Clarify steps taken to simplify health insurance claims

Wanting to know about the grievances of consumers of health insurance, the Bombay high court on Monday asked the central government, especially the union health ministry, what steps had been had taken so far. A division bench of Chief Justice Mohit Shah and justice SJ Vazifdar also directed the central government to place on record the guidelines, if any issued by the Insurance Regulatory and Development Authority (IRDA), for simplifying medical insurance claims.

The counter was hearing a public interest legal action filed by city-based advanced Gaurang Damani seeking direction to bring more clarity in the insurance document so that the consumer knows closely what amount to expect in case he lays a claim.

"The policyholder has completely no idea what would be the amount at which his assert would be settled," Damani submitted while addressing the court on Monday. "In absence of any clear guidelines, the claims are settled randomly."

"There is complete chaos," Damani said when the judges inquired if there were no guidelines framed by the IRDA for settling medical insurance claims. Damani has also sought abolition of the third party agencies (TPAs) stating insurance companies have outsourced their core work to these agencies when legally they have no place in the contract between insurance companies and the policy holders.

"It is very unfortunate that the TPAs are guiding policyholders to hospitals, they are negotiating with hospitals, and even settling claims," he said, adding, "In the fight between TPAs and the hospitals, the ordinary consumer is suffering."

Damani informed the court that so far 5.5 crore persons have availed medical insurance and as on April 1, 2010, aggregate claims of Rs29,000 crore were pending settlement.

The activist also raised grievance about scrapping of cashless scheme. The scheme, under which the hospitals receive their payments directly from the insurance company, ended in 2010

Source: [Hindustan Times]