IRDAI new norms: Enhancements in cashless facilities and claim settlements
June 10, 2024
The latest IRDAI norms aim to provide policyholders with a smoother, faster and hassle-free claims experience and ensure improved service standards across the health insurance sector.
Health and Benefits|Benessere integrato|Ukupne nagrade |Global Benefits Management|Inclusion-and-Diversity
N/A
The Insurance Regulatory and Development Authority of India (IRDAI) has introduced new norms recently with an aim to enhance the efficiency and convenience of the cashless facility and claim settlement process. These changes are designed to provide policyholders with a seamless experience during medical emergencies. Salient features include:
Approval for cashless facility
100% cashless claim settlement: All insurers are now mandated to aim for 100% cashless claim settlements, minimising instances of claims being settled through reimbursement. This approach is to be followed stringently, ensuring reimbursement in only exceptional circumstances.
Quick cashless authorisation: Insurers must decide on cashless authorisation requests within one hour of receipt. The necessary systems and procedures to facilitate this must be in place by July 31, 2024.
Help desks at hospitals: Dedicated help desks will be arranged in physical mode at hospitals to help with cashless requests, ensuring policyholders receive prompt support.
Digital pre-authorisation: Insurers will also provide pre-authorisation through digital modes to enhance accessibility and speed.
Final authorisation for discharge from hospital
Timely discharge authorisation: Insurers are required to grant final discharge authorisation within three hours of receiving the discharge request from the hospital. Any delay beyond this period will result in the insurer bearing any additional charges incurred.
Immediate claim processing in case of death: In unfortunate events where the policyholder passes away during treatment, insurers will immediately process the claim and ensure the release of the mortal remains without any delay.
Claim settlements
Claim repudiation protocol: No claim can be repudiated without the approval of the Policyholders' Medical Committee (PMC) or a three-member sub-group called the Claims Review Committee (CRC).
Detailed communication on claim decisions: In cases where a claim is repudiated or partially disallowed, detailed explanations will be provided to the claimant, referencing the specific terms and conditions of the policy.
Document collection by insurers and TPAs: Post intimation of a claim, insurers and Third-Party Administrators (TPAs) will collect required documents directly from hospitals. Policyholders are not required to submit these documents themselves.
Looking forward: Initial adjustments and alignment
These are new initiatives and may involve initial challenges as various entities within the healthcare and insurance ecosystem align to meet the said objectives. The implementation of these norms will require coordination and adjustment across multiple stakeholders, including insurers, hospitals and TPAs. We at WTW are committed to navigating these challenges and ensuring that the transition is as smooth as possible for policyholders.
These measures are set to significantly empower policyholders, improve the claim settlement process, ensuring a more transparent, quicker and efficient service for them. We are committed to implementing these norms that help in promoting trust and transparency in the health insurance sector.
Please feel free to download a brief flyer which outlines the new norms, enhancements and changes for your reference. Should you have any questions or need any further assistance, please do not hesitate to reach out to our client management team assigned to your account or write to wtwindia@wtwco.com. The WTW team is available and happy to help you.
