Insurance regulator IRDAI has issued a master circular on health insurance repealing as many as 55 circulars, putting in one document all entitlements of the customers and advising insurers to decide on cashless authorisation requests in one hour, grant final authorisation within three hours and not deny policy renewal on the grounds of claims in preceding years.
Urging health insurers to strive towards achieving facilitation of 100% cashless claim settlement by July 31, the Insurance Regulatory and Development Authority of India listed among the compliance measures required by the insurers’ end-to-end technology solutions for effective, efficient and seamless onboarding of policyholders, policy renewal and servicing as well as grievance redressal.
The regulator, in the master circular covering various aspects, wanted the insurers to empanel all categories of hospitals/health service providers considering the affordability of different segments of population. It is also for the insurers to provide wider choice by making available products, addons and riders, diverse insurance products for to all ages, regions, occupational categories, medical conditions/ treatments, all types of hospitals and health care providers.
On the features of the master circular for customers, the regulator said customer information sheet (CIS) listing basic features of the policies in simple words such as type of insurance, sum insured, coverage details, exclusions, sub-limits, deductibles, and waiting periods has to be provided by the insurer. In the event of no claims during the policy period, the insurers may reward the policyholders by providing an option to choose no-claim bonus in the form of increasing the sum insured or discounting the premium amount.
The insurer can deny renewal of the health insurance policy only in case of established fraud or non-disclosure or misrepresentation by the insured. Also, the insurer should not resort to fresh underwriting unless there is an increase in sum insured.
Health insuers will not only have to ensure Ayush treatment is covered under the policy at par with the other treatments but give policyholders option to choose treatment of their choice. Cashless authorisation requests should be decided within one hour of the receipt by the insurers, final authorisation on discharge from hospital within three hours of request from the hospital and in the event of death during the treatment, mortal remains to be released from the hospital immediately, IRDAI said.
“If there is any delay beyond three hours, the additional amount if any charged by the hospital shall be borne by the insurer from shareholder’s fund,” IRDAI said.
“The master circular will simplify insurance buying and servicing process even further. By addressing servicing gaps and eliminating ambiguities through the mandated measures, both prospective customers and existing policyholders will benefit... newly introduced measures such as the processing of cashless authorization requests within one hour, freedom to choose treatment of choice including Ayush-certified therapies and the choice of adjusting No Claim Bonus by discounting future premiums or increasing the sum assured are bound to delight existing policyholders,” said Sharad Mathur, MD and CEO of Universal Sompo General Insurance Company.
He expected the master circular to lead to a marked improvement in health insurance adoption in the near term and facilitate higher transparency and disclosure standards in the sector.
Other aspects covered by the IRDAI master circular include one on the performance of third party administrators. “Payments to be made to the TPAs only upon full discharge of satisfactory service. Claw back of remuneration/charges paid to TPA basis customer feedback, which shall be passed on to the policyholders,” it said.
Also, it will insurers and TPAs and not the policyholder who will collect the required documents from the hospitals for claim settlements, the circular said.
The regulator wanted the insurers to cover technological advancements and treatments in their products such as deep brain stimulation; oral chemotherapy; immunotherapy- monoclonal antibody; robotic surgeries. The insurers should also offer products in accordance with The Mental Healthcare Act, 2017; The Rights of Persons with Disabilities Act, 2016; The Surrogacy (Regulation) Act, 2021; The Transgender Persons (Protection of Rights) Act, 2019; and The HIV and AIDS (Prevention and Control) Act, 2017.
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