New Health Insurance Claim Rule: Cashless Claims Approval Time Reduced to 3 Hours, Insurer to Cover Hospital Charges for Delayed Discharge

The Insurance Regulatory and Development Authority of India (IRDAI) has implemented new guidelines aimed at simplifying and expediting the cashless claim settlement process for health insurance. Under these directives, insurers are mandated to approve cashless claims within three hours of receiving the discharge authorization request from the hospital. Any delay beyond this timeframe will result in the insurer covering any additional charges imposed by the hospital, utilizing funds from shareholders.

Additionally, IRDAI has emphasized the importance of insurers striving to achieve 100% cashless claim settlement within defined timelines, minimizing instances where claims are settled through reimbursement. Insurers are also required to establish robust grievance redressal processes, with response letters including contact details for insurance ombudsmen in case policyholders are dissatisfied with the initial redressal provided.

Policyholders retain the flexibility to file claim settlements under their chosen policy, with the insurer of that policy being considered the primary insurer. In cases where the coverage under the chosen policy is insufficient, the primary insurer must collaborate with other insurers to settle the remaining amount per policy conditions, ensuring a seamless experience for the policyholder.

Furthermore, policyholders have a 30-day window from the receipt of the policy document to review its terms and conditions. If dissatisfied, they have the option to cancel the policy, applicable to policies with a term of one year or more. These measures aim to enhance transparency, efficiency, and customer satisfaction in the health insurance claims settlement process.