What are the New IRDAI Rules for Health Insurance Claim Settlement?

Posted on: Sep 1, 2023 | 3 mins | Written by: HDFC ERGO Team

What are the New IRDAI Rules for Health Insurance Claim Settlement?

Imagine you are all set for a dream vacation, brimming with excitement, when suddenly, out of the blue, a medical emergency strikes. It’s like a plot twist you never saw coming and never wanted. Amid the whirlwind of emotions, you also anticipate the financial burden staring at you. Well, the silver lining here is your health insurance plan that can keep financial woes at bay. Choosing health insurance isn’t a government mandate; it’s your call. You get to pick the policy that aligns perfectly with your needs and budget. But are you placing your faith in the right insurance company? Well, ask the Insurance Regulatory and Development Authority of India (IRDAI). The IRDA-issued guidelines on standardization in health insurance ensure every insurer abides by the rules. Let’s delve deep to understand what’s in it for policyholders.

IRDAI rules for health insurance claims

The IRDAI rules are meant to help both the insurer and the insured in terms of health insurance claims and other services.

Let’s take a look at some of the IRDA-issued guidelines on standardization in health insurance.

1. If a health insurance policy gets renewed on time without any break, it may not have an exit age.

2. Group Health Insurance can be valid for a maximum duration of one year.

3. It is the responsibility of the insurance provider to inform policyholders about the policy terms and conditions for availing of medical treatments in hospitals across India.

4. The insurance provider must give the insured an option to switch to another provider after meeting the exit criteria. The insured must be awarded appropriate credits for renewing the policy without any break.

5. If an application to buy a health insurance policy gets rejected, the insurer must justify the reason in writing.

6. A policyholder must be rewarded if he/she buys healthcare coverage when young, renews the policy on time or gives positive feedback on claims experience with the insurer. The rewards must be clearly mentioned in the policy document.

7. Before issuing the policy, the insurer must give the list of medical facilities, government or non-government, from where the insurance company will accept the medical reports.

8. The premium charged, especially for senior citizen health insurance, should be reasonable, and the same should be clearly communicated to the senior citizens.

IRDAI new rules for claim settlement

The new rules by the IRDAI for claim rejection and claim settlement are listed below.

1. For claim rejection

An insurance company cannot deny a claim raised by a policyholder if he/she has renewed the policy for 8 years without a break. The insurance provider cannot appeal to the IRDAI against settling any claim except in case of fraud or if the event against which the claim gets raised is in the exclusions list of the policy. This 8-year period is called the moratorium period. After the moratorium period, a claim cannot get rejected on the basis of non-disclosure or misinterpretation of facts because the IRDAI gives this period for verifying the information provided by the policyholder.

2. For claim settlement

After you submit the necessary documents for claim settlement and the verification process gets completed, the insurer should settle your claim within 30 to 45 days from the date of submission of all the documents. The time duration can vary based on the nature of the claim. If there’s any delay from the insurer’s end, the insurance company is liable to pay interest on the claim amount at 2% more than the current bank rate. So, based on your health insurance plan and policy terms, the claim amount will be transferred to your account (in case of a reimbursement claim) or to the hospital directly in case of cashless claims.

Inclusion Of Telemedicine Under Health Insurance

During the COVID-19 pandemic, people were asked to use a telemedicine facility wherein patients could consult medical practitioners through online chats, videos, and telephone calls. This was done to prevent the spread of the virus through physical contact. In order to reduce the financial burden on the policyholders and make it accessible to all, IRDAI directed insurance companies to include telemedicine under health insurance.

Here’s what the IRDAI guidelines say:

• Telemedicine will be covered only if the policyholder has opted for outpatient department (OPD) coverage in the base health insurance plan.

• Telemedicine will be a part of the health insurance claim, and a policyholder is not required to file a separate claim.

• Any sub-limits of the healthcare plan will also apply to telemedicine claims.

Conclusion

While purchasing a health insurance policy, it’s important to read the guidelines laid down by the insurance regulator, IRDAI, to enjoy optimum benefits. With the insurance industry undergoing constant changes and upgradation, being aware of the rules and regulations will help you make the right choice, meet all your medical requirements, and keep you financially safe. If you have senior citizens living with you, it’s good to buy senior citizen health insurance with a critical illness insurance add-on. If diagnosed with a critical illness such as cancer, critical illness insurance will provide a lump sum to the insured irrespective of the treatment costs.

Disclaimer: The above information is for illustrative purposes only. For more details, please refer to policy wordings and prospectus before concluding the sales.

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