Final Insurance Authorization In 3 Hours Of Discharge: Revolutionary Changes From IRDAI Health Claims In Master Circular

In a landmark move to enhance policyholder empowerment and streamline health insurance claims, the Insurance Regulatory and Development Authority of India (IRDAI) has released a comprehensive Master Circular on Health Insurance Products, repealing 55 previous circulars. The master circular comes at a time when many policy holders are claiming that the insurance companies are not complying with the regulations. This initiative, according to the insurance regulator, aims to provide a seamless, faster, and hassle-free claims experience while ensuring superior service standards across the health insurance sector.

Every insurer is mandated to strive for 100% cashless claim settlement in a time-bound manner, ensuring that instances of reimbursement-based claims are kept to a minimum and only occur in exceptional circumstances. Insurers must decide on cashless authorization requests immediately, with a maximum timeframe of one hour from receipt. To support this, insurers are required to implement necessary systems and procedures by July 31, 2024. Additionally, insurers may establish dedicated help desks at hospitals to assist with cashless requests and provide pre-authorization to policyholders through digital means.

Insurers must grant final authorization for discharge within three hours of receiving the discharge authorization request from the hospital. Under no circumstances should policyholders be made to wait for discharge due to delays in authorization. If there is any delay beyond the stipulated three hours, any additional charges incurred by the hospital will be borne by the insurer from the shareholder”s fund. In the unfortunate event of a policyholder”s death during treatment, the insurer is required to process the claim settlement request immediately and ensure the release of the mortal remains from the hospital without delay.

No claim can be repudiated without the approval of the Policyholder Management Committee (PMC) or a three-member subgroup called the Claims Review Committee (CRC). If a claim is repudiated or partially disallowed, the insurer must provide the claimant with detailed information, referencing the specific terms and conditions of the policy document. After a claim is initiated, insurers and Third-Party Administrators (TPAs) are responsible for collecting the necessary documents from hospitals, ensuring that policyholders are not required to submit any documents themselves.

Key Features for Policyholders:

1. Wider Product Choice: Insurers must offer a diverse range of products, addons, and riders catering to all demographics, medical conditions, and healthcare providers.
2. Customer Information Sheet: Each policy will include a Customer Information Sheet (CIS), simplifying complex policy details for better understanding.
3. Flexible Product Selection: Policyholders can choose products and addons that suit their medical needs.
4. Multiple Policy Claims: Holders of multiple health insurance policies can choose which policy to claim from first, with coordination for settlement of remaining amounts by other insurers.
5. No Claim Bonus: Policyholders may receive rewards for no claims during the policy period, either as increased sum insured or discounted premiums.
6. Policy Cancellation Refund: Policyholders can get a refund for the unexpired policy period if they cancel their policy.
7. Guaranteed Renewability: Policies are renewable regardless of claims made in previous years, barring fraud or misrepresentation.
8. Ayush Treatment Parity: Ayush treatments are covered on par with other treatments, with policyholders having the option to choose their preferred treatment.

Insurer Compliance Mandates:

1. Technology Integration: Insurers must provide comprehensive technology solutions for policy management and grievance redressal.
2. Cashless Claim Settlement: Insurers are to strive for 100% cashless claim settlement. They must decide on cashless requests within one hour and provide final discharge authorization within three hours.
3. Hospital Empanelment: Insurers must list empanelled hospitals for cashless claims and provide guidelines for claim settlement.
4. Claims Process: Insurers must collect required documents directly from hospitals, with no need for policyholders to submit them.
5. Timely Ombudsman Awards: Insurers must implement ombudsman awards within 30 days, or pay Rs. 5000 per day as a penalty.
6. Claims Review Committee: No claim can be repudiated without approval from the Claims Review Committee.