Cashless facility for treatment of covid-19 can not be denied where policyholder is notified of availability of the facility at empanelled network provider
IRDAI, has directed all insurance companies to make provision of cashless facility to the policyholders for treatment of Covid-19
In a circular issued , the Authority has stated that as per its notice, certain hospitals are denying cashless facility to policyholders for treatment of covid-19.
Attention has been drawn to the provisions of regulation 31 (d) of IRDAI (Health insurance) Regulations, 2016 wherein it is mandated that every general and health insurance company shall endeavour to enter into agreements with adequate number of both public and private sector network providers across the geographical spread.
Insurance companies has been advised to ensure that where the policyholder is notified about availability of cashless facility at the empanelled network provider, the cashless facility at such network provider is made available to the policyholder in accordance to the terms and conditions of the policy contract and as per the terms agreed in Service Level Agreement (SLA).
Insurance companies have also been advised to put in place an exclusive grievance redressal mechanism to address the grievances of policyholders relating to the denial of cashless facility for covid-19 and other grievances against such hospitals that are enlisted as network providers. Insurance companies to also put in place continuous communication channel with all the network providers for prompt resolution of the grievances of policyholders.
It has been stated that where any network provider denies cashless facility and deviates from agreed terms of the SLA, insurance company shall take an appropriate action against such network providers as provided in SLA.
Also, the Authority has directed that where policyholders’ interests are adversely affected due to the conduct of the network providers, such instances may be immediately reported to the appropriate Government agencies of the concerned State/area. Action taken against such network providers shall also be published on the website of the insurance company for the information of the insured public.
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