NEW DELHI: The Insurance Regulatory and Development Authority of India (IRDAI) has cautioned insurers against not being transparent to policyholders while rejecting health insurance claims. “Insurer shall ensure that the repudiation of the claim is not based on presumptions and conjectures,” the IRDAI said in a circular to Life, General and Standalone Health Insurance Companies as well as TPAs.
IRDAI said when a claim is denied or repudiated, the insurer should communicate the same, specifically mentioning reasons and also referring to the corresponding policy conditions. Details of the grievance redressal procedures available with the insurer as well as the Insurance Ombudsman along with addresses of the respective offices should also be furnished to the policyholders.
Besides processing of the claims in a “transparent, seamless and efficient manner within prescribed timelines,” the insurance companies should ensure the policyholder is provided with granular details of the payments made, amounts disallowed and the reasons for the amount disallowed.
The insurance regulator said it is essential for all insurers to establish procedures to let policyholders get clear and transparent communication at various stages of claim processing.