We had covered in the past that KPMG was appointed by 4 PSU's to advise them about a common TPA with a view to protect their interests.
Yes it is going to happen.It may be 1 TPA to be selected by all of them so that they can give good service to them ( 4 PSu's).As it will be a good business therefore naturally all the instructions of PSU's will be followed.
Let us wait for many things to happen.With big hospitals being deleted - Is it going to be market segmentation where HNI's will start moving to private companies like Max Bupa /Apollo Munich .
Monday, July 12, 2010
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2 comments:
It would be a disaster if all PSU's use a common TPA. I respect Mr. Suresh's view but would present my personal opinion.
Reality is that irrespective of private or public sector, insurance companies would always want to compete to better there respective market share. This would be by various means viz. formulating innovative healthcare plans, manage product mix based on their existing as well as forecasted (projected) clientele, commercial decisions(under cutting) due to cross subsidizing benefit (for corporate clients) etc... One Insurance company will never want to share information of there clients with other insurance companies.
PSU's using a common TPA will never yield results in the Indian context.
What would be the most ideal option in the Indian context is that let each PSU insurance company set up its own inhouse but independent Medi-claims Processing Unit (MPU) with medical professionals as presently managed by TPA's. This would not only retain integrity but also facilitate GOOD and INNOVATIVE decision making. Inhouse but independent MPU's would provide authentic data for formulating future underwriting guidelines. Non admissible items in a claim and matters relating to inclusions/exclusions/limits/etc and be then uniformly applied.
Since is a vast subject which includes mutliple stake holders and a critical role outlined for each one of them I would not be able to place my view here in totality but I would be extremely happy to lead a presentation in this regard.
In India we need to address REALITY .... here utopian ideas really needs a committed set of intellectual who inturn would whittle out a team to address SPECIFIC ISSUE such as these.
Dear sir,
Administrtion in most of the TPA's are handled by clerks and no responsible officer goes into the representations made.No effort is also made to seek respnsible legal opinion whwther within the Organistion or outside
The doctor sitting in TPA is completely ignorant of the judgment of the Apex Court and mechanically reduces the claim on the basis of excluision clauses which have no legal basis.
For the enhanced amount, exemption is claimed for 4 years. Having collected the enhanced premium, question of exemption for 4 years would amount to unjust enrichment of the PSUs. Many medi-claim policies started 15 or 20 years ago and the new exemption clause of 4 years for enhancement amount cannot be applied since such a condition was not in existence at that time.
The PSUs did not negotiate for inclusion of new exemption clause of 4 years for enhanced amount and it was also not brought to the notice of the insured at the time of enhancement by collecting higher premiun
In many cases the enhanced amount does not cover the escalation in hospital and medical expenses taking place in a long span of years. In fact the insured person is in terms of 'health beneits'having less coverage, than what he was having 15 or 20 years ago.
This may be brought to the notice of PSUs and Insurance Regulatory Authority not to introduce new exclusion clauses which did not exist when the policy was first taken. This is contrary to the judgment of the Apex Court, since such a clause can only be introduced by negotiation with the insured person
Thanking You
Yours Faithfully
N.Jayaraman. IAS (Retd)
Ex. I/c Lokayukta, Maharashtra
email: njayaraman.ias@gmail.com
njayaraman@rediffmail.com
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