Insurance regulator IRDAI has said that hospitals cannot deny cashless facility claims to policyholders for treatment of coronavirus. It also said that if the hospitals' conduct adversely impacted the policyholder, then they must be reported to the concerned government agencies. IRDAI has also asked insurance companies to maintain a communication channel with hospitals for prompt resolution of grievances of policyholders. The regulator has stated that insurance providers must put in place an exclusive grievance redressal mechanism to address the complaints of policyholders.The circular was issued following reports that some hospitals are not ranting cashless acility for COVID-19 treatment.
Cashless facility ensures that policyholders don't have to pay for treatment costs from their own pocket. According to Aegon Life, "The insurance company settles the bill with the hospital. Insurance companies have tie-ups with hospitals, which are known as 'network hospitals'. You don't have to stump up the cash if you are admitted to one such network hospital. The insurer will directly settle the bill with the hospital."
The IRDAI added that every general and health insurance company must endeavour to enter into agreements "with an adequate number of both public and private sector network providers across the geographical spread".
"Insurance companies are also advised to put in place an exclusive grievance redressal mechanism to address the grievances of policyholders relating to the denial of the cashless facility for COVID-19 and other grievances against such hospitals that are enlisted as network providers. Insurance companies shall also put in place a continuous communication channel with all the network providers for prompt resolution of the grievances of policyholders," it said.
The IRDAI said that if a hospital deviates from the cashless facility agreement as mentioned in the Service Level Agreement (SLA), the insurance company would take appropriate action against it. It said that insurance companies could also display on its website the action taken against the hospitals for violation and in order to inform the insured public.
In another circular, the IRDAI said that all insurers are expected to enter into an agreement with hospitals. "Where such service level agreements (SLA) are entered with the Network Providers (hospitals), it is essential for all such hospitals to provide the cashless facility for any treatment to the policyholders including Covid-19 treatment in accordance with agreed provisions of SLA and terms and conditions of policy contract," it said.