The insurer has to decide on the claim within seven days of receipt of the survey report. This condition will not apply in case of policies issued on the property/building on reinstatement value basis. Any delay in settlement of the claims beyond the above stipulated timelines is a violation of legislation/ regulations. The insurer is liable to be imposed a penalty for such delay, said the IRDAI
Hyderabad: Issuing new directives to the general insurers on customer services, insurance regulator IRDAI has said no claim can be rejected for want of documents and all the required documents need to be called at the time of underwriting the proposal.
The insurer has to decide on the claim within seven days of receipt of the survey report. This condition will not apply in case of policies issued on the property/building on reinstatement value basis. Any delay in settlement of the claims beyond the above stipulated timelines is a violation of legislation/ regulations. The insurer is liable to be imposed a penalty for such delay, cautioned the IRDAI adding that adding that with more flexibility being given to insurers, it is imperative that the policyholders’ interest be safeguarded at all times.
“The customer will not be asked to submit the documents at the time of claim except claim form, and repair bills (only in cases where cashless is not available) and any other document which can’t be collected at the time of underwriting like bank account details, nominee ID proof, wage register, attendance register, stocks register, FIR report, fire brigade report etc etc,” said the IRDAI.
The shift from rule based to principle-based regulations facilitates ease of doing business and encourages innovation, enabling faster adaptation to changing market dynamics and allows for reduction in the response time for emerging market needs, said the IRDAI while issuing the Master Circular on General Insurance on Friday last that had come into force with immediate effect.
This would in turn encourage best practices in product design, pricing and enables provision of seamless journey for the customer, said the IRDAI.
Claims for Retail Customer/Policyholder:
-The retail customer/ policyholder will be informed of the timelines/ Turn Around Times for settlement of claim,
-The allocation of surveyors through the General Insurance Council tech-based solution need to happen within 24 hours of report of claim,
-The surveyor has to submit the survey report to the insurer within seven days of allocation. It will be the duty of the insurer to obtain the survey within the specified time limits.
The insurer cannot repudiate the claim in full or part:
-where the breach of warranty or condition is not relevant to nature or circumstances of loss.
-on account of any delay on part of the policyholder, where such delay has not resulted in the amount of assessed loss being increased
In case of partial loss, the retail customer can’t be burdened with disposal of salvage. The policyholder has to be paid his/ her claim amount. It will be the responsibility of the insurer to collect the salvage from the customer.
The insurers must display the following on their website prominently :
-Turn Around Timelines, acceptance of proposal form, issuing of policies, passing an endorsement, policy servicing, appointment of surveyor, receipt of survey report, claim approvals, settlement of claims, along-with list of products on offer and products withdrawn.
Further, every insurer will have a retail product which is identified and designated as base product defining the necessary minimum coverage in each line of business. The same will be displayed on its website allowing customers to compare with its variants or alternatives.
The regulator has also allowed claim settlement on parametric products. On the basis of specified loss occurrence, the stated limit of liability in parametric cover will be settled without evaluation or measurement of the actual extent or amount of loss or damage incurred.
Insurers have to put in place end to end technology solutions so as to ensure an effective, efficient and seamless onboarding of policyholders, policy servicing, renewal of policy, claim settlement and grievance redressal, said the IRDAI.
Cancellation:
The retail policyholder can cancel the policy at any time during the term, by informing the insurer. In case the policyholder cancels the policy, he/ she is not required to give reasons for cancellation. The insurer can cancel the policy only on the grounds of established fraud or misrepresentation, by giving minimum notice of seven days to the retail policyholder
The insurer will refund proportion premium for unexpired policy period, if the term of the policy is upto one year and there is no claim(s) made during the policy period.
Also the premium for the unexpired policy period has to refunded in respect of policy with the term more than one year and where the risk coverage for such policy years has not commenced.
It is just the reverse on Mediclaim Insurance where premium has gone up but marginally. Further, senior citizens like who have no claim for last 30 years do not get any benefit on GST. It is currently at 18%. It can be reduced to 5% if not completely waived. IRDAI is not serious on its commitment.
Does regulator has TAT for services being rendered by the insurers?
Can these new rules be applied retrospectively?
In respect of ayush treatment, hardly need arises for in-patient treatment and patient get treated on OPD basis and many times treating hospitals do not fulfill this criteria. Under the circumstances is there any way out to get the claim reimbursed as cashless treatment is not allowed.
Exactly.. and these affiliated cashless hospitals also hand in gloves with Insurance companies and agents.. most hospital force insured patients to pay advance. Why 😡😡
Upon asking they give lame reasons of system is down, we are getting confirmation from Insurance company and loot poor helpless patients. Besides their refunds of treatment is so measly or are turned down for any unknown reasons . All are thieves. For old age only dentures are allowed that too peanuts..no other dental treatment.
Same with Eye treatment.
The stipulated guidelines is more theological than possible practically.
Barring small Motor; PA; individuals claims, other claims are not objectively decided as they contain many questionable findings or have unanswered queries.
Unfortunately IRDA has not ever spoken for Fraudulent Claims and penalties on such claimants.
Many claims are tainted and exaggerated which need thorough probing by insurer also.
Insurers are increasing premium for senior citizens’ policies as they can’t opt for other alternative insurers ,and no one will offer them new policy so they are increasing premium arbitrarily and IRDA is also approving it.
I purchased policy in 2018 and now premium is increased by Manipal Cigna by almost by 50%.
Even some companies are not giving policies to seniors having PED, that is highly objectionable. In fact when Pearson is earning, higher premium should be levied and as customer gets old and continue the policy, premium should be decreased in on the basis of claim free years
First of all IRDAI must work on reduction of GST with immediate effect from 18 to 5, to help citizens
Exactly.. and these affiliated cashless hospitals also hand in gloves with Insurance companies and agents.. most hospital force insured patients to pay advance. Why 😡😡
Upon asking they give lame reasons of system is down, we are getting confirmation from Insurance company and loot poor helpless patients. Besides their refunds of treatment is so measly or are turned down for any unknown reasons . All are thieves. For old age only dentures are allowed that to peanuts..no other dental treatment.
Same with Eye treatment.
No one is bothered of these rules and regulations, looks good only on paper only
No heavy penalty on insurers for breach of norms
It is heartening that the IRDA is alive to the market realities and bringing in changes in the regulations.
Health Insurance is one area where unbridled increase in premium is being implemented in the pretext of new policy migration.
Many regulation are imposed by the IRDAI but everything is in papers only. Insureds are toiling a lot to get claims. On other hand hospital bills have no regulations and they impose charges as they like. This factor causes insurance company to increase premium year after year.
Under Mediclaim Policy of NIAC there is a clause by which once in 3 years the policy holder can claim 1 % of the sum assured for health checkup provided there has been no claim during that period. Claims made by me for Rs 1000 (1%) rejected on some specious interpretation in 2022 for health checkup done between 2018 and 2022.NIAC Anna Nagar 712900
Premium should be reasonable , static for senior citizens and GST should be reduced drastically irrespective of age as its social responsibility
Premia in health insurance increasing almost every year, products are withdrawn and forcing to migrate to higher premium products which is against the principle of insurance .unable to understand how IRDA is approving it.
Claims mostly in case of Reimbursement in health insurance taking longtime even after complying with the shortfalls. Asking again & again same documents just to delay the claim.
Appreciable job