Insurance regulator IRDAI on Wednesday issued a master circular on health insurance stating that insurers must decide on cashless approval within one hour of the request.
IRDAI said in a statement that the master circular on health insurance products repeals 55 circulars issued earlier and is a significant step forward in empowering policyholders and strengthening comprehensive health insurance.
“The circular brings together rights on health insurance policies in one place for easy reference by policyholders/prospects, provides smooth, fast and hassle-free claims experience to policyholders procuring health insurance policies and ensures enhanced coverage. Emphasizes actions to be taken. It was announced that service standards have been set across the health insurance sector.
Faster, cashless bill payments
A master circular pitch that strives to promote 100% cashless claim settlement on time.
“Cashless approval requests are decided immediately within one hour, and final approval is decided within three hours of the hospital request upon discharge.”
Cashless facility approval:
- All insurers must strive to achieve 100% cashless claims settlement on time. Insurance companies should seek to ensure that claims are covered through compensation to a minimum and only in exceptional circumstances.
- Insurers must decide on cashless authorization requests immediately, but no further. one hour After receiving your request.
- Insurers can set up a dedicated help desk in physical mode in hospitals to process and support cashless requests.
- Insurers must also provide pre-approval to policyholders through digital mode.
Final approval for hospital discharge:
The insurance company will issue final approval within 3 hours of receiving the discharge approval request from the hospital. Under no circumstances should the insured wait until discharge from the hospital.
If there is a further delay three hoursIf the hospital makes a claim, the additional amount will be covered by the insurer from shareholder funds.
If the policyholder dies during treatment, the insurance company will:
1. Process claims for damages immediately.
2. Immediately discharge the body (cadaver) from the hospital
Customer-centric approach
Sanjiv Bajaj, Co-Chairman and MD, BajajCapital, said IRDAI's recent circular setting a three-hour time limit for insurers to process cashless claims marks a significant step forward in the area of customer-centric health insurance reforms.
“By requiring faster cashless approvals and encouraging insurers to offer a wider range of products, add-ons and riders, IRDAI is demonstrating its commitment to improving customer experience and satisfaction. These measures are expected to increase the adoption of health insurance across India as well as increase the level of trust between insurers and policyholders,” Bajaj added.
“With a more rigorous review process and a focus on maintaining high levels of customer service, IRDAI is ensuring a more transparent and trustworthy health insurance environment that ultimately benefits consumers.”
Wide choice for policyholders
The breadth of choice that insurers can offer by making available products/add-ons/riders by offering a variety of insurance products to suit all ages, geographies, health conditions/all types of hospitals and healthcare, while sharing the salient features of the Master Circular. He said he had expanded it. Providers that fit the policyholder’s economics.
It also specifies the Customer Information Sheet (CIS) that the insurer provides with every policy document.
It explains the basic features of the insurance product in simple terms, including type of insurance, amount covered, details of coverage, exclusions, limits, deductibles, waiting period, etc.
If there are no claims during the policy period, the insurer can compensate the policyholder by giving them the option of opting for a no claims bonus by either increasing the sum insured or discounting the premium amount.
It also addresses providing end-to-end technology solutions for effective, efficient and seamless onboarding, policy renewal, insurance servicing and complaint resolution of policyholders.
For claim settlement, policyholders are not required to submit any documents and insurers said TPAs should collect required documents from hospitals.
A stricter timeline is being imposed on existing and acquiring insurers to take action regarding portability requests on the Insurance Information Bureau (IIB) portal of India.
The insurer is liable to pay Rs 5,000 per day to the policyholder if the ombudsman compensation is not fulfilled within 30 days.
This master circular represents a groundbreaking effort to empower policyholders and ensure they receive the highest level of care and service. Creating an environment of trust and transparency in the health insurance sector.
Grievance handling
Insurance companies must have a robust grievance process system in place.
The insurer's response letter to the complaint must include contact information for the applicable Insurance Ombudsman to whom the complaint can be escalated if the policyholder is dissatisfied with the complaint resolution provided by the insurer.