Medical insurance to Bank employees- a farce

 A brief note placed to General secretary AIBOC for 6th October meeting with IBA

 

ISSUES FACED IN THE ADMINISTRATION OF THE MEDICAL INSURANCE POLICY

 

 

During the X Wage settlement against the existing provision of managing medical reimbursement and hospitalisation scheme managed by the respective banks, the IBA suggested new  insurance scheme for medical reimbursement.

After deliberation, a joint note was signed between the IBA and officers organisations.  

Further, on the trade unions’ specific  request, a clause to this effect on the following terms was also inserted in Joint Note dated 25.05.2015: 

“While reimbursement to the officers / employees shall be made by the Banks as hitherto, the Scheme shall be administered by the Banks through a scheme worked out between IBA/Banks and Insurance companies and officers / employees would in no way be directly bound by the terms and conditions of such scheme or arrangements.

However, for the purpose of clarity and information, the details of the Scheme worked out between IBA/Banks and insurance companies, is appended herein as Appendix I & II.”

It may be inferred from the above said paragraphs that the spirit and scope of the newly designed hospitalisation scheme are

1.    To extend better coverage for the officers and dependents.

2.    To reimburse the expenditures to the fullest extent which was having restriction hitherto.

3.    Fullest reimbursement in the case of domiciliary hospitalisation and treatment to the officers and dependents.

4.    The arrangement / agreement is between the banks and insurance companies only.

5.    The officers would  in  no  way  be  directly  bound  by  the terms and conditions of such scheme or arrangements.

6.    The purpose of the Annexure IV to the joint note is for the purpose of clarity and information only.

7.    Scheme  would  not  supersede  the  continuation  of  any  bank-level  arrangement  or scheme  providing  for  reimbursement  of  medical  expenses,  which  is  not  covered  herein,  that  may be  in operation in any  Bank.

 

 

Accordingly, a new scheme was introduced from October 2016.

HOWEVER IT WAS PRIMARILY OBJECTED BECAUSE,

1.   NO INSURANCE COMPANY WILL DO THE BUSINESS AT LOSS AND NECESSARILY THE OVERALL CLAIM SETTLED WOULD BE LESSER THAN THE PREMIUM PAID TO THE COMPANY AFTER SETTING APART A CUSHION TOWARDS PROFIT FOR THE COMPANY AND THIRD PARTY ADMINISTRATOR.

2.   THE PREMIUM ALSO NEED TO BE PAID IN ADVANCE WHICH WAS OTHERWISE BEING SETTLED OVER A PERIOD OF WHOLE YEAR BY THE BANK.

3.   EVEN AFTER PAID THE PREMIUM IN FULL IN ADVANCE WHICH WOULD BE MORE THAN THE CLAIM, THE BANKS HAVE TO INCUR ADDITIONAL AMOUNT TOWARDS BUFFER AND TO SETTLE BEYOND BUFFER TOO.

4.   EVEN IN THE INITIAL YEAR, IF THE COMPANY FACES A LOSS, IT WOULD CERTAINLY INCREASE THE PREMIUM DURING NEXT YEAR

To our utter shock, but as expected,   the demand of the premium for continuing the subject scheme for the year 2016 17  was increased beyond 110% against the agreed norms which was paid by the banks on force. 

It was totally unjustified that when the eligible claim remain unchanged, the insurance company doubled the premium.

It is an obvious attempt of earning profit by the company which is resulting in spending more money by the bank to get lesser benefit to the employees which is illogical.

It is reliably learnt that the total claim from the Insurance company is lesser than the premium paid.

During the current year, medical expenses gone up sizeably, but the total eligible claim remains same on the higher premium enhanced last year.

While premiums remains same for the retirees without domiciliary  treatment, it is increased almost four times incase of retirees with domiciliary treatment which is also unjustifiable.

ISSUES OBSERVED

A.    Mediassist insist for getting prior approval for undergoing surgery and if an employee undergoes surgery on account of serious complications and medical emergency they will not sanction the claim amount fully and reject the claim citing the reason “prior approval not obtained”.

B.    In the case of Bills submitted to the Banks for domiciliary treatment, there are many complaints of undue delay by the TPAs. There have been innumerable instances of delay in settling the domiciliary treatment claims and normally there is a delay of over 2 months in settling the claims. They always insist for copy of the medical certificate which is not older than 3 months each time along with the bills which is contrary to the terms and conditions of the settlement reached between the Trade unions and IBA.  Hitherto when the Bank was settling the domiciliary treatment claims our officers used to submit the certificate once in a year.

