🆕Proposed resolution process
Proposed process guidelines for dispute resolution
Objectives
Build a better dispute resolution experience for digital claims
Aim for 95% of the claims disputes related to the scope as outlined in the document for Phase 1 to be resolved before reaching IGMS/ombudsman
In subsequent phases, the dispute resolution system referred to in this document would aim to integrate with the dispute resolution processes instituted by IRDAI to provide a comprehensive dispute resolution process for the ecosystem.
Process
Key idea of the process given below are:
The HCX resolution platform implementation should aim to provide a single window (digital) to log all disputes and track status
All participants in the HCX ecosystem should adhere to lodging all disputes mentioned in the scope through the HCX resolution platform only
The following table provides an illustration of steps and SLA time for HCX network dispute resolution. Please note that it is intended to serve as a guide and may be further extended/customised by teh HCX oeprators to suit the ecoystem needs.
Step | Process | Proposed Timeline | Participants |
1 | Dispute is lodged | Day 0 | Complainant, HCX, Defendant |
2 | Parties in the dispute are informed. Parties
| Day 2 | |
3 | Discovery file is created with inputs from all parties involved | Day 5 | |
4 | Fast track (Faceless Only) Arbitration facilitate by empanelled arbitrators : (1st Level)
<Link to FTA section> | Day 15 | Complainant, Defendant, Arbitrator |
Activities to aid dispute resolution
Contractual agreement from all the stakeholders to adhere to the terms and conditions of HCX dispute resolutions framework.
Reference contractual templates for Terms of Use and proposed addendums to Payer-Provider and Payer-Policyholder contract have attempted to cover these aspects in a contractual format to help seed the ecosystem.
Escalation SOP for entities not satisfied with HCX dispute resolution
Decision needs to be taken on the scope of HCX dispute resolution
Limited to arbitration
Enforcement of penalties on non-adherence of arbitration awards (Setting-up of TATs on acknowledgment, acceptance and implementation of arbitration awards)
Enforcement of compliance (linked to adjudication, hence may not be in the scope)
HCX Switch Considerations
The HCX switch needs to take into consideration the below mentioned points to play an effective role in dispute resolution
Data storage: Data has to be stored by the HCX switch for a minimum period of [5 years] to be able to provide data for any dispute resolution. Disputes on insurance claims in India can be filed upto a maximum of 3 years (Claim dispute comes under limitation act, and for three years if the customer doesn’t say anything he is said to have waived off his rights. Unless of course he has solid ground. Insurers need to maintain record for at least [5 years].)
*[] indicate the recommended value of the time period, however it may differ based on the context.
Next steps
An effective and comprehensive digital dispute resolution system is vital to the success of HCX. While this document refers to the first phase - commercial health insurance for in-patient procedures, the end goal is to resolve a majority of insurance claims related disputes before it reaches the legal system. Initiatives like integrating with various existing and emerging grievance resolution mechanisms in the insurance and healthcare ecosystem is important for HCX to achieve this vision.
Keeping this in mind, the policy guidelines workign groups would keep working to evolve the guidelines based on ecosystem needs. It would mainly cover following aspects:
Further simplification and posiible automation of the process
Broadening of scope for other use cases - reimbursement, OPD, etc.
Integration of HCX scope into the larger ecosystem process like insurance ombudsman and other upcoming grievance redressal system in healthcare
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