Ensure insurers give consumers proper services : HC to IRDA

Written By Unknown on Kamis, 05 Maret 2015 | 22.23

MUMBAI: Bombay high court on Thursday told Insurance Regulatory and Development Authority (IRDA) to ensure that insurance companies provide proper services to consumers and not involve third party administrators (TPA) in mediclaim settlement.

TPAs act as intermediaries between hospitals, insurers and consumers.

A bench of chief justice Mohit Shah and justice B P Colabawalla heard a public interest litigation by activist Gaurang Damani highlighting the woes of mediclaim consumers and the lack of transparency in claim settlement. Damani argued that despite the Health Insurance Regulations 12(b) prohibiting them, TPAs are settling claims. He referred to IRDA's affidavit which has admitted lapses by four insurers and five TPAs.

Association of TPAs said some of its members may still be doing it but they are in the process of complying with the Regulations. "IRDA shall inform above insurers to implement regulation 12 in letter and spirit to see that decision for rejection or allowing claims are taken by the companies and not TPAs," the bench noted in its order.

General Insurance Council (GIC) which represents 25 non-life insurance companies pointed out that the Regulations state that TPAs shall communicate the decision of claim settlement. 'This is a grey area which has to be looked into as there are cases where TPAs have outsourced work. We want decision-making to be restricted only to insurance companies. It is a core activity which cannot be outsourced," said its advocate.

Damani also argued that on account of stopping of cashless claims, the overall claim settlement ratio has come down. He said data compiled by Insurance Information Bureau shows that claims ratio had dropped from nearly 100 percent to 68 percent in 2012-13.

The court directed that IIB shall inform it of the overall ratio of cashless versus non-cashless claims settled for 2013-14 and also average claim amount settled for a particular ailment between cashless and non-cashless for the same period at the next date of hearing on April 7. The bench at the previous hearing had directed IIB to be impleaded. Since it was not represented by an advocate, the bench directed IRDA to inform it along with copies of the court's orders.

http://timesofindia.indiatimes.com/followceleb.cms?alias=Mohit Shah,IRDA,Insurance Regulatory and Development Authority

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