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IRDAI has issued a master circular, 100% cashless claim, and authorization within 1 hour


IRDAI has issued a master circular regarding health insurance. In this, special attention has been given to the interests of policyholders. It has been said in the circular that there should be an attempt for a 100% cashless claim and its decision has to be taken within 1 hour.

Insurance regulator IRDAI has issued a master circular regarding health insurance. Let us understand the main points of this circular in detail. In this circular, special attention has been given to the interests of policyholders. Under the circular, if the policyholder has not taken any mediclaim for the whole year, then the insurance company can give him a No Claim Bonus. As a Claim Bonus, the health insurance company can either increase the sum insured or give a discount on the premium. It has been said to give time bound 100% cashless claim.

Refund of premium for the remaining tenure on cancellation of policy

If a policy holder cancels his health insurance policy, then the insurance company should refund the premium for the unexpired policy period. The insurance company cannot refuse to renew the policy saying that the claim has been taken last year. The health insurance company will not do fresh underwriting while renewing the policy if the policy holder has not increased the sum insured.

Can claim from the policy of his choice

If a policy holder has multiple health insurance policies, then it is the policy holder's choice from which policy he takes the claim. The health insurance company with which the policy holder files the claim will settle the said claim with the other health insurance companies of the policy holder. The policy holder himself will not do this.

Freedom to choose rider while buying the policy

While buying a health insurance policy, the customer has the freedom to choose the product or add on or rider according to his medical condition. While purchasing the policy, the insurance company will give the customer a customer information sheet in which the policy will be explained in clear terms, stating what is included in the policy and what is not.

Companies should focus on technology advancement

Health insurance companies will give customers the option of various products that suit their age, health condition, hospital choice, pocket etc. Health insurance companies should provide end to end technology solution to the customers so that all services like on-boarding, claim fining and renewal are easy for the policy holder.

Efforts should be made to provide 100% cashless claim

Every health insurance company should try its best to provide 100% cashless claim. Companies should settle the cashless authorization request within 1 hour and final authorization at the time of discharge within 3 hours. Health insurance companies should tie up with hospitals or health service providers keeping in mind each individual group. There should be a clear list on the website of the insurance company with which hospitals the company has a tie-up.

List of tie-up hospitals should be put on the website

Health insurance company should make it clear on its website that if the hospital is outside its tie-up, then how the policy holder should file claim reimbursement. The method of getting claim through cashless or reimbursement should be explained properly on the website of the health insurance company.

Claim will not be rejected without approval of Claim Review Committee

Health insurance company will not reject any claim without approval of Claim Review Committee. Health insurance companies will take the documents required for claim settlement from TPA or hospital - not from the policy holder. If the health insurance company does not settle the claim after the decision of the ombudsman, then a penalty of Rs 5000 per day will be imposed.

Insurance company should keep an eye on TPA performance

Ayush will be considered in the underriding policy. It is the decision of the policy holder to choose what kind of treatment for his treatment. Health insurance company should keep an eye on the performance of TPA and settle the payment with him after the service is completed.