Articles April 23, 2021

The Insurance Regulatory Authority of India (IRDAI) has asked health and other general insurance companies to communicate cashless claim approvals to their network hospitals within 30 to 60 minutes of receiving the pre-authorization request from them. A pre-authorization request is a form that customers need to fill and submit to the insurance/TPA desk of the network hospital, which then sends it to the insurer for approval. The latest directive issued by the IRDAI would ensure patients get beds and discharged without any delay. On April 18, 2020, the insurance regulator had given insurers a maximum of 2 hours to grant approvals for cashless pre-authorization and discharge of patients.

The latest order from the IRDAI comes in the wake of rising COVID cases and the directions of the Delhi High Court. So, insurers will now have to communicate regarding cashless authorization for COVID-19 claims within 1 hour from receiving the request. Insurers will need to communicate the decision regarding the discharge of patients within one hour of receiving the final bill as well as all necessary requirements from the hospital. To ensure these, insurers are directed to issue appropriate directions to their respective Third-party Administrators (TPAs).

What Led the IRDAI to Tell Insurers to Communicate Cashless Approvals Within 1 Hour?

The IRDAI came to know from a series of tweets by the Finance Minister Nirmala Sitharaman that network hospitals were denying cashless claims for COVID-19 patients. Taking note of such incidents, the IRDAI, in a letter issued on April 22, 2021, had asked health insurance and other general insurance companies to take action against network hospitals denying cashless health insurance claims for COVID patients. While issuing the order, the regulator also stated that it is up to insurance companies to ensure the smooth availability of cashless treatment at network hospitals.

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In quoted lines, the regulator said, “All the Network Providers (Hospitals) who have signed Service Level Agreements (SLA) with health and other general insurers have to mandatorily provide cashless facility to policyholders including COVID-19 treatment in accordance with agreed provisions of SLA and terms and conditions of policy contract”.

Policyholders can even complain against the denial of cashless claims at Grievance Redressal Cell. Let’s check out here how they can do it.

How Can Customers Complain at Grievance Redressal Cell?

Customers need to first approach the Grievance Redressal Cell of the particular insurer. They can send an email, which can be obtained on the official website of the IRDAI, to the Grievance Redressal Officers of insurers. Upon failing to receive a response from the insurer within a reasonable period or not a satisfactory reply from it, they can approach the Grievance Redressal Cell in the Consumer Affairs Department of the IRDAI.

The redressal cell will entertain the complaints filed by the insured and the claimant only. Complaints filed by advocates, agents or any third parties on behalf of policyholders shall not be entertained by the cell. So, the insured or claimant needs to provide complete details of the complaint as specified in the Complaint Registration Form available on the official website of the IRDAI. Remember, the complaint won’t get registered if the required information is not specified clearly in the form.

Other Ways to Register Complaints Against Health Insurers

You can also register your complaint by using any of the following modes –

  • Email to complaints@irdai.gov.in
  • Dial the Toll-Free Number – 155255 or 18004254732
  • A physical form to –

General Manager

IRDAI

Consumer Affairs Department – Grievance Redressal Cell

Sy. No 115/1, Financial District, Nanakramguda,

Gachibowli, Hyderabad – 500032

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