Student Dissertation

Agency : Reimbursement; Claim; TPA; Repudiation; Inward

Objective : • Specific- To bring standardization in the processes and to enhance the efficiency of TPA. • General- • To find out the reasons of delay in claims settlement. • To find out the reasons of repudiation of claims. • To recommend solutions to prevent the delay and repudiation of claims.

Background : “Claim” is the only reason the consumer (insured) buys an insurance product. After filing a claim the insured wants it to be reimbursed as soon as possible and if delay occurs or the claim gets rejected due to some reason the insured becomes dissatisfied. Sometimes insured files case against the insurance company or TPA. The fast administration of Claims is, therefore not only a legal obligation of an insurance firm, but a strong public relations and marketing strategy. Studies show that every four out of nine policyholders have faced problems with their health insurance providers and third party administrators (TPA) at the time of getting their claims approved which resulted in lot of delay in claims settlement or rejection of claims. Ultimately they feel dissatisfied with the services offered by the Insurance Company/TPA.

Methodology : • Area of the study: E-meditek TPA Services Ltd. (Gurgaon) – Head Office • Study Design: Descriptive study • Type of data: Quantitative Data • Sample size: Total 260 claims study: - 130 IPD and 130 OPD claims for delay in claims settlement. Apart from that total 200 claims (100 IPD & 100 OPD) study for repudiation. • Sampling Technique: Random sampling technique • Data Collection Tool: Data of claims to be collected and entered in MS Excel sheet and analyzed by calculations, graphs and charts. • Data collection o Primary Data o Direct observation: claim files to observe and process. o Discussion with medical and administrative staff for the understanding of process and issues related to claims settlement.

Findings : Results revealed that most of the claims settled after delay (64% and 57% in IPD and OPD respectively) and a considerable percentage of claims are repudiated (8% and 13% in IPD and OPD respectively). Further reasons were identified for the above issues and recommendations were given accordingly. By virtue of findings after the study, it can be concluded that there is lot of scope for improvement to prevent delays in settlement and to repudiation of the claims. By preventing this, the TPA can effectively prevent the negative impacts of such delays leading to creating value for the organization in terms of time, money and labour.