C.   When our officers enquire for delay in settling the claims, the stock reply is “claim is under process” and they do not give any plausible reasons for the delay.

D.   An important advantage of the Scheme is the Cashless facility available for treatment in hospitals.  But instances are coming to our attention that in many centres, many hospitals are not covered by tie-up and hence employees are asked to pay for the treatment and then seek reimbursement.  Though Mediassist insist that officers have to utilize “cashless facility” wherever it is available, many a time our officers have to pay security deposit due to inordinate delay in getting authorization from Mediassist and have to wait for several hours to get approval at the time of discharge.

E.    In case of reimbursement of claims the employees are being forced to apply to the TPA/ Insurance Company, instead of Banks reimbursing the amount and claiming back from the Insurance Company. In case of emergent hospitalisation involving huge expenses the officers are being forced to run from pillar to post for the amount beyond the sum assured and corporate buffer.  They are also being advised to wait for up to year end for the left out sum if any under corporate buffer.

RECOMMENDATION: The above issues need thorough analysis and the claims are to be settled with an intention to benefit the employees as the very scheme is a welfare scheme and any failure will affect the Interpersonal relationship in the respective banks.

F.    Crediting the approved amount inordinate delay:

 

The common issue / complaint received from the staff members is “Crediting the amount with inordinate delay”

 

It is observed that the pending claims at any point of time running to more than 20000, leading to lot of complaints from our staff members. Further, these are not the cases which have bounced back as such these are not pending on account of problem in data, like missing account numbers. 

 

Apart from the above, certain bounced back claims numbering huge are not cleared in time though the correct account numbers are furnished long back. 

 

The reason for  pendency is reported by the companies that it is due to certain issue with recent modification of IRDA guidelines, Package of Insurance Company, their Existing Bankers, etc.  

 

As per clause 27 of Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016:  An insurer shall settle or reject a claim, as may be the case, within thirty days of the receipt of the last ‘necessary’ document. 

 

The majority part of these 30 days are required for processing the claims, getting the required information, and once the claim is found to correct and approved it should not take much time for crediting the amount.  

 

It is observed that in more than 50% of the cases, the time taken after excluding the  processing the claim is more than one week upto 6 months for crediting the amount to employees account.

 

The Insurance Company is citing the reason of not furnishing dependent details, furnishing wrong account numbers as a reason for pending claims. 

 

But same is wrong. 

 

If the dependent data is not furnished then how the claim was processed, without dependents not getting added in the insurance policy the claim cannot be processed.  

 

Here the delay is happening after the claim is processed for giving the credit to the accounts staff members as such their claim of delay in submission of dependent details cannot be a reason for keeping pending the credit.

 

As regards wrong account numbers,even after 2 to 3 months of correcting the data by duly providing necessary documents also, the accounts are not credited in bounced back cases. 

 

 

RECOMMENDATION:The delay in crediting the amount needs to be plugged and concrete steps needs to be taken to resolve the issue.

 

G.   Repudiation of Claims:

 

As per the Bipartite Settlement and norms of the policy the TPA after analyzing the claims, in case come to a conclusion that same needs to rejected, has to communicate their recommendations to a Committee constituting representative of Bank, M/s K M Dastur, Insurance Company & TPA. The rejection needs to be examined by the committee.  It is mentioned that no claim would be rejected by the Insurance Company/ TPA unless the same is rejected by the said Committee.

 

Contrary to this clause of BPS/ which was agreed by the Insurance Company also, in the Insurance Policy it is mentioned that “the final decision will however be of underwrite i.e. United India Insurance Company ltd.” 

 

Even though it was pointed out, the same  is not rectified and repudiations are taking place without consulting the Committee constituted for this purpose.

 

RECOMMENDATION:Thus no claim shall be rejected without referring to the committee.

 

H.   Old Claims:

 

There are certain genuine old cases pending pertaining to the previous years’ policy.  In the majority of the cases the employees could not submit the further information sought by the TPA mainly for the following reasons:-

 

a.    Maternity cases. Where women employees who were on Maternity Leave could submit the bills after rejoining the duties only.

b.    In case of Male Employees they could not submit the bill as their wife was at parents’ house and the bills could be collected only once she joined him.

c.     During November and December 2016 the employees were fully immersed with demonetization activity. 

d.    Some are of accident cases, cases involving death of employees, etc., which are very genuine cases.

e.    The TPA had not nominated the representatives at the administrative units which had affected the smooth flow of documents/ claim papers. 

f.      The last year being the beginning of the new scheme the staff members were yet got accustomed to the new system.

