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Manoj Verma Faculty, MAIMS



Insurance intermediaries
Insurance business has a peculiarity where interface and interaction of a customer is more often with an Intermediary than with

the Insurer.
Agents, Corporate Agents Brokers, TPAS and

Surveyors are recognized and licensed intermediaries.

Surveyors and Loss assessors are independent licensed professionals appointed by an insurance company to assess

the loss or damage, when a claim is notified under a policy issued by them.
Legal status under S.64UM of the Insurance

Act and Surveyors Regulations.

Surveyors role
His duties include: investigate and confirm the cause of loss. advise the insured to take good care of salvage to mitigate the loss. To ensure that insured has taken all necessary steps to contain the loss. assess the quantum of loss. Determine the liability of the insurers within the framework of the policy conditions. To act on behalf of the insurance company in disposal of salvage to realize maximum value.


Loss admissible ? Total loss ? Emotional loss?

No records or evidence - best judgement method

Grievance situations
Policy Holder refuses to co-operate or agree or interact with a surveyor for various reasons

Grievances arise - Insurer is duty bound to

intervene, mediate and sort out issues.

Grievance redressal
Many times this does not happen as Insurers are reluctant to overrule a surveyors findings on cause or quantum of loss for concern of

audit or vigilance action.

This results in a large number of grievances

moving to Adjudication or to IRDA.

Legal Status Licensed by IRDA under TPA Regulations to act as support services in the health insurance sector.

In short, the job of the TPA's is to maintain databases of policyholders and issue them

identity cards with unique identification numbers and handle all the post policy issues including claim settlements.

In terms of infrastructure, TPA's run a 24-hour toll-free number, which can be accessed from anywhere in the country.
They have full-time medical practitioners under their employment who immediately take a view

on whether the ailment is covered under the policy.

All the records of medical insurance policies of an

insurer are transferred to the TPA.

In case of a claim, policyholder has to inform TPA on

24 hr toll free line provided by the TPA.

On informing the TPA, policy holder will be directed

to a hospital where the TPA has a tied arrangement. However policyholder will have the option to join any other hospital of his choice, but in such case payment shall be on reimbursement basis.

TPA issues an authorization letter to the hospital, for the treatment.
TPA tracks the case of the insured at the hospital and TPA makes the payment to the hospital.

at the point of discharge all the bills will be sent to TPA.

TPA sends all the documents necessary for consideration of claims, along with bills to the insurer.
Insurer reimburses the TPA.

Grievance situations
Delayed pre- authorization resulting in delayed admission and treatment. Differences in interpretation of pre-existing diseases and exclusion clauses. Delay in issuance of ID cards and issuance of incorrect cards. Non submission of complete and correct documents by insurance company to TPA resulting in deficient service. Non accreditation of hospitals due to differences between hospitals and TPAS.

Grievance Redressal
Insurer must intervene and settle issue one way or the other as TPA is only an extended service arm of the Insurer. Failure to intervene results in grievances and petitions to grievance redressal authorities.

Recently, Insurers and TPAs have launched The Package Deal Pricing. As per the move, healthcare institutes are graded and package charges for various medical services and procedures have been decided as per the grade

of the healthcare institute.

The move aims to control the abnormal claims ratio

in health insurance. Since package charges are predetermined, they will act as a ceiling and prevent healthcare providers and hospitals to charge above a certain limit

News clippings
Delhi healthcare providers have found the charges

abysmally low and allege that the TPAs have threatened to withdraw cashless service from those hospitals that do not agree to the package charges.
According to them, the scheme will force them to provide sub-standard treatment and they fear that incase they dont sign the agreement, TPAs will divert their clientele to those hospitals which agree to carry out treatment at the package charges fixed by the TPAs.

Institutional voices
Says Dr Vinay Aggarwal, honorary secretary general of IMA,

TPAs do not have the expertise to accreditate healthcare institutes. Its the job of the government and rating agencies. But here, the TPAs are acting as accrediting agencies. Besides they are determining rates for hospitals.

Institutional voices
Healthcare providers argue that the treatment for two patients suffering from the same disease can

be different. For instance, if the patient is diabetic and has to undergo an appendicitis operation, a lot of care goes in management of diabetes before the surgery. Also the stay in such a case will be extended for more than two days, and so it wont be possible for a hospital to provide treatment in the pre-determined package charge of Rs 10,000 in X hospital and the treatment will be out of pocket for the patient.

View from the other side

The TPAs on the other hand feel that the cashless system has been abused to the hilt and so it is imperative to bring in

standardization and regulation in the healthcare industry. An insured patient admitted to the hospital is made to undergo an array of unnecessary tests by the hospitals thereby increasing the bill.

Says Dr Nayan Shah, managing director, Paramount Health Services, There has to be some kind of regulation in the healthcare industry. If arbitrary charging by healthcare providers is allowed, then consumers will end up paying higher premium. Can an airline charge 10 times higher because the client is wealthy? Then how can a healthcare provider/hospital charge more from the insured patient? We have decided customary and reasonable charges,

Medical and insurance costs should come down if meaningful medical coverage is to be provided to large sections of society.