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New Era in Health Insurance Faster Approvals and Discharges admin June 5, 2024

New Era in Health Insurance Faster Approvals and Discharges

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New Customer-Friendly Health Insurance: Starting Aug 1
1-Hour Cashless Approvals, 3-Hour Discharge Authorizations

To help ease the pains of running from pillar to post for health insurance policyholders, the insurance regulatory and development authority of India (IRDAI) has asked insurance companies to strive to achieve 100% cashless claim settlement in a time-bound manner w.e.f 1st August'24
 

  • Insurers to decide on the cashless request within an hour and grant final authorisation within three hours after receiving the request.
  • If there is any delay beyond three hours, the additional amount if any, charged by the hospital shall be borne by the insurer from the shareholder's fund.
  • In the event of the policyholder's death during the treatment, the insurer should immediately process the request for claim settlement and get the mortal remains (dead body) released from the hospital immediately.
  • No claim shall be repudiated by the Insurer without the approval of product management committee (PMC) or a three-member sub-group of PMC called the claims review committee (CRC). 
  • Policyholder shall not be required to submit the documents.insurers and third-party administrators (TPAs) should collect the required documents from the hospitals.In case the claim is repudiated or disallowed partially, details should be conveyed to the claimant along with full details giving reference to the specific terms and conditions of the policy document. Pursuant to the intimation of the claim
  • For policyholders who have multiple health insurance from various insurers, the policyholder can file the claim settlement under any policy of choice. The Insurer of that chosen policy shall be treated as the primary insurer. In case the available coverage under the said policy is less than the admissible claim amount, the primary insurer will seek the details of other available policies of the policyholder and should coordinate with other insurers to ensure settlement of the balance amount as per the policy conditions, without causing any hassles to the policyholder.
  • On the occurrence of the insured event, the policyholders can claim from all insurers under all policies.
  • IRDAI has also asked insurers to have a robust system for grievance redressal. The response letter of the insurer in any grievance will include the contact details of concerned insurance ombudsmen where her complaint can be escalated in case, the policyholder is not satisfied by the grievance redressal provided by the insurer. 
  • Further, insurers are required to comply with the award of the insurance ombudsman within 30 days of receipt of the award. In case the insurer does not honour the ombudsman award, a penalty of Rs. 5000 per day shall be payable to the complainant. Such penalty is in addition to the penal interest liable to be paid by the Insurer under The Insurance Ombudsman Rules.
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(Not-for-Profit Institution for Growth & Development of MSMEs)
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Faridabad- 121006, Haryana, India
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E-mail: info@iamsmeofindia.com ; Website: www.iamsmeofindia.com  

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