The Insurance Regulatory and Development Authority of India (IRDAI) has introduced a series of significant reforms aimed at improving the service standards for health insurance policyholders. These reforms are designed to streamline the claims process, enhance policyholder benefits, and ensure better service delivery. Here are the key changes mandated by IRDAI:

Quick Claim Approvals and Discharge Authorization

• Cashless Claims: Insurers are now required to approve cashless claims within one hour.
• Discharge Authorization: Final authorization for discharge from a hospital must be provided within three hours.

Enhanced Renewal and Policyholder Benefits

• Grace Period for Renewals: A one-month grace period for annual renewal of health policies will be provided, ensuring benefits under policies renewed within this period are protected.
• No-Claim Benefits: Policyholders with no claims during the policy period can be rewarded with either an increased sum insured or discounted premium amounts.

Comprehensive Policyholder Protections

• Immediate Release of Mortal Remains: In the event of a death during treatment, insurers must ensure hospitals release the mortal remains immediately.
• Claims Review Committee: Insurers cannot repudiate a claim without the approval of a Claims Review Committee.
• Document Collection: Insurers and Third-Party Administrators (TPAs) must collect necessary documents directly from hospitals, not from the insured.

Flexibility and Coordination in Claims Settlement

• Choice of Policy for Claims: Policyholders with multiple health insurance policies can select the policy under which they wish to claim the admissible amount.
• Primary Insurer Coordination: The primary insurer will coordinate the settlement of the balance amount from other insurers. Policy Cancellations and Renewals
• Refund on Cancellation: Policyholders who cancel their policies can receive a refund of the premium for the unexpired policy period.
• Renewability of Policies: All individual health insurance policies are renewable and cannot be denied on the basis of previous claims, except in cases of fraud, non-disclosure, or misrepresentation.
• No Fresh Underwriting: Fresh underwriting is not required unless there is an increase in the sum insured.

Moving Towards 100% Cashless Claim Settlements

• Empaneling Healthcare Providers: Insurers are directed to empanel all categories of hospitals and healthcare providers, considering affordability for different population segments.
• Stricter Timelines for Portability Requests: Stricter timelines are imposed on portability requests via the Insurance Information Bureau of India (IIB) portal.

Master Circular on Health Insurance

• Consolidation of Norms: The new circular consolidates entitlements in a health insurance policy, repealing 55 previous circulars.
• Immediate Effect: The master circular comes into effect immediately, with certain exceptions.

These reforms by IRDAI aim to create a more transparent, efficient, and policyholder-friendly health insurance ecosystem. By mandating quick claim settlements, offering enhanced benefits, and ensuring better coordination among insurers, the new norms are set to significantly improve the overall experience for health insurance policyholders in India.