Health insurance norms: Cashless claims must be settled in a three-hour window

Insurance companies (insurers) are now required to clear cashless claims within a three-hour approval time window.

The Insurance Regulatory and Development Authority of India (IRDAI) has introduced a few major changes in the regulatory guidelines for health insurance policies.

In case of delay after the three-hour limit, any additional amount that the hospital charges shall be borne by the insurer from the shareholder’s fund.

Delays in settling health insurance claims by insurers or third-party administrators (TPAs) — intermediaries between insurance companies—the insured, and hospitals have been a cause of concern among patients and their families. This is especially true at the time of hospital discharge.

Also, in the eventuality of the death of the policyholder during the treatment, the insurer shall:

• Immediately process the request for claim settlement.
• Get the mortal remains (body) released from the hospital immediately.

Insurers should aim to achieve 100% cashless claim settlement in a time-bound manner. In emergency cases, the insurer must decide on cashless claims within one hour of receiving the request.

Insurers are required to introduce necessary procedures in place up to July 31, 2024. Insurers could arrange for dedicated help desks in physical mode at the hospital to address and assist with cashless claim requests.

Additionally, insurers are required to provide policyholders with wider choices by making available products, add-ons or riders by offering a range of insurance products directed towards all ages, regions, occupational categories, medical conditions or treatments, all types of hospitals and healthcare providers.

Besides, a policyholder with various health insurance policies gets to choose the policy under which they can receive the admissible claim amount.

Insurers will also need to provide a Customer Information Sheet (CIS) additionally with every policy document.

If there are no claims during the policy period, then the insurers may reward the policyholders. This can be done by providing an option to choose a No Claim Bonus (NCB) either by increasing the sum insured or discounting the premium amount.

Also, the policyholder is liable to get a refund of premium or proportionate premium for the unexpired policy period, if they choose to cancel their policy at any time during the policy term.

These latest norms could introduce a level of trust among policyholders and insurers.