Breaking: No More Waiting!! IRDAI Mandates Cashless Claim within an Hour

Approval for Cashless Facility: New Directive for Insurers

In a significant move aimed at streamlining the health insurance claim process, the Insurance Regulatory and Development Authority of India (IRDAI) has mandated insurers to achieve 100% cashless claim settlement in a time-bound manner. As per the new directive, insurers must decide on cashless authorization requests immediately, with a maximum turnaround time of one hour from receipt of the request.

To facilitate this, insurers are required to implement necessary systems and procedures immediately, with full compliance expected no later than July 31, 2024. This includes setting up dedicated Help Desks in physical mode at hospitals to handle and assist with cashless requests, ensuring that policyholders receive prompt and effective support.

Additionally, insurers are mandated to provide pre-authorization to policyholders through digital modes, further simplifying the process.

Final Hospital Discharge Authorization for Insurers

Insurers are now mandated to grant final authorization within three hours of receiving a discharge authorization request from the hospital. Under no circumstances should the policyholder be made to wait for discharge beyond this period.

In cases where there is a delay exceeding three hours, any additional charges incurred by the hospital will be covered by the insurer from the shareholder's fund. This measure is designed to ensure that policyholders are not financially penalized due to delays in the authorization process.
Additionally, in the unfortunate event of the policyholder's death during treatment, insurers are required to:
- Immediately process the request for claim settlement.
- Ensure the prompt release of the mortal remains from the hospital.

Settlement of Claims

The directive aims to enhance the efficiency of the claims process and ensure that policyholders and their families receive the support they need without unnecessary delays.

Claims Review Committee (CRC) Approval: No claim shall be refused without the approval of the Policyholders' Management Committee (PMC) or a three-member sub-group of the PMC known as the Claims Review Committee (CRC).
Detailed Explanation for Claim Denials: If a claim is refused or partially disallowed, the claimant will receive a detailed explanation, citing specific terms and conditions from the policy document. This aims to provide clarity and understanding for policyholders.
Document Collection by Insurers and TPAs: Insurers and third-party administrators (TPAs) are responsible for collecting the required documents from hospitals, relieving policyholders of the burden of submitting documents. This initiative simplifies the claims process and reduces administrative hassles for policyholders.

Health insurance companies

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Disclaimer: The list mentioned is according to the alphabetical order of the insurance companies. Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by any insurer. For complete list of insurers in India refer to the Insurance Regulatory and Development Authority of India website www.irdai.gov.in