IRDAI mandates insurers to decide on cashless claims in one hour

In some good news to policyholders, the Insurance Regulatory and Development Authority of India has mandated health insurers to decide on cashless claims in one hour and clear the claims within 3 hours. Along with this, IRDAI has also introduced significant reforms aimed at enhancing policyholder experience and inclusivity in the health insurance sector.

Health insurance reforms

The 3 hours window to clear cashless claims measure comes as a part of a broader effort to streamline and expedite the claims process, ensuring policyholders receive timely care. IRDAI's circular replaces 55 previous circulars, consolidating all health insurance entitlements and guidelines for easier reference.

IRDAI emphasized that the circular aims to provide a seamless, faster, and hassle-free claims experience. It requires insurers to offer a diverse range of products, addons, and riders catering to different ages, regions, medical conditions, and types of healthcare providers, thus making health insurance more accessible and affordable.

Additionally, insurers must provide a Customer Information Sheet (CIS) with every policy document, explaining the basic features of insurance policies in clear, simple terms. This includes details on the type of insurance, sum insured, coverage, exclusions, sub-limits, deductibles, and waiting periods.

Policyholders may be rewarded with a No Claim Bonus if they do not make any claims during the policy period. This can be in the form of an increased sum insured or a discounted premium.

The circular also emphasizes achieving 100% cashless claim settlements promptly, with final authorization on hospital discharge within three hours. It advocates for the use of end-to-end technology solutions for policyholder onboarding, renewal, servicing, and grievance redressal.

For claim settlements, policyholders will no longer need to submit documents themselves, as insurers and TPAs are tasked with collecting necessary documentation from hospitals. Additionally, strict timelines for portability requests and penalties for delayed ombudsman awards have been established.

This initiative marks a significant step towards empowering policyholders, ensuring high standards of service, and fostering trust and transparency in the health insurance sector.

[With PTI inputs]

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