The government plans to move oversight of the National Health Claims Exchange (NHCX), a digital platform for processing health insurance claims, to the finance ministry from the health ministry to curb excessive charging by hospitals from insured patients, leading to a rise in annual health insurance premiums, government sources said.
The NHCX will be housed under the department of financial services and will be regulated by the Insurance Regulatory and Development Authority (IRDA), sources said.
NHCX acts as a centralized platform for the exchange of health claim information between various stakeholders, including insurers, third-party administrators (TPAs), healthcare providers, and beneficiaries. However, the body has so far been lacking in curbing the overcharging of insured patients by hospitals vis-à-vis the charges levied by the healthcare providers to the uninsured patients for the same procedures.
“The operations of the portal will be strengthened, which will give insurance companies collective bargaining power to ensure that hospitals standardise their rates for various treatments or procedures,” an official said.
It has been found that hospitals are trying to find out whether patients have health insurance, their insurance limits, before undertaking procedures and accordingly inflate charges once they have this information, the official said.
While health insurance premiums are going up every year and most insurance companies are reporting losses in their health portfolio, only hospitals are making money at the cost of insured patients.
“The white elephant in this line of business is hospitals,” another official said.
Separately, the IRDA has issued show cause notices to a few private health insurance companies for indulging in unfair premium increases annually even while showing a low claims settlement ratio, sources said.
Incurred claims ratios, the total value of claims paid as against the premium collected in a year, which had peaked during the COVID-19 pandemic in FY21 with the ratio for the public sector general insurance companies at 126% and private insurers at 105%, have since declined. By FY24, these ratios had moderated to 103% for public sector insurers, 89% for private insurers.
The government is understood to be concerned about the annual increase in health insurance premiums by as much as 20%, which is causing hardships for the poor and middle class and ultimately impacting insurance penetration.