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Two years on, Ayushman Bharat has ground to cover on universal health care

Sept 24, 2020

Private hospitals suggest private-private partnerships, upscaling of teaching hospitals The Centre’s flagship Ayushman Bharat health insurance programme has completed two years. But this time, the buzz around the milestone has been low-key, coming at a time when hospitals are coping with the surge in Covid-19 numbers.

Launched on September 23, 2018, in Ranchi, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana has seen over 1.26 crore hospitalisations, involving a spend of over ₹15,772 crore to cover these healthcare bills. In fact, Health Minister Dr Harsh Vardhan said the two-year milestone is as significant as his involvement with polio eradication efforts in the country.

The National Health Authority’s Chief Executive Dr Indu Bhushan said, at an event to herald the two-year milestone, over 23,311 hospitals were on board the scheme covering over 1,500 procedures. The scheme has generated savings to the tune of ₹30,000 crore, he said.

But the scheme still has ground to cover in terms of being more universal in its coverage, say public health voices, even as private healthcare representatives seek greater dialogue to “iron out the wrinkles”.


Making a case for universal healthcare, KM Gopakumar with the Third World Network, points out that a bulk of the middle class remains outside the scheme. And the “package system”, where a set number of procedures are covered for reimbursement by the government, leads to further exclusion of ailments and people, he said.

The scheme is the first step towards providing universal healthcare, said Dr Sudarshan Ballal, Chairman, Manipal Health Enterprises. “Not just the Western nations, but even countries such as Thailand have a well-developed healthcare system,” said Dr Ballal, who is also a former president of NATHEALTH, a platform for hospitals, diagnostics, insurance providers etc.

The last six-odd months have been low-key, he admits, as all efforts have been redirected to tackling Covid. But the effort now should be to dialogue with private providers, address their viability problems and encourage more low-cost or no-frills hospitals, upscaling of teaching hospitals, and even private-private partnerships like the one Manipal Health has with the Tata’s hospital in Jamshedpur for clinical training, he said.

Private players ask for more support

In the early days of the scheme, the pricing of procedures had been a major bone of contention for private healthcare providers, including smaller nursing homes run by medical professionals. In fact, Ballal says, large corporate hospitals are still not entirely participating in the scheme for these reasons.

Lauding the concept of wellness centres, he said there should be attention on prevention and greater screening at the primary centres before a patient lands up at a tertiary care hospital. Hospitals will be willing to get more involved if there was a viability-gap funding mechanism to help hospitals support low-cost procedures. Other alternatives that private healthcare providers have been suggesting to the government include a differential pricing of sorts to support cross-subsidisation of those who cannot pay, by those who can.

Patient woes

Patient experiences, though, include difficulties in getting covered when there are repeated procedures, for instance, as in a chemotherapy that has multiple cycles; or when they travel to a different State for treatment. Presently, Odisha, West Bengal and Telangana are not part of the scheme. These are some of the ground realities the scheme will have to fix, so it can deliver the benefit it sets out to provide.


Be worry-free when making health claims

Sept 24, 2020

Covid-19 has increased the awareness about the importance of buying health insurance. In August, premium collection by stand-alone insurers went up by 25.85% compared to the same time last year, according to data from the Insurance Regulatory and Development Authority of India (Irdai).

However, the awareness about the details of the policies such as coverage, disclosures, sub-limits, exclusions and so on is still a matter of concern as it directly affects the policyholder at the time of claims. This is reflected in the number of claims reported for covid-19 against the number of claims settled: according to data General Insurance Council shared with Mint, from March last week to 10 September, 130,080 claims were settled against the total claims of 207,291. While some of these claims may still be in process, the gap is quite wide.

“The top reasons for health claims to be rejected are non-submission of complete documents, waiting period, non-declaration of pre-existing conditions, non-coverage under policy terms and conditions and fraudulent papers," said Bhaskar Nerurkar, head, health claims, Bajaj Allianz General Insurance Co. Ltd.

We tell you what to keep in mind to not land yourself in trouble at the time of making a claim.

Disclose all details

At the time of purchase, disclosing all information to the best of your knowledge is important. It is best to fill in all the details yourself and not rely on your agent or broker.

Read all the terms and conditions on pre-existing diseases (PED) and waiting period. Concealing details related to pre-existing conditions or family history will only make things difficult for you when a claim arises. Remember that insurers apply a waiting period for some PEDs. Nerurkar said if a claim materializes due to any of the prevailing conditions listed in the terms and conditions of the policy contract, then the claim gets rejected.

