Cashless Health Insurance Claims to be Cleared in 3 hours: What Does it Mean for Policyholders?

The Insurance Regulatory and Development Authority of India (IRDAI) rolled out several customer-centric guidelines regarding cashless claims on May 29, 2024. The rule made it mandatory for insurers to approve initial cashless authorisation in a maximum one hour and final claim settlements within three hours of receiving the request. It also urged them to aim for 100% cashless facilitation.

But what does it mean for policyholders?

1. The policyholder does not have to wait for any medical treatment due to the delayed authorisation of cashless payment.

2. They do not have to wait long or pay extra because of delayed discharge.

This guideline has made the claim settlement process faster and hassle-free for policyholders, ensuring they get the health insurance coverage benefit when they need it the most. It allows them to put medical treatment on priority instead of hustling to complete formalities.

In this guideline, IRDAI also highlighted that in case of a delayed authorisation which results in additional hospital charges, the insurer will be responsible for bearing this extra charge.

Moreover, the policyholders are not required to submit the documents themselves, instead the insurers and TPAs are instructed to collect them from hospitals, saving the policyholders from the hassle of immediate paperwork.

Why Was There a Need for a More Efficient Claim Settlement Process?

Before this IRDAI guideline was ruled out, the policyholders were facing several issues. Some of them were:

Payment Pressure from the Hospital

The patient's family had the undue pressure of early payment completion/authorisation, and at times, required them to arrange for immediate funds. This rule reduces hospital pressure for payment as the authorisation has to be done within one hour.

Delay in Treatment & Discharge

Delays in discharge often mean the patient will have to stay until the formalities are completed, even when the treatment is completed. This resulted in additional room and hospitalisation charges, thereby increasing the burden of costs along with mental strain.

While in cases of delayed authorisation, some treatment or tests were put on hold by the hospital until payment confirmation, which could mean an adverse effect on patient's health.

Hassle of Paperwork

Before this guideline, the policyholder had to submit policy documents and coordinate with the hospital as well as the insurer multiple times to get their claim approved timely manner. This rule has simplified the claim settlement process for policyholders.

Benefits of Cashless Health Insurance Claims for Policyholders

This guideline has eased the claim settlement process for policyholders. Here's how:

Ensures Faster Claim Approvals

As the claim approvals become faster, the policyholder’s hospital stay reduces, thereby saving them from unnecessary stress.

Avoids Unnecessary Costs

Timely cashless authorisation and discharge ensure that the policyholder's hospital stay reduces and they are not unnecessarily charged.

Better Handling of Emergency Situations

With payment matters and discharge formalities taking a backseat, the insured and their family can focus more accurately on the treatment stress-free.

Increases Transparency

Since most data exchange takes place in digital form, it increases transparency, thereby increasing the policyholder's trust in the health insurance ecosystem.

Better Adaption of Health Insurance

This customer-centric, trustworthy approach would help people to understand the benefits of health insurance more and penetrate to grassroot levels.

How is IRDAI Expanding the Efficient Claim Settlement Process?

To ensure better adaptability of the guideline and expand the ambit of the efficient claim settlement process, IRDAI had taken the following steps:

1. They launched the digital platform NCHX for smoother and faster exchange of data between insurers, TPAs, hospitals and the government. This would, in turn, ensure that the claim settlement process is more efficient and quicker for the policyholders.

2. IRDAI had also urged hospitals to have specific and more help desks dedicated to cashless assistance so that people can easily get their queries resolved.

Final Verdict on Cashless Health Insurance Claims

While currently there may be certain gaps in the guideline's implementation, IRDAI's stricter laws and digital push can ensure that this turns into a progressive, successful model. Overall, this IRDAI rule is empowering policyholders, ensuring a hassle-free claim experience along with improved customer experience in the health insurance sector.

(The views, opinions, and claims in this article are solely those of the author’s and do not represent the editorial stance of The Assam Tribune)