Page 52 - The Insurance Times May 2021

CIR/164/06/2020 dated 26.06.2020 are permitted to be insurer shall also furnish the grievance redressal
offered and renewed by all insurers up to 30.9.2021. procedures available with the Insurance Company and
4. All other terms and conditions remain valid as specified with the Insurance Ombudsman along with the detailed
under the respective guidelines. addresses of the respective offices. Claims shall be
processed in a transparent, seamless and efficient
5. This has the approval of competent authority.
manner within the prescribed timelines.
5. Insurer shall also ensure that the policyholder is provided
(DVS RAMESH)
GENERAL MANAGER (Health) with granular details of the payments made, amounts
disallowed and the reasons for the amount disallowed
as specified in the within referred provisions of IRDAI
Health Insurance Claims Settlement
(Third Party Administrators - Health Services)
IRDAI/HLT/CIR/MISC/053/03/2021 Regulations, 2016.
Date:19-03-2021 6. Insurers and TPAs, wherever applicable, are advised to
ensure compliance of these instructions without fail.
1. Reference is drawn to the provisions of Regulation 27 This has the approval of the competent authority.
(Settlement/Rejection of claim by insurer), Regulation 30
(Administration of Health Policies) and Regulation 33 (D V S Ramesh)
(Engagement of Services of TPAs by Insurers in relation
General Manager (Health)
to Health Insurance Policies) of the IRDAI (Health
Insurance) Regulations, 2016, Regulation 21 (3) (c) (i) (b) Modification in Guidelines on Standard
of IRDAI (Third Party Administrators - Health Services)
Regulations, 2016 and circular Ref: IRDAI/CAD/CIR/PPHI/ Individual Health Insurance Product
059/04/2019 dated 10.04.2019 regarding information to IRDAI/HLT/REG/CIR/051/03/2021
be provided to the insurance policyholders/claimants
about various insurance policy services. Date:18-03-2021
2. It is essential that all insurers establish procedures to 1. Reference is drawn to Guidelines on standard individual
let policyholders get clear and transparent health insurance product circular Ref No: IRDAI/HLT/
communication at various stages of claim processing. REG/CIR/172/07/2020 dated 07.07.2020 specifying
As specified in the within referred circular dated norms on minimum and maximum sum insured limits.
10.4.2019, all the insurers shall ensure putting in place
systems to enable policyholders track the status of 2. In order to enhance the coverage available under
cashless requests/ claims filed with the Insurer/TPA “Arogya Sanjeevani Policy”, in partial modification of the
through the Website/Portal/App or any other extant guidelines, insurers shall mandatorily offer the
authorized electronic means on an ongoing basis. The sum insured between Rs. 50,000/- to Rs.10,00,000/-
status shall cover from the time of receipt of request under the standard product Arogya Sanjeevani w.e.f 1st
to the time of disposal of the claim along with the May,2021 or earlier.
decision thereon. 3. The tables of premium rates for revised sum assured
3. Where claims are processed through TPAs, the insurers slabs shall be filed in terms of Clause C (10) of
are permitted to let their respective Third Party “Guidelines on Filing of Minor Modifications in the
Administrators operationalize the claim tracking approved Individual Insurance Products offered by
General and Stand Alone Health Insurers on
mechanism. The policyholders shall be invariably notified
in all the communications, the location to track the Certification Basis” (Ref No: IRDA/HLT/CIR/MISC/151/
claim status. 09/2019 dated 20th September,2019).
4. Insurers may launch the modified version of the “Arogya
4. Insurer shall ensure that the repudiation of the claim is
not based on “presumptions and conjectures”. As Sanjeevani Policy” after filing the same on Certification
specified in the IRDAI (Health Insurance) Regulations, Basis as referred to at Para (3) above. The UIN allotted
2016, where a claim is denied or repudiated, the by the Authority will be retained.
communication about the denial or the repudiation shall 5. This has approval of the competent authority.
be made only by the Insurer by specifically stating the
reasons for the denial or repudiation, while necessarily D V S Ramesh,
referring to the corresponding policy conditions. The General Manager (Health)

52 The Insurance Times, May 2021