2020-07-14 20:42:00

Covid-19 patients in some parts of India are dealing with hospitals denying cashless claims facility offered by their insurers, adding to their distress at a time of crisis. Mint reported this on 8 July. You can find the details here.

In order to discourage healthcare providers from taking large sums of money as deposits and denying cashless claims, the Insurance Regulatory and Development Authority of India, on Tuesday, said a list of network providers shall be published on the website of all general and standalone insurance companies. Further, the regulator has said that the third-party administrators (TPAs) too shall publish the list of the network providers and all such hospitals shall hospitals the cashless claims facility for all treatments including Covid-19 to the policyholders.

“It is clarified that the policyholders are entitled to cashless facility at all such network providers (hospital) with whom the Insurance company/TPA has entered into an agreement in accordance to the norms of service level agreement (SLA),” said Irdai in its circular. The regulator added that in case of denial of the cashless facility at any of the enlisted network providers, policyholders may file a complaint with the concerned insurance company by writing to the grievance redressal officer of the insurer details of which can be found on the company’s website. Insurers have been advised to put in place an exclusive grievance redressal mechanism to address complaints relating to denial of cashless claims.

For cases where policyholders’ interest has been adversely affected because of the conduct of the network providers, Irdai said such instances may immediately be reported to the appropriate government agencies in the state or are.

Hospitals’ representatives had earlier said that many insurers have not revised the cashless agreement rates in the last four years and given the medical inflation, the old rates are tenable. Also due to the pandemic, providers are cash-strapped which gets only worse if insurers don’t settle claims on time. Given these reasons, can insurers push hospitals to comply with cashless claims facility now that Irdai has issued an advisory?

Insurance experts we spoke with said that Irdai can only issue an advisory on the basis of which insurance companies can negotiate with the network providers. However, this by no means can push hospitals to comply with what insurers or the regulator demand. “There are dialogues going on between hospitals and insurers on this as well as standardizing rates in line with the prices prescribed by the general insurance council. Negotiations and discussions with network providers are the only solutions,” said the chief underwriting officer of a general insurance company who didn’t want to be named. In normal circumstances, policyholders have the option of choosing a hospital but given the high infection rate for Covid-19, finding a bed itself is a task and experts said in a situation like this, some amount of regulator intervention could help in the negotiation process.

Despite increased awareness, Health insurers see a 31% drop in premiums in June quarter FY21

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