India: IRDAI orders insurers to be more transparent in health claims handling

| 24 Mar 2021

The IRDAI has asked all insurers to be more transparent in their health insurance claim settlement process and apprise the policyholder of the reasons in the event that they deny any claim.

It is essential that all insurers establish procedures to let policyholders have clear and transparent communication at various stages of claim process, the IRDAI said in a circular.

“All the insurers shall ensure putting in place systems to enable policyholders to track the status of cashless requests/claims filed with the insurer/TPA through the website/portal/app or any other authorised electronic means on an ongoing basis.

“The status shall cover from the time of receipt of request to the time of disposal of the claim along with the decision thereon,” said the regulator.

The circular is addressed to life, general and standalone health insurance companies including third party administrators (TPAs).

In cases where the TPAs are settling the claims on behalf of the insurers, policyholders should be notified about all the communications as well as location to track the claims.

In addition, the IRDAI said, “As specified in the IRDAI (Health Insurance) Regulations, 2016, where a claim is denied or repudiated, the communication about the denial or the repudiation shall be made only by the insurer by specifically stating the reasons for the denial or repudiation, while necessarily referring to the corresponding policy conditions.”

The regulator has said insurers should ensure that policyholders are provided granular details of the payments, amounts disallowed and the reasons for the amount disallowed.

Besides, they should also inform policyholders about grievance redressal procedures and the insurance ombudsman, along with detailed addresses of the respective offices.


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