“Many times, customers are unaware of this condition or assume that the hospitalization is not linked to the PED or waiting period. This linkage is purely decided by the medical professionals of the insurance company. Sometimes they get in touch with treating doctors to evaluate exact linkages," said Nerurkar.

Even if you feel that a particular surgery was minor and happened long ago, being transparent about the status of the PED at the time of policy purchase is crucial.

Look at the clauses

The annual MintSecureNow Mediclaim Ratings (MSMR) rates down policies that come with sub-limits. If your policy has sub-limits such as a cap on room rent and if you opt for a room with a higher tariff, the insurer will apply proportionate deduction on other expenses too as, typically, most expenses are related to the room rent. This means you will have to pay the balance.

“To avoid paying inflated bills on medicines and incidentals when staying in a deluxe or premium hospital room, try to get a health insurance policy that has no room rent capping or has a higher ceiling on room rent so that it can cover any room you may have to take," said Indraneel Chatterjee, co-founder and principal officer,

The usual, customary and reasonable (UCR) clause to avoid the abuse of services may also affect claims, said Nerurkar. This clause is used by insurers to restrict the claim amount payable in accordance to what they deem reasonable. A lot of claims are settled only partially due to this clause, said experts.

“While the clause is justified in certain cases, it can be misused to restrict the insurer’s liability. It is tough to fight against it unless the insurer has settled the claim with blatant deduction. Hospital charges in India are not regulated and, hence, insurers, based on their experience, decide on how much is reasonable payment for a procedure at a specific grade of hospital," said Chatterjee.

If you have two indemnity policies and the first insurer deducts a chunk of the claim amount, you have the right to claim the balance under the second policy, but it isn’t easily done.

The only way to lower the burden—in case of planned hospitalization—is to get an estimate of expenses from multiple hospitals and choose a reasonable one.

Avoid Hospitaliazation

If your insurer finds that an outpatient claim has been converted into an in-patient claim, there is a possibility of your claim getting rejected. “Sometimes the patient is admitted only to be kept under observation due to the caregiver’s insistence. Such claims are not payable," said Nerurkar.

If hospitalization was indeed required and the claim is still denied, gather all the proof. “Get additional certificates and declarations from your doctor. Show the pre-hospitalisation diagnostic reports. If you can convince the insurer that you were rightfully hospitalized, the claim may get honoured," said Chatterjee.

Ensure that the details shared by you at the time of purchasing the policy match with those filled in the claims form. Attach all relevant documents. “Concealment may lead to repudiation of claim and cancellation of policy contract as well," said Nerurkar. Multiple instances of claim rejection may impact future claims.

If you’ve done all the due diligence and the claim is still rejected, you can ask the insurer to review it. The next recourse is to approach the insurance ombudsman.


HC brings about shift in accident compensation claim procedures

Sept 23, 2020

Tribunals told to treat police report as claim plea

The Madras High Court has ordered a major shift in procedures adopted to claim and pay motor accident compensation in the State. It has directed all tribunals to treat detailed accident reports uploaded by the police on the Criminal Tracking Network and Systems (CCTNS) portal as claim petitions without waiting for the victims to file such petitions.

Justice S.M. Subramaniam issued the directions to simplify procedures for obtaining compensation, avoid bogus claims and ensure speedy disposal of claims. The judge pointed out that Section 166(4) of the Motor Vehicles Act of 1988 empowers the tribunals to treat accident reports as an application for compensation but hardly any tribunal invokes the provision.

Now making it mandatory for all motor accident claims tribunals to download the First Information Reports and other documents from the CCTNS portal, the judge held that they should be numbered as claim petitions within 15 days and notices issued to victims, insurance companies and the transport corporations or private vehicle owners. The judge also said that every endeavour should be made to settle the compensation amount through pre-litigation proceedings after referring the issue to the Legal Services Authority. It was only if no settlement could be reached between the parties, they should be asked to undergo a full-fledged trial to determine the liability and the quantum of compensation, he added.

To assist the tribunal to undertake such an exercise, the judge asked the Director General of Police to ensure that FIRs were registered promptly in motor accident cases and uploaded along with documents on the CCTNS portal without any delay. Investigation should also be completed within 90 days in all accident cases.

The documents uploaded on the portal should have been verified with the insurance companies and other departments concerned and they must be authenticated with a watermark. Names, address, phone numbers, Aadhaar card numbers of the victims and their family members should also be uploaded on the portal and those details must be legible, he ordered.

