The Insurance Regulatory and Development Authority of India (IRDAI) has introduced significant changes in the regulatory norms for health insurance policies. These changes are encapsulated in a comprehensive Master Circular on Health Insurance Products, which consolidates all entitlements available to a policyholder into one document, repealing 55 previous circulars.
Faster Claims Processing
- Final Authorization: Insurers must grant final authorization within three hours of receiving the discharge request from the hospital.
- Discharge Waiting Time: Policyholders should not wait for discharge due to pending claims. Any delay beyond three hours means additional charges by the hospital will be borne by the insurer from the shareholder’s fund.
- Death of Policyholder: In the event of the policyholder’s death during treatment, insurers must immediately process the claim settlement and ensure the release of the mortal remains.
100% Cashless Claims
- Immediate Authorization in Emergencies: Insurers should aim for 100% cashless claim settlement, with emergency cases receiving cashless authorization within one hour.
- Implementation Deadline: Necessary procedures to achieve this should be in place by July 31, 2024.
- Dedicated Help Desks: Insurers may establish physical help desks at hospitals to assist with cashless requests.
Wider Choices for Policyholders
- Diverse Insurance Products: Insurers are encouraged to offer a variety of products/add-ons/riders catering to different ages, regions, occupations, medical conditions, treatments, hospitals, and healthcare providers.
- Multiple Policies: Policyholders with multiple health insurance policies can choose under which policy to claim.
Additional Policyholder Benefits
- Customer Information Sheet (CIS): Insurers must provide a CIS along with every policy document.
- No Claim Bonus: Insurers may reward policyholders for no claims during the policy period by either increasing the sum insured or discounting the premium amount.
- Refund of Premium: Policyholders can get a refund or a proportionate premium for the unexpired policy period if they cancel their policy at any time during the policy term.
Survey Findings on Claim Processing
A survey by Local Circles found that 43% of policyholders faced difficulties processing their health insurance claims in the past three years. The process is often time-consuming, with policyholders and their families sometimes spending the last day of hospital admission trying to get their claim processed, leading to additional costs and delays.
Multiple Choice Questions (MCQs):
- What major regulatory document did IRDAI issue to consolidate entitlements in health insurance?
- A) Health Insurance Act
- B) Master Circular on Health Insurance Products
- C) Health Policy Manual
- D) Insurance Handbook
- Within how many hours must insurers grant final authorization after receiving a discharge request from the hospital?
- A) 1 hour
- B) 2 hours
- C) 3 hours
- D) 4 hours
- What should insurers establish at hospitals to assist with cashless requests?
- A) Online portals
- B) Call centers
- C) Physical help desks
- D) Mobile apps
- What options may insurers provide to policyholders for a No Claim Bonus?
- A) Increasing the sum insured or discounting the premium amount
- B) Providing free medical check-ups
- C) Offering gift vouchers
- D) Extending the policy period
- By what date must insurers have necessary procedures in place to achieve 100% cashless claim settlement?
- A) June 30, 2024
- B) July 31, 2024
- C) August 31, 2024
- D) December 31, 2024