Insurers cannot reject claims based on presumptions and conjectures: Irdai

Insurers need to put in place systems by which policyholders can track the status of claims, says regulator

The insurance regulator on Friday said that general and health insurance companies cannot reject claims based on “presumptions and conjectures” and have to specify the reason for denial or rejection of claims by referring to the corresponding policy conditions. 

In a circular addressed to the insurers, the regulator said, “Claims shall be processed in a transparent, seamless and efficient manner within the prescribed timelines”. 

And, in the case of rejection or denial of a claim, the insurance company has to provide the policyholders with the grievance redressal procedures of the company as well as the insurance ombudsman, along with the detailed addresses of the respective offices.

Furthermore, insurers have to establish certain procedures by virtue of which policyholders get clear communication from the companies at various stages of claim processing. Insurers have to put in place systems to enable policyholders to track the status of cashless requests/claims filed with the insurer/TPA through the website/portal/app or any other authorised electronic means on an ongoing basis.