IRDA came out with numerous initiatives last year including draft health insurance guidelines. While these will help to confine the role of TPA to claims processing and not settlement, there are other vital issues that has to be addressed.
• Senior citizens disallowed increase in Sum Insured (SI) – Survivors of critical illness like cancer are also not given any increase in SI by the insurance company.
Action required – There should be mandatory allowance for inflation-linked increase in sum insured irrespective of past claims history.
• Need to cover prosthetics and artificial limbs for disabled – All insurance providers to be mandated by regulations to offer mediclaim and accident cover policies to cover the cost of provision of prosthesis/artificial limbs to the insured person, up to the sum insured and without any artificial cap. At the moment, not all insurance companies cover the cost of prosthetics.
Action required – need for mediclaim to cover prosthesis.
• 24 hour hospitalisation mandatory to approve claims – Today technological advancement does not necessitate hospitals to keep the insured for more than 24 hours in many cases.
Action required – More day-care procedures need to be added to mediclaim. IRDA should make insurance companies’ needs realistic rather than mechanical
• Cashless facility is restricted to preferred-provider-network (PPN) which does not include majority of high-end hospitals for government insurers. This issue is only for retail and not for corporate mediclaim policies.
Action required – If cashless is offered for corporate mediclaim, the same insurance company cannot disallow retail mediclam policies from getting same benefit. Just because individuals have less bargaining power, insurance companies can get away with it. Cashless facility must be re-started for retail consumers, at all Quality Council of India (QCI) accredited hospitals and nursing homes.