The Insurance Regulatory and Development Authority of India (IRDAI) has introduced significant changes to health insurance regulations. In a new Master Circular, IRDAI has mandated that insurers must decide on cashless authorization requests within one hour and complete final authorization for hospital discharge within three hours. This change is expected to greatly enhance the experience for patients and their families.
Faster Discharge and Immediate Settlement
The IRDAI emphasized that policyholders should not face delays when being discharged from the hospital. If there is a delay beyond the three-hour window, any extra charges will be covered by the insurer’s shareholders’ fund. Furthermore, no claim can be rejected without the Claims Review Committee’s approval, which must review all claim rejections.
Streamlined Document Collection and Claim Processing
To ease the claim settlement process, policyholders will not need to submit any documents; insurers and TPAs are responsible for collecting required documents from the hospital. In the unfortunate event of a policyholder’s death during treatment, the insurer must promptly process the claim to release the mortal remains from the hospital.
Policyholder Rights and Protections
The circular ensures policies are portable and prohibits discriminatory underwriting practices. If an ombudsman’s award is not implemented within 30 days, insurers must pay the policyholder Rs 5000 per day. Policyholders can also receive a refund of premiums for the unused policy period if they cancel early. Health insurance policies are renewable and cannot be denied based on claims from the previous year, except in cases of fraud or misrepresentation.
Technological Advancements and Non-Coercive Practices
Insurers are urged to adopt end-to-end technological solutions, including e-cards for policyholders and efficient grievance redressal systems. They must avoid coercive practices concerning hospital selection and provide cashless services for both planned and emergency treatments.
Industry Reaction
Narendra Bharindwal, vice president of the Insurance Brokers Association of India (IBAI), stated that the goal is to achieve 100% cashless claim settlements and streamline the health insurance process.
This comprehensive Master Circular consolidates entitlements available to policyholders and replaces 55 previous circulars.