Insurers to report hospitals levying excess charges, denying cashless facility
(IRDAI) Hospitals Denying Cashless Facility has ask insurance companies to report excess charges being levy to respective state governments for appropriate action.
The regulator’s advisory reports
Certain hospitals are charging high rates & insisting on cash payments from policyholders for providing treatment to covid-19 patients.
Despite having a cashless arrangement with Insurers.
In compliance with the provisions of Regulation 31of IRDAI ( Health Insurance ) Regulations, 2016.
The Insurers, in case of “cashless claim” under a health insurance policy & are advise to ensure expeditious settlement of such claims on a cashless basis in accordance to.
The Service Level Agreements ( SLAs) enter with hospitals,” the regulator said in a note release on 23 April.
The regulator add that while reviewing cashless requests.
Insurers are also advise to ensure that policyholders are charge as per rates agree to by network providers wherever applicable.
Insurers are also advise to ensure that hospitals Denying Cashless Facility.
The same treatment other than those rates that are agree with the insurers.
Insurance companies have been advise to put in place effective communication channels
The network providers for prompt resolution of grievances of policyholders to ensure that all network providers extend cashless services.
Policyholders and to address any issues causing inconvenience to policyholders while availing cashless service.
They have also been ask to ensure that reimbursement claims under a health insurance policy be settle as per the terms & conditions of the respective policy contract expeditiously.
“Insurers are advise to issue suitable guidelines on this to all TPAs,” IRDAI said.
Coronavirus cases are rapidly rising across the country.
While all the insurers have been ask to honor insurance claims of Covid-19 patients on priority.
(IRDAI) has take cognizance of the issue
There are reports of certain network providers (hospitals) charging high rates & insisting on cash payments.
The policyholders for providing treatment to COVID-19 infect patients despite having cashless arrangement with Insurers”.
IRDAI chairman SC Kunthia to “act immediately” to address the complaints of denial of cashless claims by insurance companies.
She also mention that more than 9 lakh COVID-19 relate claims for Rs 8,642 crore have been settle by insurance companies.
Reports are being received of some hospitals denying cashless insurance.
Spoken to Chairman, IRDAI Shri SC Khuntia to act immediately.
In March’20 #Covid included as a part of comprehensive health insurance.
Cashless available at networked or even temporary hospitals,” the minister said in a series of tweets.
The regulator, she added, has asked insurance companies to priorities settlement of COVID claims.
Following FM’s order, the regulator also directed insurers to ensure the availability of cashless facilities with.
All empaneled network providers by putting in place a continuous communication channel with all
The network providers for prompt cashless services and for resolution of grievances of policyholders.
However, some policyholders are still facing issues as hospitals are denying claims.
Here’s what you can do if you face the same issue:
Talk to your TPA:
If you face any difficulty in a situation like this, you should make a formal request with your (TPA) for the cashless admission in the network hospital.
In case you are still deny admission on cashless basis, you can use this denial to lodge a formal complaint with your insurer against the hospital.
Opt of reimbursement:
In case of emergency, getting treatment as soon as possible should be the priority.
If the situation is critical and if the network hospital is offering admission on a payment basis, you can go for it & later get the money reimburse.
“All Insurers are direct to ensure that the “reimbursement claims under a health insurance policy shall be settle as per the terms & conditions of the respective policy contract expeditiously.
Insurers are advise to issue suitable guidelines on this to all TPAs” IRDAI said circular.
The cashless facility is convenient but it also limits your choices as you have to stick to only network hospitals which are empaneled with your insurer or the TPA.
In case of denial by a network hospital, you can also go for treatment at a non-network hospital as the priority remains to save the life of the patient.
The re-imbursement method allows you to claim the expenses with your health insurance provider after the treatment.
While the cashless insurance claim facility eliminates hurdles face by policyholders with reimbursement mode.
In an emergency situation, you can go for another network hospital to get the cashless facility.
IRDA has caution the insurance providers to make sure that hospitals are following the agree pricing.
While reviewing cashless requests the Insurers are also advise to ensure that the policyholders are charged as per the rates agree to by network providers wherever applicable.
Insurers are also advise to ensure that hospitals do not levy any additional charges for the same treatment other than those rates that are agree with the insurers.
Lodge a complaint against the hospital:
The insurance regulator has direct insurers to regularly communicate to their network providers to ensure hassle-free service to the policyholders.
It has also asked insurers to report such cases to local authorities for appropriate penal action.
Insurers are advise to put in place an effective communication channel with all the network
Providers for prompt resolution of grievances of policyholders.
Insurers are advised to report levying of excess charges facility to the respective State Governments for appropriate action.
While the insurance company will follow its set course to complain against hospitals.
You must register your own complaint in case of any deficiency in availing medical services because of the hospital.
Approach the regulator if issue not resolve:
In order to make sure that your issue is resolve you should also be aware of the process of lodging your complaint
escalating it further if you don’t get a satisfactory response.
The insurer’s Grievance Redressal Mechanism as spelt out in the insurance policy document.
In case the complaint is not fully attend to by the Insurer within 15 days of lodging it.
You may use the Integrate Grievance Management System (IGMS) for escalating the complaint further to IRDAI.