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Topic : IRDAI Announces Major Changes to Streamline Health Insurance in India

GS-2 Mains  : Health and Insurance 

Revision Notes

Enhanced Claims Experience:

  • Faster Claims & Improved Service: IRDAI aims to ensure a smoother and faster claims experience for policyholders.
  • 3-Hour Claim Authorization: Insurers must grant final claim authorization within 3 hours of receiving the discharge request from the hospital. Policyholders cannot be forced to wait for discharge due to delays. Insurers face penalties for exceeding the 3-hour window.
  • Quick Claim Settlement in Death Cases: Insurers must prioritize claim settlements in death cases and ensure the immediate release of mortal remains from the hospital.
  • 100% Cashless Goal: Insurers are urged to achieve 100% cashless claim settlements. The deadline for implementing necessary procedures is July 31, 2024. For emergencies, a 1-hour authorization window applies. Dedicated help desks at hospitals may be established to assist with cashless claims.

Wider Choices & Flexibility for Policyholders:

  • Diverse Product Offerings: Insurers are encouraged to develop a wider range of products, add-ons, and riders to cater to various needs.
  • Multi-Policy Claim Choice: Policyholders with multiple health insurance policies can choose which policy to claim under.

Improved Transparency & Policyholder Benefits:

  • Mandatory Customer Information Sheet (CIS): Insurers must provide a CIS with every policy document for clear communication.
  • No Claim Bonus (NCB) Option: Insurers can offer NCBs for not making claims during the policy period, either by increasing the sum insured or providing a premium discount.
  • Policy Cancellation Refund: Policyholders can receive a refund of the premium or a proportionate amount for the unexpired policy period if they choose to cancel their policy.

Addressing Past Issues:

  • A Local Circles survey revealed that 43% of policyholders faced claim processing difficulties in the past 3 years.
  • The claims process was often time-consuming, causing delays and additional hospital stays.
  • Pre-approval from the TPA desk did not always guarantee a smooth claims experience.

Expected Outcome:

  • The new IRDAI regulations aim to address these past issues by offering policyholders more choices, flexibility, and improved service standards. These measures are expected to lead to a faster, more efficient, and hassle-free claims process for health insurance policyholders in India.


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