Insurer-hospital panel may resolve claim disputes

Insurers and hospitals are reportedly nearing an agreement that could address claim disputes. The General Insurance Council issued guidelines in July recommending outpatient care for uncomplicated fever and infectious diseases, with hospitalisation reserved for patients showing persistent high fever, dehydration, or organ dysfunction. However, hospitals worry insurers might use the advisory to deny claims without explicit mention of these red flags.

The council's Dr S. Prakash discussed broader issues affecting policyholders, including claim settlement and premium hikes. Over the past five months, they have held regular roundtable advisories with major hospital associations, insurance companies, and industry bodies. These discussions have fostered collaboration to resolve challenges impacting policyholders.

Key points of friction have included the need for a structured payer-provider grievance redressal framework, strengthening the common empanelment framework, and greater standardisation in treatment workflows. Insurer-hospital disputes over cashless claims persist, with hospitals alleging that insurers reject claims arbitrarily and question the treating doctors' judgment.

The council has proposed creating a Medical Advisory Panel of experts from different specialties to provide clinical inputs. Hospitals are urged to adopt standardised tariffs, clearer billing, stronger Hospital Management Information Systems, and better data capture and monitoring of patient outcomes. Premium hikes are attributed to rising healthcare costs and medical inflation, but premiums are determined by factors like claims experience, incurred claims ratio, actuarial assessment, and overall product performance.