Management of Claims and Reimbursements: The Case of Mediclaim Insurance Policy

Abstract

The Mediclaim scheme run by the government- owned General Insurance Corporation (GIC) of India is currently the only private voluntary health insurance scheme available in India. This scheme has been in operation since 1986 and from time to time a number of revisions has been made to address the needs of its clients. The analysis of claims and reimbursements under this scheme is scanty. This paper analyses 621 claims and reimbursements pertaining to policy initiation years 1997- 98 and 1998-99 of the Ahmedabad branch of GIC's subsidiary. The study estimates that about a third of claims amount increase is due to the problems of adverse selection or provider- induced demand. The analysis of breakup of reimbursements suggests that more than one-third of reimbursements are made towards doctor's fees, followed by diagnostic charges which account for about one-fourth. The findings also suggest that the insurance company took on an average 121 days to settle the claim.