Hospitals Cannot Deny Cashless Claim For COVID-19 Treatment, Could Face Action For Refusal
Ever since the COVID-19 outbreak began reporting in India, there has bee a lot of confusion over the treatment cost, health insurance coverage, cashless claim and much more.
Recently there were some reports that several hospitals were denying cashless claims of COVID-19 patients.
Now the Insurance Regulatory and Development Authority (IRDAI) has asked insurers to take action against hospitals that decline cashless treatment facility for Covid-19 to policyholders.
"As per the provisions of regulation 31 (d) of IRDAI (Health insurance) Regulations, 2016, general and health insurance companies are expected to enter into agreements with public and private sector healthcare providers across the geographical spread," the IRDAI said in a release.
The list of the network providers (hospitals) with whom the insurance company has entered into a service level agreement shall be published in the websites of the insurers and TPAs (Third Party Administrators)," it stated.?
"Where such service level agreements (SLA) are entered with the Network Providers (hospitals), it is essential for all such hospitals to provide a cashless facility for any treatment to the policyholders including Covid-19 treatment in accordance with agreed provisions of SLA and terms and conditions of policy contract," the IRDAI said.?
Policyholders are entitled to a cashless facility at all such network providers (hospital) with whom the Insurance company/TPA has entered into an agreement in accordance with the norms of SLA, the IRDAI has said.?
Citing complaints against such hospitals' refusal despite their agreements with insurers and claims processing agencies, the IRDAI has asked insurers to make complaints to the appropriate government agencies in different states.
The IRDAI added that every general and health insurance company must endeavour to enter into agreements "with an adequate number of both public and private sector network providers across the geographical spread".
"Insurance companies are also advised to put in place an exclusive grievance redressal mechanism to address the grievances of policyholders relating to the denial of the cashless facility for COVID-19 and other grievances against such hospitals that are enlisted as network providers. Insurance companies shall also put in place a continuous communication channel with all the network providers for prompt resolution of the grievances of policyholders," it said.
The IRDAI also asked the insurers to publish the action taken on the complaints against hospitals on their website.
The insurance regulator has also asked the insurers to have an exclusive grievance redress mechanism relating to cashless treatment for COVID-19 and other grievances against such hospitals that are enlisted as network providers.
