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What Policyholders Must Know about IRDA's Master Circular on Health Insurance Business (29/05/2024)?

Posted on 18 Jun 2024
Author: Sayan Sircar

Tags: Health Insurance

4 mins read
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This article discusses the latest Master Circular on Health Insurance Business, issued on 29/05/2024, which introduced significant changes aimed at enhancing policyholder protection and streamlining claim settlements.

What Policyholders Must Know about IRDA's Master Circular on Health Insurance Business (29/05/2024)?

📚 Topics covered:

Key Changes for Insurance Policy Holders as per the Master Circular on Health Insurance Business (29/05/2024)
FAQs for Understanding the Master Circular on Health Insurance Business (29/05/2024)
Where is the full IRDA Master Circular on Health Insurance Business (29/05/2024)?

Key Changes for Insurance Policy Holders as per the Master Circular on Health Insurance Business (29/05/2024)

Non-Contestability of Claims Post Moratorium

Once you have 60 months of continuous coverage, your claims cannot be contested for non-disclosure or misrepresentation except in fraud cases. This change provides greater security and reliability for long-term policyholders. This figure used to be 8 years earlier.

Faster Cashless Facility

New guidelines require insurers to decide on cashless authorization within one hour, aiming for 100% cashless claim settlements. This helps reduce the financial burden on policyholders during emergencies and hospitalizations.

No Claim Bonus (NCB) Options

Policyholders can now choose between a cumulative bonus or a discount in renewal premiums, offering more flexibility and rewards for maintaining good health.

Maximum 3-Hour Authorization Delay for Hospital Discharge

Insurers must process discharge authorizations within three hours. Any delay costs will be covered by the insurer, ensuring prompt discharge and reducing additional costs for policyholders.

Enhanced Claim Settlement Process

The Claims Review Committee ensures that no claims are unjustly denied without a thorough review. Insurers or TPAs are responsible for collecting all required documents, making the claim process smoother for policyholders.

FAQs for Understanding the Master Circular on Health Insurance Business (29/05/2024)

What is the Moratorium Period?

The Moratorium Period is a 60-month duration of continuous coverage after which no health insurance policy or claim can be contested for non-disclosure or misrepresentation, except for fraud. Credits from ported and migrated policies count towards this period.

What is the No Claim Bonus (NCB)?

The No Claim Bonus rewards policyholders who do not make a claim. It can be given as:

A Cumulative Bonus: An increase in the Sum Insured without a premium increase.
A Discount in Renewal Premium.

What are the Guidelines for the Cashless Facility?

Insurers must aim for 100% cashless claim settlements, making reimbursement claims rare.
Insurers must decide on cashless authorization requests within one hour of receipt.
Insurers should set up Help Desks in hospitals and provide pre-authorization digitally.

What is the Process for Final Authorization for Discharge from the Hospital?

Insurers must grant final authorization within three hours of the discharge authorization request from the hospital. Delays beyond three hours will result in the insurer covering additional costs.
In case of the policyholder’s death during treatment, insurers must immediately process the claim and facilitate the release of the body from the hospital.

What are the Rules for the Settlement of Claims?

No claim shall be denied without the approval of the Policy Management Committee (PMC) or a three-member Claims Review Committee (CRC).
If a claim is denied or partially disallowed, insurers must provide detailed reasons referencing specific policy terms.
Insurers and Third Party Administrators (TPAs) are responsible for collecting the required documents from hospitals; policyholders do not need to submit them.

Can Policyholders Hold Multiple Policies?

Yes, policyholders can hold multiple health insurance policies. In the event of a claim, they can choose which policy to claim benefits from, and insurers must coordinate to ensure seamless settlement in case there is a need to claim from a second policy.

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Also read
How much EMI do I have to pay for my home loan?

Where is the full IRDA Master Circular on Health Insurance Business (29/05/2024)?

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