Uplift has a centralized benefit management committee comprising two-member representative from each partner organization. All partner organizations that have 3000 + members will get a seat in the benefit management committee.
Around 70% of the claims in Uplift are processed by the software as they meet all the criteria. These are settled through the fast track claim process wherein members are reimbursed within a few days. The remaining 30% of the claims, which do not tick all the boxes or are rejected as per the policy rules through technical and medical validation are settled by the centralized benefit management committee when they meet once a month. This benefit management committee is trained and educated on the product and services offered by Uplift.
At present the benefit management Committee consists of two members from Prem Sewa Mrs. Alice Dsouza and Mrs. Shakila Bhanu Sheikh.
Below are the committee members in discussion with our intern, Jennifer D’Souza
How long have you been a member of benefit management committee? How do you feel being at this position?
We have been members for the last two months. This is a position of great power and responsibility, we must take decisions, which are fair and in larger interest of the mutual and at the same time empathize with the women member whose claim is pending for approval. It also makes us feel that we are positively contributing to the community as we help our fellow members at times of need and great stress.
What kind of capacity building did you go through to become a member?
Uplift has told us that our capacity building to discharge our duties will be a continuous process. For now, we have undergone detailed training on the product, its exclusions and inclusions and the things that we should keep in mind while deciding a claim. As our claims committee expands, we will have more capacity building sessions.
But if you ask us the learnings that come with experience of deciding these claims are the most valuable.
Does this powerful position bring you in pressure or any kind of influence?
None. As such there has been no pressure or influence of the members on us because when the moderator (Uplift staff) presents the case, the name and area of the patient is not disclosed. Therefore, we decide upon the claims objectively based on the rules.
How does it feel to reject a claim?
It is not a nice feeling, as we are rejecting the claim of one of our fellow members who is in need and not financially well-off. However, we cannot make emotional decisions and must abide by the rules for the greater good.
Any special case that you would like to discuss?
Recently, a member submitted her medical bills for claim and increased the amount in one of the medicine bill by changing the figures. The Uplift doctor discovered this during the medical validation and the case was put in front of us for decision. Although, it was just one bill where the amount was increased, we felt that the entire claim should be rejected.
Members should not indulge in such unfortunate acts as it will ultimately harm our mutual. We directed the Uplift staff to speak with the concerned member, who accepted her mistake and apologised. Hence, we did not revoke her membership. Although we could have partially paid her claim, we decided to very strict with frauds or wrong doing of any kind as we need to set standards from the beginning.
About the Project
Through ICMIF’s 5-5-5 Mutual Microinsurance Strategy, Uplift aims to bring health mutual aid solutions to an additional half a million low-income people in Mumbai and Pune over the next five years. The project was launched in August 2016 and is supported by ICMIF members, The Co-operators (Canada), Länsförsäkringar (Sweden) and the Achmea Foundation (The Netherlands).