01 Jun 2012
New Delhi: Health insurers must provide policy cover to people up to 65 years and settle all claims within a month, the Insurance Regulatory and Development Authority has proposed in its draft guidelines for insurance companies.
The IRDA said insurers would have to provide cashless facility to policy holders undergoing treatment in a particular hospital even after it is removed from the list of preferred service providers.
The provisions form part of IRDA’s exposure draft on IRDA (Health Insurance) Regulations 2012. The draft also talks about portability, under which a policy holder can migrateto another health insurance providing company without losing any benefit and special provisions for senior citizens whose need for healthcare is pressing.
Under the proposed norms, the insurer will have to provide customers all relevant information in simple language on a single page. Reasons for denial of claims should also be provided.
As per the draft norms, insurers must ensure that empanelled hospitals — where cashless facilities are offered to policy holders — are spread across different cities of the country and not confined only to metro cities. “The insurance company shall ensure that adequate number of both public and private providersshallbeempanelled,” it said.
Also, "if the policyholder is already undergoing such treatment at a hospital, and such hospital is proposed to be removed from the list of network providers, then insurers shall provide the benefits of cashless facility for such policy holder as if such hospital continues to be on the network provider list."
The guidelines seek to address the problems of the health insurance sector which came into light in 2010 after four public sector insurers removed private hospitals from their preferred list citing over charging by them under the cashless scheme.
IRDA has also suggested that insurers keep policy holders informed at all times on the nearest hospital where cashless facility is available. The insurers should also display the updated list of network providers on their websites. "For the purpose of claim settlement, insurer shall make direct payments to the network provider and to the policy holders by integrating their banking system platform with the network provider or the insured, as the case may be," the draft said.
It has also provided for issuance of travel insurance policies by companies on standalone basis. The insurers, it said, will also be allowed to come out with "health-plus life combi" products which would be a combination of life and health insurance cover.
There are currently more than seven crore health insurance customers and their premiums add up to more than Rs 11,000 crore. PTI