A health insurance policy is renewable and can’t not be denied on the ground that claim (s) was made in the preceding policy years, except in case of established fraud or non-disclosure or misrepresentation by the insured
Insurers have grant final authorization within three hours of the receipt of discharge authorization request from the hospital. In no case, the policyholder shall be made to 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 shareholder’s fund
Hyderabad:
In a significant move, the insurance regulator IRDAI has made it mandatory for insurance companies to increase the sum insured or discounting the premium amount In case of no claims by the customers during the policy period.
Emphasizing 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, the regulator has issued a comprehensive master circular today on health insurance products repealing 55 circulars.
Salient features of the Master Circular are:
-A policyholder with multiple health insurance policies gets to choose the policy (s) under which he/she can get the admissible claim amount. The primary insurer with whom claim is first submitted will have to coordinate and facilitate settlement of balance amount from the other insurers,
-Policyholder to get refund of premium/ proportionate premium for unexpired policy period, if he chooses to cancel his/her policy at any time during the policy term,
– A health insurance policy is renewable and can’t not be denied on the ground that claim (s) was made in the preceding policy years, except in case of established fraud or non-disclosure or misrepresentation by the Insured. Insurer will not be allowed to resort to fresh underwriting unless there is an increase in sum insured compliance required by them,
-Every insurer has to achieve 100 per cent 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 bare minimum and only in exceptional circumstances. Insurer has to decide on the request for cashless authorization immediately but not more than one hour of receipt of request. Necessary systems and procedures has to be put in place by the Insurer immediately and not later than 31 st July, 2024. Insurers may arrange for dedicated help desks in physical mode at the hospital to deal and assist with the cashless requests. Insurers shall also provide pre-authorization to the policyholder through digital mode,
-Insurers have grant final authorization within three hours of the receipt of discharge authorization request from the hospital. In no case, the policyholder shall be made to 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 shareholder’s fund
-Empanelment of all categories of hospitals /health service providers considering the affordability of different segments of population.
Display prominently on insurer’s website
– list of hospitals/healthcare service providers with whom they have tie up for cashless claim settlement,
– Specify that a policyholder has to file for claim reimbursement in case services are availed in other than empanelled hospitals / healthcare service providers,
-Procedures to be followed for claim settlement under cashless facility and reimbursement of claims
— In the event of death during the treatment, mortal remains to be released from the hospital immediately,
-For claim settlements, the policyholder shall not be required to submit any documents. Insurers and TPAs shall collect the required documents from the Hospitals For portability requests on Insurance Information Bureau of India (IIB) https://iib.gov.in/ portal, stricter timelines being imposed for the existing insurer and the acquiring insurers to act,
-Performance of TPAs to be monitored. Payments to be made to the TPAs only upon full discharge of satisfactory service. Claw back of remuneration/charges paid to TPA basis customer feedback, which shall be passed on to the policyholders,
-No claim shall be repudiated without the approval of PMC or a threemember sub-group of PMC called the Claims Review Committee (CRC). In case, the claim is repudiated or disallowed partially, details shall be conveyed to the claimant along with full details giving reference to the specific terms and conditions of the policy document.
Redressal of Grievances of the Policyholder:
The Insurer is required to have 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
Implementation of Ombudsman Award:
The insurer is required to comply with the award of the Insurance Ombudsman within 30 days of receipt of award by the Insurer. In case the Insurer does not honour the ombudsman award, a penalty of Rs. 5000/- 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.