborn should be accepted by Insurance Company say two months before birth. In any case, the child must be covered under Mediclaim at the time of birth.