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IRDAI enforces strict measures to expedite health insurance claims

IRDAI tightens rules on health insurance claims

A latest opinion poll found out that about 42% of the policy holders across health insurance policies experienced major challenges while making claims after availing treatment. Due to this, the Insurance Regulatory and Development Authority of India (IRDAI) has come up with strict measures to reduce such hurdles.

IRDAI’s plan

IRDAI has developed a long-term strategy to tackle the problem and be ready to meet the demand for prompt claim settlements. These changes must be made by July 31, 2024. New processes would improve the current health insurance policy experience of all health policyholders starting August 1, 2024. The major amendment is the requirement to make all claims truly cashless. Thus, insurance firms will have to pay all the costs of treatment on behalf of policyholders. The system of paying and applying for reimbursement with complete sets of papers, which often involved weeks of waiting, is to be completely stopped.

To ensure this, IRDAI has required the presence of help desks in the various hospitals offering medical services to offer the necessary help to policyholders. These help desks will guarantee that formulation and processing of the entire claims process takes not more than three hours. Their insurance carriers are forced to compensate these extra charges if they occur and if the delay arises in the hospitals.

A comprehensive strategy

Additionally, IRDAI’s master circular requires insurance companies to pre-authorize treatments within one hour of receiving a cost estimate from the hospital. This ensures that patients can begin their treatment without delay. Hospitals will send an estimated cost draft to the insurance company upon a patient’s arrival, and the company must confirm coverage within the stipulated time.

The regulations also specify discharge procedures. Insurance companies must provide final approval for discharge within three hours, ensuring that patients are not held up due to financial issues. In a situation where the policy holder has expired, the insurance company is obliged to effect payment immediately. The hospital cannot hold the body due to inability to pay the hospital bills.

With a view to making the claims process less cumbersome and more transparent, these new regulating measures carried by the IRDAI will create a considerably improved health insurance environment for policyholders.

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