Health insurers must decide coronavirus treatment requests within 2 hours: IRDAI

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Health insurers have been directed to decide/clear requests for cashless treatment and final discharge from hospitals within two hours of receipt of the request in view of the current coronavirus pandemic. The Insurance Regulatory and Development Authority of India (IRDAI) has issued norms for general and health insurers for quick settlement of claims filed by policyholders for coronavirus (COVID-19) disease/infection.

The circular issued by the IRDAI on norms for settlement of health insurance claims states:

In light of prevailing conditions owing to COVID 19 as also taking into consideration, the need for alleviating the pressure on the healthcare infrastructure all the insurers shall decide health insurance claims expeditiously. In order to ensure all health insurance claims are responded to quickly, insurers are directed to comply with the following timelines:

a. Decision on authorization for cashless treatment shall be communicated to the network provider (hospital) within two hours from the time of receipt of authorization request and last necessary requirement from the hospital either to the insurer or to the TPA whichever is earlier.

b. Decision on final discharge shall be communicated to the network provider within two hours from the time of receipt of the final bill and last necessary requirement from the hospital either to the insurer or to the TPA whichever is earlier.

Insurers are advised to issue appropriate guidelines to their respective Third-Party Administrators, says the circular.

In an earlier circular in March, 2020 the IRDAI had advised all insurers to expeditiously handle the health insurance claims pertaining to COVID 19.

In yesterday’s circular, the insurance regulator has also asked insurers to establish systems, procedures to enable efficient issuance of pre authorisations on a 24 hour basis and for prompt settlement of claims.

Earlier, the regulator, IRDAI had also asked insurers that the cost of medical expenses incurred during treatment including the quarantine period has to be settled in accordance with the applicable terms and conditions within the policy contract and the regulatory framework. However, the regulator had asked insurers to thoroughly assess the claims filed for COVID 19 disease/infection wherein the claims had to be reviewed by the claims review committee before repudiating the claims.

According to a report in the Times of India, “The cases where treatments are covered under health insurance are few – Just 2% of COVID-19 patients have filed insurance claims. As of Monday (April 13, 2020), General Insurance Council (GIC) reported about 200 COVID-19 claims to Finance Ministry against 10,586 cases.”



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