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ANNUAL REPORT 2007-08

Box Item 3

HEALTH INSURANCE: INITIATIVES

In October 2007, the Confederation of Indian Industry organized its first Health Insurance Summit in Mumbai, and the deliberations in the summit made it clear that there were several issues in the health insurance domain that required greater deliberation, efforts and initiatives by the industry bodies, regulator and the government. IRDA actively supported CII in the constitution of four working groups to go into further details of pertinent issues surrounding health insurance data, providers’ and payor standards and health insurance awareness and communication. These groups comprised of IRDA and CII representatives, insurers, providers, TPAs, actuaries, IT companies, international development agencies and other stakeholders in the health insurance eco-system, and after several months of deliberations, within the group and with other stakeholders outside these groups, presented their key recommendations in a conference in Mumbai

held in May 2008.

The Data Standards group was constituted with the objective of suggesting mechanisms for streamlining and development of health insurance data repository and mechanisms for information exchange among stakeholders. The group concluded that the existing data with IRDA is of sufficient quality and is amenable for extensive data analysis and helps in critical business intelligence which can strengthen and further the growth by providing a scientific rationale for most business decisions. The group suggested that data submitted to the repository should be regularly analyzed under the guidance of a group of experts. It also suggested that IRDA can make available the results of the detailed analysis in the public domain. The data collection system should be extended to cover all insurers (both life and general) selling health products. IRDA should maintain the data repository and ensure compliance of data submission by the insurers and TPAs as per the regulatory provisions. The group recommended that a mechanism may be evolved to facilitate submission of information by the hospitals and health providers to the repository, so that data on the uninsured population is also

available which will strengthen the information base on morbidity.

A common standard claims format could be introduced for submitting health insurance claims which will not only facilitate capturing of required information but also in quick settlement of claims. Standardized coding of diagnosis (using ICD-10 codes) and procedures (using ICD 9 PCS codes) must be strengthened. This will require continuous training of data entry operators,

underwriters and claim settlement officers of insurance companies and TPAs. A simple drop-down ICD 10 coding tool to assist in training the staff of insurers / TPAs in easy assignment of diagnosis codes was developed by the group and has been hosted on the IRDA website. Insurers and TPA’s should be required to demonstrate their IT capabilities for data compilation and submission. The group suggested that IRDA may mandate Health Insurance as a separate line of business by the insurance companies, so that Health Insurance gets a better focus and generates better quality data and facilitates scientific underwriting. Health insurance should be a focus point for IRDA. IRDA should strengthen the health department and consider a separate self regulatory organization like a Health Insurance Council. The group also suggested that a sample of records could be put on the IRDA website for analysts / researchers.

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