GIPSA (General Insurance Public Sector Association) has far-reaching implications for health insurance policyholders, as can be seen from several latest developments concerning the same. GIPSA is basically a group made up of four top public sector insurance companies, namely Oriental Insurance Company, New India Assurance Company, National Insurance Company and United India Insurance Company. This group of insurance companies has limited cashless services solely for hospitals which take their price bands and join their own preferred provider network or PPN. This decision has impacted more than 5.49 crore health insurance policyholders as per reports.

Even a PIL (public interest litigation) was filed sometime earlier against this GIPSA decision in the Bombay High Court. Without any cashless insurance facilities, when customers go to hospitals for treatment, they end up paying a certain amount for the same which may eventually be disallowed on multiple grounds partially or fully by the TPA (third-party administrator) as per the statement in the PIL filed by the founder of the NGO Karmayogi Pratishthan, Gaurang Damani.

Yet, the insurance companies believe that they are only smoothening the entire system and the PPN could immensely benefit customers only in the future. GIPSA members have reportedly opined that the PPN system is tailored to bring in greater rationalization of the cost structure from the customers’ perspective as well. Standardized packages and rates will safeguard customers from being charged more and will ensure better utilization of the sum assured in the health insurance policy as per GIPSA authorities. Other experts have pointed out that in case of higher claims from healthcare providers, there will only be higher customer premiums payable in the long run. They have termed this as a system of collective bargaining by GIPSA for the benefit of insurance companies and customers alike.

Several leading hospitals (560 at last count) have already enrolled for GIPSA according to reports. However, reputed hospital chains such as Fortis and Apollo continue to remain outside the GIPSA umbrella due to issues regarding standardization of rates. GIPSA reportedly wants similar rates throughout all hospitals which is a bone of contention for these top healthcare chains. Private insurance companies such as ICICI Lombard, Bajaj Allianz and others are not reliant for claim settlement on TPAs since they administer the claim settlement process in-house itself. However, public sector insurance companies are now planning for a JV with a third party administrator which will be administering claims of GIPSA members. This move could get more hospitals into the PPN network. GIPSA is hopeful that the industry will get multifarious advantages from this new system of operations. The TPA set-up will establish a new customer service benchmark in this regard. The rate-standardization procedure has already started being implemented in key Indian cities.

In case of customers who visit non-PPN hospitals, they should be intimating the TPA within the stipulated period and make payment in full to the hospital post treatment completion. Thereafter, the ID card, policy copy, discharge summary, payment receipts, investigation reports and signed claims form should be provided to the TPA for swift reimbursement. GIPSA thus comes with far-reaching implications for customers and the entire health insurance sector in general. There are several positives and a few doubts. However, a change in the system will certainly shake up things in the sector.

GIPSA is causing many grievances because of the rates disparity. Medical Policy holders are not aware of the complexity and presume that at least 80% of medical expenses will be paid but claim is reimbursed for less than 60% .

Moreover, GIPSA does not accept alternative medical treatment which may be advanced but more expensive. Cases are rejected because standard acceptable procedure is not followed.

Even the Hospital staff and TPAs are not able to clarify doubts thus leading to confusion.