Document Detail

Title: Circular
Reference No.: IRDAI/HLT/MISC/CIR/102/04/2021
Date: 23/04/2021
Communication on settlement of Health Insurance Claims

Ref: IRDAI/HLT/MISC/CIR/102/04/2021

23rdApril, 2021

To

All General and Health Insurers (Except AIC &ECGC)

Subject: Communication on settlementof Health Insurance Claims

1.  Thereare reports of certain network providers (hospitals) charging high rates andinsisting on cash payments from the policyholders for providing treatment toCOVID-19 infected patients despite having cashless arrangement with Insurers.

2.  Incompliance with the provisions of Regulation 31of IRDAI ( Health Insurance )Regulations, 2016, the Insurers, in case of “cashless claim” under a healthinsurance policy, are advised to ensure expeditious settlement of such claims oncashless basis in accordance to the Service Level Agreements ( SLAs) enteredwith hospitals.

3.  Whilereviewing cashless requests the Insurers are also advised to ensure that thepolicyholders are charged as per the rates agreed to by network providerswherever applicable. Insurers are also advised to ensure that hospitals do notlevy any additional charges for the same treatment other than those rates thatare agreed with the insurers.

4.  Inorder to ensure that all network providers extend cashless services topolicyholders and to address any issues causing inconvenience to policyholders whileavailing cashless service, the Insurers are advised to put in place aneffective communication channel with all the network providers for promptresolution of grievances of policyholders. Insurers are advised to reportlevying of excess charges or denial of cashless facility to the respectiveState Governments for appropriate action.

5.  AllInsurers are directed to ensure that the “reimbursement claims “under a healthinsurance policy shall be settled as per the terms and conditions of the respectivepolicy contract expeditiously. Insurers are advised to issue suitableguidelines on this to all TPAs.

6.  Thishas the approval of the Competent Authority.

 

Sd/-

(DV S Ramesh)

GeneralManager

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