The Insurance Regulatory and Development Authority of India (IRDAI) has significantly updated the rules for health insurance policies.
The regulator released a detailed Master Circular on Wednesday (May 29, 2024) on Health Insurance Products, replacing 55 previous circulars. This Master Circular combines all the entitlements available to a policyholder in one place.
One of the major changes introduced by IRDAI aims to provide policyholders with a smoother, faster, and trouble-free claims experience, ensuring better service standards across the health insurance sector.
In its master circular, the IRDAI said that insurers must give final authorization within three hours of receiving the discharge request from the hospital.
“Insurer shall grant final authorization within three hours of the receipt of discharge authorization request from the hospital. In no case, the policyholder shall be made to wait to be discharged from the Hospital,” said IRDAI in the master circular.
The IRDAI also mentioned that if a delay beyond three hours occurs, extra charges by the hospital must be covered by the insurer’s shareholders’ fund.
In case of the policyholder’s death during treatment, the insurer must:
- Process the claim settlement immediately.
- Ensure the release of the mortal remains from the hospital without delay.
100% Cashless Claims
IRDAI said that insurers should aim for 100% cashless claim settlements immediately. In emergencies, insurers must decide on cashless authorization within one hour of receiving the request.
Insurers are also required to implement the necessary procedures by July 31, 2024, to meet this goal. They may set up dedicated help desks in hospitals to assist with cashless requests.
Other Changes
– IRDAI said that insurers should offer a wide range of products, add-ons, and riders to cater to all ages, regions, occupations, medical conditions, treatments, and types of hospitals and healthcare providers.
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– Policyholders with multiple health insurance policies can choose which policy to use for their claims.
– Insurers must provide a Customer Information Sheet (CIS) with every policy document.
– If there are no claims during the policy period, insurers can reward policyholders with a No Claim Bonus, either by increasing the sum insured or offering a premium discount.
– Policyholders can receive a refund or a proportionate premium for the remaining policy period if they choose to cancel their policy at any time during the term.
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