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IRDAI New Health Insurance Guidelines on No-Claim Bonus, Cashless Authorization

IRDAI New Health Insurance Guidelines on No-Claim Bonus, Cashless Authorization

IRDAI’s New Health Insurance Guidelines: Empowering Policyholders and Enhancing Service Standards

In a significant stride towards reinforcing the empowerment of policyholders and bolstering inclusive health insurance, the Insurance Regulatory and Development Authority of India (IRDAI) has issued a comprehensive Master Circular on Health Insurance Products. This new circular consolidates and replaces 55 previous circulars, providing clear and accessible guidelines for policyholders and prospects.

Key Features of the Master Circular

Wider Choice of Health Insurance Products

Insurers are now required to offer a broader range of products, add-ons, and riders. These offerings must cater to all ages, regions, occupational categories, medical conditions, treatments, and all types of hospitals and healthcare providers. This ensures that every policyholder can find a suitable plan within their budget.

Customer Information Sheet (CIS)

Every policy document must include a Customer Information Sheet (CIS), which explains the basic features of the insurance policy in simple terms. This sheet covers the type of insurance, sum insured, coverage details, exclusions, sub-limits, deductibles, and waiting periods, helping customers understand their policies better.

Flexibility in Choosing Add-ons and Riders

Customers can now select products, add-ons, and riders based on their specific medical conditions and needs. This flexibility ensures that policyholders can tailor their health insurance to fit their unique requirements.

Coordination Among Multiple Policies

Policyholders with multiple health insurance policies can choose which policy to use for their claim. The primary insurer, where the claim is first submitted, will coordinate with other insurers to settle any remaining amounts. This ensures smooth and efficient claim processing.

No-Claim Bonus Options

If no claims are made during the policy period, insurers may reward policyholders with a No-Claim Bonus. This bonus can either increase the sum insured or provide a discount on the premium amount, encouraging policyholders to maintain a claim-free record.

Refund for Unexpired Policy Period

Policyholders can cancel their policies at any time during the policy term and receive a refund for the unexpired portion of the premium. This offers flexibility and financial relief if the policy is no longer needed.

Guaranteed Renewability

Health insurance policies are now renewable and cannot be denied based on claims made in previous policy years. Exceptions are made only in cases of proven fraud, non-disclosure, or misrepresentation by the insured. Insurers cannot resort to fresh underwriting unless there is an increase in the sum insured.

Compliance Requirements for Insurers

Technological Integration

Insurers must provide end-to-end technological solutions to ensure effective, efficient, and seamless onboarding of policyholders, renewal of policies, policy servicing, and grievance redressal. This includes facilitating 100% cashless claim settlement in a time-bound manner.

Empanelment of Hospitals

Insurers must empanel all categories of hospitals and healthcare service providers, considering the affordability of different population segments. They must prominently display the list of empaneled hospitals on their websites and specify claim procedures for non-empaneled hospitals.

Prompt Cashless Authorization

Insurers are required to decide on cashless authorization requests immediately, within one hour, and provide final authorization upon discharge within three hours of receiving the hospital’s request. This ensures faster and hassle-free claim processing for policyholders.

Release of Mortal Remains

In the event of a policyholder’s death during treatment, hospitals must release the mortal remains to the relatives immediately, ensuring dignity and respect for the deceased.

Claims Review Committee Approval

No claim can be repudiated without the approval of the Claims Review Committee. This committee must review and decide on the repudiation of every claim, ensuring fairness and transparency in the claims process.

Document Collection by Insurers

Policyholders are no longer required to submit any documents for claim settlements. Insurers and Third-Party Administrators (TPAs) must collect the necessary documents from the hospitals directly.

Stricter Timelines for Portability Requests

For portability requests made through the Insurance Information Bureau of India (IIB) portal, stricter timelines are imposed on both the existing and acquiring insurers to act promptly, ensuring a smooth transition for the policyholder.

Compliance with Ombudsman Orders

If an insurer fails to implement ombudsman awards within 30 days, they are liable to pay the policyholder Rs. 5,000 per day. This ensures accountability and adherence to regulatory decisions.

Ayush Treatment Coverage

Underwriting policies must ensure that Ayush treatments are covered at par with other treatments. Policyholders should have the option to choose their preferred treatment method.

Monitoring TPAs’ Performance

Insurers must monitor the performance of TPAs and make payments only upon satisfactory service discharge. Remuneration or charges paid to TPAs can be clawed back based on customer feedback, which will benefit policyholders.

Options for Policy Withdrawal

In case of product withdrawal, policyholders should be given suitable options to migrate to another product or renew the withdrawn product if renewal falls within 90 days from the withdrawal date.

Free Look Period: A period of 30 days from the date of receipt of the policy document is available to the policyholder to review the terms and conditions of the policy. If unsatisfied, the policyholder has the option to cancel the policy. This option is available for policies with a term of one year or more.

Conclusion

The IRDAI’s Master Circular represents a landmark effort to empower policyholders and ensure they receive the highest standards of care and service. By fostering an environment of trust and transparency, these new guidelines aim to elevate the overall experience in the health insurance sector.

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