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Cashless Health Claim Settlement
Context
Starting August 1, 2024, insurance companies in India are mandated to settle health insurance claims through cashless methods. This move by the Insurance Regulatory and Development Authority of India (IRDAI) aims to streamline and expedite the process of hospital bill settlement for policyholders.
Key-highlights of IRDAI’s decision:
- Cashless Settlement: Insurance companies must adopt cashless settlement of health insurance claims, ensuring smoother and faster processing of claims for policyholders.
- Procedures for Insurers: Insurers must establish dedicated Help Desks at hospitals to assist with cashless requests and provide pre-authorization through digital means.
- Timely Settlement: Insurers are encouraged to achieve 100% cashless claim settlement within a specified timeframe, minimizing the need for reimbursement except in exceptional circumstances.
- Claim Processing Timeframe: Insurers are required to decide on cashless authorization requests promptly, within one hour of receipt, and grant final authorization within three hours of discharge authorization from the hospital.
- Compensation for Delays: In case of delays beyond the stipulated timeframe, insurers are liable to cover any additional charges imposed by the hospital from their shareholder's fund.
- Dealing with Mortal Remains: In unfortunate instances of the policyholder's death during treatment, insurers must promptly process the claim and facilitate the release of the mortal remains from the hospital.
What are the likely impacts?
- Positive Impact: The move towards cashless settlement of health insurance claims is expected to alleviate the burden on policyholders, making the process more efficient and less stressful, especially during times of illness or emergencies.
- Reducing Challenges: With a significant percentage of policyholders facing difficulties in processing health insurance claims, the new mandate addresses concerns raised in surveys regarding claim rejection and time-consuming processes.
- Policyholder Rights: IRDAI emphasizes policyholders' rights, including the option to port policies between insurers and ensuring seamless transfer of underwriting details and claim history.
- Regulatory Oversight: The requirement for insurers to seek approval before repudiating claims and the establishment of clear procedures for claim processing aim to enhance transparency and accountability in the insurance sector.
- Improving Accessibility: By eliminating the need for policyholders to submit documents directly, the process becomes more accessible and convenient for individuals seeking health insurance benefits.
Fact Box:Indian Insurance market
Important Government Interventions
Other recent initiatives taken by IRDAI
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