All General and Health Insurers (Except AIC &
Subject: Communication on settlement
of Health Insurance Claims
are reports of certain network providers (hospitals) charging high rates and
insisting on cash payments from the policyholders for providing treatment to
COVID-19 infected patients despite having cashless arrangement with Insurers.
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
reviewing cashless requests the Insurers are also advised to ensure that the
policyholders 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.
order to ensure that all network providers extend cashless services to
policyholders and to address any issues causing inconvenience to policyholders 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 policyholders. Insurers are advised to report
levying of excess charges or denial of cashless facility to the respective
State Governments for appropriate action.
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.
has the approval of the Competent Authority.
V S Ramesh)