IRDAI has issued guidance to insurers on settling of cashless health insurance claims for Covid-19 treatment.
The Reference Rates for COVID-19 of General Insurance Council will be applicable to both cashless and reimbursement claims.
The cost of hospitalisation due to COVID-19 may run into a few lakhs as the hospital stay is generally around 14 days. The General Insurance Council (GI Council) has prepared a rate chart for the COVID-19 treatment, taking into account rates published by various state governments and also after discussions with health claim experts. The rates are proposed by the GIC to be considered during treatments in hospitals. The IRDAI has sent a communication to all life and health insurance companies regarding the settlement of health insurance claims against General Insurance Council’s instructions dated 20th June 2020 on ‘Reference Rates for COVID-19’.
The treatment for dealing with Coronavirus appears to be different from treatments done in other medical conditions as it entails the use of PPE Kits and specific procedures for medications. It is important that the hospitals across the country follow a standardised rate chart and the insurance companies keep the claim settlement process smooth and simple for the policyholders.
In the communication to the insurers, IRDAI has stated that in case of ‘Cashless Claims’ under a health insurance policy, the claims shall be settled as per the tariff decided by the parties as per the provisions of Regulation 31 of IRDAI (Health Insurance) Regulations, 2016.
However, the insurers shall make efforts to have an agreement with health providers on rates for treatment of Covid-19 similar to other diseases for which rate agreements are in place.
Also, while entering into such agreements, the reference rate of General Insurance council can be kept in view for guidance along with rates fixed by State Governments and Union Territory administration, if any and as relevant.
Further, all the insurers have been directed by IRDAI to ensure that the ‘Reimbursement claims’ under a health insurance policy shall be settled as per the terms and conditions of the respective policy contract.
The Reference Rates for COVID-19 of GI Council will be applicable to both cashless and reimbursement Covid-19 claims where any Government Authority has not published standard charges for Covid-19 treatment. Wherever Covid-19 treatment charges have been published by any Government Authority, those charges shall be applicable to insurance claims with member companies.