Page 52 - Insurance Times June 2021

Norms on settlement of COVID-19 health 7. The above instructions shall be in force with immediate
effect.
insurance claims
(DVS RAMESH)
IRDAI/HLT/MISC/CIR/113/04/2021
General Manager (Health)
Date:29-04-2021
Communication on settlement of Health
1. Reference is invited to Order dated 28.4.2021 passed
by Hon’ble High Court of New Delhi in WP(C) No.5026 Insurance Claims
/2021 wherein IRDAI was directed to advise Insurers to IRDAI/HLT/MISC/CIR/102/04/2021
communicate their cashless approvals to the concerned
Date:23-04-2021
hospitals/establishments within a maximum time period
of 30 to 60 minutes so that there shall not be any delay 1. There are reports of certain network providers
in discharge of patients and hospital beds do not remain (hospitals) charging high rates and insisting on cash
unoccupied. payments from the policyholders for providing
treatment to COVID-19 infected patients despite having
2. In this regard, attention is invited to circular ref.no.
cashless arrangement with Insurers.
IRDAI/HLT/MISC/CIR/95/04/2020 dated 18.4.2020
2. In compliance with the provisions of Regulation 31of
wherein a fixed turnaround time (TAT) of two hours for
IRDAI ( Health Insurance ) Regulations, 2016, the
granting both cashless pre-authorization and for final Insurers, in case of “cashless claim” under a health
discharge of the insured patient was specified.
insurance policy, are advised to ensure expeditious
3. In the wake of prevailing conditions of COVID-19 cases settlement of such claims on cashless basis in
in the form of second wave and in line with aforesaid accordance to the Service Level Agreements ( SLAs)
directions of the Hon’ble High Court, the following entered with hospitals.
directions are issued to all insurers: 3. While reviewing cashless requests the Insurers are also

a. Decision on authorization for cashless treatment advised to ensure that the policyholders are charged
as per the rates agreed to by network providers
for COVID-19 claims shall be communicated to the
wherever applicable. Insurers are also advised to
network provider (hospital) within a period of 60
minutes from the time of receipt of authorization ensure that hospitals do not levy any additional charges
for the same treatment other than those rates that are
request along with all necessary requirements from
agreed with the insurers.
the hospital.
4. In order to ensure that all network providers extend
b. Decision on final discharge of patients covered in cashless services to policyholders and to address any
COVID-19 claims shall be communicated to the issues causing inconvenience to policyholders while
network provider within a period of ONE hour from availing cashless service, the Insurers are advised to put
the time of receipt of final bill along with all in place an effective communication channel with all
necessary requirements from the hospital. the network providers for prompt resolution of
grievances of policyholders. Insurers are advised to
4. Notwithstanding the above outer limits of timelines
specified, the insurers are advised to process such report levying of excess charges or denial of cashless
facility to the respective State Governments for
requests promptly so that both authorisation for cashless
appropriate action.
treatment and discharge of the patient can be
hastened to the maximum extent. 5. All Insurers are directed to ensure that the
“reimbursement claims “under a health insurance policy
5. The Insurers shall issue appropriate directions to their shall be settled as per the terms and conditions of the
respective Third Party Administrators for ensuring respective policy contract expeditiously. Insurers are
compliance with the timelines specified above. advised to issue suitable guidelines on this to all TPAs.
6. These guidelines are issued under the powers vested 6. This has the approval of the Competent Authority.
with Regulation 27 (vi) of IRDAI (Health Insurance)
Regulations, 2016 read with Section 34 (1) of Insurance D V S Ramesh
Act, 1938. General Manager (Health)

52 The Insurance Times, June 2021