IRDAI asks insurers to approve cashless claim in 3 hours: Check all changes

Insurer will be responsible for covering additional charges levied by hospital if the deadline is not met, says IRDAI

Health insurance companies have to do final authorisation for cashless claims within three hours of receiving a patient discharge request from the hospital, the insurance regulator said in a new master circular released on Wednesday.

Policyholders should not be kept waiting to be discharged from a hospital under any circumstance, said the Insurance Regulatory and Development Authority of India (IRDAI). If there is any delay beyond the three-hour deadline, the insurer will be responsible for covering any additional charges levied by the hospital. Insurers have time till July 31, 2024 to put the required infrastructure in place to facilitate these changes.

What are the key changes

Cashless claims approval: Insurers must approve cashless claims within three hours of receiving a discharge request from a hospital.

Additional charges coverage: If there is any delay beyond three hours, any additional charges incurred by the hospital will be covered by the insurer.

In the case of the policyholder’s death during treatment: The insurers will now be required to allow the release of mortal remains from the hospital immediately.

Emergency cases: In emergency cases, the insurer should decide on the request for cashless authorisation immediately, within one hour of receiving the request.

Pre-authorisation process: Insurers are encouraged to provide a pre-authorisation process to policyholders through digital mode, ensuring that the initial amount is sanctioned along with an acknowledgment that the claim will be paid subject to final invoice received from the hospital.

Discount on premium: Health insurance policy-holders will also be able to avail a discount on the premium payable if there were no claims made in the previous year. Customers will be given the option to choose between increasing the sum insured or the discount on the premium at the time of renewal.

No claim bonus: The IRDAI has asked general and health insurance companies to reward the policyholders by giving them ‘No Claims Bonus’ (NCB) in the form of either increasing the sum insured or by offering a discount on the premium amount if they have not made any claims.

At present, no claim bonus is given by offering health insurance policyholders only the cumulative bonus which is an addition to the sum insured.

Premium refunds on cancelling: Customers can cancel their policy at any time during the term and receive a refund of the premium for the remaining period.

Insurers must offer a variety of products, add-ons, and riders to cater to different ages, regions, occupations, medical conditions, treatments, and types of hospitals and healthcare providers.