Page 13 - The Insurance Times November 2025

address long-pending concerns, ensur- IRDAI guidelines mandate that the mentation varies between insurers and
ing fair reimbursement and improved porting process must be completed often leads to disputes during claims,
patient access. within 45 days, and insurers are ex- especially for procedures conducted in
pected to maintain continuity in cov- premium hospitals.
Can your claim be rejected erage. Consumers are advised to en- Policyholders are advised to read their
sure all medical disclosures are made
after porting health insur- policy wording carefully, especially the
accurately while porting and to confirm fine print around terms like 'reason-
ance? Here's what experts acceptance from the new insurer be- able,' 'customary,' and 'medically nec-
fore cancellation of the old policy.
say essary.' Transparency in how insurers
arrive at such benchmarks is being
As health insurance portability gains Decoding 'reasonable and
traction among consumers, questions called for to ensure fair treatment of
are being raised about the implica- customary' clause in customers.
tions for claim settlement. According health insurance policies
to experts, while policyholders have Delayed discharges con-
The "reasonable and customary"
the right to switch insurers without clause in health insurance policies is tinue to trouble policy-
losing benefits like waiting periods, the increasingly drawing attention for its holders despite insurer-
new insurer does have the right to impact on claims settlements. This
scrutinise claims - especially if there are clause allows insurers to cap reim- hospital tie-ups
material discrepancies or non-disclo- bursements based on the average cost Despite improvements in health insur-
sures during the porting process. of a medical procedure in a given geo- ance penetration and the growing
Industry professionals clarify that if the graphic area, regardless of what a adoption of cashless claims, delayed
policyholder has declared all pre-exist- hospital actually charges. If a hospital's hospital discharges remain a major
ing conditions and completed waiting fees are significantly higher than what pain point for policyholders. These de-
periods with the previous insurer, the is considered 'reasonable' by the in- lays typically occur due to long turn-
new insurer generally honours these surer, the policyholder may have to around times for final approvals from
benefits. However, if any fresh illness bear the additional cost. insurers after treatment is complete,
often resulting in patients waiting sev-
arises or there is evidence of non-dis- Experts say this clause is a standard
closure, claims could be rejected even cost-containment measure but can be eral hours or even an entire day to be
discharged.
under the new policy. opaque to many consumers. Its imple-
Experts say that while digitisation and
integrated claim processing have re-
High Court order brings hope for GST relief on bank duced delays to an extent, coordina-

retirees' health insurance tion gaps between hospitals and insur-
ers persist. Insurers argue that final
A recent Kerala High Court order has raised hopes for thousands of bank
retirees seeking relief from Goods and Services Tax (GST) on group health audits and checks are essential to avoid
fraudulent claims, while hospitals often
insurance premiums. The court observed that retirees, who are not em-
cite cumbersome documentation and
ployed by the banks anymore, should not be subjected to GST as if they were
approval protocols.
receiving a supply of service from the bank. The petitioners, all retired bank
employees, argued that group insurance was a welfare measure and not a To address this issue, insurers and hos-
taxable supply under GST laws. pitals are increasingly signing service-
The court noted that the issue required deeper examination and directed level agreements (SLAs) that commit
authorities to reconsider the levy of GST on such policies. While the verdict to fixed timelines for approvals. Some
is specific to the petitioners, it may serve as a precedent for similar cases players are also exploring automated
across the country. pre-discharge checks. However, real-
time integration and trust between
Bank retirees' associations have welcomed the judgment, stating that GST
both parties will be key to resolving this
on health premiums significantly burdens elderly policyholders. The decision
is expected to influence future regulatory clarifications and policy decisions. friction and improving customer expe-
rience.

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