The Insurance Regulatory and Development Authority of India (IRDAI) has introduced a slew of groundbreaking reforms aimed at streamlining the health insurance claim settlement process and enhancing customer experience. These reforms address long-standing pain points faced by policyholders and aim to foster transparency, efficiency, and trust in the industry.

 

Eliminating Discharge Delays with 3-Hour Claim Approval Mandate

One of the most significant changes introduced by IRDAI is the mandate for insurers to grant final authorization within three hours of receiving a discharge request from a hospital. This move aims to put an end to the nightmarish scenario where policyholders, despite being declared fit for discharge, are forced to wait for extended periods, often incurring additional expenses due to delayed claim approvals.

 

IRDAI has made it clear that policyholders shall not be made to wait for discharge from the hospital, and if there is any delay beyond the three-hour window, the insurer must bear the additional costs charged by the hospital from their shareholder's fund. This measure ensures that policyholders are not burdened with the financial consequences of administrative delays.

 

Expediting Claim Settlement in Emergencies and Facilitating Cashless Processes

Recognizing the urgency of emergency situations, IRDAI has directed insurers to strive for 100% cashless claim settlement in a time-bound manner. In emergency cases, insurers must decide on requests for cashless authorization within an hour of receiving the request. To support this initiative, insurers have been instructed to establish dedicated help desks at hospitals to assist with cashless requests by 31 July 2024.

 

Furthermore, IRDAI has mandated insurers to provide a pre-authorization process to policyholders through digital modes. This measure aims to streamline the claim settlement process, ensuring that policyholders receive prompt acknowledgment and initial sanctions for treatment, subject to final invoice verification.

 

Robust Claim Review Process and Protection Against Arbitrary Rejections

To safeguard policyholders' interests and ensure fairness in claim settlements, IRDAI has mandated that no claim shall be repudiated without the approval of a Product Management Committee (PMC) or a three-member Claims Review Committee (CRC). In cases where a claim is partially disallowed or rejected, insurers must convey the specific policy terms and conditions that led to the decision, providing transparency and enabling policyholders to understand the rationale behind such decisions.

 

This measure is expected to significantly reduce arbitrary claim rejections and ensure that due process is followed, potentially resulting in lower claim rejection rates.

 

Diverse Product Offerings and Portability

IRDAI has emphasized the need for a diverse range of health insurance products to cater to varying age groups, regions, occupations, medical conditions, treatments, and healthcare providers. This diversity aims to empower customers with the ability to choose affordable and suitable schemes based on their unique requirements.

 

Additionally, the regulator has mandated that policies must be portable, and underwriting policies should not discriminate against any particular group. This move promotes inclusivity and facilitates seamless transitions for policyholders, should they wish to switch providers or seek better coverage options.

 

Coordination for Multiple Policy Claims

Recognizing the reality of policyholders holding multiple health insurance policies, IRDAI has introduced guidelines to streamline the claim settlement process in such scenarios. Policyholders will have the option to choose the policy under which they wish to settle claims, with the insurer of that policy being treated as the primary insurer.

 

The primary insurer will be responsible for coordinating and facilitating the settlement of the remaining balance from other insurers, ensuring a seamless and hassle-free experience for policyholders.

 

These groundbreaking reforms introduced by IRDAI are poised to transform the health insurance landscape in India. By addressing long-standing grievances, promoting transparency, and prioritizing customer convenience, the regulator is paving the way for a more reliable, efficient, and consumer-friendly health insurance ecosystem. As the industry adapts to these changes, policyholders can look forward to a heightened sense of trust and confidence in their health insurance providers, ultimately benefiting the overall healthcare sector.