Introduction
With healthcare prices on the rise, it is now widely believed that having health insurance is essential. Nevertheless, selecting an insurance can be difficult, and policyholders frequently have to deal with a lot of difficulties when their claims are resolved. A new master circular from the Insurance Regulatory and Development Authority of India (IRDAI) attempts to streamline the entire process and benefit the policy holder. “The master circular emphasizes measures towards providing seamless, faster and hassle-free claims experience to a policy holder procuring health insurance policy and ensuring enhanced service standards across the health insurance sector,” the insurance regulator stated. Insurance companies, according to IRDAI, should work toward facilitating 100% cashless claim settlement in a timely way.
The regulator requires the businesses to respond to requests for cashless authorization within an hour. Additionally, the hospital should obtain a final authorization for discharge, and that decision should be made within three hours. In the event that a claim is settled, the policyholder will not be required to provide any documentation, according to IRDAI. Rather, it stated that the necessary paperwork should be obtained from the hospitals by the insurance companies and TPAs (third-party administrators). “No policy and claim of health insurance shall be contestable on any grounds of non-disclosure and/ or misrepresentation except for established fraud, after the completion of the moratorium period, i.e. 60 months of continuous coverage,” stated IRDAI. “The claims review committee’s approval is necessary before any claim can be renounced. a choice to reject each and every allegation,” it continued. In the event that a patient passes away while receiving treatment, the hospital must release their mortal remains right away.
Insurance Regulatory and Development Authority of India (IRDAI)
In most cases, the insurer rewards a policyholder who maintains no claims over the policy period with a no-claims bonus, which takes the shape of a larger sum assured. According to IRDAI, the insurer may provide the policyholder the choice of receiving a no claims bonus by either raising the sum insured or lowering the premium price. Clients must have the freedom to select products, add-ons, and riders based on their needs and medical conditions. Crucially, as per IRDAI, “A health insurance coverage is renewed and cannot be refused based just on the fact that unless there was proof of proven fraud, non-disclosure, or misrepresentation by the insured, no claim was filed in the years prior to the policy.” If a policyholder neglects to renew the coverage, the insurer is required to offer a grace period of thirty days during which the premium can be paid in full each year, in half-yearly increments, or in quarterly installments, with all accumulated credits under the policy.
There will be a grace period of 15 days for policies when premiums are paid on a monthly basis. “In addition, unless there is a rise in the amount insured, an insurer may not pursue new underwriting,” the statement stated. Notably, if the policyholder decides to terminate at any point throughout the policy term, they will also be eligible for a refund of the premium or a prorated cost for the unexpired insurance period term in accordance with IRDAI. In the event that a client wishes to transfer the insurance to a different insurer, the regulator has now established stringent deadlines. If the policyholder does not receive the ombudsman’s award within 30 days, the insurer would be responsible for paying the policyholder Rs 5,000 each day. TPA performance will also need to be observed, according to IRDAI. Payments to the TPAs must only be given when they have completed their work satisfactorily.
Claim back of compensation/fees based on customer feedback paid to TPA, which will be distributed to policyholders,” it emphasized. The policy holder must be offered the choice to switch to other acceptable products or a one-time chance to renew the product if an insurance provider withdraws a specific product. According to IRDAI, the renewal occurs within 90 days of the withdrawal date. In the event that a client wishes to transfer the insurance to a different insurer, the regulator has now established stringent deadlines. If the policyholder does not receive the ombudsman’s award within 30 days, the insurer would be responsible for paying the policyholder Rs 5,000 each day. TPA performance will also need to be observed, according to IRDAI. Payments to the TPAs must only be given when they have completed their work satisfactorily. Claim back of compensation/fees based on customer feedback paid to TPA, which will be distributed to policyholders,” it emphasized. In the event that an insurance provider discontinues a specific product, the policyholder must be offered the opportunity to switch to another appropriate products or a one-time opportunity to renew the product provided it is done within ninety days of the withdrawal date.
