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General and health insurers must ensure expeditious settlement of cashless and reimbursement health insurance claims in compliance with policy terms and Service Level Agreements. Insurers must check that network providers charge agreed rates for COVID-19 treatment without levying additional charges or insisting on cash payments. Insurers must establish effective communication channels with network providers for prompt grievance resolution and report excessive charges or denial of cashless facilities to respective state governments. Insurers must also issue suitable guidelines to Third Party Administrators regarding reimbursement claims.
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भारतीय बीमा विनियामक और विकास प्राधिकरण INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA
संदर्भि:आईआरिीएआई/एचएलटी/शर्वशर्वध/सीआईआर/102/04/2021 Ref: IRDAI/HLT/MISC/CIR/102/04/2021
23 अप्रैल, 2021 23rd April, 2021
परिपत्र Circular
प्रशि / To,
सभी साधारण और स्वास्थ्य बीमाकिाभ (एआईसी एर्वं ईसीजीसी के शसर्वाय) All General and Health Insurers (Except AIC & ECGC)
विषय: स्वास्थ्य बीमा दाि ों के विपटाि के सोंबोंध में सूचिा Subject: Communication on settlement of Health Insurance Claims
There are reports of certain network providers (hospitals) charging high rates and insisting on cash payments from the policy holders for providing treatment to COVID-19 infected patients despite having cashless arrangement with Insurers.
In compliance with the provisions of Regulation 31of IRDAI (Health Insurance) Regulations, 2016, the Insurers, in case of “cashless claim” under a health insurance policy, are advised to ensure expeditious settlement of such claims on cashless basis in accordance to the Service Level Agreements (SLAs) entered with hospitals.
While reviewing cashless requests the Insurers are also advised to ensure that the policy holders are charged as per the rates agreed to by network providers wherever applicable. Insurers are also advised to ensure that hospitals do not levy any additional charges for the same treatment other than those rates that are agreed with the insurers.
In order to ensure that all network providers extend cashless services to policy holders and to address any issues causing inconvenience to policy holders while availing cashless service, the Insurers are advised to put in place an effective communication channel with all the network providers for prompt resolution of grievances of policy holders. Insurers are advised to report levying of excess charges or denial of cashless facility to the respective State Governments for appropriate action.
All Insurers are directed to ensure that the “reimbursement claims “under a health insurance policy shall be settled as per the terms and conditions of the respective policy contract expeditiously. Insurers are advised to issue suitable guidelines on this to all TPAs.
This has the approval of the Competent Authority.
हस्ताक्षरित / Sd/- (डी िी एस िमेश / D V S Ramesh) महाप्रबोंधक / General Manager
