Gopal Verma,
Chairman, E“Meditek Group

Gopal Verma, Chairman, E“Meditek Group, has spent almost two decades in the insurance industry. He interacts with Monalisa, ENN, about the integral role that Third Party Administrators play in the health insurance supply chain

With 31 insurance companies and 10,000+ health providers under its network, E-Meditek (TPA) Services Ltd is among the leading Third Party Administrators (TPAs) in the health insurance sector in India. Its TPA services include cashless hospitalisation at network hospitals/ nursing homes; policy holders enrollment, online profile management; round-the-clock helpline; claims adjudication, payments and negotiation of tariffs and discounts; Data Analytics and Underwriting Support, etc. Moreover, it offers additional services such as Pre-Policy Health Check-ups, RSBY (Rashtriya Swasthya Bima Yojna) Implementation and Hospital Bill Re-pricing for overseas travel claims, thus offering an end-to-end solution in the health insurance sector.

Versatile Role
TPAs have become an integral part of the health insurance supply chain, says Gopal Verma, Chairman, E“Meditek Group. Right after the sale of the policy, the service interface is assigned to the TPA with respect to all claim related services. Right from enrolling customer data to providing all relevant information to the policy holders, TPAs play many roles at multiple levels. Many times policy holders call on our customer care to enquire about policies, claim limits, hospitals networks, etc. So we provide post-sales call centre services too, he adds. In fact, TPAs have brought in a revolutionary change in the health insurance sector, making it more customerfriendly. TPAs were introduced in 2001-02, after which cashless facility was introduced to the masses. People started seeing value in health insurance. This marked the beginning of health insurance growth in the country, which is now growing at 25 percent year-on-year, explains Verma.

Controlling Costs
One of the core competencies of TPAs lies in controlling cost of claims. Thanks to them, the average cost of health insurance claims has remained much lesser than the normal inflation rate of the country. In 2002, average claim size was `14,000 (which in present time would be valued up to `40,000). This has grown up to `30,000 now, which is still less than the rate of inflation. This proves we have been able to control cost of claims, else, insurance companies would have been compelled to increase their premiums, says Verma.
This is primarily because TPAs act as aggregators and deal with large volumes of data. For instance, in E-Meditek we are aggregating data from all 31 insurers into one entity. This way we also get lots of leverage in negotiating with healthcare providers, explains Verma. Secondly, our constant monitoring system during treatments also helps us to overrule unnecessary procedures, exaggeration of bills, hospital overstays, etc, thus keeping costs under control he adds.

Challenges
Despite being such an important stakeholder in the industry, TPAs face a couple of challenges. The biggest roadblock is the lack of system integration, points out Verma. When a patient reports to a hospital, his policy record for a couple of years should be accessible to the TPA. But because system integration between TPAs and insurance companies is not of that magnitude, the TPA is often unable to access the relevant policy data immediately, and hence cannot deciding whether to admit the liability or not, adds Verma. This often leads to delays in claims settlements or putting treatments on hold, thus leaving the policy holder dissatisfied.

Technology Adoption
Technology is an essential tool that can help address most challenges of the sector. E-Meditek is much ahead of its times as far as IT implementation is concerned, says Verma. For instance, IRDA guidelines says that hospital tariffs, discounts, package rates, etc should be accessible to the policy holders. We launched our online portal way back in 2007, and currently 4-5 insurance companies are approving claims using our claims management software, informs Verma.
Another achievement has been the TPAs paperless operations. The moment any document enters our office, it is scanned and thereafter the entire team works on scanned copy which bears the claim number and policy number. We are not doing it for mere archiving purpose after claim settlement is done. Rather we do it right at the beginning, so that the entire process of verification and claims settlement can be done online, says Verma.
Last month we started our mobile app for policy holders to access claims information, claims tracker, cashless tracker, hospital search, hospital tariff, etc. on phone. Any information that the customer would need is present in the mobile app. We are soon going to launch it, says Verma. The Group has recently won an International Award for Best Consumer Prepaid Programmes and has been a finalist in the category of Best Global Prepaid Innovation. It has won another FIPS Award in India for its Bio-Metric Card that has the potential to replace the current technology being used in various government initiatives including the RSBY. Corporate Wellness Integration of wellness services with corporate is another interesting initiative. We are offering end-to-end wellness services to corporates. This includes creating awareness and education for preventive healthcare and providing basic medical services. We are also operating 180+ medical rooms in various corporate offices across the country, says Verma. This is an initiative taken up by corporate with the aim of adopting a proactive approach in healthcare, thus reducing cost of claims, he adds.

TPAs introduced cashless facility to the masses, which marked the beginning of health insurance growthin the country 

Way Forward
Verma is optimistic about the growth of health insurance sector and says that by next year it might overtake motor insurance which is currently the leading segment in non-life insurance in India. According to him, outpatient and dental insurance are likely to emerge in a big way.
Outpatient treatment constitutes 67 percent of total healthcare expenditure. This clearly shows that a larger pie has remained untapped by the insurance sector, says Verma. This has primarily happened due to small tickets size (claim amounts) and high risks of misuse “ issues which can be addressed by IT. eMeditek is designed to meet both the challenges. We have the provision of giving online approvals for treatments and have access to real-time information. This will make the entire process instant and online, he concludes.

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