3 min read.Updated: 06 Sep 2016, 03:22 AM ISTMunish Daga
In many cases, dependents are not enrolled in the TPA systems even though the relevant forms may have been filled in the beginning
Health insurance adoption, utilisation, and administration each pose a unique set of challenges for various stakeholders—insurance companies, third-party administrators (TPAs), regulators and government bodies, and hospitals—of the insurance ecosystem. Seamless individual processes and functions from each of the stakeholders that come together cohesively can provide customers with a health insurance cover that they can use without experiencing a financial crisis for the treatment.
Over the last decade or so, corporate group health insurance covers, offered by employers to their employees, has come to form a significant chunk of health insurance penetration in India. Under such a policy, not only is the employee covered, (depending on the policy terms) their dependents such as spouse, children and parents are also covered. The sign up process involves the employee submitting forms that contain the employee’s and her dependents’ details to the human resources (HR) department, which in turn consolidate and send the information to the insurance company or the TPA. Following this, the health insurance policy ID cards are handed over to the employee.
In most cases, corporate policies are cashless health insurance policies, wherein the patient is not required to pay upfront cash and the bill is settled between the hospital and the payer or the TPA (with a small percentage of copayment or exceptions not covered under the policy being borne by the patient). At the hospital, the claim is processed by the hospital TPA desk, which coordinates with the TPA who adjudicates the claims on behalf of the insurer to settle the insurance claim against the bill. Thus, pre-authorisation of the sum payable and patient’s eligibility are processes that rely on the information shared by the patient at the time of sign up.
In the case of a dependent, to utilise the policy, they have to be enrolled as dependents in the TPA systems. In many cases, dependents are not enrolled in the TPA systems even though the relevant forms may have been filled in the beginning. Owing to various reasons including, the use of unstructured communication channels between HR and the insurer or the TPA, this information does not flow to the TPAs. Thus, even though the employee may have filled the forms to include dependents under the employee provided cover, there can be significant delays in receiving the approvals from the TPA leading to avoidable heartburn and stress for the policyholder at the time of availing the treatment.
In such scenarios, the primary policyholder and her dependents using the policy for treatment are likely to face problems such as the ones mentioned below:
Difficulty in enrolment: To get the dependent enrolled with the TPA, the primary policyholder will have to get in touch with all parties involved—the HR team with the employer, the insurance company, and the TPA. Various rounds of back and forth involving calls and e-mails, documentation with each and response time that can go up to several hours derails the treatment and adds to the patient’s woes.
Mounting costs: As a result of the added time (and days) spent in getting the insurance procedure going, along with delays at all stages, the time spent at the hospital can potentially escalate costs or there may be a need to make a deposit to the hospital upfront due to lack of approval from the TPA. This, in turn, can add unnecessary costs to your final bill and become a financial burden that could have otherwise been avoided.
What should the primary policyholder do?
To ensure that the dependents are enrolled in the TPA systems, it is best that the employee follows up with the relevant department and the company’s HR team to get a confirmation regarding this as soon as sign-up is completed.
This will ensure that in the unfortunate situation of a medical need for any of the dependents, precious time is not lost. At the time of crisis, the primary member and her family does not have to go through a bad experience while availing cashless treatment. Taking a few precautions and being prepared for such situations can help policyholders greatly reduce the stress related to availing insurance.
While the health insurance ecosystem gears up to adopt electronic platforms, it is wise for the policyholder to take necessary precautions to ensure that this does not add to the worries and stress at the time of any hospitalisation.