Health Insurance: GIPSA, PPN & cashless claims
Know Your Rights
Ahealth insurance policy must have a cashless claim settlement feature for a hassle-free experience to deal with any untoward medical emergency. A common feature in mediclaim policies these days, the cashless claim settlement feature lets a policyholder's insurer directly settle the hospital bills. Compared to this, a claim settlement under the reimbursement process could be a tedious and long process for policyholders involving, lots of paperwork and upfront hospital charges.
What is GIPSA?
The General Insurance Public Sector Association – popularly known as GIPSA – comprises four public sector general insurance companies namely...
The New India Assurance Company Ltd
National Insurance Company Ltd
United India Insurance Company Ltd
The Oriental Insurance Company
This association created a network of hospitals to standardise pricing for certain procedures. This network of hospitals is called PPN. Now, when a policyholder goes to any hospital in the network, the prices will be similar for certain medical procedures. They have comparatively reduced prices from hospitals across India, in the 12 cities included in the network. These are Mumbai, Ahmedabad, Bangalore, Chandigarh, Chennai, Coimbatore, Delhi, Hyderabad, Indore, Jaipur, Kolkata and Pune.
This also makes it easy for policyholders to process claims. If they go to any of the network hospitals, they can easily get cashless treatment.
The main idea behind the advent of GIPSA is to provide a safety net to customers. Very often, hospitals might charge more than the actual amount, therefore to protect the customers from paying more, GIPSA ensures standardised rates for basic medical procedures. This in turn ensures the better utilisation of the sum insured in a health insurance policy.
What is PPN?
GIPSA provides cashless services in hospitals that accept their policies and prices and join the Preferred
Provider Network (PPN). It requires hospitals to accept GIPSA rules and work on standardised rates. Those who accept this fall under the GIPSA umbrella and can be called PPN hospitals. Across the nation around 550 hospitals have enrolled for GIPSA.
Cashless claims
You can avail of cashless claim services only in GIPSA-approved PPN hospitals.
Reimbursement claims
Reimbursement claims, if asked for, can be done only as per the GIPSA rate in a PPN hospital. If you wish to file a reimbursement claim for treatment taken at a non-PPN hospital, the insurance company reimburses you according to the reasonable and customary clause. This means you will be reimbursed based on the general prevailing cost of the specific service in a particular geographical area (usually calculated by your insurer).
Standardisation of hospital rates
Hospitals that come under GIPSA are required to charge their customers on the basis of standardised rates only.
Overcharging by hospitals
If any policy holder faces higher rates through PPN hospitals, they can raise their grievance with their insurance company. If you wish to avail of GIPSA rates, do not sign any GIPSA rate-waiver form at the hospital. If you do sign such a waiver form, you cannot raise a complaint for overcharging or contest for your rights legally in any forum.
Reduction in higher policy premiums
GIPSA rates ensure health insurance becomes cost-effective for the general public and the insurance company. The insurance holders will not be charged more than what is due by the hospital. GIPSA will greatly reduce costs for customers as well as companies thereby also ensuring reasonable premiums for policyholders.