Insurance Regulatory and Development Authority of India
Ref. No: IRDAI/HLT/MISC/CIR/146/06/2020
Date: 10-06-2020
To
All General and Health Insurers (except ECGC and AIC),
and
All Third Party Administrators,
Re: Guidelines on Public Disclosures by Insurers on the qualitative and quantitative parameters of the health services rendered to policyholders
1. All general and health insurers registered with IRDAI rendering health services both through TPA and/or in-house shall make the captioned TPA wise public disclosures in the format specified at Annexure -1. The data in the specified format shall be duly signed by either CEO or one of the Whole Time Directors of the Insurer.
2. The information shall be published within a period of ninety days after the close of every financial year.
3. All TPAs shall provide the link of every insurance company where the said information is available. The link shall be made available in respect of the insurers with whom the TPA had a service level agreement.
4. All TPAs shall also provide the requisite data or information to the Insurers, wherever called for, in order to enable insurers publish the above information in their respective websites.
5. The policyholders desirous of knowing the details referred in annexure-1 shall be able to access all the above information on visiting the website of respective Insurer or the TPA.
6. In case of termination of services of a TPA, the Insurer shall publish the same in its website along with the reasons for termination within three days from the effective date of termination.
7. The above directions shall come into force with immediate effect and data as at 31st March, 2020 shall be published by 30th September, 2020.
8. These guidelines are issued under the powers vested with Section 34(1) of the Insurance Act, 1938 read with Regulation 3 (5) of Insurance Regulatory and Development Authority of India (Third Party Administrators – Health Services) Regulations, 2016.
9. This is issued with the approval of Competent Authority.
(DVS Ramesh)
General Manager (Health)
Annexure-1
PUBLIC DISCLOSURES ON QUANTITATIVE AND QUALITATIVE PARAMETERS OF HEALTH SERVICES RENDERED
(INFORMATION AS AT —–)
NAME OF THE INSURANCE COMPANY: ——–
a. Specify in-house claim settlement (if, data is in respect of in-house claim settlement) / Specify name of the TPA with whom insurer entered into service level agreement (if data relates to the health services rendered by TPA) as may be the case.
[Note: Data shall be consolidated at insurer level in case of in house claim settlements and at the level of the concerned TPA in case of services rendered by TPA.]
(i) Validity of agreement with the TPA: from dd/mm/yyyy to dd/mm/yyyy
b. Number of policies and lives serviced in respect of which public disclosures are made:
| Description | Individual | Group | Government |
| Number of policies serviced | |||
| Number of lives serviced |
c. Information with regards to the geographical area in which services are rendered by the TPAs/insurer (States Names-District names shall be provided) in respect of which public disclosures are made.
d. Data of number of claims processed:
i. Outstanding number of claims at the beginning of the year: —
ii. Number of claims received during the year —-
iii. Number of claims paid during the year: —- (also to specify % in brackets)
iv. Number of Claims repudiated during the year: — (also to specify % in brackets)
v. Number of claims outstanding at the end of the year: —
e. Turn Around Time (TAT) for cashless claims (in respect of number of claims):
| S. No | Description | Individual policies (in %) | Group policies (in %) | ||
| TAT for pre-auth** | TAT for discharge*** | TAT for pre-auth** | TAT for discharge*** | ||
| 1 | Within <1 hour | ||||
| 2 | Within 1-2 hours | ||||
| 3 | Within 2-6 hours | ||||
| 4 | Within 6-12 hours | ||||
| 5 | Within 12-24 hours | ||||
| 6 | >24 hours | ||||
| Total | |||||
*Percentage to be calculated on total of the respective column.
**reckoned from the time last necessary document is received by insurer /TPA (whichever is earlier) and till final pre-auth is issued to the hospitals
***reckoned as final discharge summary sent to hospital from the time discharge bill is received by TPA
f. Turn Around Time in case of payment/repudiation of claims:
| Desc-ription (to be reckoned from the date of receipt of last necessary docu-ment) | Individual | Group | Government | Total | ||||
| Number of Claims | Perce-ntage | Number of Claims | Perce-ntage | Number of Claims | Perce-ntage | No of claims | Perce-ntage | |
| within 1 months | ||||||||
| Between 1 – 3 Months | ||||||||
| Between 3 to 6 Months | ||||||||
| More than 6 months | ||||||||
| Total | ||||||||
*Percentage shall be calculated on total of the respective column
g. Data of grievances received against the TPA:
| S. no. | Description | Number of Grievances |
| 1 | Grievance outstanding at the beginning of year | |
| 2 | Grievances received during the year | |
| 3 | Grievances resolved during the year | |
| 4 | Grievances outstanding at the end of the year |
Place:
Date:
Signature of CEO / Whole Time Director
Name of the Insurer:
