Page 48 - Insurance Times May 2020

7. Specific consent of having agreed to the conditions shall to comply with the following timelines:
be obtained from the policyholders. a. Decision on authorization for cashless treatment
8. The names of the products that are offered the facility shall be communicated to the network provider
(hospital) within two hours from the time of receipt
of payment of premiums in instalments shall be
of authorization request and last necessary
published in the websites of insurers for the information
of policyholders. requirement from the hospital either to the insurer
or to the TPA whichever is earlier.
9. The details of products in respect of which the
b. Decision on final discharge shall be communicated
Instalments facility is made available shall be filed with
to the network provider within two hours from the
the Authority as per Annexure – 1 specified in the
within referred guidelines and within seven days from time of receipt of final bill and last necessary
the date of offering the facility. There will no change requirement from the hospital either to the insurer
to the UIN allotted to the product. or to the TPA whichever is earlier.
4. Insurers are advised to issue appropriate guidelines to
10. These Guidelines are issued under the powers vested
in Section 34 (1) of Insurance Act, 1938 read with their respective Third Party Administrators.
Regulation 2(i)(g) read with Regulation 2 (i)(o) of IRDAI 5. These guidelines are issued under the powers vested
(Health Insurance) Regulations, 2016. with Regulation 27 (vi) of IRDAI (Health Insurance)
Regulations, 2016 read with Section 34 (1) of Insurance
11. This has the approval of the competent authority.
Act, 1938.
D V S Ramesh
T L Alamelu
General Manager (Health)
Member (NL)
Norms on settlement of health
Providing mandatory medical insurance
insurance claims
coverage to workers as part of the
IRDAI/HLT/MISC/CIR/95/04/2020
National Directives of MHA, GOI
Date:18-04-2020 IRDAI/HLT/CIR/MISC/093/04/2020.
16th April, 2020
1. Reference is invited to the Circular Ref. No. IRDAI/HLT/
REG/CIR/054/03/2020dated 04th March, 2020 wherein 1. Reference is invited to Order No. 40-3/2020-DM-I (A)
all insurers were advised to expeditiously handle the dated 15th April, 2020 issued as part of the Consolidated
health insurance claims pertaining to COVID 19. Revised Guidelines by Ministry of Home Affairs, GOI. As
per the said order, inter alia; the following are
2. Reference is also invited to the provisions of Regulation
stipulated:
27 of IRDAI (Health Insurance) Regulations, 2016 that
i. All industrial and commercial establishments, work
specified norms on settlement / rejection of claim by
places, offices etc. shall put in place arrangements
insurers. In terms of Regulation 26 of these Regulations,
for implementation of Standard Operating
inter alia, insurers shall establish systems, procedures
Procedure (SOP) before starting their functioning.
to enable efficient issuance of pre authorisations on a
24 hour basis and for prompt settlement of claims. ii. As per clause no. 5 of Annexure – II of the said SOP
for social distancing for offices, workplace, factories
3. In light of prevailing conditions owing to COVID 19 as
also taking into consideration the need for alleviating and establishments, medical insurance for the
workers to be made mandatory.
the pressure on the healthcare infrastructure all the
insurers shall decide health insurance claims 2. In light of the above, all General and Health Insurance
expeditiously. In order to ensure all health insurance companies may offer comprehensive health insurance
claims are responded to quickly, insurers are directed policies either to individuals or groups in order to enable

48 The Insurance Times, May 2020