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30th May 2024 (13 Topics)

IRDAI Introduces New Rules to Speed Up Health Insurance Claims

Context

Delays in settling health insurance claims by insurance companies or third-party administrators (TPAs) have often caused significant stress for patients and their families. To address these issues, the Insurance Regulatory and Development Authority of India (IRDAI) has introduced new rules to streamline the health insurance claim process.

The Need for New Rules

  • Policyholders have frequently faced long waiting times for their health insurance claims to be processed, even when pre-approval was already given before hospital admission.
  • This delay not only causes inconvenience but also imposes extra financial burdens on patients who have to pay for additional nights in the hospital due to claim processing delays.
  • These issues highlight the need for a more efficient and timely claim settlement process.

About the New Rules

  • Time Limit for Approving Cashless Claims: IRDAI has mandated that insurers must grant final authorisation within three hours of receiving the discharge request from the hospital. If there is any delay beyond three hours, the additional amount charged by the hospital will be borne by the insurer from the shareholder’s fund.
  • Immediate Processing in Case of Death: In the event of a policyholder’s death during treatment, the insurer is required to:
  • Immediately process the claim settlement request.
  • Ensure the immediate release of the mortal remains (dead body) from the hospital.
  • Striving for 100% Cashless Claims: IRDAI has directed insurers to achieve 100% cashless claim settlement in a timely manner.
  • Digital Pre-Authorisation Process: Insurers must provide a pre-authorisation process through digital means.

Fact Box: About IRDAI

  • Jurisdiction: Ministry of Finance
  • The Insurance Regulatory and Development Authority of India (IRDAI) is an autonomous and statutory body which is responsible for managing and regulating insurance and re-insurance industry in India.
  • It was constituted under an Act of Parliament in 1999. 

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