To help ease the pain of running from pillar to post for health insurance policyholders, the insurance regulatory and development authority of India (IRDAI) has asked insurance companies to strive to achieve 100% cashless claim settlement in a time-bound manner. Insurers are asked to decide on the cashless request in an hour starting from 1 August 2024 and grant final authorisation within three hours after receiving the request.
In a
circular, IRDAI says, "Every insurer shall strive to achieve 100% cashless claim settlement in a time bound manner. The insurers shall endeavour to ensure that the instances of claims being settled through reimbursement are at a bare minimum and only in exceptional circumstances."
"Insurer shall decide on the request for cashless authorisation immediately but not more than one hour of receipt of the request. Necessary systems and procedures shall be put in place by the insurer immediately and not later than 31 July 2024. Insurers may arrange for dedicated help desks in physical mode at the hospital to deal and assist with cashless requests. Insurers shall also provide pre-authorisation to the policyholder through digital mode," the regulator says.
Warning that policyholders should not be made to wait to be discharged from the hospital, IRDAI says the insurer should grant final authorisation within three hours of the receipt of the discharge authorisation request from the hospital.
"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," it says.
In the event of the policyholder's death during the treatment, the insurer should immediately process the request for claim settlement and get the mortal remains (dead body) released from the hospital immediately.
IRDAI also issued instructions on the settlement of claims. It says, "No claim shall be repudiated without the approval of product management committee (PMC) or a three-member sub-group of PMC called the claims review committee (CRC)."
"In case the claim is repudiated or disallowed partially, details should be conveyed to the claimant along with full details giving reference to the specific terms and conditions of the policy document. Pursuant to the intimation of the claim, insurers and third-party administrators (TPAs) should collect the required documents from the hospitals. Policyholder shall not be required to submit the documents," IRDAI says.
For policyholders who have multiple health insurance from various insurers, the regulator says the policyholder can file the claim settlement under any policy of choice. "The Insurer of that chosen policy shall be treated as the primary insurer. In case the available coverage under the said policy is less than the admissible claim amount, the primary insurer will seek the details of other available policies of the policyholder and should coordinate with other insurers to ensure settlement of the balance amount as per the policy conditions, without causing any hassles to the policyholder."
On the occurrence of the insured event, the policyholders can claim from all insurers under all policies, it added.
IRDAI has also asked insurers to have a robust system for grievance redressal. "The response letter of the insurer in any grievance will include the contact details of concerned insurance ombudsmen where her complaint can be escalated in case, the policyholder is not satisfied by the grievance redressal provided by the insurer."
Further, insurers are required to comply with the award of the insurance ombudsman within 30 days of receipt of the award. "In case the insurer does not honour the ombudsman award, a penalty of Rs5000 per day shall be payable to the complainant. Such penalty is in addition to the penal interest liable to be paid by the Insurer under The Insurance Ombudsman Rules, 2017," IRDAI says.
One more issue with the insurance people is they have a list of hospitals and there may not be anyone near your house.IRDAI should clearly specify that all hospitals should be covered by the insurance firms.