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A study on the claim trend analysis of corporates in Noida being serviced by Vipul Medcorp TPA Private Limited and developing claim control methods for cost containment of the organization


  • Manisha Singh
  • Agency : Claim Trend Analysis, Claim Control Methods, cost Containment
  • Objective : This study is an attempt to understand the diseases for which most of the hospitalization takes place in corporates of Noida and the preferred hospital of the employees so that an initiative could be taken to establish a preferred   provider   network   where   a   discounted   and package rates for the treatment can be availed for the corporate clients thereby decreasing the cost of healthcare. This would also reduce the risk of fraud claims. The claim pattern trend with respect to the terms and conditions of the group mediclaim policy of the corporate has also been studied so that the principle of excess clause or co payment can be brought into picture to bring down the claims ratio of corporates by directly controlling the claims.
  • Background : Not Available
  • Methodology : On the basis of primary data collected through questionnaire and the interview with the personnel engaged in looking after the mediclaim policy of the corporate and the secondary data from the MIS analysis was done.
  • Findings : The analysis of the data shows that the corporate policy where parents are also insured, claims of age related disorders like cataract also increases. A study has shown that the lens used in the cataract worth Rs. 8000 is as effective and efficient as a 15,000 lens. But since the insured has a mediclaim policy moral hazard comes into picture and he goes for the treatment at a tertiary care hospital   and   the   cost   shoots   significantly.   that   the maternity benefit is availed by the maximum employees of the corporates. Even though the limit for maternity (normal delivery + LSCS) is explicit in the policy, the variation in the claimed amount is significant in case of cashless and reimbursement.  13 out of 15 corporates said that there claims ratio has been increasing down the years. The two corporates managed to stabilize their claims ratio by understanding the root cause of their claims. They introduced cab facilities for their employees to bring down their accidental claims. Insurers play a passive role, providing fairly standard insurance products, processing claims, and adjusting premiums to maintain acceptable profit argins. Physicians generally are insensitive to the costs of care at different hospitals, because fee-for-service insurance coverage insulates both them and their patients from these costs.
  • Recommendations : Employees should be advised to go to tertiary care hospitals only in case of advanced surgeries. Surgeries like cataract, hernia, Hydrocele, appendicectomy etc. need not require tertiary care hospitals. Photograph of the employee and there dependant should be made compulsory  on  the  Vipul  I.D  card.  Accidental  claims should be encouraged to be reimbursed from Personal accidental policy not from group mediclaim policy. Compulsory  induction  programme  for  mediclaim awareness should be held at the corporate premises.
This study is an attempt to understand the diseases for which most of the hospitalization takes place in corporates of Noida and the preferred hospital of the employees