Norms on settlement of COVID-19 health insurance claims

Insurance Regulatory and Development Authority of India

Circular

Ref. No:IRDAI/HLT/MISC/CIR/113/04/2021

Date:29-04-2021

To

All General and Health Insurers (Except ECGC & AIC)

Dear Madam /Sir, 

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

1. Reference is invited to Order dated 28.4.2021 passed by Hon’ble High Court of New Delhi in WP(C) No.5026 /2021 wherein IRDAI was directed to advise Insurers to communicate their cashless approvals to the concerned hospitals/establishments within a maximum time period of 30 to 60 minutes so that there shall not be any delay in discharge of patients and hospital beds do not remain unoccupied.

2. In this regard, attention is invited to circular ref.no. IRDAI/HLT/MISC/CIR/95/04/2020 dated 18.4.2021 wherein a fixed  turnaround time (TAT) of two hours for granting both cashless pre-authorization and for final discharge of the insured patient was specified.

3.In the wake of prevailing conditions of  COVID-19 cases in the form of second wave and in line with aforesaid directions of the Hon’ble High Court, the following directions are issued to all insurers:

a. Decision on authorization for cashless treatment for COVID-19 claims shall be communicated to the network provider (hospital) within a period of 60 minutes from the time of receipt of authorization request along with all necessary requirements from the hospital.

b. Decision on final discharge of patients covered in COVID-19 claims shall be communicated to the network provider within a period of ONE hour from the time of receipt of final bill along with all necessary requirements from the hospital.

4. Notwithstanding the above outer limits of timelines specified, the insurers are advised to process such requests promptly so that both authorisation for cashless treatment and discharge of the patient can be hastened to the maximum extent.

5. The Insurers shall issue appropriate directions to their respective Third Party Administrators for ensuring compliance with the timelines specified above.

6. These guidelines 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 be in force with immediate effect.

Sd/-

(D V S Ramesh)

General Manager (Health)