Big Update - New IRDAI Rules Released To Ensure Faster Health Insurance Claims

Many insurance companies take a lot of time to process settlement claims and patients have to face problems like extended hospital stays and increased bills due to slow claim processing by insurance companies.

But now the Insurance Regulatory and Development Authority of India (IRDAI) has released a circular to make changes in India's health insurance sector and to bring easy and cashless claims immediately to those who are in need in various situations.

IRDAI Mandates Faster Approval For Cashless Claims Within Three Hours Of A Hospital's Discharge Request

The Insurance Regulatory and Development Authority of India (IRDAI) has now mandated insurers to grant final authorization within three hours of a hospital's discharge request. Any delay beyond three hours means the insurer must cover any additional hospital charges from their own funds.

Immediate Claim Settlement in the Case of Death

In the case of a policyholder's death during treatment, insurers must:

• Immediately process the claim settlement request.
• Release the mortal (body) from the hospital without any delay.

Cashless Claims in a One-Hour Decision for Emergency Cases

IRDAI has instructed insurers to decide on emergency cashless claim requests within one hour. Insurers must establish procedures by July 31, 2024, to achieve this goal, including setting up dedicated help desks at hospitals for cashless requests.

Digital Pre-Authorization for Treatments

Insurers are encouraged to offer pre-authorization processes digitally.

Approval for Claim Rejection

No claim can be rejected without approval from the policyholder's membership committee (PMC) or its sub-group, the Claims Review Committee (CRC). If a claim is partially or fully denied, the insurer must provide detailed reasons, referencing policy terms.

Claims for Multiple Policies

Insurance companies should offer a wide range of insurance products to cover different needs and help customers find affordable options that suit their specific requirements. It means policyholders can choose any policy for claim settlement. If the claim exceeds the coverage, the primary insurer coordinates with other insurers to settle the balance.

Benefit-Based Policies: Policyholders can claim from all policies upon the occurrence of the insured event.

No-Claim Bonus Rewards

Policyholders who have not made any claims can receive no-claim bonus rewards in the following forms at renewal:

• Increase in the sum insured without raising the premium.
• Reduction or discounted premium in the renewal premium.