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General and health insurers must treat government-permitted make-shift or temporary hospitals as hospitals or network providers for COVID-19 treatment claims. Insurers settle claims when a policyholder with a positive COVID-19 diagnosis enters a temporary hospital upon advice from a medical practitioner or a government authority. Insurers also provide cashless facilities when a network provider establishes a temporary hospital, because the temporary hospital counts as an extension of that network provider. Insurers must expedite claims, update their claim guidelines, and inform all Third Party Administrators immediately. These guidelines take effect immediately.
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[Image omitted. See the official document.]
Ref: IRDAI / HLT/ MISC / CIR /190 / 07 / 2020
16th July, 2020
To
All General and Health Insurers (Except ECGC and AIC)
Re: Guidelines on settlement of claims on treatment at 'make-shift or temporary hospitals' as permitted by Government
Reference is invited to IRDAI circular Ref. No: IRDAI/HLT/REG/CIR/054/03/2020 dated 04th March, 2020, specifying guidelines on handling of claims reported under Covid-19.
In view of increase in number of COVID-19 cases, in order to leverage on the extant healthcare systems put in place, it is important to recognise the make-shift or temporary hospitals permitted by Government for settlement of health insurance claims for insurance companies.
In the above backdrop, in order to ensure that the costs of treatment of COVID - 19 are covered as per the terms and conditions of policy contract, a make-shift or temporary hospital permitted by Central / State government shall be regarded as a hospital or network provider and insurers shall settle the claims as per the following norms.
(a) Where a policyholder who is diagnosed as Covid-19 positive is admitted into any such make-shift or temporary hospital on the advice of a medical practitioner or appropriate Government authorities, notwithstanding the definition of hospital specified in the terms and conditions of policy contract, the treatment costs shall be settled by insurers.
(b) Where any network provider has set up any such make-shift or temporary hospital, such make-shift or temporary hospital shall be regarded as the extension of the network provider and cashless facility shall be made available.
Insurers are advised to expedite settlement of all such claims in accordance to the applicable regulatory framework.
All insurers are also advised to incorporate the above norms in claim guidelines and inform to all the TPAs immediately.
These guidelines shall come in to force with immediate effect.
These guidelines are issued under the powers vested with Regulation 27 (vi) of IRDAI (Health Insurance) Regulations, 2016 read with Section 34 (1) of Insurance Act, 1938.
This has the approval of the competent authority.
[Image omitted. See the official document.]
(D V S Ramesh) General Manager (Health)
Sy No. 115/1, Financial District, Nanakramguda, Hyderabad - 500 032 www.irdai.gov.in
