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Title: Circular
Reference No.: IRDAI/HLT/MISC/CIR/113/04/2021
Date: 29/04/2021
Norms on settlement of COVID-19 health insurance claims

Ref: IRDAI/HLT/MISC/CIR/113/04/2021 29th April, 2021

To
All Generaland Health Insurers (Except ECGC & AIC)

 

Dear Madam/Sir,

Re:Norms on settlement of COVID-19 health insurance claims

  1. Reference isinvited to Order dated 28.4.2021 passed by Hon’ble High Court of New Delhi inWP(C) No.5026 /2021 wherein IRDAI was directed to advise Insurers to communicatetheir cashless approvals to the concerned hospitals/establishments within amaximum time period of 30 to 60 minutes so that there shall not be any delay indischarge of patients and hospital beds do not remain unoccupied.
  2. In thisregard, attention is invited to circular ref.no. IRDAI/HLT/MISC/CIR/95/04/2020dated 18.4.2020 wherein a fixed turnaround time (TAT) of twohours for granting both cashless pre-authorization and for final discharge ofthe insured patient was specified.
  3. In the wake ofprevailing conditions of COVID-19 cases in the form of second wave andin line with aforesaid directions of the Hon’ble High Court, the followingdirections are issued to all insurers:
    • Decision onauthorization for cashless treatment for COVID-19 claims shall be communicatedto the network provider (hospital) within a period of 60 minutes from the timeof receipt of authorization request along with all necessary requirements fromthe hospital.
    • Decision onfinal discharge of patients covered in COVID-19 claims shall be communicated tothe network provider within a period of ONE hour from the time of receipt offinal bill along with all necessary requirements from the hospital.
  4. Notwithstandingthe above outer limits of timelines specified, the insurers are advised toprocess such requests promptly so that both authorisation for cashlesstreatment and discharge of the patient can be hastened to the maximum extent.
  5. The Insurers shallissue appropriate directions to their respective Third Party Administrators forensuring compliance with the timelines specified above.
  6. Theseguidelines are issued under the powers vested with Regulation 27 (vi) of IRDAI(Health Insurance) Regulations, 2016 read with Section 34 (1) of Insurance Act,1938.
  7. The above instructions shall bein force with immediate effect.
 

Sd/-
(D V S Ramesh)
GeneralManager (Health)

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