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IRDAI Asks All Insurers to be More Transparent In Health Insurance Claim Settlement Process

Updated On Mar 23, 2021

The Insurance Regulatory and Development Authority of India (IRDA) has issued a circular addressed to general, life, and health insurance companies, asking them to be more transparent in their health insurance claim settlement process. The insurance companies are now required to inform the policyholders about the reasons in case of denial of claims filed. 

As per the circular, the insurers shall establish procedures and offer transparent communication at different stages of the health insurance claim settlement process. The insurance regulatory has asked the insurance companies to provide granular details to the policyholders, regarding payment, amounts disallowed, and the reasons for the amount disallowed. 

The insurance companies are asked to put in place systems so that they enable the policyholders are able to track the status of cashless requests/claims filed with the insurance company or the Third Party Administrator through the website/application/portal or any other electronic means. 

In cases where Third Party Administrators (TPAs) are involved in the process to settle the claims on behalf of insurance companies, the policyholders will be notified about all the communications and locations to track the claims, as asked by the insurance regulatory authority. Also, the insurers must ensure that the claims are not rejected on the basis of “presumptions and conjectures”. 

Apart from this, the insurance companies shall also provide the policyholders information related to the process of redressal procedures, along with detailed addresses of the offices. 

The claims shall be processed in an efficient, seamless manner, within the stipulated time. 

Disclaimer: This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

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