Health Claim Settlement process today is highly manual and needs manual checks from various industry participants. This results in delays in processing of claims, errors and omissions. One part of the checks are related to establishing the authenticity of the claim – checking the validity of the policy, verifying documents, judging the medical necessity for the procedure / treatment. The other and an important part is the application of rules, terms and conditions that are laid out in the Health Insurance Policy.
Simply put, the basic verification that is needed to authorize or settle a claim is applying the rules that are provided in the Policy in an unambiguous and consistent manner. This can be achieved if the Policy’s rules are digitized and are readable by a software application. In the context of claims settlement, a Claims adjudication software needs access to a service that immediately runs the data related to the claim through multiple rules written in the policy and immediately gives
- Its assessment on the admissibility of the claim, and
- The limit of amount that can be covered for the particular case
How complex are Health Insurance Policies?
At a high level, Insurers define multiple products for Individuals and families. Individual Policy, Family Floater Policy are terms you would have heard if you have purchased Health Insurance Policies.
The complexity goes to the next level for Corporate Policies. Corporates negotiate terms and conditions and pricing with the Health Insurance Companies and offer Health Insurance as benefits to their employees. These Corporate Policies increase the complexity in terms of varieties of exclusions, waiting periods, varying degrees of coverage to the families of the employees, varying coverages / limits to the employees on the basis of their designation, tenure etc.
Consider some example Policy rules below:
- Policy A, which is an individual policy excludes Plastic surgery unless the surgery is required for medical reasons / accident.
- Policy B which is a Corporate Policy provides maternity cover for the employees but limits the amount to Rs 70,000. However, any complications during maternity are covered upto the Sum Insured.
- Policy C which is a Corporate Policy covers upto Rs 7 Lakhs, but in case of a new employee (first year of employment), the parents of the employee have coverage only upto Rs 2 lakhs.
The above are just a few examples which help us establish the need for a digitized policy which can be accessed during Claims process. Also, having a language gives the Insurers the flexibility to keep evolving these rules as per Business needs with a guarantee that the Claims follow the rules specified seamlessly.
Health claims in an ideal Healthcare ecosystem
An ideal Healthcare ecosystem would integrate the whole journey of the patient / policyholder and ensure transparency and consistency in the claims settlement. Key ingredients to the transparency and consistency are the objective definition of policy rules, terms & conditions and objective application of these rules in real-time.