Legal Consequences
The Ministry of Health has put out an advisory strongly urging Third Party Administrators from
intervening in clinical decision making, as this may breach the law and attract legal repercussions.
This advisory is aimed at ensuring that healthcare practitioners make decisions regarding diagnosis,
treatment and management of patient care independently, without any external commercial or
administrative pressure.
Third party administrators are intermediary organizations, responsible for processing claims, handling
admission process into hospital and providing cashless healthcare services. However, worries have
been expressed that in some cases, third-party administrators may be exercising too much influence
on treatment approval, length of stay or the billing process, thus interfering with doctors’ ability to
take independent decisions.
According to the Ministry of Health, clinical decisions should remain within the jurisdiction of
medical experts alone. Any involvement of any other organization in the treatment and patient
management procedure can be regarded as breaching of medical ethics and could also be termed as a
breach of law.
Experts in healthcare suggest that increasing involvement of insurance intermediaries in healthcare
systems calls for defining certain regulatory boundaries. Although TPAs are useful for facilitating the
operations and making the process of accessing health insurance services easier, such intermediaries
should only be used as an operational tool.
MOH’s statement is perceived as the step towards reinforcing patients’ rights and strengthening ethical
principles in the field of medicine. The document helps ensure that medical professionals can base
their decisions on clinical evidence alone and not succumb to any influence from financial and
operational factors from outside.
Industry experts point out that as healthcare systems get more sophisticated and dependent on
insurance, chances of conflicts between administrative efficiency and clinical freedom increase. For
this reason, regulators will most likely need to develop new compliance rules to specify the scope of
responsibilities and activities of TPAs.
The Ministry stated once again that the preservation of independence of medical practice was crucial
to maintain the integrity of the healthcare system and provide for quality of patient treatment. TPAs
were urged to comply with their respective obligations, warning them about regulatory consequences.
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