‘Companies must specify reasons of health claim denial’


NEW DELHI: Insurance sector regulator Irdai has asked all insurers to be more transparent in their health insurance claim settlement process and apprise policyholders of reasons in case of denial of claims. It essential that all insurers establish procedures to let policyholders get clear and transparent communication at various stages of claim process, Irdai said in a circular.
“All the insurers shall ensure putting in place systems to enable policyholders track the status of cashless requests/claims filed with the insurer/TPA through the website/portal/ app or any other authorised electronic means on an ongoing basis.
“The status shall cover from the time of receipt of request to the time of disposal of the claim along with the decision thereon,” said the regulator. The circular on ‘Health Insurance Claims Settlement’ is addressed to life, general and standalone health insurance companies including the thirdparty administrators (TPAs).
In case the TPAs are settling the claims on behalf of the insurers, policyholders should be notified about all the communications as well as location to track the claims, Irdai said. Irdai has asked the insurance companies to ensure that repudiation of the claim is not based on “presumptions and conjectures”.


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