Page 99 - MEDICAL AND HEALTH INSURANCE
P. 99

MEDICAL AND HEALTH INSURANCE


               Insured  must,  of  course,  provide  all  assistance  and  documentation  and  the  Insurance

               company will pursue the case at their own expense in the subrogation recovery.




               5.6     THIRD-PARTY ADMINISTRATION IN THE CLAIMS MANAGEMENT




               Third-party  administrators  have  developed  considerably  in  Malaysia  as  more  and
               many insurers are engaging their services.

               Their administrative functions include:

                     Customer  servicing  through  a  24  hours  helpline  service  for  policy  benefits

                       enquiry, claims enquiry and hospital admission

                     Negotiation  with  providers  and  panel  clinics  on  pricing  and  overcharging  issues
                       and negotiated case pricing

                     Utilization  analysis  reporting  and  advice  to  clients;  and  other  related

                       information for management feedback
                     Administering  claims  from  admission  to  discharge,  vetting  of  the  eligibility  of

                       cover  and  the  issuance  of  the  guaranteed  letter  to  the  final  discharge  and

                       follow up



               Third-Party  Administration  is  commonly  seen  to  be  used  by  insurer  who  wishes  to
               concentrate    on    underwriting    risks   and   marketing,    rather   than    on    claims

               administration.

               Other  than  that,  big  corporates  also  engage  Third-Party  Administration  to  handle  all
               claims  administration  on  self-funded  schemes  to  avoid  paying  a  premium  to  the

               insurance  company  and  to  manage  their  own  utilization.  In  such  a  self-administered

               programmed,  they  would  pay  a  fee  to  the  TPA,  usually  on  the  basis  of  'per  member

               per annum'.







               98 | P a g e
   94   95   96   97   98   99   100   101   102   103   104