INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA
All General and Health insurers (except ECGC and AIC)
Re: Communication on settlement of health insurance claims against General Insurance Council’s instructions dated 20th June 2020 on “Reference Rates for COVID-19”
1. Attention is drawn to the Circular ref: “Reference rates for COVID-19 treatment” dated 20th June 2020 issued by General Insurance Council (GIC).
2. In case of “Cashless Claims” under a health insurance policy, the claims shall be settled as per the tariff decided by the parties in compliance to provisions of Regulation 31 of IRDAI (Health Insurance) Regulations, 2016. However, the insurers shall make efforts to have agreement with health providers on rates for treatment of Covid-19 similar to other diseases for which rate agreements are in place. Also, while entering into such agreements, the reference rate of GI council can be kept in view for guidance alongwith rates fixed by State Governments and Union Territory administration, if any and as relevant.
3. All the insurers are directed to ensure that the “Reimbursement claims” under a health insurance policy shall be settled as per the terms and conditions of the respective policy contract. Hence, the insurers shall honor all the health insurance claims as per the terms and conditions of the policy contract.
4. Insurers are advised to issue suitable guidelines on this to all TPAs.
5. This has the approval of Competent Authority.
(D V S Ramesh)
General Manager (Health)