Insurance Regulatory and Development Authority of India
All General and Health Insurers (except ECGC and AIC),
Re: Norms on settlement of health insurance claims.
1. Reference is invited to the Circular Ref. No. IRDAI/HLT/REG/CIR/054/03/2020 dated 04th March, 2020 wherein all insurers were advised to expeditiously handle the health insurance claims pertaining to COVID 19.
2. Reference is also invited to the provisions of Regulation 27 of IRDAI (Health Insurance) Regulations, 2016 that specified norms on settlement / rejection of claim by insurers. In terms of Regulation 26 of these Regulations, inter alia, insurers shall establish systems, procedures to enable efficient issuance of pre authorisations on a 24 hour basis and for prompt settlement of claims.
3. In light of prevailing conditions owing to COVID 19 as also taking into consideration the need for alleviating the pressure on the healthcare infrastructure all the insurers shall decide health insurance claims expeditiously. In order to ensure all health insurance claims are responded to quickly, insurers are directed to comply with the following timelines:
a. Decision on authorization for cashless treatment shall be communicated to the network provider (hospital) within two hours from the time of receipt of authorization request and last necessary requirement from the hospital either to the insurer or to the TPA whichever is earlier.
b. Decision on final discharge shall be communicated to the network provider within two hours from the time of receipt of final bill and last necessary requirement from the hospital either to the insurer or to the TPA whichever is earlier.
4. Insurers are advised to issue appropriate guidelines to their respective Third Party Administrators.
5. These guidelines are issued under the powers vested with Regulation 27 (vi) of IRDAI (Health Insurance) Regulations, 2016 read with Section 34 (1) of Insurance Act, 1938.
T L Alamelu