Guidelines for Grievance Redressal

Key policy considerations to design grievance redressal policy

While the actual grievance redressal policy for an HCX ecosystem would be drafted by its operator and agreed upon by its participants, this section outlines key design guidelines and an overall approach to arrive at such a policy. These guidelines and approach are aligned with earlier thinking from IRDAI in its publication Re: GUIDELINES FOR GRIEVANCE REDRESSAL BY INSURANCE COMPANIES, however, these are now envisioned to cover grievance from any actor of the ecosystem with respect to other actors.

Key Policy Design Guidelines

Final operational policies for grievance redressal are expected to be drafted by the HCX operators as these may change over time based on the need of the ecosystem and use cases under consideration. However, to make the policies consistent and effective, the following key grievance policy design guidelines are proposed:

  1. Each HCX operator must publish a dispute/grievance resolution policy to allow digital initiation, routing and tracking of the grievances of any of the participants.

  2. The policy should clearly list out all the grievances that would be addressed under it and mechanism to resolve grievances that are not covered under it.

  3. The policy should require all participating actors to set up nodal governance bodies contactable at the digital and physical communication mechanisms provided as part of onboarding. These communication details are made available to all participants using the read access to the registry.

  4. As part of the participant registry, the HCX instance also publishes the details of its governance body.

  5. The policy should publish the types and priority of the grievances handled by each type/role of the participant including any required as per prevailing regulations.

  6. The policy should publish SLA for each grievance type including any required as per prevailing regulations.

  7. The policy should be versioned, required to be signed by new members at the time of onboarding and any change has to be proactively informed to all existing network participants.

  8. The policy should require ample due diligence cycle to address the grievance and review the redressal before responding back to the requester

  9. The policy should allow for the reopening of the grievances

  10. The policy should allow for escalation to the network operator in case the requestor does not feel satisfied with the resolution. Escalated grievances should follow accelerated timelines for resolution.

  11. The policy should clearly layout review and resolution criteria for a grievance to be escalated and the approach the operator would take to reach a resolution.

  12. The policy should include ways of keeping requesters informed about the latest status and any additional requirements to help address the grievance.

Proposed Approach for Policy Formulation

Drafting and evolving an efficient and truly implementable policy for grievance resolution would need active participation from the HCX ecosystem. Keeping this in mind, the following high level approach is proposed in line with the overall Approach for Open Specifications:

  1. Like with the specifications so far, constitute a new working group for Dispute Resolution policies.

  2. The working group contextualises and adopts the open specifications design principles and high level approach as detailed in HCX - Cover note for the dispute resolution context.

  3. The working group drafts a model policy in accordance with the above principles and in line with the detailed approach from step 2 above.

  4. The principles, detailed approach and model dispute resolution policy draft is versioned and released for public consultation.

  5. The domain working group deliberates the feedback and enhances principles/model policy as needed.

  6. HCX Operators adopt the model policy according to the needs of their network

  7. Further enhancements, e.g. for new use cases, changes in approach, improvements in model policy due to on-ground observations undergo steps 3-6 and result in a newer version of the artefacts (principles, approach or model policy).

Based on the key design considerations and aproach listed above, policy guidelines working group had setup an explicit workstream that worked on the first version of the Multi Party dispute resolution process. To ensure prinsiples of minimalism, applicability and easy adoption of the guidelines working group defined the scope of guidelines in this version to include:

  • Non Government Commercial Insurance (Group + Retail)

  • For insurance claims regarding In-patient procedures only

  • Disputes related to claims transmission

Please note that following topics were explicitly kept out of scope for the current guidelines:

  • Government schemes

  • Payor rates agreed with the provider network

  • Quality and Compliance of policy adjudication

Following sub sections details the key aspects of the proposed Multi PartyDispute resolution process:

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