IRDAI Claim Settlement Guidlines
  • Understand Claim Settlement
  • Telemedicine Inclusion
  • Claim Settlement & Rejection
IRDAI Claim Settlement Guidlines
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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 the 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 familiarise yourself with the IRDAI ground rules laid by the organization regarding claim settlements and rejections. The IRDAI stands between the customers and insurance providers maintaining trust between the buyer and seller.

This article talks more about all 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 or IRDAI is the regulatory body of the insurance sector in India. It was incorporated in April 2020. The objective was to increase customer choice and lower premiums by promoting healthy competition among insurance companies.

IRDAI turned the tide of the insurance sector in India by opening the market for foreign insurance companies. Foreign companies were allowed up to 26% ownership.

IRDAI has framed various insurance regulations since 2000. Right from registering insurance companies along with thinking in the best interest of the policyholders is all a part of IRDAI.

With daily regulations and evolving guidelines, the Indian insurance services credit about 7% of India’s GDP along with the banking sector.

New IRDAI Guidelines For Health Insurance Claim Settlement

Scroll below to discover 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 between 35 to 40 days from the day of submission of all documents. However, when the insurer delays settling claims on their end, 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 to the hospital directly in case of cashless claims.

  2. Claim Rejection Guideline

    If you renew your health plan consistently for 8 years, also known as the moratorium period you are about to gain some serious claim settlement perks!

    As per the guidelines laid by IRDAI, an individual can not be rejected for a claim if he/she has completed the moratorium period. However, there are some conditions.

    Claims can not be rejected by your insurance provider unless the claim is raised against a condition mentioned in the exclusions list of the policy or is fraudulent.

  3. Telemedicine Inclusion In Health Insurance

    With COVID-19 putting a chokehold on the healthcare systems of the world, a need for the digital transformation of healthcare was long due.

    Due to 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.

    This was recognized by IRDAI bringing in the guideline of covering 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

There are certain guidelines set in place for a fair business transaction between the insurance provider and buyer which are highlighted below:

  • If you renew your health policy regularly without any interruptions within scheduled dates, your policy will not have an exit age making it lifelong renewable
  • 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
  • In case your request to purchase a health insurance plan is denied by the insurance provider, you are entitled to receive a detailed and honest explanation for the same.
  • You are entitled to gain rewards if you purchase health insurance at a young age, renew your health plan regularly, or give 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 a particular group of people (students, children under a certain age group, etc.)
  • 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 various benefits of familiarising yourself with IRDAI guidelines are:

  • Less 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 you with the confidence to resolve any claim-related concerns.

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

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New IRDAI Rules for Health Insurance: FAQ's

1. What is IRDAI?

IRDAI is the Insurance Regulatory and Development Authority of India which governs the Indian Insurance sector. It commenced operations in the year 2000. The objective was to increase customer choice and lower premiums by promoting healthy competition among insurance companies.

2. What is the claim settlement rule as per IRDAI?

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

3. What is the claim rejection rule as per IRDAI?

The claim rejection rule as per IRDAI states that an individual can not be rejected for a claim if he/she has completed the 8 years of policy renewal without any breaks. Unless the claim filed is fraudulent or is for a condition that is mentioned in the exclusions of the policy schedule.

4. Who can avail of Telemedicine Inclusion In Health Insurance?

Telemedicine coverage like on-call consultations, and digital consultations, was approved by IRDAI recognizing the need during the COVID-19 pandemic. Individuals who have opted for OPD coverage in their base cover are eligible for telemedicine inclusions.

5. What does CSR indicate in the claim settlement?

Claim Settlement Ratio is the ratio of claims received by a health insurer in a financial year compared to claims settled. A high CSR indicates the trust and reliability of a health insurance provider.

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Simran Kaur Vij

Written By: Simran Kaur Vij

Simran is an insurance expert with more than 3 years of experience in the industry. She may have all the answers to your insurance queries. With a background in Banking, she proactively helps her readers to stay on par with all the latest Insurance industry developments.