Health insurance claims: 5 IRDAI rules that can make a difference when you need to claim

The latest market report highlights that Buying health insurance is one thing. Using it when a hospitalisation actually happens is another. Many policyholders are familiar with premiums and sum insured, but the claim process can raise questions at a time when there is already enough stress.

IRDAI has laid down several rules around health insurance claims. Knowing these provisions can help policyholders understand what an insurer or third-party administrator can ask for and when a claim should be processed.

One, cashless claims have defined timelines. Under IRDAI's current health insurance framework, an insurer has to decide on a cashless pre-authorisation request immediately and within one hour of receiving it. Once the hospital sends the discharge authorisation request, the insurer has up to three hours to provide final authorisation.

This does not mean every hospital bill will automatically be paid in full. The amount approved still depends on the policy's coverage, exclusions, deductibles, co-payments and other terms. But the timelines are useful when a patient is waiting for discharge.

Two, reimbursement claims additionally have a time limit. IRDAI's health insurance FAQ says insurers should settle or reject a claim within 30 days of receiving the last necessary document. Where an investigation is warranted, the insurer should complete it at the earliest and, in any case, within 30 days of receiving the last necessary document. The claim should then be settled within 45 days.

This makes one point particularly useful: keep a record of when you submitted the documents and what was submitted. If the insurer keeps asking for documents one by one, the policyholder can check whether those documents are actually required under the policy.

Three, claim documents cannot be demanded endlessly. IRDAI says that, except where fraud is suspected, documents not listed in the policy terms should ordinarily not be treated as necessary. Insurers should additionally call for the required documents together rather than repeatedly asking for additional paperwork in pieces.

That does not mean a policyholder can submit incomplete information and expect payment. Medical bills, discharge summaries, prescriptions and other documents specified in the policy may still be required.

Four, a rejected claim should come with reasons. If an insurer denies or repudiates a claim, the communication should specifically state the reason and refer to the relevant policy condition. The insurer must additionally provide information around the available grievance redressal process.

So, if a claim is rejected because a particular treatment is excluded, the policyholder can check the exact exclusion instead of relying only on a verbal explanation from a hospital desk or TPA.

Five, there is a route for escalation if a dispute is not resolved. A policyholder can first approach the insurer's grievance mechanism. If the matter stays unresolved and falls within the Insurance Ombudsman framework, complaints can include delays in claim settlement and partial or total repudiation of health insurance claims.

Another point worth remembering is the 60-month moratorium. After 60 continuous months of health insurance coverage, including portability and migration, a policy and claim generally cannot be contested on grounds of non-disclosure or misrepresentation, except in cases of established fraud. If the sum insured is increased, the 60-month period applies separately to the enhanced portion.

These rules do not guarantee that every claim will be approved. Health insurance stays a contract, and exclusions, waiting periods, sub-limits, deductibles and co-payments can affect the amount payable.

The practical step is to keep the policy document, Customer Information Sheet, hospital records and claim correspondence together. When a claim goes wrong, knowing what the policy says and when each document was submitted can be far more useful than relying on a verbal assurance at the hospital counter.