Cashless Facility in Hospitals Cannot Be Denied to Policyholders: IRDAI

The Insurance Regulatory and Development Authority of India (IRDAI) received reports of some hospitals denying cashless treatment facilities to policyholders for coronavirus despite the arrangements made by the insurance companies. Moreover, some of these hospitals are also asking policyholders to make cash deposits. As a result, IRDAI reiterated that hospitals cannot deny cashless facilities to policyholders.

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      As per the provisions of regulation 31 (d) of IRDAI (Health insurance) Regulations, 2016, health and general insurance companies should have an agreement with both private and public healthcare providers and hospitals across the geographical spread. The Insurance Companies are required to publish a (list of the network hospitals) with whom they have a service level agreement shall be published on their websites along with the TPA.

      All General and Health Insurers (Except ECGC and AIC)

      All the Insurance providers in this regard are advised to ensure that where the insured person is notified about the cashless facility at network hospitals, the policy holder should receive cashless hospitalization benefits as per the policy terms and conditions and the Service Level Agreement between the insurer and the hospitals.

      • Therefore, IRDAI has advised the insurance companies to put a grievance redressal mechanism in place to address the issues faced by policyholders relating to the denial of COVID-19 cashless treatment in the listed network hospitals.
      • The insurer shall ensure a well-established communication channel with all the network hospitals for prompt resolution of the issues faced by the policyholders
      • In case any network hospital denies cashless treatment against the agreed Service Level Agreement (SLA), the insurer shall take an appropriate action
      • Also, if the network hospitals misconduct with the policyholders’ interests against the SLA, such instances shall be reported to the concerned State Government agencies. The insurance companies should publish about the actions taken against such hospitals on their website to keep the public informed
      • And all this has the approval of the competent authority

      The details and email ids of Grievance redressal officers of Insurers can be accessed from their website.

      IRDAI has directed the Insurance companies to ensure smooth cashless treatment to the policyholders in all the network hospitals as per the agreed policy terms.  

      Therefore, it is clear that the policyholders can avail cashless facility in all the network providers’ or hospitals that are registered with the insurer as per the norms of the Service Level Agreement (SLA)

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