Guideline process for dispute resolution

Envisioned guideline process for dispute resolution

Objectives

• Build a better dispute resolution experience for digital claims

• Aim for 95% of the claims disputes related to the scope as outlined in the document for Phase 1 to be resolved before reaching IGMS/ombudsman

In subsequent phases, the dispute resolution system referred to in this document would aim to integrate with the dispute resolution processes instituted by IRDAI to provide a comprehensive dispute resolution process for the ecosystem.

Guideline Process

Key idea of the process given below are:

• The HCX resolution platform implementation should aim to provide a single window (digital) to log all disputes and track status

• All participants in the HCX ecosystem should adhere to lodging all disputes mentioned in the scope through the HCX resolution platform only

The following table provides an illustration of steps and SLA time for HCX network dispute resolution. Please note that it is intended to serve as a guide and may be further extended/customised by the HCX operators to suit the ecosystem needs.

Step	Process	Proposed Timeline	Participants
1	Dispute is lodged	Day 0	Complainant, HCX, Defendant
2	Parties in the dispute are informed. Parties Provide information to the discovery file Provide consent to get information from third parties including HCX switch operator to populate the discovery file In-built consent from complainant	Day 2
3	Discovery file is created with inputs from all parties involved	Day 5
4	Fast track (Faceless Only) Arbitration facilitate by empanelled arbitrators : (1st Level) Responses and counter arguments from the defendant and complainant. (there should be limit to frequency (maximum two times) of queries to be raised by insurer , as it will be difficult for the claimant to respond multiple times )	Day 15	Complainant, Defendant, Arbitrator

Activities to aid dispute resolution

• Contractual agreement from all the stakeholders to adhere to the terms and conditions of HCX dispute resolutions framework.

  • Reference contractual templates for Terms of Use and proposed addendums to Payer-Provider and Payer-Policyholder contract have attempted to cover these aspects in a contractual format to help seed the ecosystem.

• Escalation SOP for entities not satisfied with HCX dispute resolution

• Decision needs to be taken on the scope of HCX dispute resolution

  • Limited to arbitration

  • Enforcement of penalties on non-adherence of arbitration awards (Setting-up of TATs on acknowledgment, acceptance and implementation of arbitration awards)

  • Enforcement of compliance (linked to adjudication, hence may not be in the scope)

HCX Switch Considerations

The HCX switch needs to take into consideration the below mentioned points to play an effective role in dispute resolution

Data storage: Data has to be stored by the HCX switch for a minimum period of [5 years] to be able to provide data for any dispute resolution. Disputes on insurance claims in India can be filed upto a maximum of 3 years (Claim dispute comes under limitation act, and for three years if the customer doesn’t say anything he is said to have waived off his rights. Unless of course he has solid ground. Insurers need to maintain record for at least [5 years].)

*[] indicate the recommended value of the time period, however it may differ based on the context.