DOI: 10.5176/2251-3833_GHC17.32

Authors: Pamela N Rooplekha Jathanna, Seema Mahabal

Abstract: The Health insurance market is a fast-growing market in India, and the fastest growing segment of the overall insurance industry. Approximately 30 percent of India's total population is covered with health insurance. Despite many efforts and much progress made in recent past, there still scope to improve health insurance in India as it is facing many challenges and call effective participation of various intermediaries to solve this. The way healthcare organizations handle denials has impact on its reputation. Most organizations have work lists or queues to work denials. Fewer have comprehensive denial management programs. The study was conducted to investigate reasons for claims denial and to identify the barriers in effective claims processing. The study is an observational hospital-based study. The result showed 18{6e6090cdd558c53a8bc18225ef4499fead9160abd3419ad4f137e902b483c465} and 19{6e6090cdd558c53a8bc18225ef4499fead9160abd3419ad4f137e902b483c465} denied claims for the year 2012 and 13 respectively. The reasons being ‘treatments not covered under the policy’, ‘not eligible for cashless facility’, ‘package, preexisting condition, member not covered’, ‘sum assured exhausted’, ‘discrepancy found’ as the policy-holders did not have much awareness and knowledge of their health insurance policy. Result also indicated denial reasons varied significantly among selected insurance schemes. There is a need for strategic planning by the Regulatory bodies, intermediaries to control & bring down the denial rates and help to the consumer with awareness & rights. It is high time that Indian Healthcare providers come up with comprehensive denial management programs & policies to combat the problem.

Keywords: health insurance, India, claims, claims denial, denial types


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