IRDAI: New Health Insurance Claim Settlement Rules

Unannounced medical emergencies cause financial as well as emotional stress. Investing in the best health insurance plans is key to combat such situations. However, many times customers may face claim rejection, causing further distress.

How can we avoid such instances? The answer is to familiarize yourself with the IRDAI ground rules regarding claim settlements and rejections. The IRDAI acts as a bridge between customers and insurance providers, maintaining trust between the buyer and seller.

This article discusses the new health insurance claim settlement rules formed by the IRDAI, which will help you minimize health claim rejections.

What Is IRDAI?

The Insurance Regulatory and Development Authority of India (IRDAI) is the regulatory body of the insurance sector in India. It was incorporated in April 2020 with the objective of increasing customer choice and lowering premiums by promoting healthy competition among insurance companies.

IRDAI transformed the insurance sector in India by opening the market to foreign insurance companies, allowing up to 26% ownership.

Since 2000, IRDAI has framed various insurance regulations, from registering insurance companies to safeguarding the best interests of policyholders.

With daily regulations and evolving guidelines, the Indian insurance sector, along with the banking sector, contributes about 7% to India's GDP.

New IRDAI Guidelines For Health Insurance Claim Settlement

Discover the new health insurance claim settlement rules by IRDAI for claim settlement and claim rejections:

1. Claim Settlement Guideline

   Delayed claim settlements are unfortunately still a problem for many policyholders, causing financial and emotional stress.

   As per IRDAI, claims should be settled within 35 to 40 days from the day of submission of all documents. If the insurer delays settling claims, they are liable to pay 2% interest on the claim amount.

   The increased amount will be transferred to your bank account in case of a reimbursement claim or directly to the hospital in case of cashless claims.

2. Claim Rejection Guideline

   If you consistently renew your health plan for 8 years, also known as the moratorium period, you gain significant claim settlement benefits.

   As per IRDAI guidelines, a claim cannot be rejected if the individual has completed the moratorium period. However, there are some conditions.

   Claims cannot be rejected by your insurance provider unless the claim is raised against a condition mentioned in the policy's exclusions list or is fraudulent.

3. Telemedicine Inclusion In Health Insurance

   With COVID-19 putting a chokehold on global healthcare systems, the digital transformation of healthcare was long overdue.

   Due to the need for no physical contact, doctors were asked to consult patients via telephones, video calls, and other digital means, which were earlier not covered by health insurance plans.

   IRDAI recognized this need, introducing a guideline to cover the cost of teleconsultations in almost every health insurance plan.

   It is available for policyholders who have opted for OPD coverage in their base insurance plan.

IRDAI Health Insurance Guidelines

IRDAI has set certain guidelines to ensure fair business transactions between insurance providers and buyers:

• If you renew your health policy regularly without interruptions within scheduled dates, your policy will have lifelong renewability, with no exit age.
• Your health insurance provider is responsible for informing you of all terms and conditions for availing treatments in medical facilities across India.
• Group health plans are valid for only 1 year.
• If your request to purchase a health insurance plan is denied by the insurance provider, you are entitled to receive a detailed and honest explanation.
• You are entitled to rewards if you purchase health insurance at a young age, renew your health plan regularly, or provide positive feedback regarding claims settlement experiences with the insurer.
• Migration of health policy is allowed if the policyholder meets the exit criteria. However, this option applies to health plans catering to specific groups (e.g., students, children under a certain age group).
• Insurance providers must give senior citizens clear and correct communication regarding their health insurance premiums at the time of purchase.

Why You Should Keep Up With IRDAI Health Insurance Rules

The benefits of familiarizing yourself with IRDAI guidelines include:

• Reduced chances of being conned by fraudulent or fake insurance sellers.
• Awareness of your insurance purchase rights.
• Up-to-date information concerning the evolving insurance sector of India.
• Minimal chances of claim rejections at the time of hospitalization.
• Clarity of thought and better purchase decisions.

Summing It Up

With the ever-changing landscape of the health insurance sector, it is essential to be familiar with IRDAI claim settlement guidelines.

Being aware of the new IRDAI health insurance claim settlement rules not only enhances your insurance purchase experience but also provides the confidence to resolve any claim-related concerns.

For further information regarding claim settlement or rejection, contact our insurance experts at PolicyX.