• *TPA is not permitted to settle/ reject/
repudiate claims*, as per Sec 33(c) of HIR 2016
• The claims settlement (rejection) letter
should mention the specific *grounds for denial/ rejection of claim*, as per
Sec 33(d)(iv) of HIR 2016
• Consumer will *get interest of 2% over the
prevailing bank rates, on claims payment delayed beyond 30 days* and will have
to mentioned in the policy document, as per Sec 28(iv) of HIR 2016
• The *claims payment* will be made from the
Insurer’s bank account and *not the TPA’s*, as per Sec 32 of HIR 2016 Earlier
claim cheques were issued to the customer by the TPA (Third party Administrator),
but now the insurance company would have to write a claim cheque or ECS
directly to the customer. This would eliminate the float that some of the TPAs
were enjoying. Also, there was never any public audit of the claims funds
sanctioned by the Insurance company v/s actual amount disbursed by the TPA.
• TPA has to electronically transfer the claims
document to Insurer for a decision as per Sec 35(a) of HIR 2016
• The TPA will ask for claims related *papers in
one time only*, and not in a piece meal manner as per Sec 27(ii) of HIR 2016
• Non-allopathic (AYUSH) treatments may be
covered, as per Sec 18 of HIR 2016
• Fees to the TPA shall not be related to
reduction of claims costs as per Sec 20(6) of Health Services Regulations for
TPA, 2016
• Discounts offered by hospitals have to passed
on to the policyholders, as per Sec 20(9) of Health Services Regulations for
TPA, 2016
• Change of TPA will be intimated to the
consumer in writing 30 days before hand as per Sec 34(a) of HIR 2016
Related to policy document:
• Premium for individual policies cannot be
increased at renewals in an arbitrary way, especially after a claim is made, as
per Sec 25(i) of HIR 2016.
• There will be no change in premiums in
individual policies *for 3 years* after initial offering, as per Sec 10(c) of
HIR 2016
• Cannot force consumer to shift to other
product as per Sec 11(c) and 17 of HIR 2016
• All policies will be ordinarily renewable as
per Sec 13 of HIR 2016
• Customer Information Sheet must be part of the
policy document, as per sec 26 of HIR, 2016
• *ID card to have logo of Insurance company
(not of TPA)* and the card may be permanent, as per Sec 30(f) of HIR 2016
• Policy is portable from one Insurer to
another, 45 days prior to maturity of policy (including cumulative bonus would
also be portable), as per Schedule I, Sec(1) & (18) of HIR 2016
• Free-look period is 15 days as per Sec 14 of
HIR 2016
• Cumulative bonus amount to be clearly
mentioned in the policy, as per sec 16(i) of HIR, 2016
• All disclosures as per the new regulations
have to be included in the policy document, as per sec 28 of HIR, 2016
• For multiple policies, claims under other
policy can be made after exhaustion of Sum Insured in the earlier policy, as
per Sec 24 (ii)2 of HIR 2016. The option to chose will remain with the insured
Related to Senior citizens:
• Entry age is *up to 65 years* and there will
not be any exit date for a policy as per Sec 12 of HIR 2016
• Premiums shall be fair, justified, transparent
and duly disclosed upfront, as per Sec 23(i) of HIR 2016
• Separate claims & grievance cell, as per
Sec 23(ii) of HIR 2016
Other regulations:
• Withdrawal of a product needs prior IRDA
approval and atleast 3 months notice, as per Sec 5(ii) of HIR 2016
• Group Insurance cannot be offered to groups
specifically formed to avail insurance, as per Sec 7(a) of HIR 2016
• Pre-insurance check-up cost included in
premium as per Sec 15(i) of HIR 2016
Important precautions to be taken in case of
claims:
• Best option for the consumer is to obtain
Cashless facility i.e. the Insurance company pays the bills directly to the
hospital. But the hospital must be part of their preferred network (PPN), which
list should be available on the insurance company website.
• If you wish to take treatment in a hospital,
which is not on the PPN cashless list, then make sure you intimate the
Insurance company/ TPA within 24 hours of admission in any hospital.
• In case of a pre-planned surgery, it is better
to inform the Insurance company/ TPA much earlier.
• As per IRDA’s guidelines to the Insurance
companies, *the consumer cannot be forced to sign the discharge or Settlement
Intimation voucher*. Signing the discharge voucher does not mean that the
Insurer’s liability is over.
Disputes resolution, especially Claims
processing
For claims-related complaints, consumers can
write to the Grievance cell of the Insurance company. As per IRDA guidelines,
grievances must be acknowledged by the Insurance company in 3 working days and
it must be *resolved in 15 working days*. If there is no response to the
letter, you can file a Right to Information (RTI) application with the
Grievance Officer.
The *IRDA Call Centre (toll-free at 155255*)
also offers an alternative channel for policyholders, serving from 8 AM to 8
PM, Monday to Saturday in Hindi, English and various Indian languages.
Consumer Affairs Department
Insurance Regulatory and Development Authority
(IRDA)
3rd floor, Parishram Bhavan,
Basheer Bagh, Hyderabad
For still unresolved disputes of *less than Rs
20 lakhs* pertaining to claims settlement or regarding premiums paid/ payable
and non-issue of insurance documents, the *Insurance Ombudsman* can be
approached. The written complaint with the relevant claim papers can be send by
the customer himself (*no lawyer is required*), within 1 year of dispute. After
registering with the Ombudsman office, attach this application document.
Contact details of Insurance Ombudsmen in India
*Contact Details*
Jurisdiction
MUMBAI
Office of the Insurance Ombudsman,
3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W),
Mumbai – 400 054.
