AGREEMENTS WITH ADEQUATE NUMBER OF SERVICE PROVIDERS WIDESPREAD GEOGRAPHICALLY

CIRCULAR NO.IRDA/HLT/REG/CIR/001/01/2016, DATED 4-1-2016

The Hon’ble High Court of Mumbai while closing PIL 12 of 2011, mentioned the concerns raised by the petitioner in its final order, which inter-alia included the following:

The Insurance companies have provided cashless facility at about 250 hospitals/clinics in Mumbai under the PPN facility. There are in all 3000 hospitals/public clinics in the city of Mumbai and that therefore more and more hospitals and clinics ought to be brought under this PPN facility.

On a similar matter, the Hon’ble High Court of Gujarat while closing PIL 81 of 2011 advised the petitioner/any other stakeholder to make representation to IRDAI. Accordingly, the petitioner/other stakeholders forwarded their representations, which inter-alia included the following:

“Very few hospitals for mysterious reasons known only to insurance companies or TPA are empanelled which definitely raises eyebrows and it seems that they are favoured by the Insurance Companies/TPAs. This makes the limited choice of the hospitals. Again Ahmedabad is a Metro city where from one corner of city to other will take minimum 1.5 hours so at the time of emergency it will be difficult to reach hospital having PPN facility, thereby we feel that there should be empanelled hospitals in each and every corner of city”.

“Insurance companies/TPAs have enrolled under PPN network only 98 hospitals which are approximately 0.5% of the total number of hospitals situated in the Ahmedabad Municipal Corporation Limits”

In view of the above, reference is invited to Regulation (10) (c) of the IRDA (Health Insurance) Regulations 2013 which is reproduced below:

10. Agreement between Insurers, Network Providers and TPAs

(c) The Insurance Company shall endeavour to enter into Agreements with adequate number of both Public and Private Sector Providers with adequate geographical spread.

In pursuance to the adherence to the above Regulation, it is reiterated that all insurers may continue to endeavour to enter into agreements with sufficient number of Service Providers adequately covering geographical spread in compliance with the Regulation (10) (c) of the Health Insurance Regulations 2013.