Insurance companies will have to go for cashless settlement of health insurance claims from August 1 this year, making hospital bill settlement of policyholders smoother and faster. The Insurance Regulatory and Development Authority of India (IRDAI) has said necessary systems and procedures should be put in place by the insurer immediately and not later than July 31, 2024. The regulator said insurers should arrange for dedicated Help Desks in physical mode at the hospital to deal and assist with the cashless requests. “Insurers should also provide pre-authorisation to the policyholder through the digital mode,” it said. Every insurer should strive to achieve 100 per cent cashless claim settlement in a time bound manner, the Irdai said. The insurers should endeavour to ensure that the instances of claims being settled through reimbursement are at bare minimum and only in exceptional circumstances, it said. “Insurer should decide on the request for cashless authorisation immediately but not more than one hour of receipt of request,” it said in the Master Circular on health insurance business. Irdai has said insurer should grant final authorisation within three hours of the receipt of discharge authorisation request from the hospital. In no case, the policyholder should be made to wait to be discharged from the hospital, it said. If there is any delay beyond three hours, the additional amount if any charged by the hospital should be borne by the insurer from shareholder’s fund. In the event of the death of the policyholder during the treatment, the insurer should immediately process the request for claim settlement and get the mortal remains (dead body) released from the hospital immediately, Irdai has said. Claim settlement has been a cumbersome procedure for policyholders. As many as 43 per cent of insurance policyholders had difficulties processing their “health insurance” claims in the last 3 years on an aggregate basis, according to a survey. “Challenges faced ranged from insurance companies rejecting claims by classifying a health condition as a pre-existing condition to only approving a partial amount,” said the survey conducted by LocalCircles. According to majority of those who commented on the subject, the process of claiming health insurance is extremely time consuming with many policyholders and their family members literally spending the last day of their hospital admission running around trying to get their claim processed. “In several cases cited by policy holders on LocalCircles, it took 10-12 hours after the patient was ready for discharge for them to actually get discharged because the health insurance claim was still getting processed,” the survey said. Irdai has said no claim should be repudiated without the approval of Product Management Committee (PMC) or a three-member sub-group of PMC called the Claims Review Committee (CRC). In case, the claim is repudiated or disallowed partially, details should be conveyed to the claimant along with full details giving reference to the specific terms and conditions of the policy document. Pursuant to intimation of the claim, insurers and Third Party Administrators (TPAs) should collect the required documents from the Hospitals. Policyholder shall not be required to submit the documents, the regulator said. According to the Irdai, a policyholder has the choice to port his/ her policies from one insurer to another. The acquiring and the existing Insurers shall jointly, ensure that the entire underwriting details and claim history of the policyholders are seamlessly transferred, it said. The existing insurer should provide the information sought by the acquiring insurer immediately but not more than 72 hours of receipt of request through Insurance Information Bureau of India (IIB). The acquiring insurer should decide and communicate on the proposal immediately but not more than 5 days of receipt of information from the existing insurer. The policyholder is entitled to transfer the credits gained to the extent of the sum insured, no claim bonus, specific waiting periods, waiting period for pre-existing disease, moratorium period from the existing insurer to the acquiring insurer in the previous policy, Irdai said.
