Standardisation of cost and treatment protocols for various diseases, such as diabetes and cataract, would go a long way in resolving differences between private hospitals and insurance companies over
medical claims , according to a report on health insurance in India compiled by apex business chamber the Federation of Indian Chambers of Commerce and Industry (FICCI).
The FICCI team members said that they had prepared a list of "standardised treatment protocols and cost indicators" for 20 diseases and were in touch with the health ministry and Insurance Regulatory Development Authority ( IRDA) on the issue.
The list will be submitted to the health ministry in the next four to six weeks.
Health ministry officials along with a team of the country's leading medical specialists are then expected to deliberate on the issue and draw up a standard template. This is expected to enable private hospitals and health insurance companies to settle medical claims bills in a fair and quicker manner so that policyholders do not lose out.
However, the Ficci team admits that finalising the standardised protocol is not an easy task as both diseases and their treatment can be quite complex and could vary from one individual case to another. The report states that the medical fraternity led by the Medical Council of India (MCI) needs to be encouraged to agree to standard treatment protocols with cost indications.
"All healthcare providers would need certification from the National Accreditation Board for Hospital and Healthcare Providers, National Accreditation Board for Testing and Calibration Laboratories and similar accrediting agencies for being empanelled," the report adds.
The report released on Friday observes that the health insurance industry has various stakeholders, such as healthcare service providers, insurance companies, consumers, regulators and policymakers whose interests may conflict with each other.
"The turbulence the health industry is currently experiencing in the matter of the role of Third Party Administrators ( TPAs) in managing cashless facility for policyholders is just one evidence of such complexities and challenges," the report admits.
According to the report, the insurers are wary of rising claims and believe that not all of them are genuine. The TPAs feel that the system does not reward them with a firm return on investment ( RoI) and on their effort. The consumers are angry about poor service and delay in claim settlement.
Around 14 crore people in urban areas are still outside the ambit of health insurance and can be brought in with suitable government policies and initiatives by the insurance companies. Only 4.2 per cent of the Indian population is currently covered by health insurance and this includes the rural poor that have been brought under government health insurance schemes.
The study notes that the IRDA can create a positive growth environment if it legitimises and encourages additional sales channels to serve consumers.
The report is in favour of widening the portability scheme which will be allowed for individuals from July 1 to group medical policies in order to ensure continuity of the cover when people change jobs.
It is necessary to introduce portability in group health insurance products to cater to the needs of people when they switch jobs, are laid- off or attain superannuation, the study adds.
Special 
