Matching Global Health Insurance Standards

Digitisation is a necessity as technology advances itself globally. It can be used to better service delivery and create better product designs, claims procedures and whatnot, to make the lives of our customers easier

The insurance sector in India stretches back to the early 1800s and has evolved with increased openness and an emphasis on policyholder protection. When it comes to drafting rules and regulations, the IRDA plays a critical role in emphasising the importance of policyholders and their interests. 

The following are some of the IRDAI's key responsibilities

To safeguard the interests of the insured.

To assist in the orderly growth of the insurance business for the benefit of the general public.

To give long-term financing to help the country's economy grow faster.

Promoting, establishing, enforcing, and monitoring high standards of integrity, fair dealing, financial soundness, and insurance provider competence.

To ensure that legitimate claims are resolved quickly and efficiently.

The IRDA has established a grievance redress forum to protect policyholders from malpractice and fraud.

To encourage the financial markets to conduct insurance in a transparent, fair, and methodical manner.

To create a dependable management system that ensures insurers adhere to strong financial stability norms.

When such high standards are not met, appropriate action must be taken.

To ensure that the industry has the maximum level of self-regulation possible.

Role of TPAs in enabling the smooth functioning of the health insurance sector.

Claim processing and seamless integrations with the Insurer for better service/customer experience.

A TPA is in charge of processing a health insurance claim as soon as the policyholder informs them. TPAs can choose to develop their own services to ensure that services are delivered consistently. Their duty also includes checking all of the policyholder's documentation properly and carefully, as well as obtaining as much information as possible.

These claims may be cashless or reimbursed. In the former situation, the TPA can obtain the paperwork directly from the hospital. The TPA requests the policyholder's supporting documentation and bills in the latter scenario.

Extend value-added services or improvise the existent for the policyholder.

Aside from claim processing, a TPA is also responsible for informing policyholders about health insurance and improving services to ensure smooth service delivery. They also arrange for other services that a customer may require, such as ambulances, emergency assistance and well-being programs.

Issue health cards/ecards to the policyholder and their dependents

Each insurance that TPA issues to a policyholder must be validated by the TPA. The method is carried out by providing health cards/ecards that contain information about the policyholder, dependents, the TPA in charge of claim processing and the policy number. A policyholder can present these cards to the hospital's insurance desk at the time of admission, ensuring that the TPA or insurer is informed to be prepared.

Provide dedicated helplines for policyholders to reach out to

All policyholders should be able to get information and help with their claims. A TPA is responsible for establishing helplines through which policyholders can contact them by phone or email. Customers should have access to this feature 24 hours a day, seven days a week and it must be available throughout India.

Have a strong hospital network and nurture existing providers

The TPA will have a list of network providers, and they will continue to try to enlist more hospitals across the country that can swiftly arrange for cashless payments at agreed rates, which will benefit the policyholder.

Future trends in health insurance and the role of TPAs


- To better serve their consumers, health insurers have been rapidly developing digital capabilities across functions.

- We may expect to see more aggressive use of technologies like AI and ML in the future, which will aid in the reshaping of product designs, claims procedures, underwriting, and distribution, resulting in a greater connection with clients.

- We've put a lot of money into improving our digital skills across the board at Medi Assist. We've upgraded our self-serving digital capabilities and digitised our underwriting and risk assessment processes.

- In FY-22, over 81 per cent of cashless claims were submitted online. Furthermore, the advanced technology enables members to preauthorise cashless hospitalisation approvals in under 45 minutes on average.

- To facilitate automated claims adjudication, we've implemented AI and machine learning capabilities. 

- More than 20 per cent of our entire claim volume is processed through the automated channel with a processing time of fewer than 10 minutes.

Product innovation

- Product innovation will be critical in meeting the diverse needs of various client segments.

- Other age groups are more inclined to select comprehensive products that cover a wide range of conditions, whereas GenZ is more likely to focus on bite-sized items.

- According to trends, people are also opting for products with a more extensive sum insured that is adequate, given the rising expense of medical care.

- Customers also want insurance products that are easy to understand.

Extended coverage for the missing middle

According to a recent Niti Aayog report, while the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and State government extension schemes provide comprehensive hospitalisation coverage to the bottom half of the population – around 70 crore people – another 20 per cent of the population or 25 crore people, are covered by social health insurance and private voluntary health insurance.

The remaining 30 per cent of the population, known as the 'missing middle,' is without health insurance. In rural areas, this segment mostly consists of the self-employed (agricultural and non-agriculture) informal sector, while in urban areas, it consists of a wide range of jobs – informal, semi-formal and formal.

The existing Ayushman Bharat infrastructure can be used to provide coverage to the uninsured middle class.

Digitisation is a necessity as technology advances itself globally. It can be used to better service delivery and create better product designs, claims procedures and whatnot, to make the lives of our customers easier. Product Innovation is imperative to serve a larger customer base, including the late Millennials and GenZers, who look at simpler ways to consume technology. Moreover, the missing middle needs better representation and reach in terms of technology consumption and availability of health insurance.


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