IRDA- Does IRDA controls the insurance industry or is it the Consortium of Insurance Companies that uses IRDA? Especially the Health Insurance Companies on the private sector; the units under government control there seems not much of this breaking rules;

Insurance Regulatory and Development Authority[IRDA in short] was established in 1999,vide IRDA ACT 1999; The Insurance Act 1938, having become obsolete and the necessity for IRDA was now necessary with private players coming into the field of insurance – both LIFE & GENERAL[INCLDUING HEALTH SERVICES]; IRDA did not replace the Insurance Act, a point to be noted;

I have been studying the picture of the Industry[more out of interest – as I was one of the earliest employees of GIC, nascent in those days; nothing in the industry ever surprised me as all insurance companies across the globe begin in and with // insiliunt mala fide// meaning LEAP OF BAD FAITH and they believe in the very old adage //negare ius primum// meaning DENY THE CLAIM FIRST – and world over insurance companies have paid millions in court ruling penalties and yet they are profit based organizations; in India alone they escape with all kinds of atrocities and it is needless to add that our judicial system is so weak and lacks energy that by the time justice is done to the insurer it is possible that the benefits may reach the next generation or the next. Secondly the consortium of health service providers is so strong and deep rooted [after all IRDA is filled with cabals and bureaucrats] and the old boys network is too strong for an individual to take them on – in most cases the insured offers an out of court settlement and this being much smaller than the compensation that must have been paid including the penalties – the insurer having lost out in terms of energy/time/legal costs/plus jumps at the opportunity and that ends the claim,and,whatnot.

In this part of the article I will not be naming the health services companies [not out of fear but out moral stand that the insurer needs to submit his/her contentions – IRDA has not been responsive so far and neither are the two private insurers; 2 nationalized insurers promptly have answered and it is obvious that they have nothing to hide or lock it in the cupboard;

This article is more of a prelude and as time moves on more will come out and it may be possibly the biggest Pandora’s box opened out in recent times; so let us begin:-

The insured raises the claims or the reimbursement needed and invariably the claims department seeks more documents – this is their 1st trick up their sleeve; as and when the documents are submitted they officer 60 to 70% of the claims – citing various clauses which is never explained by the insurer when the policy is spoken about and premiums paid in good faith by the insurer;

If the insurer is dissatisfied he/she can approach the GRO [grievance redressal officer – who at their convenience informs the insurer that having scrutinized the case they simply state that there appeal cannot be upheld and is rejected; if the insurer is strong enough he/she approaches the OMBUDSMAN and if the insured even gets a response than he/she is blessed, indeed;

Now let us get into an interesting FACT: there is a judgment by the APEX in Citibank vs. A Mukherjee that any form that is issued for the bank for any service offered by them and /or loan/advances whatever the case may be – the font must be minimum 10 points is size and should be spaced at a minimum of 1.15 spacing – NONE FOLLOW IT AND FOR APEX THEY HAVE GIVEN THE INSTRUCITIONS AND THE MATTER OS CLOSED.

TWO important or is it THREE that will be discussed here:-

To begin with IRDA in its wisdom brought in what is called THIRD PARTY ADMINSITRATORS[TPA on short] and this is where the game begins; the TPA is appointed by the insurer – which means they are paid by the concerned insurance company and as defined a TPA must have a share capital and must be registered under the Companies Act 1950; the insurer is allowed form his own company as TPA – not a subsidiary; all private hospitals have desks for TPA’s; having stated this – apart from the card issued by the insurer the TPA issues another identity card and helps the insured [SUPPOSED TO HELP], to facilitate and ensure smooth process – the catch is – THEY CANNOT BE HELD RESPONSIBLE FOR THE INSURER DENYING THE CLAIM AND / OR CASHLESS TREATEMENT citing reasons beyond the comprehension of the insured; he/she resigns themselves to their fate; one particular definition by IRDA on TPA is that they save costs for the employer – now the definition of employer is very vague – it hastens to add, that the premium paying company if the insured is covered by the organization – it makes no sense on any reasonable count –

Now the next point that is to be touched here – is talk about INTERMEDIARY SERVICES AND/OR A BROKEARGE COMPANY accredited by IRDA – which has agents on its rolls and secure business and can handle all insurers’ accounts. The catch is they cannot act as TPA and yet they do and at least 2 companies which I have been looking into encourages this and it is evident on records –

Now the whole issue of the insurer is between the insurer and the insured – and done in good faith between the two parties – the role of TPA is not only confusing and is also a great suspect – I can name at least 2 TPA’s who use dubious methods in criminal collusion between the insurer and the hospital – in the TPA has on record advised the insurer to change the hospital; this is but a tip of the iceberg.

The insurer who needs to operate on faith is actively seeking an independent investigator[EEK] who is authorized to obtain the medical records of the insurer [ whereas he has the authority to do so as and when there is a claim – because in most cases it is the hospital that seeks sanction] .I reiterate that at this point I am not revealing the name of the 2 privately owned health services companies- they are on a deadline – somewhere these kind of nefarious and unacceptable pattern of denial of claims needs to stop.

I am only surprised at the apathy of all concerned on a serious issue like this, especially the Covid explosion.

-to be continued




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