The Insurance Regulatory and Development Authority of India (IRDAI) has cautioned insurance companies not to be transparent to policyholders, rejecting health insurance claims.
“The insurer will ensure that the repatriation of a claim is not based on estimates and estimates,” the IRDAI said in a circular to TPA, along with Life, General and Standalone Health Insurance companies.
IRDAI stated that when a claim is denied or denied, the insurer should, equally, mention the reasons and the same policy conditions. The details of the grievance redressal procedures available with the insurer as well as the Insurance Ombudsman should also be submitted to the policy holders along with the addresses of the respective offices.
In addition to processing claims “in a transparent, uninterrupted and efficient manner within the stipulated deadline”, insurance companies must ensure that the policyholder is provided with details of payments made, reasons for the discounted amount and the disallowed amount . The regulator stated that it is necessary for all insurers to establish procedures for obtaining clear and transparent communication to policyholders at various stages of claim processing.
To enable policyholders to track the status of cashless requests / claims filed with the insurer / TPA through the website / app or any other authorized electronic means to be provided by the insurance companies. General Manager (Health) DVSRamesh said in the circular, the position will be covered from the time of the request as well as the time of settlement of the claim at the time of receipt of the decision.
A circular of Friday has been issued by the regulator advising health insurers to modify existing benefits or add new benefits to existing products, resulting in an increase in premiums. Any additions and upgrades to existing benefits can only be made as an add-on cover or as an optional cover with a standalone premium rate.
Separately, IRDAI asked insurers to make special arrangements to facilitate immunization against eligible policyholders as a group against COVID-19 or individually or as per the choice of policyholders in government or private facilities. The IRDAI stated that the insurer should send a reminder through the pre-booking slot to arrange and take a second shot of vaccination.
A similar arrangement can also be made for all employees of insurance companies, so that they can be immune to future COVID-19 transition.
The regulator did not specify whether the cost of vaccination for those taking shots in private hospitals would be covered under the policies. However, on Thursday, the regulator clarified that “hospitalization is unlikely to occur following adverse reactions to COVID-19 vaccination, subject to the specific terms and conditions of the policy under hospitalized health insurance policies.”
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