Student Dissertation

Agency : TPA, Claim, Rejection, Deduction, Policy, EMSL, Cashless and Reimbursement

Objective : The objectives of the present study were; 1) To understand the claim process in terms of acceptance and rejection and deduction of claimed cases, 2) To identify the reasons behind rejection & deduction of claims, 3) To know the level of knowledge and awareness of claimant about the claimed health insurance scheme/ policy, 4) To suggest the ways to reduce the rejection and deduction of genuine cases, if identified

Background : Claims can be defined as the formal request to the insurance company asking for the payment based upon the terms of the insurance policy. The process of claims commences only after treatment of the patient is complete and patient is discharged from hospital and claim is submitted for approval. If the documents of the treatment are not submitted properly or in a correct manner, then the cases are rejected or the claim amount is deducted and paid to the hospital. In this regard, the present study made an attempt to study the process of claim, the reasons of deductions and rejections of claims to smoothen the process for both the provider as well as the claimant

Methodology : The study was conducted at E- Meditek Services Limited (EMSL) Gurgaon and the duration of study was February 2014 to April 2014 (3 months). Both quantitative and qualitative approaches were adopted to gather the relevant information. The respondents for the study from the Provider side were EMSL officials and Doctors and Beneficiary side were the Claimants. 6 officials of EMSL were the interviewed in-depth with the help of the guideline to understand the claim process and reasons of deduction or rejection of claims. All the 1200 processed cases were analysed to understand the outcome of claims and reasons of deduction(s) and rejection(s). 28 claimant were interviewed with the help of semi-structured interview schedule to know there level of knowledge and awareness regarding the health policy and the details of claim made

Findings : The total 1200 claimed cases processed and among those the approved cases were 1188 and only 12 cases got rejected. Among the approved cases, 90 percent cases were fully approved and 9 percent cases got deducted. Statistically significant association was found between the knowledge of claimant and number of times claims were filed, mode of claims and the outcome of the claims.

Recommendations : The study shows that there is hardly any knowledge of policy details among the policy holders, due to that they claimed more times than provided for in the policy to avail the complete amount, This increases length of the procedure leading to greater workload for the organization and greater dissatisfaction among patients. There is a need to create awareness among the policy holders about the policy and regular update should be given to the claimants from the provider side to reduce the claim process as well as the rejection and deduction of claims.


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