Cashless claims within an hour and discharge from hospital in 3 hours says IRDAI's master circular

New Delhi [India], May 30 : The Insurance Regulatory and Development Authority of India (IRDAI) has directed the insurance companies to settle the cashless claims within one hour of hospital admission and the claim settlement with three hours of hospital discharge.
The insurance regulatory IRDAI has issued a Master Circular for health insurance, detailing several key mandates aimed at improving the efficiency and transparency of health insurance services.
The highlights of this circular include many important provisions for both policyholders and insurers. One of the crucial directives is the fast processing of cashless claims. Insurers are now required to approve cashless authorization requests within one hour.
Furthermore, the circular also says that the final authorization upon discharge from the hospital must be completed within three hours of the hospital's request. This is done to reduce the waiting time for patients and streamline the discharge process.
The circular adds that in the unfortunate event of a policyholder's death, the IRDAI mandates that the mortal remains should be released immediately by the hospital, ensuring no unnecessary delays or complications for the grieving family.
Moreover, the circular allows policyholders to cancel their policies at any time during the policy term. In such instances, they are entitled to a refund of the premium for the unexpired policy period on a proportionate basis. This provision offers flexibility and ensures that policyholders are not financially disadvantaged if they choose to terminate their policy prematurely.
Additionally, to ensure compliance with ombudsman awards, the circular mandates that insurers must implement such awards within 30 days. If an insurer fails to do so, they are liable to pay a penalty of Rs. 5000 per day to the policyholder until the award is executed.
An insurance ombudsman award is a binding decision made by an insurance ombudsman within three months of receiving a complaint from an insured. The ombudsman acts as a mediator and makes a fair recommendation based on the facts of the dispute.
If the insured accepts the recommendation as a full and final settlement, the ombudsman informs the insurance company, which must comply with the terms within 15 days.
But If the recommendation doesn't work, the ombudsman passes an award that's binding on the insurance company. The insurer must comply with the award within 30 days of receiving it and notify the ombudsman of their compliance.
The IRDAI circular also addresses the situation when an insurer decides to withdraw a product. In such cases, policyholders must be provided with suitable options to switch to another product, ensuring continuity of coverage without inconvenience.
Transparency in claim settlements is another key focus. Insurers are required to prominently display the list of empaneled hospitals and the procedures for claim settlement. This helps policyholders make informed decisions and understand the processes involved.
The circular reinforces the policyholder's right to renew health insurance policies. Health insurance policies are renewable and cannot be denied renewal except in cases of established fraud. This provides policyholders with a sense of security and continuity in their health coverage.
Overall, the IRDAI's Master Circular introduces various measures to enhance the efficiency, transparency, and fairness of health insurance policies in India. These steps are designed to protect the interests of policyholders and ensure a more responsive and accountable health insurance system.