Amidst rising claims on account of Covid-19 pandemic, the insurance regulator IRDAI has reminded the insurers about their duties and responsibilities towards policy holders in the matter of claims settlement without fail.
It is essential that all insurers establish procedures to let policyholders get clear and transparent communication at various stages of claim processing. As specified in the relevant regulations, all the insurers should ensure putting in place systems to enable policyholders track the status of cashless requests/ claims filed with the Insurer/TPA through the Website/Portal/App or any other authorized electronic means on an ongoing basis, said the IRDAI..
The status should cover from the time of receipt of request to the time of disposal of the claim along with the decision thereon.
Where claims are processed through TPAs, the insurers are permitted to let their respective Third Party Administrators operationalize the claim tracking mechanism. The policyholders shall be invariably notified in all the communications, the location to track the claim status.
Insurers should ensure that the repudiation of the claim is not based on “presumptions and conjectures”.
Where a claim is denied or repudiated, the communication about the denial or the repudiation should be made only by the Insurers by specifically stating the reasons for the denial or repudiation, while necessarily referring to the corresponding policy conditions. The insurer shall also furnish the grievance redressal procedures available with the Insurance company and with the Insurance Ombudsman along with the detailed addresses of the respective offices. Claims shall be processed in a transparent, seamless and efficient manner within the prescribed timelines, sai the IRDAI..
Insurer should also ensure that the policyholder is provided with granular details of the payments made, amounts disallowed and the reasons for the amount disallowed as specified in the regulations