Dear Editor,
I happened to read Sri Gangaraju's post in LIC PC regarding the deficiency in our medical scheme which due to delay in procedural entanglement ended with the sad demise of a senior pensioner from Hyderabad. The reading of the post was heartrending and I was wondering whether our group medical scheme has been properly administered. The medical scheme per se may be good but the utility can be judged only by the outcome of execution.
The central theme of Sri Gangaraju's post, if I have understood correctly, is about the issues involved in examining the roles played by the parties to the scheme. As I see there are four parties having some involvement in the proper execution of the scheme. They are, LIC, New India Assurance Co., TPA appointed by New India Assurance Co., and the Member(in our context the pensioner who has joined the mediclaim policy).
What are the roles played by each of the above parties? LIC and New India Assurance have negotiated and agreed to extend certain hospitalization facilities through a group mediclaim plan. LIC is a channelising agent for remitting the premium after collecting the same from the participating members apart from routing the claim documents to the insurer/TPA. New India Assurance Co. is to appoint a TPA, which I believe has been done by the Insurer. The last party is, member (in our case those pensioners who have opted to join the scheme). The scheme provides for limited cashless facility for getting medical treatment without requiring the member to pay upfront the hospital deposit for getting admitted to the designated hospital for treatment.The TPA is supposed to issue an identity card to the member to avail of this facility. What is expected of the member is at least to know the group policy no. and some identification details (in the absence of ID card issued by the TPA).
From the reading of Sri Gangaraju's post it appears that a senior pensioner had an emergency requiring hospitalisation. Unfortunately the hospital could not admit him in the absence of the required documents for extending cashless facility. Though some efforts were made to get the required documents from the relevant authorities, there was delay in obtaining the same.
Unfortunately in the meantime the pensioner passed away. The hospital insisted on the family members of the deceased pensioner to settle the bill for completing the formalities.
This raises a few fundamental issues. What are the roles (responsibility/accountability) of the parties to our medical insurance scheme?
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| Mediclaim cashless service. |
- LIC -- As a master policy holder is it not necessary for LIC to inform each participating member about the broad features of the scheme including the policy details, member identification details etc. by way of certificate of membership? In the absence of the above, is LIC not indirectly responsible for ensuring that all the participating members are issued with an ID card, at least for availing cashless treatment facility?
- New India Insurance Co. (insurer) -- As an insurer it has to do all those acts for proper administration of the policy. I feel that as part of this responsibility it has also to ensure that all the members of the mediclaim policy are issued with ID card by the TPA. It appears that there is no machinery in place to furnish details of the membership to the enquiring parties through a 24/7 customer care centre (In today's environment many organisations are making use of latest available technology to meet contingencies such as emergency hospitalisation).
- TPA - Though sufficient time has elapsed since the introduction of the group medical scheme, I wonder whether members are issued with ID cards for availing cashless hospitalisation facility. TPAs can also set up suitable machinery to respond to emergency calls from the participating members.
- Participating pensioners -- At least what they can do is to obtain a certificate of participation from the office from where they are drawing pension so that they will have some document to show to the hospital authorities for extending cashless hospitalisation facility.
If you feel it is a print-worthy matter for posting in LIC PC, you may do so exercising editorial prerogative.
Regards
T K S Narayanan