No More Waiting!! IRDAI Mandates Cashless Claim within an Hour

The Insurance Regulatory and Development Authority of India (IRDAI) has issued a master circular to enhance the claims settlement process, promoting transparency and efficiency in the health insurance sector.

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      Approval for Cashless Facility: New Directive for Insurers

      In a significant move aimed at streamlining the health insurance claim process, the Insurance Regulatory and Development Authority of India (IRDAI) has mandated insurers to achieve 100% cashless claim settlement in a time-bound manner. As per the new directive, insurers must decide on cashless authorization requests immediately, with a maximum turnaround time of one hour from receipt of the request.

      To facilitate this, insurers are required to implement necessary systems and procedures immediately, with full compliance expected no later than July 31, 2024. This includes setting up dedicated Help Desks in physical mode at hospitals to handle and assist with cashless requests, ensuring that policyholders receive prompt and effective support.

      Additionally, insurers are mandated to provide pre-authorization to policyholders through digital modes, further simplifying the process.

      Final Hospital Discharge Authorization for Insurers

      Insurers are now mandated to grant final authorization within three hours of receiving a discharge authorization request from the hospital. Under no circumstances should the policyholder be made to wait for discharge beyond this period.

      1. In cases where there is a delay exceeding three hours, any additional charges incurred by the hospital will be covered by the insurer from the shareholder's fund. This measure is designed to ensure that policyholders are not financially penalized due to delays in the authorization process.
      2. Additionally, in the unfortunate event of the policyholder's death during treatment, insurers are required to:
        • Immediately process the request for claim settlement.
        • Ensure the prompt release of the mortal remains from the hospital.

      Settlement of Claims

      The directive aims to enhance the efficiency of the claims process and ensure that policyholders and their families receive the support they need without unnecessary delays.

      • Claims Review Committee (CRC) Approval: No claim shall be refused without the approval of the Policyholders' Management Committee (PMC) or a three-member sub-group of the PMC known as the Claims Review Committee (CRC).
      • Detailed Explanation for Claim Denials: If a claim is refused or partially disallowed, the claimant will receive a detailed explanation, citing specific terms and conditions from the policy document. This aims to provide clarity and understanding for policyholders.
      • Document Collection by Insurers and TPAs: Insurers and third-party administrators (TPAs) are responsible for collecting the required documents from hospitals, relieving policyholders of the burden of submitting documents. This initiative simplifies the claims process and reduces administrative hassles for policyholders.
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      Disclaimer: The list mentioned is according to the alphabetical order of the insurance companies. Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by any insurer. For complete list of insurers in India refer to the Insurance Regulatory and Development Authority of India website www.irdai.gov.in

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      *We will respond in the first instance within 30 minutes of the customers contacting us. 30-minute claim support service is for the purpose of giving reasonable assistance to the policyholder in pursuance of the claim. Settlement of claim (including cashless claim) is the responsibility of the insurer as per policy terms and conditions. The 30- minute claim support is subject to our operations not being impacted by a system failure or force majeure event or for reasons beyond our control. For further details, 24x7 Claims Support Helpline can be reached out at 1800-258-5881.

      *Product information is authentic and solely based on the information received from the Insurer. Policybazaar is acting only as a facilitator and claims settlement shall be at the sole discretion of the Insurer. Policybazaar does not provide any medical or surgical advice or diagnosis and is not responsible for your interactions / treatment by a medical practitioner/hospital. Please consult a registered medical practitioner for any medical or surgical advice. The Information that you obtain or receive from Policybazaar, and its employees, or otherwise on the Website is for informational purposes only. As per the Insurance guidelines, you are allowed to cancel the policy with-in 30 days from the date of Issuance of policy.This option is available incase of policies with a term of one year or more.

      *All the health insurance plans cover hospitalization expenses including COVID-19 treatment cover up to the specified limits. You can also buy specific COVID-19 health insurance policies such as Corona Kavach Policy and Corona Rakshak policy.

      **All savings and online discounts are provided by insurers as per IRDAI approved insurance plans. #Tax Benefits are subject to changes in tax laws. GST Exemptions depend on fulfilment of qualification criteria and submission of relevant documents.

      *₹1748/month is the starting price for a 1 crore health insurance for an 18-year-old male, with no pre-existing diseases. Discount on renewal premium is subject to the number of wellness points earned in the health insurance policy. For more details about the plans, please read the sale brochure carefully to get upto 100% discount on renewal premium.

      *₹400/month is the starting price for ₹ 5 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

      *₹541/month is the starting price for ₹ 10 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

      *₹762/month is the starting price for ₹ 1 Crore Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

      *₹243/month(₹ 8/day) is the starting price for a 5 lakh health insurance for a 20-year-old male, non-smoker, living in Bengaluru with no pre-existing diseases

      *₹2020/month is the starting price for ₹ 1 Cr Health insurance for a 50 year old male & 50 years old female, living in Bangalore with no pre-existing diseases rounded off to nearest 10.

      *₹390/month (₹13 per day) is starting price for 1 cr. Health insurance for 25 years old male, with pre-existing diseases, residing from tier 1 city rounded off to the nearest 10.

      *No medical tests are required unless requested by the insurer’s underwriter. In-case of pre-existing diseases relevant medical proof would be required as per the terms and condition of the policy opted.

      *The values taken for effective cost calculation are indicative values and may change as per the selected plan.

      *Coverage upto double the amount of Sum Insured is available on certain covers for a minimum plan of Rs. 5 Lakh on the first claim only to an individual of upto 45 years of age with no pre-existing diseases. The benefit is available with or without extra cost depending on the plan chosen.

      *Coverage of pre-existing diseases is provided by insurer as per their underwriting policy.

      *The scope of coverage may vary from plan to plan.

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