annual report 2008-09 - IRDA

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.
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