Sucheta Dalal :The TPA-doctor spat continues
Sucheta Dalal

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The TPA-doctor spat continues  

April 30, 2010

The issues over administration of cashless facilities provided by insurers for hospitalisation between city-based doctors and third-party administrators (TPAs) who facilitate medical insurance, have yet to be resolved. Policyholders will have to wait a little longer to gain more clarity on these issues, as both TPAs and the medical community have still not come up with any concrete provisions.


According to the Association of Medical Consultants (AMC), TPAs have been giving out impractical ideas for implementation, while TPAs claim that doctors are being stubborn.


In March, miffed over low rates and unpaid dues from TPAs, about 1,500 nursing homes and various doctors under the AMC banner had decided to boycott TPAs completely. This drastic measure meant that patients in hospitals covered by these TPAs could not avail of cashless facilities.


“Talks (between TPAs and doctors) will still take time and with TPAs not giving us anything to go with, one can’t predict how long would these talks take to conclude,” says Sudhir Nayak, honorary secretary, AMC. 


According to Mr Nayak, TPAs are trying to push discount offers based on the number of patients admitted to a hospital and a policy of ‘best-preferred’ hospitals. Both these TPA schemes have been rejected by doctors. According to the discount offer policy being pushed by TPAs, hospitals would get a 10% concession if they were to provide Rs10 lakh of business; the best-preferred hospitals scheme will see TPAs choosing 50 hospitals for working with them.


“How can you ask hospitals and doctors such things? We can’t provide them such business on a regular basis. It won’t be fair on the profession. And the best-preferred hospitals scheme will definitely not go down well with nursing homes. Only those who have good relations with TPAs will be on the list,” says Mr Nayak. He also adds that this scheme is not feasible.


However, Dr Nayan Shah, managing director, Paramount Health Service, says that these policies are being preferred by some hospitals. “It’s a business and some hospitals are looking for some kind of concessions. It all depends on the hospital,” he said.


However, Mr Nayak also argues that TPAs have been misinforming their customers and payments have not been coming on time.


In the midst of this, corporate health insurance is become an expensive business for insurers. Premiums have shot up, but claims are also going up. Many industry experts believe that health insurance companies are in a lose-lose situation.


“The claims ratio in the corporate group health insurance segment is over 100% in most cases,” said Balaji C, Bharti AXA’s head of underwriting.


He also added that insurance companies are trying to manage the cost of claims, putting in place better customer service and opting for in-house TPAs. Private insurance companies like ICICI Lombard and Bajaj Allianz have done away with TPAs. By the end of this year, Future Generali will have its own in-house team to service health policies, instead of making customers deal with TPAs for facilitating medical insurance payouts.


“TPAs have not been able to live up to the service standards that had been expected from them when they were introduced. For us, as an insurer, it would be better if we have our own team which can interact both with the customers and hospitals directly, to ensure that our clients are getting prompt service,” KG Krishnamoorthy Rao, Future Generali India’s managing director and chief operating officer, had earlier told Moneylife.— Aaron Rodrigues

-- Sucheta Dalal