A new master circular has been released by the Insurance Regulatory and Development Authority of India (IRDAI) to expedite the processing of health insurance claims. The salient points are as follows:
Cashless Claim Settlement: Insurers must strive for 100% cashless claim settlement within a certain timeframe. Requests for cashless permission should be decided upon right away, ideally within an hour. Within three hours of the request, a final authorization should be determined for hospital discharge. In order to settle claims, policyholders are no longer required to provide documentation; instead, third-party administrators (TPAs) and insurers will obtain the required paperwork straight from hospitals.
Non-Contestability Period: After a continuous 60-month coverage period, health insurance policies and claims cannot be disputed on the basis of non-disclosure or misrepresentation. A claim cannot be rejected without the claim’s consent committee for review. Health insurance plans are renewable and cannot be refused based on claims made in previous policy years (unless proven fraud or non-disclosure occurs). This is known as the No-Claims Bonus. Insurance companies are required to give policy renewals a grace period of 30 days. Policyholders have the option to obtain premium savings or an enhanced sum assured as a no-claims bonus. The goal of these changes is to improve service quality and make the claims process easier for policyholders.
Simplifying Health Insurance Claim Settlement
Certain exclusions are included in health insurance policies to make it clear what is and is not covered. These are a few typical exclusions:
Pre-existing medical conditions: These are ailments that a policyholder had at the time of purchasing the policy. However, following a waiting time (often four years), many pre-existing conditions may be covered. Cosmetic surgery: Generally speaking, operations performed to improve the appearance of the face or body are not included. Alternative therapies and treatments: Some non-traditional therapies could not be reimbursed. Self-inflicted injuries: The insured person is not covered for injuries they purposefully cause.
Maternity and childbirth: Unless otherwise noted, maternity-related costs are frequently waived.
Diagnostic costs: You may be able to deduct costs for diagnostic testing. Permanent exclusions: These are particular treatment categories (such chronic illnesses) that are not covered by health insurance.
Common Exclusions in Health Insurance Policies
Pre-existing condition exclusions from health insurance policies usually include a four-year waiting period. Any treatment for pre-existing conditions might not be covered during this time. But coverage for certain conditions normally starts after the waiting period. Remember that waiting times can change based on the insurer and the particular policy.
Waiting Period for Pre-existing Conditions
If you require quick coverage for a pre-existing condition, explore the following options: If you are employed, find out if your place of employment has group health insurance. Pre-existing conditions are frequently covered by group policies without waiting periods.
Super Top-Up or Top-Up Plans: These plans offer extra coverage in addition to what your current health insurance covers. There may be no waiting periods for pre-existing diseases they cover.
Plans for Particular Diseases: Certain insurance companies provide plans for particular diseases (such diabetes or hypertension) that cover pre-existing disorders right away.
Portability: Consider moving your current policy to a different insurer if you already have one. You can keep the benefits of your previous policy’s waiting period if you have portability.
References
1.https://www.renewbuy.com/articles/health-insurance/common-health-insurance-exclusions
2. https://www.onsurity.com/blog/exclusions-in-health-insurance/
3. https://www.myinsuranceclub.com/articles/inclusions-and-exclusions-in-your-health-insurance-policy
4. https://www.canstar.com.au/health-insurance/inclusions-exclusions-restrictions/
5. https://health.howstuffworks.com/health-insurance/exclusion.htm
6. https://www.theweek.in/news/india/2024/05/30/irdai-issues-new-master-circular-to-make-health-insurance-claims-process-more-seamless.html
7. https://timesofindia.indiatimes.com/business/india-business/irdai-sets-3-hour-limit-to-settle-health-claims/articleshow/110544039.cms
8. https://www.msn.com/en-in/health/health-news/health-insurance-claim-new-rules-irdai-issues-circular-for-insurers-to-decide-on-cashless-authorisation-in-1-hour/ar-BB1nitJ3
9.https://www.newsbytesapp.com/news/business/irdai-introduces-new-directive-for-swift-health-insurance-claims/story
“PRIME LEGAL is a full-service law firm that has won a National Award and has more than 20 years of experience in an array of sectors and practice areas. Prime legal fall into a category of best law firm, best lawyer, best family lawyer, best divorce lawyer, best divorce law firm, best criminal lawyer, best criminal law firm, best consumer lawyer, best civil lawyer.”
Written by – K.Immey Grace
