Co-payment in health insurance only after netting hospital discounts, says IRDAI

The insurers and the TPAs have been asked by the regulator to mandate the hospitals to reflect such agreed discounts in the final hospitalisation bill of each claim

The Insurance Regulatory and Development Authority of India (Irdai) has said in health insurance policies with co-payment or the deductible conditions, the insurer or the third party administrator (TPA) should ensure that the co-payment or deductible is effected only after netting discounts offered by the hospital, if any.

The regulator said during the course of settlement of claims, either the insurer or the TPA might be obtaining discounts from various network providers or also from other hospitals outside the network. Where by virtue of any agreement, discounts are agreed to be received on the aggregated bills raised by the hospitals, Irdai said every insurer or TPA should appropriately identify and apportion the eligible amount of the discount to the underlying health insurance policy in respect of which the claim is settled so as to pass on the benefits to the concerned policyholder or the claimant.

Insurers have been asked by the regulator to mandate hospitals to reflect such agreed discounts in the final hospitalisation bill of each claim, whereby the policyholder or the claimant can also be aware of the actual bill raised by the hospital.

The above procedures shall be applicable with immediate effect for cashless services and reimbursements.