The Insurance Regulatory and Development Authority of India(Irdai) has made several announcements recently that relate to health insurance claims.
Cases of people not getting paid health insurance claims often make headlines. A survey by the community social media platform Localcircles revealed that 43 per cent faced difficulties in health insurance claims. Such rejections may be happening due to lapses on the part of the insured or the insurer, and the Irdai has been on a mission to tweak rules so that the health insurance claim rules become more seamless for policyholders.
Cashless Everywhere: Cashless treatment is a prime feature of health insurance policies as it does not require the insured to pay any money upfront.
The Cashless Everywhere initiative will ensure that you can get cashless treatment at any hospital of your choice. Usually, an insurer’s cashless network list has about 10-15k hospitals - you can get cashless treatment at any of these hospitals. “But if you want to get treatment at a hospital that’s not a part of this list, you can approach your insurer for approval. One thing to keep in mind is that you should inform your insurer 24 hours in advance in case of planned treatments. This initiative will significantly reduce the burden on customers to arrange last-minute funds for treatment in case of reimbursement,” says Siddharth Singhal, business head - health insurance, Policybazaar.com.
Instant Settlement Of Cashless Claims: Irdai has issued guidelines for all insurers to settle all cashless claims within three hours. “This means that any cashless claim request that customers make will be settled within three hours. The insurer will also have to decide on the cashless claim request within one hour after the submission of a request. The regulator has also advised insurers to set up help desks in hospitals to smoothly settle all cashless claims,” says Singhal. This is expected to significantly reduce the time required in claim settlement.
Reduction In Waiting Period: The Irdai has significantly improved the inclusivity of health insurance by reducing the maximum waiting period for pre-existing diseases from four years to three years. “This means that policyholders with conditions like diabetes or hypertension can now claim treatment costs after a shorter waiting period. Similarly, the waiting period for specific diseases and procedures, such as joint replacement surgery, has also been cut from four years to four years, allowing faster access to necessary treatments,” says Gurpal Singh Dhingra - Joint MD, Prudent Insurance Brokers.
Reduction In Moratorium Period: Earlier, if a customer had continuous health insurance coverage for eight years, the insurer could not dispute any claim on grounds of non-disclosure or misrepresentation (except fraud). This limit has now been reduced to 5 years. “This move will significantly enhance customer confidence and reduce doubts about claim denial,” says Singhal.
Says Pankaj Nawani, CEO, CarePal Secure: “Reducing the moratorium period where insurers cannot contest claims from eight years to five years means they have a shorter window to identify and address any non-disclosure issues, potentially leading to higher claim payouts.”
Removal Of Sublimits On AYUSH Treatment: Additionally, the removal of sub-limits on AYUSH treatments allows policyholders to claim costs for alternative medical treatments, including Ayurveda, Yoga, Naturopathy, Siddha, Unani, and Homeopathy, up to the sum insured. “This broadened coverage provides more treatment options for those seeking non-traditional medical care,” says Dhingra.