Collaboration in Group Health Insurance
- A Case Study
Indian Health Insurance Industry
Overview: Risk-based Underwriting of Health Insurance Policies
Health insurance is administered by TPAs in India, while insurance is sold by the insurance companies. Employers often buy group insurance for their employees' health insurance benefits. TPAs manage such policies. Employees need insurance cards or some documentation that they can use at hospitals for insurance benefits. It is important for employers (the insured), insurance companies, and TPAs to have complete and accurate information about beneficiaries covered in the policies.
There are two main transactions for which collaboration is needed between the different entities in health insurance. The first is enrolment and the second is claims settlement and reporting. Insurance companies sell policies to groups. The policy needs (benefits) are also many times informally communicated by the employers. The insurance companies need beneficiary information to compute premium. TPAs also need beneficiary information to issue cards to the insured and also for claims administration.
Insurance companies receive beneficiary information in different formats and media today, including, fax, Excel, MS Word document, list of employees sent in an email, or just hard copy. The insurance companies have to manually input this information into their system, so do TPAs. This leads to unnecessary manual data entry and errors. In many cases, insurance companies maintain beneficiary information in hard copy files and only reference them in their insurance application.
Claims reports are sent to insurance companies, usually in hard copy formats, by TPAs. The reports are for specific operating offices from each TPA. The overall claims experience is hard to discern for insurance companies (See Claims Analytics Case Study).
IndiaVima, a collaborative online platform for insurance companies, TPAs, insured and brokers, provides unprecedented connectivity and collaborative experience.
The insured is able to specify the insurance needs (benefits) in a structured manner. IndiaVima enables the insured to specify different subgroups - any number and any level. In addition, the insured is able to specify sub-limits.
IndiaVima also provides standardized representation of beneficiary information. The information is provided to IndiaVima by insured in MS Excel format. IndiaVima validates the information to validate that clean and accurate data is presented to insured. Further, IndiaVima analyzes the data to provide various risk metrics to insurance companies for each group.
Once insurance companies complete the underwriting, the beneficiary data is available to TPAs instantaneously. IndiaVima integrates well with insurance company's back office systems, like Genisys and Premia. Insurance companies and TPAs are able to import the beneficiary information directly into their systems and avoid manual data entry.
IndiaVima generates cards for beneficiaries automatically when the policy underwriting is complete. This saves TPAs significant effort and cards can be reliably sent to beneficiaries.
- Standardized representation of beneficiary information, resulting in higher efficiency and accuracy of processing beneficiary data
- Connectivity between stake holders improves communication, reduces errors and results in lower cost of underwriting
- Interfacing with back office systems results in avoiding unnecessary and repetitive data entry, resulting in increased accuracy and cost savings
- Better and more timely access to enrolment data for TPAs
IndiaVima - at a glance
RFQ (Request for Quotation)
- PIOs(Policy Issuing Offices) can compute the Premium even with minimal available information like - No. of employees to be covered, no. of beneficiaries to be covered, average age of the employees and the sum insured.
|Response to online RFP (Request for proposal)
- PIOs can respond to RFPs (floater/non-floater policies) by sending proposals online without any delay.
|Highly versatile Premium Calculator
- Base Premium can be calculated based on several criteria like self age, maximum age, average age per family, average age of all beneficiaries in the policy etc.,
- Multiple Rate Tables can be used for the computation of the Premium.
|Online transfer of beneficiary info from Employer
- Re-entry of beneficiary information at the PIO and TPA is eliminated.
- As and when policy is activated or Endorsement is issued by PIO, TPA can access the same information instantaneously.
- Eliminates the delays and errors in the TPA cards by reducing manual intervention.
|Reports & Audits
- RO can view RFPs received, Proposals sent, policies issued and the claims detail of all the policies issued by all PIOs under it.
- HO can view RFPs received, Proposals sent, policies issued and the claims detail of all the policies issued by all PIOs.
- Policy information provided by IndiaVima helps in Audits at various levels.
- View the performance of the policies in terms of claims, claims ratio, trends according to disease codes, hospitals, corporate, industry sector, age group, etc
- Helps in scientifically computing the Premium for a policy at the time of renewal.
|Issue of TPA cards
- TPAs can generate TPA cards and issue without delay and errors