Dr. Nayan Shah (M.D., D.M.R.D.,M.B.B.S.,) is a Founder & Managing Director of Paramount Health Group, is an experienced and astute Healthcare & Technology professional with exposure of working in challenging and high growth environments.  He has been pioneer in bringing concepts of Third Party Administration in India and various innovations in Health Insurance products.   He has a 360° experience in Healthcare being a Physician, having constructed and run tertiary care hospitals and having a long stint in Health Insurance and TPA Industry.

Q.1 What are the challenges you have faced in the last 4 months?

The Challenges which were faced by most of the TPAs including us, there are mainly two types (1) due to lock down lot of employees could not travel to the office and we have to resort to work from home. The connectivity with our main system was provided to employees who are working from home and it took couple of days for the new system to stabilized.

Certain activities like investigation of the cases and visits to the hospitals could not happened. This was informed to all the insurance companies and also the Regulators and everyone cooperated and all TPAs are doing telephonic verification.

Initially, there are lot of queries regarding Covid coverage and also in case if the admissions are required where should one go. The depending on the states there were different rules and as a TPA, we have to collect data from every place.  The Covid protocols also kept on changing and we had to keep abreast with them.

When the admission started in private hospitals, we had to organize admission for Covid patients who wanted to go private hospitals and not to Government pathalic, therefore, we needed to know where are the beds for Covid cases available and also which are the Covid centers approved by Government. Initially, the Covid billings were very high till the Government and GI Council came up with certain recommendations.  

The PPE kits usages was also not consistence amongst various hospitals and even the insurers were not clear what would be reasonable and customized. As a TPA we had to negotiate with hospitals for reasonable use of consumables. Though, therefore in initial days the insurers would allow a certain amount for coverage of consumables only which created some confusion amongst the policy holders. However, subsequently when GI Council guideline and the Government guideline came up the payment of treatment become very transparent. 

There were other small challenges like non availability of travel, meeting with insurers not taking place, visit to hospitals not happening etc however the above mentioned challenges are unique and TPAs being on the front line had to deal with them and overcome the same.

Q.2   What are the challenges you assume for the next 8 months?

Going forward opening of office, keeping safe distance between employees, allowing percentage employees work from home, frequent sanitization per day and appropriate checking of employees, checking of visitors who come to deliver the documents etc is going to be there till the vaccine or full proof treatment for Covid 19 is not found. Also, providing of Covid coverage if it is not in the Group policy of TPAs will need to be done.  

We also expect that the old cases of surgery like Cataract, or  noncomplicated Hernia, Hydrocele, who want to get operated once the situation become normal and we may see higher incidence of such cases after normalization of the situation. 

Q.3.     How many Covid-related death claims has the company received so far and how many have been paid.

Data as on : 13/08/2020

Insurance_co	Reported Cases	Paid Cases	Death Cases	Paid Death Cases
The New India Assurance Company Ltd.	1255	550	32	18
United India Insurance Company Ltd.	1087	313	36	13
The Oriental Insurance Company Ltd.	936	477	58	22
National Insurance Company Ltd.	929	351	33	10
Sbi General Insurance Company Ltd.	557	253	14	8
Iffco Tokio General Insurance Company Ltd.	458	207	19	13
Royal Sundaram General Insurance Co Ltd	183	18	4	3
Icici Lombard	79	43	2	1
Bharti Axa	67	19	3	2
Tata Aig General Insurance Company Ltd.	63	22	1	0
Aditya Birla Health Insurance Company Limited	48	27	2	2
Liberty General Insurance Company Limited	39	15	3	0
Self-Funded	39	0
Hdfc Life Insurance Company Limited	30	12	6	3
Edelweiss General Insurance Company Limited	27	8
Cholamandalam General Insurance Co Ltd	21	8
Reliance General Insurance Co. Ltd	19	11
Navi General Insurance Ltd	17	9	1	1
Bajaj Allianz	7	2
Go Digit General Insurance Ltd.	7	2
Manipalcigna Health Insurance Company Limited	5	1
Religare Health Insurance Company Limited	5	0
Magma Hdi General Insurance Company Limited	4	0
Universal Sompo General Insurance Company Ltd.	4	2
Hdfc Ergo Health Insurance Ltd.	1	0
Kotak Mahindra General Insurance Co. Ltd.	1	0
Grand Total	5888	2350	214	96

Some cases are under process and in some, we are awaiting case files from providers.

Q.4.  The IRDAI circular which is being widely published by the media you think will hamper the business and image of a TPA.

We have checked with Association of TPAs and another colleague TPAs, they are not aware of any such circular by IRDAI. However, the new IRDAI Regulation have come out some time back are very clear.  The insurance contract it between the insurance company and the policy holder therefore, the amount of reimbursement or direct payment to the hospital have to be done by the insurance company and the amount paid have to be approved by them only. This is as per the contract and the legal provision in the country.  Therefore, the Regulation allow the insurance company to outsource claim processing activities to the TPA and the TPA after completing the process will upload the payable amount with the insurance company.  This is check by the insurance company and then the payment is affected. Therefore, please understand that there is no such Circular or no new Rule which have come out from IRDAI.  This is a different intersession by someone who had no real understanding of TPA activities and the new Regulation of IRDAI. 

Q.5   What future do you see for TPA.

The TPA do the back-office work for insurance company established all over the world that outsourcing by insurance company always first then do inhouse. The over heads and the salaries for manpower is always higher for insurance companies and TPAs.  If, you look at the world scenario you will find TPAs everywhere.  In India, what we force is that going forward we may see some conciliation in the sector. The Government also are going for self-funding for their Mass policies, all these will have to be done by the TPAs. We in India feel that the top TPAs will survive and their margin may be compromised to a certain extend.  However, the smaller TPAs may have to think of consolidation or selling out.When India comes out with Comprehensive Care Plan which will include OPD, Diagnostic, Disease Management Program, Old Age Care etc., the volume of claims will increase.  For insurance company to manage high volume slow ticket play would again be very expensive. Once again, the TPAs will come in forefront.The Wellness activities, personal touch with clients cannot be provided by insurance companies and all these will again be left to the TPA.  We therefore, see that TPAs are there to say.

Q.6    What will be the bad side effects of the circular? 

Since there is no Circular and it just mentioned  interpretation of the Regulation we do not see any side effects to the TPA Industry.

                                                                                   

                  

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