Introduction
The Insurance Regulatory and Development Authority of India (IRDAI) has issued a groundbreaking Master Circular that promises to revolutionize health insurance services in India. This new circular introduces several key mandates aimed at enhancing the efficiency, transparency, and fairness of health insurance policies. Here’s a look at the most important changes and what they mean for policyholders and insurers alike.
Speeding Up Cashless Claims
One of the most notable directives in the circular is the fast-tracking of cashless claims. Insurers are now required to approve cashless authorization requests within one hour of hospital admission. Additionally, insurers must finalize the authorization for cashless claims within three hours of receiving a discharge request from the hospital. This initiative aims to significantly reduce the waiting time for patients, ensuring a smoother and quicker discharge process.
Immediate Release of Mortal Remains
In the unfortunate event of a policyholder’s death, the circular mandates that hospitals must release the mortal remains immediately, without any unnecessary delays. This provision ensures that grieving families do not face additional stress during such difficult times.
Policy Cancellation and Refunds
Policyholders now have the flexibility to cancel their health insurance policies at any time during the policy term. If they choose to do so, they are entitled to a refund of the premium for the unexpired period on a proportionate basis. This change offers greater financial flexibility and ensures that policyholders are not disadvantaged if they need to terminate their policy prematurely.
Compliance with Ombudsman Awards
To ensure that insurers adhere to ombudsman awards, the circular stipulates that these awards must be implemented within 30 days. Failure to comply will result in a penalty of Rs. 5000 per day payable to the policyholder until the award is executed. This provision reinforces the accountability of insurers and safeguards the interests of policyholders.
Transparency in Claim Settlements
The circular emphasizes transparency in claim settlements by requiring insurers to prominently display the list of empanelled hospitals and the procedures for claim settlement. This helps policyholders make informed decisions and understand the processes involved in their claims.
Renewal Rights and Continuity of Coverage
Health insurance policies are renewable and cannot be denied renewal except in cases of established fraud. This provides policyholders with a sense of security and continuity in their health coverage. Additionally, if an insurer decides to withdraw a product, policyholders must be provided with suitable options to switch to another product, ensuring uninterrupted coverage.
Emergency and Pre-authorization Processes
In emergency cases, insurers must decide on cashless authorization requests within one hour. Insurers are also encouraged to provide a pre-authorization process through digital means, allowing the initial amount to be sanctioned promptly, with the claim being paid subject to the final invoice from the hospital.
Implementation Deadline
Insurers have until July 31, 2024, to put the required infrastructure in place to facilitate these changes. This deadline ensures that all the necessary systems and processes are ready to support the new mandates effectively.
Conclusion
The IRDAI’s Master Circular introduces a host of measures designed to improve the efficiency, transparency, and fairness of health insurance in India. By speeding up cashless claims, ensuring immediate release of mortal remains, offering policy cancellation flexibility, and enforcing compliance with ombudsman awards, the circular aims to protect the interests of policyholders and create a more responsive and accountable health insurance system. These changes mark a significant step forward in the ongoing effort to elevate healthcare services in India, ensuring that policyholders receive the best possible support and care.
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