 

RECOMMENDATION:The insurance company to reopen all these claims. It is expected that when the delay in thousands of cases in crediting the amount on the part of Insurance Company is observed, similar cases would be there on the part of employees.

 

I.      Issues relating to TPA:

 

The following are the issues relating to TPA:

 

a.    Rejection of the claims on the ground of “Hospitalization not warranted.”

 

It is observed that majority of claims rejected by the TPA are on the ground that “hospitalization not warranted” and citing quoting clause No.4.7 of the insurance policy. 

 

In this regard it is pertinent to note that the hospitalization of any patient would takes place as per the advice of treating doctor and not at the instance of patient. 

 

The treating doctor would be the best person to judge the requirement of hospitalization considering the situation, condition of the patient. 

 

As such rejecting the claim on the ground that hospitalization not required is not correct.  

 

Further, clause No.4.7 of insurance policy which provides exclusion clause i.e. “Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence of presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home, unless recommended by the attending doctor.”  

 

 

 

 

 

b.    Invoking Excess and Reasonableness clause:

 

The TPA/ Insurance Company are not considering the part of the claim submitted by the staff members on the ground of “Excess and Reasonableness clause” on the ground of claim exceeding PPN rates. 

Though such cases are partially repudiated cases, same are not brought to the notice of Committee set up for examining the repudiation. 

 

 C. Claims pending for Hospital Registration Certificates:

 

The following relevant clause of the BPS in this regard which the Insurance Company has agreed and in fact similar clause is also available in the policy (2.14) (but since for us BPS clause is relevant we refer the same):

 

“HOSPITAL / NURSING HOME: A Hospital under this scheme would mean any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:

 

- Has qualified nursing staff under its employment round the clock.

- Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places;

- Has qualified medical practitioner(s) in charge, round the clock;

- Has a fully equipped Operation Theatre of its own where surgical procedures are carried out;

- Maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.

 

This clause will however be relaxed in areas where it is difficult to find such hospitals. 

 

The term ' Hospital / Nursing Home ' shall not include an establishment which is a place of rest, a place for the aged, a place for drug-addicts or place for alcoholics, a hotel or a similar place.”

 

As per the above, the Insurance Company’s authorized personnel has to visit the hospital for getting such records and moreover, the above is not a mandatory clause also.  

 

 Since, here the employee has submitted all the documents of claim, keeping the claim pending and shifting the burden of collecting such information on the employee,  will not be proper legally as well as morally.  

 

We observe that a lot of claims have been kept pending for this reason for long, whereas as per BPS the verification and processing/settling of claims needs to be done within 30 days. 

 

Same needs to be settled at the earliest. 

 

Other few issues observed need rectification are

 

                     I.         Claims pending for Investigation.

                   II.         The queries/ information sought in piecemeal basis which delays the process.

                  III.         After replying queries also reminders are being sent instead of processing and settling the claim. 

                 IV.         Post hospitalization claims are pending as they are linked to cashless claims / reimbursement of main claim with reasons being main claim is pending for approval. 

 

 

ISSUES RELATED TO THE RETIREES

Basically it is wrong to treat the retired employees with indifference as far as welfare measures are concerned.

It should be inferred by any institution that the welfare measures like medical insurance is the extended benefit to the workforce beyond retirement who dedicated their entire life for such institutions and thus, such benefits should be continuing till their life time.

It is more so in extending the benefits like medical insurance to the retired workforce who are in real need of such cover.

It is indeed illogical to collect more premium from the retired employees when their income from the institution became half.

The spirit and essence of the DFS communication to the IBA and the Banks to design a suitable medical reimbursement scheme to both retired and in service, must be interpreted that it is a direction to extend such benefit to the staff till their life time.

Thus we must demand the following that

 

The premium shall be the same to the retired staff, with or without the Domiciliary treatment, as in the case of serving employees and the same shall have to be borne by the respective Banks.

Similarly the super top up facility extended by the Insurance companies must be uniform among the companies and premium & benefits must be the same for the IBA policy as they extend to outside the IBA policy.

 

MANIMARAN G V

05 10 2017