Evaluation of health insurance and claim process at tertiary care hospital, Mangalore: A case report

The study was carried out with the objectives to study and understand the current claim process of existing health insurance schemes, to identify the barriers in the claim process at the hospital level and to study the consumer awareness and satisfaction in health insurance. Method employed was cross-sectional study with convenient sampling, data included time analysis format and validated questionnaire. Results showed Sampoorna Suraksha had more claims followed by Yeshasvini. Overall there is a delay in query justification followed by preauthorisation, preparation and faxing. Policyholders were not fully aware about health insurance, 50 per cent of policyholders knew what Third Party Administrator (TPA) means and consumers were not fully satisfied with health insurance. Overall claim process was partially smooth. Acquainted person and convenience in availing made consumers purchase health insurance policy. As conclusion, standards have to be set with standard timings for each process. Some mechanisms have to be undertaken, which will help making consumers aware about various intricacies of insurance plans. An effort has to be made to determine what healthcare customers need, tailoring their services. Distribution channels have a direct impact on the insurers' market image. There is widespread recognition of the need for qualified trained sales force to serve the increasingly discerning insurance buyers