All General and
Health Insurers (except ECGC and AIC),
on settlement of health insurance claims.
is invited to the Circular Ref. No. IRDAI/HLT/REG/CIR/054/03/2020dated 04th
March, 2020 wherein all insurers were advised to expeditiously handle the health
insurance claims pertaining to COVID 19.
is also invited to the provisions of Regulation 27 of IRDAI (Health Insurance)
Regulations, 2016 that specified norms on settlement / rejection of claim by
insurers. In terms of Regulation 26 of these Regulations, inter alia, insurers
shall establish systems, procedures to enable efficient issuance of pre
authorisations on a 24 hour basis and for prompt settlement of claims.
light of prevailing conditions owing to COVID 19 as also taking into
consideration the need for alleviating the pressure on the healthcare
infrastructure all the insurers shall decide health insurance claims expeditiously.
In order to ensure all health insurance claims are responded
insurers are directed to comply with the following timelines:
on authorization for cashless treatment shall be communicated to the network
provider (hospital) within two hours from the time of receipt of
authorization request and last necessary requirement from the hospital either
to the insurer or to the TPA whichever is earlier.
on final discharge shall be communicated to the network provider within two
hours from the time of receipt of final bill and last necessary requirement
from the hospital either to the insurer or to the TPA whichever is earlier.
are advised to issue appropriate guidelines to their respective Third Party Administrators.
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,