Insurance Regulator IRDAI on Wednesday released a master circular on health insurance specifying that an insurer must decide on cashless authorisation within one hour of request.
The master circular on Health Insurance products repeals 55 circulars issued earlier and is a significant stride towards reinforcing the empowerment of policyholders and bolstering inclusive health insurance, IRDAI said in a statement.
“The circular has brought in one place the entitlements in a health insurance policy available to a Policyholder/prospects for their easy reference and also 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, it said.
Faster Cashless Claim Settlement
The master circular pitches for striving towards achieving facilitation of 100 per cent cashless claim settlement in a time-bound manner.
“To decide on cashless authorisation requests immediately and within one hour and final authorisation on discharge from hospital within three hours of request from the hospital,” it said.
Approval for Cashless facility:
- Every insurer shall strive to achieve 100% cashless claim settlement in a time-bound manner. The insurers shall endeavor to ensure that the instances of claims being settled through reimbursement are at a bare minimum and only in exceptional circumstances.
- The insurer shall decide on the request for cashless authorisation immediately but not more than one hour after receipt of the request.
- 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.
Final authorisation for Discharge from the hospital:
The insurer shall grant final authorisation within three hours of receiving the discharge authorisation request from the hospital. In no case, the policyholder must wait to be discharged 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.
In the event of the death of the policyholder during the treatment, the insurer shall:
1. immediately process the request for claim settlement.
2. get the mortal remains (dead body) released from the hospital immediately
Customer-centric Approach
Sanjiv Bajaj, joint chairman & MD, BajajCapital, said that the recent circular by IRDAI, setting a 3-hour time limit for insurers to clear cashless claims, marks a significant step forward in the realm of customer-centric health insurance reforms.
“By mandating faster cashless authorisations and encouraging insurers to offer a wider range of products, add-ons, and riders, IRDAI is demonstrating its commitment to enhancing customer experience and satisfaction. These measures are not only expected to increase the adoption of health insurance across India but also foster higher levels of trust between insurers and policyholders,” Bajaj added.
“With stricter review processes and a focus on maintaining high standards of customer service, IRDAI is ensuring a more transparent and reliable health insurance environment, ultimately benefiting the consumer.”
Wider Choice For Policyholders
Sharing salient features of the master circular, it said, a wider choice to be provided by the insurers by making available products/addons/riders by offering diverse insurance products catering to all ages, regions, medical conditions/ all types of Hospitals and Health Care Providers to suit the affordability of the policyholders.
It also specifies Customer Information Sheet (CIS) which the insurer provides along with every policy document.
It explains the basic features of insurance policies in simple words like type of insurance, sum insured, coverage details, exclusions, sub-limits, deductibles, and waiting periods.
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.
It also talks about providing end-to-end technology solutions for effective, efficient and seamless onboarding of policyholders, renewal of policy, policy servicing, and grievance redressal.
For claim settlements, it said, the policyholder shall not be required to submit any documents rather insurers and TPAs should collect the required documents from the hospitals.
Regarding portability requests on the Insurance Information Bureau of India (IIB) portal, stricter timelines are being imposed for the existing insurer and the acquiring insurers to act.
An insurer is liable to pay Rs 5,000 per day to the policyholder in case ombudsman awards are not implemented within 30 days.
This master circular represents a landmark effort to empower the policyholders, ensuring they receive the highest standards of care and service; fostering an environment of trust and transparency in the health insurance sector.
Grievance Redressal
The insurer is required to have a robust system of grievance redressal process.
The response letter of the insurer in any grievance shall include the contact details of concerned insurance ombudsmen where his/her complaint can be escalated in case, the policyholder is not satisfied by the grievance redressal provided by the insurer.
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