The Insurance Regulatory and Development Authority of India (IRDAI) has recently implemented several significant changes to health insurance regulations. These updates aim to make health insurance policies more customer-friendly, providing policyholders with greater flexibility, transparency, and benefits. Here’s a detailed look at the key changes and how they can impact your health insurance plans.
IRDAI has removed the maximum age limit for purchasing health insurance plans. Previously, individuals could only buy a new health insurance policy until the age of 65. With the new regulations, anyone, regardless of age, can now buy a health insurance policy. This change is particularly beneficial for senior citizens who may not have had coverage before. Additionally, IRDAI has instructed insurers to introduce targeted policies for senior citizens and establish separate channels to address their claims and grievances.
In an effort to streamline the claim settlement process, IRDAI has mandated insurers to prioritize cashless claim settlements. The aim is to achieve 100% cashless transactions, except in exceptional cases. Insurers are required to decide on cashless authorization requests within one hour of receipt and implement necessary systems by July 31, 2024. Additionally, insurers are encouraged to set up dedicated Help Desks at hospitals for cashless requests and provide digital pre-authorization to policyholders for smoother claim processing.
To expedite hospital discharge processes, IRDAI has directed insurers to grant final authorization within three hours of receiving the discharge authorization request from the hospital. If there is any delay beyond three hours, any additional charges by the hospital will be borne by the insurer. In cases of the policyholder's death during treatment, insurers must immediately process the claim settlement request and ensure the release of the mortal remains without delay.
IRDAI has clarified that no claims can be denied after five years of policy holding. This means that no policy or claim can be contested by the insurer on grounds of non-disclosure or misrepresentation after this period. However, if fraud is established in a policy or claim request, it can still be contested in court even after five years.
To ensure fairness in the claim settlement process, IRDAI has asked insurers to set up a Claims Review Committee (CRC). This committee will review any claims rejected by the insurer. Claims can only be rejected after approval from this committee, and insurers must provide a reason for rejection, referencing specific terms and conditions in the policy document.
IRDAI has directed insurers and Third-Party Administrators (TPAs) to collect required documents directly from the hospital. Policyholders are no longer required to submit these documents multiple times for making a claim request. This change simplifies the claims process and reduces the burden on policyholders.
Policyholders who have not made a claim in a year can choose to either increase the sum insured or reduce their premium amount. Traditionally, general insurance companies offered discounts for no-claim renewals of motor insurance policies, but this practice will now extend to health policies. Additionally, policyholders can discontinue their health policy at any time and receive a refund of the premium on a pro-rata basis. For example, if a client has paid Rs.12,000 as the premium amount and decides to discontinue the policy after six months, they will get a refund of Rs. 6000.
Insurers are now required to comply with the awards given by the Insurance Ombudsman within 30 days of receipt. Failure to honor the Ombudsman award will result in a penalty of Rs. 5000 per day, in addition to the penal interest liable to be paid under The Insurance Ombudsman Rules, 2017. The Insurance Ombudsman acts as an independent adjudicator to resolve disputes between policyholders and insurers, ensuring fair treatment.
These updates mark significant improvements in the health insurance sector, providing greater flexibility, transparency, and benefits to policyholders. As the industry adapts to these new regulations, policyholders can expect a more streamlined and customer-centric experience. For more information or to discuss how these updates could impact your policies, please do not hesitate to contact us.
The recent changes by IRDAI aim to make health insurance more accessible and user-friendly, especially for senior citizens and those seeking alternative treatments. With greater emphasis on cashless transactions, faster claim settlements, and increased transparency, these updates are set to enhance the overall experience for policyholders. Stay informed and make the most of these improvements to ensure your health insurance coverage meets your needs effectively.
