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Network hospitals can't deny cashless claims to COVID-19 patients: IRDA

Network hospitals can't deny cashless claims to COVID-19 patients: IRDA

The circular says if a health policy is eligible for a cashless claim, the insurer has to ensure the settlement as per the agreement entered with the network hospitals

IRDA has issued a circular to general and health insurers IRDA has issued a circular to general and health insurers

After reports of hospitals denying cashless facility to the COVID-19 patients, insurance regulator IRDA has issued a circular to general and health insurers with regards to the health insurance claims.

The circular says if a health policy is eligible for a cashless claim, the insurer has to ensure the settlement as per the agreement entered with the network hospitals.

"There are reports of certain network providers (hospitals) charging high rates and insisting on cash payments from the policyholders for providing treatment to COVID-19 infected patients despite having cashless arrangement with Insurers," says the circular.

"In compliance with the provisions of Regulation 31of IRDAI (Health Insurance) Regulations, 2016, the Insurers, in case of "cashless claim" under a health insurance policy, are advised to ensure expeditious settlement of such claims on cashless basis in accordance to the Service Level Agreements (SLAs) entered with hospitals," it adds.

The regulator further says that while reviewing cashless requests the insurers are also advised to ensure that the policyholders are charged as per the rates agreed to by network providers wherever applicable. "Insurers are also advised to ensure that hospitals do not levy any additional charges for the same treatment other than those rates that are agreed with the insurers," it says.

IRDA specifies insurers to report to the respective governments if a network hospital doesn't comply with the rules. "In order to ensure that all network providers extend cashless services to policyholders and to address any issues causing inconvenience to policyholders while availing cashless service, the Insurers are advised to put in place an effective communication channel with all the network providers for prompt resolution of grievances of policyholders. Insurers are advised to report levying of excess charges or denial of cashless facility to the respective state governments for appropriate action," the circular says.

In cases where reimbursement claims have to be settled, it has to be done as per the terms and conditions of the respective policy contract expeditiously.

"Insurers are advised to issue suitable guidelines on this to all Third-Party Administrator (TPAs)," says IRDA. TPAs act as intermediaries between insurers and policyholders to process insurance claims.

The IRDA circular comes after Finance Minister Nirmala Sitharaman spoke to IRDA Chairman SC Khuntia to take immediate action on hospitals denying cashless settlement of bills.

Also read: IRDAI asks hospitals to provide cashless treatment for COVID-19 to policyholders

Published on: Apr 24, 2021, 12:34 PM IST
Posted by: anwesha madhukalya, Apr 24, 2021, 12:34 PM IST