It is clarified by IRDAI that where insurers have an arrangement with the hospitals for providing cashless facility, such network hospitals are obligated to provide cashless treatment for all treatments including treatment for COVID-19.
Insurance Regulatory and Development Authority of India
Granting cashless facility for treatment of Covid-19
PRESS RELEASE Dated 22.04.2021
There are some reports that some hospitals are not granting cashless facility for treatment of Covid-19 despite policyholders being entitled for the cashless treatment under their Policy. In this regard, it is clarified that where insurers have an arrangement with the hospitals for providing cashless facility, such network hospitals are obligated to provide cashless treatment for all treatments including treatment for COVID-19.
All the Network Providers (hospitals) who havesigned Service Level Agreements (SLA) with general and health insurers have to mandatorily provide cashless facility for any treatment to the policyholders including Covid-19 treatment in accordance with agreed provisions of SLA and terms and conditions of policy contract.
Therefore all policyholders that are entitled to cashless facility at all such network providers (hospital) with whom the Insurance company/TPA has entered into an agreement shall avail the benefit of cashless treatment.
In the event of denial of cashless facility at any such enlisted network providers (hospitals) the aggrieved policyholders may send a complaint to the concerned insurance company. The details and email ids of Grievance redressal officers of insurance companies can be accessed from the website of the insurers or at the following link:
https://www.irdai.gov.in/ADMINCMS/cms/NormalData_Layout.aspx?page=PageNo225&mid=14.2
Insurance companies have also been directed to ensure smooth availability of cashless facility with all the network providers (hospitals) empaneled with them by actively interacting with the hospitals.
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Insurance Regulatory and Development Authority of India
Ref. No: IRDAI/HLT/MISC/CIR/ 99 /04/2021 Date:22-04-2021
Facilitation by the Insurers for Cashless services at network hospitals
To
All General and Health Insurance Companies
Re: Facilitation by the Insurers for Cashless services at network hospitals
1. It has been brought to the notice of the Authority that some hospitals are denying cashless facility to policyholders for treatment of COVID-19 treatment despite having cashless arrangement with the Insurers.
2. Your attention is drawn to the Authority’s circular Ref. No: IRDAI/HLT/MISC/CIR/189/07/2020 dated 14.7.2020 on Provision of cashless facility to the policyholders where in it was specified that the Insurers shall ensure that where the policyholder is notified about availability of cashless facility at the empanelled network provider, the cashless facility at such network provider shall be made available to the policyholders in accordance to the terms and conditions of the policy contract and as per the terms agreed in Service Level Agreement (SLA).
3. Therefore, general and health Insurers shall ensure that all such network provider hospitals extend cashless facility for any treatment to the policyholder including COVID-19 treatment in accordance with agreed provisions of SLA and terms and conditions of the policy contract.
4. Where any network provider denies cashless facility and deviates from agreed terms of the SLA, insurance company shall take an appropriate action against such network providers as provided in SLA in addition to taking up appropriate action as specified in the aforesaid circular.
5. The Insurers have also been directed to ensure smooth availability of cashless facility with all network providers empanelled with them by putting in place continuous communication channel with all the network providers for prompt cashless services and for resolution of grievances of policyholders if any.
6. This has the approval of the competent authority.
Sd/-
D V S Ramesh
General Manager
