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Draft regulations on health cover ready

* Irda invites suggestions before issuing final version

Written by ENS Economic Bureau | New Delhi |
June 1, 2012 1:55:37 am

Insurance Regulatory and Development Authority (Irda) has issued a draft Health Insurance Regulations,2012,which is aimed at addressing major issues plaguing health insurance customers. Irda has invited suggestions on the draft regulations till June 30 after which it will issue the final guidelines by July 31.

According to the draft regulation,health insurers will be bound to settle claims within 30 days of receiving documents from the insured. In case insurer decides to reject a claim,it shall do so within 30 days from the receipt of complaints providing specific reasons for the denial. For settlement of claim,insurer must make direct payments to the hospital and to policyholders by integrating their banking platform with the hospital or the insured.

The insured shall also be informed of any loading charged on the premium. Irda has proposed that there should be a one page uncomplicated information sheet “covering key benefits,exclusions and grievance mechanisms” to make insurance forms easy to understand.

The regulator has proposed that all health policies should provide for entry age of at least up to 65 years. Policies shall not have an exit age for renewal once the proposal is accepted,provided policy is continuously renewed without break.

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The insurer shall be responsible for carrying out an empanelment process of hospitals or healthcare providers to provide cashless facility to policyholders. The insurer may include the Third Party Administrator (TPA) as a tri-party in the agreement with the hospital. However,the entire responsibility will lie with the insurer.

Irda’s draft regulations have come on the instruction of Bombay High Court which ordered Irda in December,2011,to display draft guidelines on its website and invite suggestions from consumers and display names and contact details of insurance advisory committee members. The order had come on a PIL filed by a Pune-based insurance activist Gaurang Damani after the TPAs of the public sector insurers stopped providing cashless services to customers.

“Irda has accepted 90 per cent of what we had demanded in the court. It will go a long way in resolving consumer issues of seven crore policyholders in India,” Damani said.

Lifeline for insurers

* All health policies to have entry age of at least 65 years

* Claims to be settled within 30 days of application

* Direct payment into the account of insured

* Non-allopathic medical expenses allowed

* Insurer to give reasons for claim denial in writing

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