A claim delayed is a claim denied

We are living in an age when brands are differentiating and delighting consumers with 'same day product delivery' assurances. Importantly, they are coming true on these promises. This shift is much needed in the health insurance sector as well. To my mind, there are three primary reasons why health insurance needs this shift. Firstly, the speed of approvals on claims is one of the major factors defining the consumers' experience and therefore, their preference for a payer brand. Secondly, process optimisation through technology can now facilitate the delivery on such promises. Thirdly, health insurance brands are constantly looking out to create product differentiators in the market. It is important to understand each one of these further. So lets look at some perspectives.

Why speed of approvals and authorizations matter
The insurance industry has evolved from the days of reimbursement-based claim settlement by the public insurers to cashless insurers in approved hospitals. We have covered a lot of ground over the past few years, but we want to achieve more and bring greater delight to the customers. One very crucial area is the claim authorization process. A fast and speedy claims delivery will surely bring better experience for customers. And that is what the industry is aiming at.

For some time now, the health industry has been using intermediaries to bridge the gap between insurers and insured for a hassle-free claims processing, provider network and utilization review. This was simply to reduce the processing time for cashless claims. Although the approach was aimed at creating more efficiency within the system, in practice it did not achieve the effect it was set out for. To offer an effortless and prompt claims experience, we would need to continuously scrutinize the practices we embrace as an industry.

There is however an effective way of approaching this - if policy holders are adequately aware of the intricacies of their policy. There are times when policy holders face claim denials or rejection. While the rejection might seem irrational and illegitimate, a closer look might show valid cause for dismissal. The anxiety and burden of having a legitimate insurance claim delayed can make an already difficult situation, much more stressful and may lead to devastating consequences. Hence, talking to your insurer to understand the plan as well as the terms and conditions at the time of policy purchase is critical. It is hence crucial to file the claims appropriately as per the policy documents. It is beneficial for the customers to understand what makes for the cashless hospitalization, how to go about it and what is covered and not covered under the policy for cashless claims.

The time taken to settle a claim is an important factor for people seeking medical insurance policy, but claims settlement is a layered process. The more informed you are as a healthcare consumer, the better the system will work for you. It's important to understand why your insurer would want to delay a particular treatment. Consequently, an assurance on quick turnaround time may not necessarily translate into real time payment of bills. While most of the industries are focussing on express delivery, the health insurance industry needs to move beyond cumbersome and time consuming delivery mechanisms. Delivering claims need to be simple, faster and efficient.

In case of an emergency hospitalization, the case is prioritised and approved exceptionally. It is advisable that the customer notifies the insurer about the claim at the earliest. In case of an emergency, a customer is only required to give the network hospital the cashless treatment card number.

An in-house claim process, wherein the insurer communicates directly with the consumer, creates greater transparency. It can also bring in operational efficiencies through investment in technology. In-house claims process reduces TAT considerably since there is direct and clear communication between the consumer and insurer. Simply put, it resolves queries, identifies anomalies and makes decision making easier, faster and smoother.

Health insurance in a technology enabled future
Technology is ruling our lives. From finding a doctor to booking a health check-up, technology is making our lives easier and more efficient. Keeping this in mind, an important aspect of promoting faster claim authorization turn-around would be to create awareness, using technology, about how the cashless authorization process works and what is covered. For a nation with 1.3 billion strong population divided in various strata, standardisation and operational efficiencies are the key. Delivery of healthcare insurance needs to include three primary goals viz. access, cost, and quality. Leveraging emerging technology, to achieve these objectives, will play a disruptive role in the healthcare transformation ahead. That indeed will define the milestones of our success story.

Having a system, which eventually falls through because of lack of customer awareness would be a shame. The key would therefore be to advance technology and convenience alongside customer education. Customers also need to be prudent, know more, and take informed decisions. As the saying goes, knowledge is power.

The writer is chief operations officer and chief quality officer, Max Bupa Health Insurance