Box 5: Uplift India: a community approach to claim management for health microinsurance
The Uplift India Association (UIA) facilitates the operation of community-owned health insurance mutuals through its programme Uplift Mutuals. This programme provides third party administrator services, as well as technical support, for partner organizations working within the community. The product covers inpatient (IP) hospital expenses and provides additional value-added services, such as discounts on prescriptions and diagnostic services. Claims are paid on a reimbursement basis. The member is required to submit claims documentation within 15 days of discharge. Employees at the branch office of the mutual organization collect the documents, check them, and assist the member with completing the claims forms. Claims assessment then follows a two-stage process: the claim is first sent to Uplift for validation against the policy rules, including verifying the claims document and encoding the claim in Uplift’s software. Uplift then prepares a monthly claims summary, using an Excel tool that allows communities to understand and make claims decisions based on prudent rules for financial sustainability. A claims meeting is held every month by the community representatives. With the assistance of the Excel-based claims decision tool, which summarizes information on approved claims, rejected claims and the amount available in the claims fund for that month, the claims committee makes the final decisions. This committee has the ability to reduce payments even for approved claims if the funds available in the pool are insufficient. It may also reject claims on grounds not part of Uplift’s standard rules and apply those criteria in the future. Claimants are reimbursed by cheque by the local organization, following the final decision. The involvement of the community in the claims process not only assists with management of potential fraud, but creates awareness of the reasons and costs for member claims, and encourages efforts to adopt preventative measures.
Additional source/reference: CIRM report, June 2013 3.1.3
POTENTIAL DRAWBACKS
The community-based approach is not without its drawbacks, which require careful consideration in programme and CLIENT VALUE process and the collection and process design. In particular, lack of control by the insurer over the claims submission verification of identity and claims documentation can lead to higher potential for fraudulent claims or collusion between community members. Claims TAT may actually increase. For example, if the process requires the local representative to meet with the client or beneficiary in person to review the claim, the timeliness of this step will depend on the availability of the local representative and may slow the process. The process of submitting the claim from the local representative to the head office may be inefficient, particularly if the method requires multiple handoffs, re-verification of manually completed documents or the use of external services such as a postal service that may not be reliable. As an example, a process that involves sending a claim from the local village to the nearest agent by runner, then from an agent to a regional branch by fax or courier, and then from a branch to head office by email, has the potential for loss of data, loss of accuracy and increased processing time. Such processes may be the best option given the circumstances and technology available, so it is important to evaluate the value of the community presence compared to the possible inefficiencies or other drawbacks. As described in Box 3, Fonkoze changed its claims reporting and assessment process due to the sheer number of claims after Hurricane Sandy. The redesign of the claims assessment process included streamlining the reporting requirements and delegating more authority to the local village centre chiefs. While this solution enabled faster processing of claims in order to better meet client needs, it resulted in less control over the accuracy of claims submitted, and increased the risk of fraud and conflicts of interest. And while the changes speeded up the process to 12 CLAIMS MANAGEMENT IN MICROINSURANCE