Health Insurance Update: IRDAI Sets 3-Hour Time Limit For Insurers To Clear Cashless Claims- Read Details

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New Delhi: The Insurance Regulatory and Development Authority of India (IRDAI) has introduced some changes to health insurance regulations. They have issued a comprehensive Master Circular on Health Insurance Products which repeals 55 previous circulars. One key update is that insurers are now required to give final authorisation within three hours of receiving a discharge request from the hospital.

According to a master circular issued by the IRDAI on May 29, 2024 "In no case, the policyholder shall be made to wait to be discharged from the hospital," The regulator added further "If there is any delay beyond three hours, the additional amount if any charged by the hospital shall be borne by the insurer from shareholder’s fund." ()

The IRDAI stated that in emergency cases the insurers must decide on cashless authorisation requests immediately. To ensure this the regulator has ordered insurers to have the necessary procedures in place by July 31, 2024. The regulator also mentioned that insurers can set up dedicated help desks at hospitals to handle cashless requests. Further, insurers must offer pre-authorisation to policyholders through digital means. ()

What are the other changes?

- The IRDAI also mentioned that insurers should offer policyholders a wider range of choices. This includes providing various products/add-ons/riders that cater to all ages, regions, occupations, medical conditions, treatments and all types of hospitals and healthcare providers.

- Policyholders who have multiple health insurance policies have the flexibility to choose which policy they want to claim the admissible amount. Insurers must also include a Customer Information Sheet (CIS) with every policy document.

- If no claims are made during the policy period, insurers may reward policyholders with a No Claim Bonus. This bonus can be chosen as either an increase in the sum insured or a discount on the premium amount.

- If a policyholders chooses to cancel their policy at any time during the policy term they will receive a refund of the premium or a proportionate amount for the remaining policy period. A survey by Local Circles revealed that 43 percent of insurance policyholders had difficulties processing their health insurance claims over the past three years.

The survey mentioned "In several cases cited by policyholders, it took 10-12 hours after the patient was ready for discharge for them to get discharged because the health insurance claim was still getting processed. If they stay back at the hospital another day to do so, the cost of that additional night's stay has to be borne by them. According to several patients, this is the experience where the insurance company has already provided a pre-approval to the hospital's TPA desk before admission of the patient."