Every insurer shall strive to achieve 100 per cent cashless claim settlement in a time-bound manner, the Insurance Regulatory and Development Authority of India (Irdai) emphasised in its Master Circular released on Wednesday. The insurance regulator has asked insurance agencies to decide on the request for cashless claims immediately not exceeding ‘one hour’ of receipt of the request. It further notified that necessary systems and procedures have to be established by the Insurer no later than 31st July 2024. “Irdai’s new guidelines setting a 3-hour limit to clear the cashless claim and 1 hour to decide on the cashless authorisation request is a remarkable step towards increasing insurance penetration in India while keeping a customer-centric approach on priority,” says Shashi Kant Dahuja, Chief Underwriting Officer of Shriram General Insurance.
The master circular on Health Insurance products has repealed 55 circulars issued earlier. “It is a significant stride towards reinforcing the empowerment of policyholders and bolstering inclusive health insurance,” Irdai stated in its release.
“We are committed to aligning our health insurance offerings with the Irdai's Master Circular on Health Insurance Business,” Rakesh Jain, CEO, of Reliance General Insurance said highlighting that these steps would guarantee more robust customer protection, comprehensive coverage, and easier access to health insurance, fostering equity and openness throughout the sector.
Customers facing emergencies will no longer have to worry about arranging upfront payments for medical care if they can bank on the faster authorisation process. This would further ensure the insured can focus on their recovery while the caretakers can also take a breather.
“This policy might incentivize hospitals to join cashless networks, giving customers more options when choosing a healthcare provider,” Dhirendra Mahyavanshi, Co-founder and CEO of Turtlemint said.
“The Irdai’s directive to clear cashless claims within three hours and respond to authorization requests within one hour is a game-changer for the health insurance industry,” Sachin Joshi, President – Claims, Liberty General Insurance said. He further noted that this move would ensure that policyholders receive swift approvals, allowing them to access necessary medical treatment without financial delays.
To boost suitability and affordability for the customers, the circular issued by Irdai requires insurers to extend a wide range of insurance products, add-ons, and riders. “These products have to be for people across all ages, regions, occupational categories, medical conditions, and treatments including different types of hospitals and health care providers,” read the norms. In addition to this, insurers have also been advised to provide a Customer Information Sheet (CIS) along with every policy document.
The CIS explains the basic features of insurance policies in simple terms such as the type of insurance, sum insured, coverage information, exclusions of the plans, sub-limits, deductibles, and waiting periods.
The circular mandates that customers should be provided with the flexibility to choose between different products, add-ons, and riders, according to their medical conditions and specific requirements.
“A health insurance policy is renewable and shall not be denied on the ground that claim (s) was made in the preceding policy years, apart from cases such as proven fraud, non-disclosure, or misrepresentation by the insured,” the Irdai stated.
- Insurers must ensure end-to-end tech services for seamless onboarding of policyholders, renewals/servicing of policy, and customer grievance redressal.
- It calls for insurers to ensure 100 per cent cashless claim settlement in a time-bound manner.
- Inclusion of hospitals /health service providers across different categories whilst taking note of the affordability aspect for different customers.
- Provide an updated list of hospitals/healthcare service providers the insurers have tied up for cashless claim settlement
- Insurers must specify if the policyholder has to file for claim reimbursement when services are availed in hospitals/healthcare service providers included in the list
- Insurers must detail procedures to be followed for claim settlement under the cashless facility and claims reimbursements.
- Authorise cashless requests immediately no later than one hour. Final authorization on discharge from the hospital must be cleared within three hours of request.
- Mortal remains should be released immediately in the event of death during the treatment at the hospital.
