New Delhi, Sept. 14: A cash-less Mediclaim service has more chances of finding takers this time, than in the eighties when it was first introduced, only to meet a poor response.
The entry of third party administrators (TPAs) and the clear mandate given to them is now expected to facilitate the entire process. This is because the TPAs are not only registered but are under the ambit of insurance watchdog, the Insurance Regulatory Development Authority (IRDA).
Gulshan Baweja, general manager of E-Meditek Solutions, a licensed TPA said: “Though TPAs existed even earlier, after the formation of the IRDA we have received formal and authorised recognition. This makes us more reliable for our policyholders”.
Gopal Verma, managing director, E-Meditek Solutions said: “The TPA setup comprises doctors, insurance professionals, medico-legal experts, medical transcriptors, 24-hour toll free helpline, online claims administration and online medical opinion. All this will make the system prompt and systematic”.
Earlier, in the 1980s, the TPAs were employed by many companies in order to get group insurance for their employees. This implied that in a way they could market for the insurance companies and find clients for them. The IRDA now bars this practice. The TPAs are not allowed to find clients for the insurers; on the contrary this has now become the job of the insurance companies. The TPAs are only authorised to handle the policyholders given to them by the insurers.
However, no insurance company covers pre-existing diseases. This means at the time of taking a policy the insurer is covering the insured against any future risk for a given amount and not for an ailment he is already suffering from. Obviously, the insurance firms are doing this to mitigate their own risk levels.
Also, the Mediclaim policy only covers a recurring disease if it lapses in the specified time period as mentioned in the policy and if it is within the limit of the sum assured of the policyholder. Medical expenses incurred beyond this will have to be borne by the policyholder .
“The system should be much smoother with TPAs having medical management skills following the managed care set up. Also, the insurance companies did not earlier possess the skill of networking with hospitals which will now do much good to them,” insurance consultant Aloke Gupta said.
Selling Mediclaim policies has always been a loss-making business for the insurance companies. This is because the claims settled were much more than premiums received by the insurers.
“The new cash-less Mediclaim is a step forward. The checks and balances that would now be maintained between the hospitals and the insurer with the help of TPAs will prove to be cost effective for the insurance companies. So, the chances of it being a success are more,” Gupta said.