The Insurance Regulatory and Development Authority of India (IRDAI) has said that in case of cashless claims under a health insurance policy, the claims should be settled as per the tariff decided by the parties in compliance with provisions of Regulation 31 of IRDAI (Health Insurance) Regulations, 2016. The regulator, however, said that insurance companies should make efforts to have agreements with health providers on the rates for treatment of COVID-19 similar to other diseases.
The IRDAI has directed all insurers to ensure that reimbursement claims under a health insurance policy should be settled as per the terms and conditions of the respective policy contract.
“In case of “Cashless Claims” under a health insurance policy, the claims shall be settled as per the tariff decided by the parties in compliance to provisions of Regulation 31 of IRDAI (Health Insurance) Regulations, 2016,” IRDAI said in a circular dated 13th January 2021.
“However, the insurers shall make efforts to have agreement with health providers on rates for treatment of Covid-19 similar to other diseases for which rate agreements are in place. Also, while entering into such agreements, the reference rate of GI council can be kept in view for guidance alongwith rates fixed by State Governments and Union Territory administration, if any and as relevant,” the circular added.
The insurance regulator further said, “All the insurers are directed to ensure that the “Reimbursement claims” under a health insurance policy shall be settled as per the terms and conditions of the respective policy contract. Hence, the insurers shall honor all the health insurance claims as per the terms and conditions of the policy contract.”
