India: IRDAI instructs insurers on processing COVID-19 claims

India: IRDAI instructs insurers on processing COVID-19 claims

Insurers must settle COVID-19 hospitalization reimbursement claims in accordance with the tariff for cashless treatment and the policy terms, says the Insurance Regulatory and Development Authority of India (IRDAI) in a circular intended to clarify claim procedures.  

This guidance, issued on 13 Jan 2021, follows a circular issued by General Insurance Council (GI Council) on 20 Jun 2020, calling for COVID-19 hospitalization claims to be settled using rates set by government authorities or published by the GI Council. 

For cashless claims under a health insurance policy, IRDAI advised that

  • Claims must be settled in accordance with the tariff decided by the parties under Regulations 31 of IRDAI Regulations, 2016. 
  • Insurers should “make efforts” to agree with health providers on the applicable treatment rates of COVID-19, similar to other diseases covered by a rate agreement. 
  • Insurers should take into consideration the guidance issued by the GI Council and the rates fixed by State Governments and Union Territory Administration.

For the reimbursement of claims under a health insurance policy, IRDAI said that claims should be settled in accordance with the terms and conditions of the policy contract.  

IRDAI also advises insurers to issue suitable guidelines to third party administrators. 

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