The Insurance Regulatory and Development Authority of India (IRDAI) has made significant modifications to the regulatory framework for health insurance products. The regulator released a comprehensive Master Circular on Health Insurance Products, abolishing 55 circulars. The Master Circular contains a comprehensive list of all the privileges available to Policyholders under a health insurance policy.
One of the primary reforms implemented by the IRDAI is a move aimed at offering a seamless, speedier, and hassle-free claims experience to policyholders purchasing health insurance policies and assuring improved service standards across the health insurance market.
According to IRDAI's master circular, the insurer must issue final approval within three hours of receiving the hospital's discharge request. "In no case shall the policyholder be required to wait to be discharged from the hospital," IRDAI stated in a master circular dated May 29, 2024.
The agency also stated: "If there is any delay beyond three hours, the additional amount if any charged by the hospital shall be borne by the insurer from shareholder's fund."
The insurance regulator stated that in the event of the policyholder's death during treatment, the insurer will
i) Respond immediately to the request for claim settlement.
ii) Have the mortal remains (dead corpse) released from the hospital right away.
100% Cashless Claims
The IRDAI stated that insurers should endeavor to achieve 100% cashless claim settlement in a timely way. In an emergency, the insurer should respond to the request for cashless authorization within one hour of receiving it. To reach this goal, IRDAI also requested that insurers put in place the essential producers as soon as possible, by July 31, 2024. The insurers may set up dedicated support desks in physical mode at the hospital to handle and assist with cashless requests.
Other Modifications
> IRDAI also stated that insurers should provide policyholders with more options by offering diverse insurance products catering to all ages, regions, occupational categories, medical conditions/treatments, all types of hospitals, and health care providers.
> A policyholder with various health insurance policies can select the policy under which he or she can receive the admissible claim amount.
> Insurers will be required to furnish a Customer Information Sheet (CIS) with each policy document.
> If there are no claims during the policy period, insurers may reward policyholders by offering a No Claim Bonus, which can be used to increase the total covered or to reduce the premium amount.
> If the policyholder chooses to cancel his or her insurance at any time throughout the policy term, he or she will get a refund of the premium/proportionate premium for the remaining policy period.
Policyholders & Health Insurance
Previously, a Local Circles poll indicated that 43 percent of insurance policyholders had difficulty submitting their "health insurance" claims during the last three years on average.
According to the report, the procedure of claiming health insurance is incredibly time consuming, with many policyholders and their family members scurrying around on the last day of their hospitalization trying to get their claim filed.
"In numerous situations highlighted by policyholders, it took 10-12 hours after the patient was ready for discharge before they were discharged because their health insurance claim was still being processed. If they need to stay at the hospital for another day, they must pay for the extra night's stay. Several patients have reported that their insurance company has previously submitted a pre-approval to the hospital's TPA desk prior to the patient's admittance."
