The insurance landscape in India has seen a major transformation over the last few years, thanks to the consistent efforts of the Insurance Regulatory and Development Authority of India (IRDAI) which has been efficiently aided by insurers turning it into a concerted effort by all stakeholders. In another landmark move, the regulator came out with a master circular with several consumer-centric reforms in health insurance.

The latest reform is no claim can be rejected due to the lack of documents. To simplify claim process, IRDAI mandated the necessary documents be sought by the insurer at the time of underwriting. Besides, the customers of general insurers are allowed to cancel policy anytime and be refunded for the unexpired policy period, while insurers can only cancel the policy on the grounds of fraud.

Hassle-free claims

The IRDAI had earlier directed while cashless claim must be cleared within a three-hour limit, the decision on cashless authorisation by the insurer has to be made within one hour of the claim request. The Master Circular, which shall be reviewed every year, also lists a number of other initiatives taken by the regulator recently.

The IRDAI circular also mandated all insurers should strive to achieve 100 per cent cashless claim settlement in a time-bound manner and ensure claim settlement through reimbursement mode is done only in exceptional circumstances. It added the ratio of reimbursement claims should be kept to the bare minimum. This directive is in line with IRDAI’s recent ‘Cashless Anywhere’ directive which asked insurers to settle claims in cashless mode even in those hospitals not in their list of network hospitals.

The IRDAI has asked insurers to immediately put in place necessary systems and procedures, by July 31. It said if required, the insurers could put in place dedicated help desks at hospitals to deal with cashless claim requests within stipulated time-frame. Moreover, they should provide digital pre-authorisation to policyholders to facilitate the claims. To address this, the IRDAI said in case the claim is not settled in three hours, any additional costs charged by the hospital would be borne by the insurer from shareholder’s fund.

Impact on sector

The only way this directive can be implemented is through better coordination between insurers and hospitals. Not only operational processes would have to be improved, haring of medical records between different stakeholders would have to be more streamlined to help insurer to take a decision on the claim.

Medical record digitisation is already happening via the National Health Claims Exchange, which is facilitating a more transparent and smooth exchange of information.

Standalone efforts won’t be able to achieve this. It requires a concerted effort on the part of the entire healthcare ecosystem.

The good news is insurers have been showing positive intent to support the regulator in all its efforts to improve the insurance experience for customers. And, hospitals would surely get on board considering it would ensure faster payouts for them too. Timely settlement will eliminate most glitches and go a long way to better healthcare experience of patients and caregivers.

The IRDAI added if policyholder dies during treatment, the insurer must immediately process the request for claim settlement and get the mortal remains released from the hospital immediately. This will surely offer the grieving family some semblance as they deal with a tragic loss. The norms are consumer-centric and prioritise policyholders’ welfare above everything else.

This commendable move is poised to revolutionise the health insurance landscape, ensuring timely and hassle-free claim settlements, enhancing customer satisfaction, and providing inclusive and affordable health insurance solutions for all.

The writer is Business Head, Health Insurance, Policybazaar.com

Related Topics