Cashless health insurance claims will now be settled in 3 hours

In a significant stride towards empowering policyholders, the Insurance Regulatory and Development Authority of India (IRDAI) has issued a comprehensive master circular on health insurance products repealing 55 old circulars.

The insurance regulator says insurers must decide on cashless authorisation requests immediately and within one hour and final authorisation on discharge from the hospital within three hours of request from the hospital.

"No claim can be repudiated without the approval of the Claims Review Committee which is required to take decision on repudiation of every claim," says the IRDAI.

For claim settlements, IRDAI says the policyholder shall not be required to submit any documents. Insurers and TPAs (third-party administrators) shall collect the required documents from the hospitals, it says.

The insurer is liable to pay ₹5,000 per day to the policyholder in case ombudsman awards are not implemented within 30 days, says the regulator.

The master circular emphasises measures towards providing seamless, faster and hassle-free claims experience to a policyholder procuring health insurance policy and ensuring enhanced service standards across the health insurance sector.

IRDAI says customers must be provided with the flexibility to choose products, add-ons, riders as per their medical conditions. A wider choice should be provided by insurers by offering diverse insurance products catering to all ages, regions, occupational categories, medical conditions, treatments, all types of hospitals and health care providers to suit the affordability of the policyholders, it says.

In case of no claims during the policy period, the insurers may reward the policyholders by providing an option to choose such No Claim Bonus either by increasing the sum insured or discounting the premium amount, the circular reads.

A policyholder with multiple health insurance policies gets to choose the policy under which he can get the admissible claim amount, says the insurance watchdog. The primary insurer with whom claim is first submitted shall coordinate and facilitate settlement of balance amount from the other insurers, it says.

Underwriting policy must ensure Ayush treatment is on par with the other treatments, says IRDAI. Policyholders should be given an option to choose treatment of their choice, the circular says.

Performance of TPAs will now be monitored. Payments to be made to the TPAs only upon full discharge of satisfactory service, says IRDAI. Claw back of remuneration, charges paid to TPA basis customer feedback, which shall be passed on to the policyholders, the circular notes.

In case of withdrawal of products suitable options should be given to policyholder to migrate to any other suitable product or one-time option to renew the products if renewal falls within 90 days from the date of withdrawal, says IRDAI.

Policyholder will get refund of premium or proportionate premium for unexpired policy period, if he chooses to cancel his policy at any time during the policy term, the circular says.

“A health insurance policy is renewable and shall not be denied on the ground that claim was made in the preceding policy years, except in case of established fraud or non-disclosure or misrepresentation by the insured,” the circular says.