annual report 2008-09 - IRDA

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ANNUAL REPORT 2008-09 The TPA industry has witnessed healthy growth as a result of the proliferation and penetration of health insurance across the country. TPAs have been receiving due recognition as valuable service providers in the health insurance services delivery chain. A large number of hospitals and nursing homes were added to the network of providers by the TPAs during the year. TABLE 39 TPA (INFRASTRUCTURE) 2008-09 Sl. Name of the TPA Hospitals added No. of offices/ Manpower, including in the branches doctors/ No. Network opened professionals added 1 Parekh Health TPA Pvt. Ltd. 1187 2 110 2 Medi Assist India TPA Pvt. Ltd. 411 9 493 3 MD India Healthcare (TPA) Services (Pvt.) Ltd. 1181 9 489 4 Paramount Health Services (TPA) Pvt. Ltd 164 0 81 5 E Meditek (TPA) Services Ltd. 321 5 87 6 Heritage Health TPA Pvt. Ltd. 422 3 43 7 Focus Healthcare Pvt. Ltd. - - - 8 Medicare TPA Services (I) Pvt. Ltd. 478 0 38 9 Family Health Plan (TPA) Ltd. 199 0 44 10 Raksha TPA Pvt. Ltd. 698 4 24 11 TTK Healthcare TPA Private Limited 763 0 9 12 Anyuta Medinet Healthcare TPA in Healthcare Pvt. Ltd. 56 2 23 13 East West Assist TPA Pvt. Ltd. 70 3 14 14 Med Save Health Care TPA Ltd. 463 6 184 15 Genins India TPA Ltd. 432 0 5 16 Alankit Health Care TPA Limited 324 8 40 17 Health India TPA Services Private Limited 329 2 29 18 Good Healthplan Ltd. 500 0 15 19 Vipul Med Corp TPA. Pvt. Ltd. 545 8 75 20 Park Mediclaim TPA Private Ltd. 216 2 18 21 Safeway TPA Services Pvt. Ltd. 382 2 15 22 Anmol Medicare TPA Ltd. 571 0 0 23 Dedicated Healthcare Services TPA (India) Pvt. Ltd. 98 2 67 24 Grand Healthcare Services TPA Private Ltd. 594 3 12 25 Rothshield Healthcare (TPA) Services Ltd. 832 4 5 26 Sri Gokulam Health Services TPA (P) Ltd. 2636 6 24 27 I Care Health Maangement & TPA Services Pvt. Ltd. 700 1 15 TOTAL 14572 81 1691 34
ANNUAL REPORT 2008-09 As intermediaries, the TPAs are expected to play a crucial role in processing health claims and other allied activities on behalf of the insurers, as the sector is witnessing growth. TABLE 40 THIRD PARTY ADMINISTRATORS - CLAIMS DATA Year Claims Within one Within 1-3 Within 3-6 More than Claims Received month months months 6 months outstanding 2007-08 1986859 1513375 302830 48908 12660 156861 (76.6) (15.24) (2.46) (0.64) (7.89) 2008-09 2446713 1847212 360173 61022 12934 185120 (75.5) (14.72) (2.50) (0.53) (7.57) Note : Figure in brackets indicates ratio (in percent) of claims settled to the total claims received. IRDA, in November 2008, constituted a Committee to evaluate the performance of TPAs. The Committee submitted its report on 1 st May 2009 and the same was disseminated on 15 th July, 2009 to the public and stakeholders for their suggestions and comments. The IRDA will take a view on the recommendations after examining the report holistically. The Committee on TPAs had meetings and interactions at various places across the country and received feedback from all stakeholders, Doctors/ hospitals, TPAs, Insurers, etc. The Committee has made recommendations under three main heads, viz. Scope of TPA activities and services, best practices and customer service issues, and Infrastructure and financial issues. The committee emphasized on the creation of a Common Health Insurance Industry Body, suggested an ideal grievance redressal matrix, and proposed adoption of standard terminology in respect of claims. The Health Industry Body is supposed to spearhead the industry’s attempts at taking Initiatives for standardization across stakeholders and especially for creating deterrents against misuse and fraud in the system. The proposed health industry body could also be a mechanism to resolve differences between insurers and TPAs, and could provide a common platform for interaction with other stake holders including hospitals. The report of the Committee has been submitted to the Authority and has been disseminated for stakeholder comments, subsequent to which it would be considered for further action. vi. Business in the rural and social sector The Authority stipulated obligations in regard to rural and social sectors to be fulfilled by insurers on an annual basis. The regulations require insurers to underwrite business based on the year of commencement of their operations. ‘For meeting these obligations the regulations further provide that if an insurance company commences operations in the second half of the financial year and is in operations for less than six months as at 31 st March of the relevant financial year, (i) no rural or social sector obligations shall be applicable for the said period and (ii) the annual obligations as indicated in the Regulations shall be reckoned from the next financial year which shall be considered as the first year of operations for the purpose of compliance. In cases where an insurance company commences operations in the first half of the financial year, the applicable obligations for the first year shall be 50 per cent of the obligations as specified in these Regulations.’ Obligations of life insurers: (a) Rural Sector Obligations: Out of the twenty one life insurers in the private sector, except HDFC Standard, all have fulfilled their obligations towards the rural sector. The number of policies underwritten by them in the rural sector as a per cent of the total policies underwritten in the year 2008-09 was as per the obligations applicable to them. 35
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