IRDAI asks insurers to settle cashless claims in 3 hours
By : Falaknaaz Syed
Update: 2024-05-29 15:49 GMT
Mumbai: The Insurance Regulatory and Development Authority of India (IRDAI) on Wednesday announced a major revamp of the regulatory norms for health insurance policies. In a Master Circular on Health Insurance Products, the regulator said that insurers must decide on cashless authorization requests within one hour and final authorization on discharge from hospital within three hours of request from the hospital. According to experts the move will significantly improve customer experience for the patient and their family members.
"In no case, the policyholder shall be made to wait to be discharged from the hospital," IRDAI said in the master circular.
The regulator further said that if there is any delay beyond three hours, the additional amount if any charged by the hospital shall be borne by the insurer from the shareholder's fund.
“No claim can be repudiated without the approval of the Claims Review Committee which is required to take decision on repudiation of every claim,” said the regulator.
For claim settlements, the policyholder shall not be required to submit any documents. Insurers and TPAs shall collect the required documents from the Hospital.
In the event of the death of the policyholder during the treatment, the insurer will have to immediately process the request for claim settlement and get the mortal remains released from the hospital immediately.
Policies must be portable and underwriting policy should not discriminate against any particular group. An insurer is liable to pay Rs 5000 per day to the policyholder in case ombudsman awards are not implemented within 30 days.
Moreover, policyholders have the right to a refund of premiums for the unexpired policy period if they cancel their policy early.
The norms state that health insurance policies are renewable and should not be denied on the grounds that a claim was made in the preceding policy year, except in cases of fraud or misrepresentation. Insurers must offer solutions for effective end-to-end technology, including e-cards for policyholders and efficient grievance redressal systems.
Insurers also have been asked to avoid coercive practices regarding the selection of hospitals. Cashless services must be provided for both planned and emergency treatments.
Narendra Bharindwal, vice president, Insurance Brokers Association of India (IBAI) explained, “The aim is to achieve 100 per cent cashless claim settlements and streamline the health insurance process.” The comprehensive Master Circular on Health Insurance Products repeals 55 circulars. All the entitlements in a health insurance policy available to a Policyholder have been brought in one place in the Master Circular, said the IRDAI.