Irdai tonic for health insurance: A regulator for hospitals and doctors

By asking health insurers to access a national list of doctors, the regulator hopes to encourage them to offer more flexible policies outside of the hospital network

Amid the blitzkrieg of orders issued by the Insurance Regulatory and Development Authority of India (Irdai) last week, one stands out. The order has asked the health insurance and general insurance companies that offer health cover to access a national list of doctors being developed by the government’s Ayushman Bharat Digital Mission.
 
Other than life insurance, Indians buy health insurance. Irdai data shows that health covers account for over 35 per cent of all non-life insurance policies by premium (April-October 2022). But dissatisfaction levels are high. Insurance companies claim the hospitals and sometimes the insured cheat them, the customers often feel their claims are wrongly repudiated.
 
In trying to introduce efficiencies in the business, Irdai has complained that no lasting improvement is possible unless a regulator is appointed for hospitals or doctors monitored. Since health is a state subject, this has proved difficult.
 
In this context, the Irdai order of last week is significant. It has asked the insurance companies to dip into the Healthcare Professional Registry (HPR) being developed by the National Health Authority, which runs the Ayushman Bharat Mission. Less than a third of India’s doctor population is listed in the HPR. The doctors are all registered by the respective state medical councils, but the list at the Medical Council of India (MCI) has not been updated for decades. Irdai has taken a proactive position of bypassing this problem and made a soft entry into regulating the health sector.
 
The implication is huge. Till now, non-life companies that offer health cover did not deal with doctors; they deal with hospitals, even if in many small towns those are nursing homes run by a single doctor. The point of contact or liability was shared by the insurance company with these hospitals. So why is Irdai introducing doctors into the health insurance policy?
 
A senior official of a state-run insurer explains that the order is designed encourage insurers to offer more health policies that do not require hospitalisation. The Irdai order makes this very clear. “The general and health insurers offering health insurance policies can also consider leveraging on the Health Professional Registry for building up the network of doctors/physicians or other healthcare professionals for providing OPD or other healthcare services,” it notes. It means health insurers can deal with the doctors directly to settle claims.