The DGP was also directed to create a system for sending e-mail notifications to the jurisdictional tribunals immediately after the uploading of accident reports on the portal. An officer in the rank of Inspector General of Police must be deputed to supervise whether all police officials in the State were following the directions scrupulously and initiate action against erring officials.

Justice Subramaniam directed the DGP to impound vehicles that get involved in road accidents without having been insured. The Director of Medical and Rural Health Services was further ordered to maintain accident registers in all government hospitals across the State and upload those particulars on the government website within seven days of every accident.

The judge wanted the Transport Secretary, the DGP and the Director of Medical and Rural Health Services to report compliance of his orders by January 18, 2021.


Insurance: Data analytics can make insurance firms smarter

Sept 23, 2020

As the value chain continues to become more digitally connected, insurers have the prerogative of better understanding customer segments and partners, and adapt to consumer needs in near real-time. In the near term, most of the digital insurance consumers will likely be young, educated and with higher levels of income.

To meet customer needs, most insurers have already started to collect a wealth of data. However, they have been slow in monetising this asset. To understand and meet consumer needs, there is an immediate need to create new business lines or models to capture the value of data and analytics. As more and more insurance consumers shift online to interact, compare products and prices, and make purchases, the volume of available data is increasing exponentially.
Data-enabled processes

Over time, Big Data and refined models will work for allowing risk pricing at an increasingly granular level. There is nothing to deny the fact that the insurance industry is a major component of the economy. It enables individuals and companies to take more risk, which further empowers innovation and growth. And the fuel of the insurance is data. Technology revolutions of the last few decades and falling cost of technology create new opportunities for insurers to harness the data.

Data-enabled processes will minimise friction and streamline the customer insurance journey, from request for coverage to claim. Digitalisation will thus help improve the customer experience and also the efficacy of back office processes. The true opportunity, however, lies in leveraging the collected data to fundamentally change how a particular business operates and delivers value to its customers.

Engaging with customers
Most insurers are striving to fundamentally change their relationship with consumers through the use of real-time monitoring and visualisation. Consumers who agree to let insurance companies track their habits can learn more about themselves, while insurers can use the derived data to influence behaviour and reduce related risks. For instance, in the auto insurance industry, telematics is being used to monitor driving habits and behaviour of the consumers in real-time.

Apart from providing digital transformation, use of more data and better tools to collect and report on data means better compliance. And this is particularly because insurance companies are subjected to increasing regulatory mandates at various levels. As insurance companies consider new uses for the data they collect, they must also be aware of the mandates from multiple agencies. In all the cases, the ability to collect, report and use data makes regulatory reporting easier and more consistent.

Yet another important reason why insurance companies need to embrace data is for fraud detection. One of the biggest issues that insurance companies are facing right now is fraud. According to most insurers, 1-1.5 out of 10 claims is fraudulently filed. This is alarming, given the limited number of policyholders that an insurance company may have. While some policyholders do it sloppily, some do it meticulously and get away with it. With the use of Big Data analytics, a large amount of data can be checked in a short amount of time. It includes a variety of Big Data solutions, such as social network analysis and telemetric. This is the biggest weapon insurers have for detection of fraud while filing claims.


Irdai permits insurers to conduct video-based KYC

Sept 21, 2020

The objective of the VIBP, Insurance Regulatory and Development Authority of India (Irdai) said, is to leverage various electronic platforms to simplify know your customer (KYC) process and make it customer-friendly.

Insurers may undertake live VBIP by developing an application, which will facilitate the KYC process either online or face-to-face in-person verification through video, the regulator said. "This may be used for establishment/continuation/verification of an account based relationship or for any other services with an individual customer/beneficiary, as the case may be, after obtaining his/her informed consent...," Irdai said in a circular.

It further said all accounts opened or any service provided based on VBIP should be activated only after being subject to proper verification by the insurer to ensure that integrity of the process is maintained and is beyond doubt. Also to ensure security, robustness and end-to-end encryption, the insurers shall carry out software and security audit and validation of the VBIP application as per extant norms before rolling it out and thereafter from time to time.

Irdai also stressed that insurers should take the assistance of latest available technology - including Artificial Intelligence (AI) and face matching technologies - to strengthen and ensure the integrity of the process as well as the confidentiality of the information furnished by the customer/beneficiary. However, the responsibility of identification will rest with the insurer, it added.

The Reserve Bank of India has already amended the know your customer (KYC) norms, allowing banks and other lending institutions regulated by it to use video-based customer identification process.


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