Gujarat chief minister Narendra Modi, at the women’s wing AGM of FICCI in Delhi, said that it is time to unleash the economic potential of 50% of the population—namely women
While IRDA guidelines are clear that a TPA cannot settle or reject health insurance claims, the regulator seems to have made a last minute change related to a TPA’s function that was absent in the previous versions of the draft. Has it created a loophole to give TPAs a role due to pressure from insurance companies?
The Insurance Regulatory and Development Authority (IRDA) health insurance guidelines address several issues like lifelong renewals, special provisions for senior citizens, transparency in premium and claims based loading as well as excluding the role of third-party-administrators (TPAs) for claims settlement and rejections.
It is a positive initiative to keep TPAs away from claims settlement or rejection due to numerous cases of inconsistencies in the payment amount as well as arbitrary rejections. But, has IRDA left a loophole that can be exploited by insurance companies working with TPAs? Did the regulator do it after feedback from insurers and TPAs? All government insurance companies use TPA services and many private ones, too.
IRDA’s health insurance guidelines state, “A TPA may handle claims admissions and recommend to the insurer for the payment of the claim settlement, provided a detailed guideline is prescribed by the insurer to the TPA for claims assessments and admissions.” It means a TPA will have a say in the amount that is to be paid for a claim or even recommend claim rejection to the insurance company. So, even though the insurance company will technically settle or reject the claim, the TPA will have major role to play in it. This will surely be exploited to its maximum by insurance companies and TPAs to meet their own needs.
On 11 January 2013, IRDA had written to CEOs of all insurance companies and TPAs stating that TPAs shall “only process claims and only the insurer shall have the right to settle or repudiate a claim.” These important wordings were omitted in the subsequent exposure draft sent by IRDA to the same stakeholders on 20 February 2013. The U-turn to allow TPA to recommend payment of claim may have been the outcome of feedback from insurance companies and TPAs.
The Insurance Act does not provide any role to the intermediary to settle or recommend claims. Interestingly, IRDA in response to a PIL (public interest litigation) filed by Gaurang Damani had stated, “The role of the TPA includes processing of the claims as per the policy documents issued by the insurer. But the onus lies on the insurer for settlement of claims.” At another time, IRDA in its own affidavit further stated that TPAs are intermediaries and not “Loss Assessors” or ‘Surveyors”. If so, why give TPAs the right to recommend the amount to be paid for a claim? Why has IRDA submitted different wordings to Bombay High Court and changed wordings in the health insurance guidelines?
How does this impact the Gaurang Damani PIL? As per the Bombay High Court directive at the last hearing on 2 April 2013, Gaurang Damani has submitted the additional affidavit in the court and the same has been served to IRDA on 4 April 2013 and to Union of India on 5 April 2013. It means that the fight continues.
The additional affidavit clearly states that “TPAs were not qualified in the field and they were acting arbitrarily to deny the rightful claim of the policyholders. As illustrated in the original petition Section III—Case Studies (Exhibits C-1 to C-11). It was been also found that TPAs were whimsically rejecting or reducing the claim amount without any cogent reasons.” It further adds that the gazetted regulations take away the right of claim settlement by the TPA (line 1 of Section 12(b)(1)), however TPAs have been given authority to recommend to the insurer for payment of claim settlement. This will defeat the purpose to be achieved by the petitioner by way of PIL filed in this matter.
The prayer in the additional affidavit states, “It is the petitioner’s humble prayer that clause 12(b)(i) of the gazetted regulations be immediately rectified in the spirit of the discussions held in the high court and also in reference to the documents submitted by Respondent No. 2 (IRDA) itself, to the high court. The words of the aforesaid clause ‘recommend to the Insurer for the payment of claim settlement’ should be removed at the earliest in the interest of justice, equity and fair-play.”
The Kalmadi promoted and now de-listed company has 1,479 minority stakeholders who together own 5.48%, while 23 people from the promoter group own the rest. In order to buy out fractional shares from minority stakeholders, Sai Service is increasing face value of its share to Rs25,000 from Rs10 and offering Rs325 per share for exit
Sai Service Station, an automotive dealer, which had delisted its shares back in 2008-2009 has now decided to increase the face value to Rs25,000 from Rs10 per share, in order to facilitate an exit route to those who did not tender their shares earlier. This will be proposed and deliberated by shareholders on 20 April 2013 in an extraordinary general meeting to be held in Pune.
The explanation given was to avail an exit route to shareholders who did not tender their shares earlier in 2008-2009. “Many members of the company, who could not participate in the “exit offer” have approached the company and are requesting for an exit opportunity. Moreover, the cost involved in handling and serving the large number of members with miniscule shareholding is very high and disproportionate to their holding.
To reduce the cost of servicing on a long-term basis in the interest of the company as a whole and providing exit opportunity to the members, it is felt advisable in the interest of the company and members, to reorganise the share capital of the company by way of consolidation of shares in larger denomination, which will not only help the company to reduce the aforesaid cost on a long-term basis but will also give better a opportunity to large number of members to liquidate their shareholdings since the equity shares of the company are delisted from the stock exchanges. The share consolidation is the practical and an economically efficient available option,” said the explanatory statement.
The total number of shareholders who are still holding shares after exit offer stands at 1,479 who collectively own 5.48% of the share capital while only 23 shareholders (promoter group) hold a 94.52% of the capital. It is likely that the resolution will be passed given the shareholding pattern.
This means the increase in face value of the share would result in “fractional ownership” which is not allowed and therefore must be consolidated to make it whole. The company has appointed a director who will be the ‘Trustee’ to oversee this process of consolidation and paying back the shareholders. The amount paid back to the fractional owners is Rs325 per share, which is higher than the buyback offer of Rs220 offered earlier. Of course, all this is pursuant to the Extraordinary Annual General Meeting to be held on 20 April 2013.
The statement given by the company said: “The board is of the opinion the resolution as proposed is in the interest of the company as a whole and hence recommends that the fractional shares arising out of the consolidation and to be sold by a trustee appointed by the board, be valued at a price of Rs8,12,500 per consolidated equity share which is equal to Rs325 per equity share of Rs10 each. The board believes that this value is in excess of the fair value of the shares and represents an attractive exit payment to members who would otherwise receive fractional entitlements pursuant to the consolidation.”
Small shareholders who are holding on to the shares of the delisted company believe that they are not getting a fair value of their shares. According to them, the company is doing extremely well and has paid dividends in the last two years. Besides, it has huge real estate which is not reflected in the Rs325 offer. Unfortunately, while this argument may be correct, outside shareholders in a delisted company have no remedies available.
The company is jointly run by promoters Sai Service Agency (Bombay) Pvt Ltd, Mukesh Kalmadi, Sumeer Kalmadi and Sandeep Kalmadi.