insurance claims

IRDA has issued a circular dated 16th July, 2020 wherein they have recognised make shift or temporary hospitals erected during the covid pandemic by the respective governments as recognised hospitals and claims to be allowed in respect thereto. Further where any network hospital provider has made arrangements for such make shift or temporary hospitals, such hospitals shall also be considered for cash less claims. 
This is a very important advisory from IRDA in respect of claims during covid pandemic. 
Gist of the circular is as below:

   Reference is invited to IRDAI circular Ref. No: IRDAI/HLT/REG/CIR/054/03/2020 dated 04th March, 2020, specifying guidelines on handling of claims reported under Covid-19.

2.        In view of increase in number of COVID-19 cases, in order to leverage on the extant healthcare systems put in place, it is important to recognise the make-shift or temporary hospitals permitted by Government for settlement of health insurance claims for insurance companies.

3.        In the above backdrop, in order to ensure that the costs of treatment of COVID – 19 are covered as per the terms and conditions of policy contract, a make-shift or temporary hospital permitted by Central / State government shall be regarded as a hospital or network provider and insurers shall settle the claims as per the following norms.

a)      Where a policyholder who is diagnosed as Covid-19 positive is admitted into any such make-shift or temporary hospital on the advice of a medical practitioner or appropriate Government authorities, notwithstanding the definition of hospital specified in the terms and conditions of policy contract, the treatment costs shall be settled by insurers. 

b)      Where any network provider has set up any such make-shift or temporary hospital, such make-shift or temporary hospital shall be regarded as the extension of the network provider and cashless facility shall be made available.  

4.        Insurers are advised to expedite settlement of all such claims in accordance to the applicable regulatory framework.

5.        All insurers are also advised to incorporate the above norms in claim guidelines and inform to all the TPAs immediately.

6.        These guidelines shall come in to force with immediate effect.

7.        These guidelines are issued under the powers vested with Regulation 27 (vi) of IRDAI (Health Insurance) Regulations, 2016 read with Section 34 (1) of Insurance Act, 1938.

Copy of the IRDA circular can be found here

https://www.irdai.gov.in/ADMINCMS/cms/Circulars_Layout.aspx?page=PageNo4189

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