IRDAI is continuously working towards making the health insurance claim process more efficient and transparent.,” says Bhabatosh Mishra, Director Underwriting, Products and Claims at Niva Bupa Health Insurance
IRDAI is continuously working towards making the health insurance claim process more efficient and transparent.,” says Bhabatosh Mishra, Director Underwriting, Products and Claims at Niva Bupa Health Insurance
National Health Claim Exchange Platform: One of the most important and much anticipated changes specific to insurance claims is the national health claim exchange platform. Once operational, it will enable auto-adjudication of claims through introduction of standard forms and standard information.
“It would be able to provide aggregated information for analysis of health and cost trends. Providing convenience to hospitals and making it easier for them to manage different patient’s data, the platform will do away with the hospital's need of having to log into multiple insurers and TPAs’ portals for addressing different patients' claims,” says Mishra.
Further, insurers will be able to auto-adjudicate claims easily as all hospitals will upload data in a standard format. “This standardised data exchange protocol will be able to integrate with the health management information system and pull out relevant details to process claims,” adds Mishra.
Cashless Everywhere: Policyholders now enjoy the convenience of cashless claims at non-network hospitals. This ensures that during emergencies, individuals can seek treatment at any hospital without worrying about upfront payments.
Faster Claim Clearance Timelines: “With a three-hour deadline for cashless claims during discharge and a one-hour timeline for admission requests, policyholders experience faster claim processing, minimising delays and enhancing the efficiency of their healthcare journey,” says Pankaj Nawani, CEO, of CarePal Secure, integrated health protection marketplace.
Reduced Waiting Period for Pre-existing Diseases: When you have a pre-existing disease, any hospitalisation due to that disease is not covered by health insurance immediately, but after a certain period. This is known as the waiting period. By reducing the waiting period for pre-existing diseases from four to three years, policyholders can access coverage for these conditions much sooner. This change offers quicker financial relief and support for those with pre-existing health issues.
Reduced Moratorium Period: The reduction of the moratorium period from eight to five years means policyholders have greater assurance that their claims will not be contested after this period, providing peace of mind and stability. This means after five years, an insurance company cannot deny a claim on any grounds apart from fraud.
Mandatory Coverage of Ayush Treatments: Now, many are exploring alternative treatments apart from allopathy which were earlier not covered under health insurance. “Including Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homeopathy
(Ayush) treatments in mandatory coverage expands the range of healthcare options available to policyholders,” says Mawani. This allows policyholders to not rely solely on allopathic treatments.
Claims Across Multiple Insurers: “Allowing claims from multiple health insurance policies for a single hospitalisation event ensures comprehensive financial protection. Policyholders can fully utilise the benefits from all their policies, optimising their coverage and reducing out-of-pocket expenses,” says Mawani.
For example, imagine Mr. X, a 35-year-old professional, has two health insurance policies: one from his employer with a sum insured of Rs 3 lakhs, and another from Insurer A with a sum insured of Rs 2 lakhs. Recently, Mr. X had a medical procedure costing Rs 4 lakhs. Under the new IRDAI rules, Raj can claim Rs 3 lakhs from Insurer A and the remaining Rs 1 lakh from Insurer B.
Previously, Mr. X might have faced difficulties if the sum insured under one policy was exhausted. Now, with the flexibility to claim across multiple insurers, Mr.X can ensure his entire medical bill is covered without incurring out-of-pocket expenses. “This change simplifies the process for policyholders with multiple policies, providing comprehensive coverage and financial protection against high medical costs
Source: BW-Businessworld.in
