Irdai mandates health insurers to decide on cashless claims within 1 hour

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Regulator Irdai on Wednesday released a master circular on health insurance specifying that an insurer will have to decide on cashless authorization within one hour of request.

The master circular on Health Insurance products repeals 55 circulars issued earlier and it is a significant stride towards reinforcing the empowerment of policyholders and bolstering inclusive health insurance, Irdai said in a statement.

"The circular has brought in one place the entitlements in a health insurance policy available to a Policyholder/prospects for their easy reference and also emphasizes 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, it said.

Sharing salient features of the master circular, it said, wider choice to be provided by the insurers by making available products/addons/riders by offering diverse insurance products catering to all ages, regions, medical conditions/ all types of Hospitals and Health Care Providers to suit the affordability of the policyholders.

It also specifies Customer Information Sheet (CIS) which is provided by the insurer along with every policy document.

It explains the basic features of insurance policies in simple words like type of insurance, sum insured, coverage details, exclusions, sub-limits, deductibles, and waiting periods.

In case of no claims during the policy period, the insurers may reward the policyholders by providing an option to choose such No Claim Bonus either by increasing the sum insured or discounting the premium amount.

The master circular pitches for striving towards achieving facilitation of 100 per cent cashless claim settlement in a time bound manner.

"To decide on cashless authorization requests immediately and within one hour and final authorization on discharge from hospital within three hours of request from the hospital," it said.

It also talks about providing end-to-end technology solutions for effective, efficient and seamless onboarding of policyholders, renewal of policy, policy servicing, and grievance redressal.

For claim settlements, it said, the policyholder shall not be required to submit any documents rather insurers and TPAs should collect the required documents from the hospitals.

With regard to portability requests on the Insurance Information Bureau of India (IIB) portal, it said, stricter timelines being imposed for the existing insurer and the acquiring insurers to act.

An insurer is liable to pay Rs 5,000 per day to the policyholder in case ombudsman awards are not implemented within 30 days.

In the event of death during the treatment, it said, mortal remains to be released from the Hospital immediately.

This master circular represents a landmark effort to empower the policyholders, ensuring they receive the highest standards of care and service; fostering an environment of trust and transparency in the health insurance sector, it added.