IRDAI has recently asked the insurance companies to state proper reasons for denial in case of rejection of health insurance claims made by policyholders. It also asked the insurers to be more transparent in the process of health claim settlement and let policyholders get clear and transparent communication at various stages of claim settlement.
The circular on ‘Health Insurance Claims Settlement’ addressed to life, general and standalone health insurance companies including the third party administrators said, “All the insurers shall ensure putting in place systems to enable policyholders track, the status of cashless requests, claims filed with the insurer, TPA through the website, portal or app or any other authorised electronic means on an ongoing basis. The status shall cover from the time of receipt of request to the time of disposal of the claim along with the decision thereon.”
IRDAI directed that the policyholders should also be notified all the communications as well as location to track the claims in case claims are being settled by TPAs on behalf of insurers.
IRDAI further added, “As specified in the IRDAI (Health Insurance) Regulations, 2016, where a claim is denied or repudiated, the communication about the denial or the repudiation shall be made only by the insurer by specifically stating the reasons for the denial or repudiation, while necessarily referring to the corresponding policy conditions.”