Reliance General Insurance Corporation Ltd. (RGICL) has won a favourable order from the National Grievances Redressal Committee (NGRC) under the National Health Agency, that it is under no obligation to honour those medical reimbursement claims under the State government’s Karunya Arogya Suraksha Padhati (KASP)-Ayushman Bharat, which were raised well beyond the timeline for claims adjudication.
A total of 463 pending KASP claims of 2019 of empanelled public and private hospitals, amounting to ₹46,37,886, will not be honoured by the insurance company any more.
In all these years of running health insurance schemes, this is the first time that the State has lost a case with the NGRC, it is pointed out.
The State Grievances Redressal Committee (SGRC) had earlier directed the RGICL to pay up the reimbursement claims, raised by 12 empanelled hospitals in various districts. Software glitches had prevented them from submitting the claims on time was the argument raised by the hospitals.
It is this order of the SGRC which has been set aside by the NGRC.
Of the 463 claims, 407 claims were rejected citing delay in submission. Of these, 137 claims amounting to ₹8,85,325 are of public sector hospitals and 270 claims amounting to ₹33,32,561 were submitted by private hospitals. Another 56 claims worth ₹4,20,000 had been submitted by Ahalia Foundation Eye Hospital, which the RGICL had rejected citing document manipulation.
Violation of contract terms
The RGICL submitted before the NGRC that the delay in claims submission and pre-authorisation by hospitals and the alleged manipulation of documents were violations of the contract executed between the insurance company and the State Health Agency (SHA) and the guidelines of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABPMJAY).
According to the agreement executed between the SHA and the RGICL, the turnaround time laid down for submission of claims by hospitals to insurance companies is 24 hours while pre-authorisations had to be submitted within five days of the patient’s admission.
Following the request of the SHA, public hospitals were given relaxation in the turnaround time for claim submission by 15 days, yet they failed to raise claims on time.
The SHA representative’s argument that software issues had resulted in the delay in raising claims was not accepted by the NGRC, which pointed out that during the same period, the hospitals had submitted other claims using the same software
The NGRC also accepted the insurance company’s argument that it had sent several reminders to the SHA and the hospitals that the turnaround time mentioned in the contract with the SHA had to be adhered to.
The NGRC agreed that the claims were genuine but that consistent violations of contractual terms and the ABPMJAY guidelines by hospitals could not be overlooked and hence the RGCIL was not under obligation to honour the said claims.
This favourable verdict won by the insurance company from the NGRC will set a precedent because there are thousands of old pending claims with public hospitals, all of which may suffer a similar fate. The NGRC has stated clearly that the insurance company was only following the contractual terms where as the public hospitals were consistently violating the agreement.
Sources at the Health Department point out that improper documentation, inefficiency in filing claims properly and lack of follow-up on rejected claims has been a perpetual issue with many public hospitals.
The Thiruvananthapuram Medical College Hospital had reimbursement claims worth ₹31 crore during 2017-18 and ₹19 crore in 2018-19, which were rejected by the insurance company. The District Grievances Redressal Committee had, after over 40 sittings, given up the verification process because most of these claims were not backed up by proper documentation.
“Most of the public hospitals have employed scores of people just to handle insurance claims but none is accountable for this loss of public money. No action has ever been taken against anyone for not initiating claims within the stipulated timeline. The government never made any attempt to rectify these issues,” sources pointed out.