Published: Aug 29, 2023 at 07:04:58 pm
, Even if some of the guilty escape the law despite having committed a crime, it should be the endeavor of the insurance industry to ensure that no valid claim is repudiated, in line with the principle of ‘no innocent being punished’. Insurance service providers should focus on plugging loopholes by scanning all aspects and on continuous training of personnel involved in the claims settlement process.
Questions on the functioning of health insurance companies
R. Of. Vijay, who has been Deputy General Manager at National Insurance Company Limited, Rajasthan’s Insurance Ombudsman recently said in an interview that 60 per cent of the complaints he receives are related to health insurance. In 91% of these complaints, the decision is in favor of the insured. According to him, this process can take a maximum of one month. This is important information. Due to this, while the insured will be more inclined towards this platform for redressal of complaints, there will be a need for introspection on the part of the insurance service providers. What is noteworthy is the practice of insurance companies, including third party administrators (TPAs), who do claim processing, that up to 91 per cent of rejected health insurance claims are found by the ombudsman to be payable? This is a mirror for insurance companies. In fact, insurance personnel are taught that it is more difficult to reject a claim than to accept it. He should, before rejecting any claim, examine the grounds of cancellation thoroughly from all angles and satisfy himself that the cancellation will be justified in any legal investigation subject to the terms of the policy. Not only this, formal notice should be given to the insured explaining the grounds of cancellation. As far as possible, this should also be done in person. In this process it is necessary to patiently understand and examine the side of the insured. Obviously, this is the result of neglecting to follow this lesson. According to the Annual Report 2021-22 of the Insurance Ombudsman Council, a total of 19,470 complaints related to health insurance were received by all the insurance ombudsmen of the country in the year. Disputes related to this in consumer forums are different. In the same year, insurance companies had paid about Rs 69,498 crore towards payment of about 2.19 crore health insurance claims, while rejected 16.37 lakh claims worth about Rs 9,070 crore.