Tel.:- 022-26106928/360/889
Fax:- 022-26106052
States of Maharashtra and Goa.
AHMEDABAD
Office of the Insurance Ombudsman,
2nd floor, Ambica House,
Near C.U. Shah College,
5, Navyug Colony, Ashram Road,
Ahmedabad – 380 014
Tel.:- 079-27546150/139
Fax:- 079-27546142
State of Gujarat and Union Territories of Dadra
& Nagar Haveli and Daman and Diu.
BHOPAL
Office of the Insurance Ombudsman,
Janak Vihar Complex,
2nd Floor, 6, Malviya Nagar,
Opp.Airtel,
Bhopal – 462 011.
Tel.:- 0755-2769200/201/202
Fax:- 0755-2769203
States of Madhya Pradesh and Chattisgarh.
BHUBANESHWAR
Office of the Insurance Ombudsman,
62, Forest park,
Bhubneshwar – 751 009.
Tel.:- 0674-2535220/3798/1607
Fax:- 0674-2531607
State of Orissa.
CHANDIGARH
Office of the Insurance Ombudsman,
S.C.O. No. 101, 102 & 103, 2nd
Floor,
Batra Building, Sector 17 – D,
Chandigarh – 160 017.
Tel.:- 0172-2706196/5861/6468
Fax:- 0172-2708274
States of Punjab, Haryana, Himachal Pradesh,
Jammu & Kashmir and Union territory of Chandigarh.
CHENNAI
Office of the Insurance Ombudsman,
Fatima Akhtar Court,
4th Floor, 453 (old 312), Anna Salai,
Teynampet,
CHENNAI – 600 018.
Tel.:- 044-24333678/664/668
Fax:- 044-24333664
State of Tamil Nadu and Union Territories –
Pondicherry Town and Karaikal (which are part of Union Territory of Pondicherry).
DELHI
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Asaf Ali Road,
New Delhi – 110 002.
Tel.:- 011-23239611/7539/7532
Fax:- 011-23230858
States of Delhi and Rajasthan.
GUWAHATI
Office of the Insurance Ombudsman,
‘Jeevan Nivesh’, 5th Floor,
Nr. Panbazar over bridge, S.S. Road,
Guwahati – 781001(ASSAM).
Tel.:- 0361-
2132204/2131307/2132205
Fax:- 0361-2732937
States of Assam, Meghalaya, Manipur, Mizoram,
Arunachal Pradesh, Nagaland and Tripura.
HYDERABAD
Office of the Insurance Ombudsman,
6-2-46, 1st floor, “Moin Court”
Lane Opp. Saleem Function Palace,
A. C. Guards, Lakdi-Ka-Pool,
Hyderabad – 500 004.
Tel.:- 040-23325325/23312122
Fax:- 040-23376599
States of Andhra Pradesh, Karnataka and Union
Territory of Yanam – a part of the Union Territory
of Pondicherry.
KOCHI
Office of the Insurance Ombudsman,
2nd Floor, CC 27 / 2603, Pulinat Bldg.,
Opp. Cochin Shipyard, M. G. Road,
Ernakulam – 682 015.
Tel.:- 0484-2358734/759/9338
Fax:- 0484-2359336
State of Kerala and Union Territory of (a)
Lakshadweep (b) Mahe-a part of Union Territory of Pondicherry.
KOLKATA
Office of the Insurance Ombudsman,
North British Bldg., 3rd Floor,
29, N. S. Road,
Kolkata – 700 001.
Tel.:- 033-22134869/67/66
Fax:- 033-22134868
States of West Bengal, Bihar, Sikkim, Jharkhand
and Union Territories of Andaman and Nicobar Islands.
LUCKNOW
Office of the Insurance Ombudsman,
6th Floor, Jeevan Bhawan,
Phase-II, Nawal Kishore Road,
Hazratganj,
Lucknow-226 001.
Tel.:- 0522-2201188/31330/1
Fax:- 0522-2231310.
States of Uttar Pradesh and Uttaranchal.
Other general guidelines:
• Generally *Family floater policy* is cheaper
than buying individual policies for family members.
• Generally *bed charges are 1-2%* of the sum
assured, depending on your Insurance carrier. All other charges like doctor
visit etc. are often related to this bed charge, so it is important to be
within these limits.
• Co-Pay means that a certain percentage or a
certain fixed amount of the claim has to be borne by the policyholder. If
co-pay is 15%, then whatever is the hospital bill you will have to pay the 15%
and balance 85% only will be paid by the Insurance company.
• Generally *exclusions and pre-existing
diseases* are not covered by a medical insurance policy (as specified in their
policy document). Generally these *could be covered after 2 years of holding
the policy*. Consumer must be honest in disclosing pre-existing ailments, if
any.
• Policy can be *renewed within 15 days grace
period* after expiry of the policy. However coverage is not available for the
days for which the premium was not received by the Insurance company.
• One can transfer the policy from one Insurance
company to another and the credits (including cumulative bonus) would also be
portable.
• New policy should be issued within 15 days of
submission of proposal
• To keep a check that people don’t try to take
a policy where they have been diagnosed with some illness and they require
immediate hospitalization, a *30 day waiting period* is kept, where Insurance
Company will not pay any kind of claim within the first 30 days of taking the
new policy, (*exception is that if policyholder meets an accident* then the
claim is payable).
• Under Section 80D, *annual deductions* upto Rs
25,000 can be availed of (Rs 30,000 for senior citizens)