Are they supporting each other Or are they fighting with each other?

Recently we came across a news item that 64% of the cases which came up before Insurance Ombudsman (located all over the India) was pertaining to health insurance portfolio. Let us look at the facts;

Health Insurance as % of non life insurance portfolio = 32%
Group policies issued under Health Insurance portfolio = 50%
Policies issued to Individual/ Families = 50%

It means policies being issued to Individuals/ Families are only 16% of total non life insurance portfolio.

General impression is that claims arising from group policy get paid because they have the bargaining /negotiating power .It means that Individuals/ Families are the worst sufferers as this is the group which is having claims being disallowed.

The question before us is how many of the dissatisfied customers are able to reach the office of Insurance Ombudsman?

64% figure is really a very high figure .Let us try to look at the reasons for this scenario or why it is so?

There are 3 players.

Role of every player is to provide good service to the customer. When the insured has to go in for hospitalization then each one ( Insurance Company /TPA/Health care Provider ) is trying to pass on the buck to other player as if the objective or job description of each one is who can harass the customer most so that he runs away and forgets about claim .
Health care provider says that this insurance company is blacklisted or this TPA is black listed

TPA says that this health care provider is black listed.

Insurance Company says that they are ready to consider the payment of the claim but it will not be on cashless but on reimbursement basis. This defeats the basic assumption of the client that when the need arises he will be able to have payment coming from insurance company.

We need the change in thinking at all levels.