Hyderabad:
The insurance regulator wants a health insurance claims to be settled or rejected within 30 days from the date of receipt of last necessary document In the case of delay in the payment of a claim, the insurer will be liable to pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate two per cent above the bank rate.
However, where the circumstances of a claim warrant an investigation in the opinion of the company, it should initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the insurer should settle the claim within 45 days from the date of receipt of last necessary document. In case of delay beyond stipulated 45 days, the insurer shall be liable to pay interest at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim
In order to bring in uniformity in the wordings of health insurance policy contracts, the IRDAI on Friday has proposed to standardize some of the general clauses that are commonly incorporated in the health insurance policy contracts of indemnity based health products. With this objective, an exposure draft on "Guidelines on Standardization of General Clauses in Health Insurance Policy Contracts” has been issued by the insurnace regulator.
All stakeholders have been asked to send their comments/suggestions on the proposed guidelines by 25th January, 2020 to the regulator.
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Further, In case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, IRDAI has suggested that the insured person will have the right to require a settlement of his/herclaim in terms of any of his/her policies. In all such cases the insurer chosen by the policy holder will be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen Policy.
Fraud
If any claim made by the insured person,is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the Insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy will be forfeited.
Any amount already paid against claims which are found fraudulent later under this policy shall be repaid by all person(s) named in the PolicySchedule, who shall be jointly and severally liable for such repayment
However,the insurer will not repudiate the policy on the ground of fraud, if the insured person / beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such mis-statement of or suppression of material fact are within the knowledge of the insurer. Onus of disproving is upon the policyholder, if alive, or beneficiaries
The insurer may cancel the policy at any time on grounds of mis-representation non-disclosure of material facts, fraud by the insured personby giving 15 days written notice. There would be no refund of premium on cancellation on grounds of mis-representation, non-disclosure of material facts or fraud.
After the expiry of eight years, no health insurance claim will be contestable except for proven fraud and permanent exclusions specified in the policy contract. The policies would however be subject to all limits, sub limits, co-payments, deductibles as per the Policy contract.
In case of any grievance the Insured Person may contact the company through Website,Toll free,E-mail,Fax,Courier:Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the grievance officer and insurer has to provide the link having details of grievance officer on website.