“All the insurers shall ensure putting in place systems to enable policyholders track the status of cashless requests/claims filed with the insurer/TPA through the website/portal/app or any other authorised electronic means on an ongoing basis.
“The status shall cover from the time of receipt of request to the time of disposal of the claim along with the decision thereon,” said the regulator.
The circular on ‘Health Insurance Claims Settlement’ is addressed to life, general and standalone health insurance companies including the third party administrators (TPAs).
In case the TPAs are settling the claims on behalf of the insurers, policyholders should be notified about all the communications as well as location to track the claims, Insurance Regulatory and Development Authority of India (Irdai) said.
Irdai has asked the insurance companies to ensure that repudiation of the claim is not based on “presumptions and conjectures”.
“As specified in the IRDAI (Health Insurance) Regulations, 2016, where a claim is denied or repudiated, the communication about the denial or the repudiation shall be made only by the insurer by specifically stating the reasons for the denial or repudiation, while necessarily referring to the corresponding policy conditions,” Irdai said.
The authority has said insurers should ensure that policyholders are provided granular details of the payments, amounts disallowed and the reasons for the amount disallowed, as per the regulatory norms.
Besides, they should also furnish the grievance redressal procedures available with them and the insurance ombudsman along with detailed addresses of the respective offices.
Claims shall be processed in a transparent, seamless and efficient manner within the prescribed timelines.
“Insurers and TPAs, wherever applicable, are advised to ensure compliance of these instructions without fail,” Irdai said.
The directions are not applicable on the two specialised PSU insurers — AIC and ECGC — that work in crop insurance and export credit insurance sector respectively.
