Most of the problems are tackled in such a way that it will benefit to a policy holder in most of the cases. The draft has answers to lots of problems related to servicing issue such as timely claim settlement, furnishing reason for claim rejection and fixing clear accountability of the insurance companies for all the actions pertained to them.
Following are some important points covered in the draft:
- Claim settlement within 30 days of a request by the policy holder.
- Insurance companies have to justify with proper evidence for all its action taken against the policy holder.
- Insurance company has to pay the hospital bills directly for settlement of claim; hence it would bypass the TPA (Third-party administrator) to reduce time and ambiguity in processing.
- The contribution clause for multiple policies would be modified in favor of a policy holder. Against sharing claim in the ratio of policies risk cover; the draft proposes to enable a policy holder to opt the policy he/she wants to use. Proposal says that in case of a multiple insurer, the claim would be shared by the insurer themselves without involving the insured.
- The "No claim" bonus methodology is proposed to be made more transparent to help the policyholder for a better understanding of the facts.
- IRDA will regularly check the increase in unscrupulous premium by the insurance companies.
- Timely renewal and fewer claims by the policyholder would get more discounts and extra cover benefit.
- Pre-policy health check expenses could be partially shared by the insurance companies.
- Senior citizens would get preferential treatment to settle the claims or for policy renewals.
- Non allopathic treatments would get cover under health insurance policy. Such treatments would be allowed only in the government-approved hospitals.
Earlier, insurer used to withdraw the schemes that were loss making for them by shifting the policy holders to a new scheme. The insured used to compromise with the insurance companies' decision. Now, the draft proposal has suggested that insurer has to continue with the old scheme if the policyholder doesn't want to shift to new one. IRDA has said, "Insurer shall not compel the insured to migrate to other health insurance products, if it is to the disadvantage of insured."
These proposed changes would not only give more business to the insurance companies but also help the policy holders to opt for a tension-free treatment. However, Insurance companies have to tackle with another challenge that would be to provide disclosure containing coverage and estimated premium for future renewals of the policy. Insurers would be submitting their response to the General Insurance Council (association of non-life insurers) to place the matter in front of IRDA and it is expected that most of the proposals would be accepted in favor of policy holders. The draft regulations on health insurance released by IRDA have plugged the various loopholes through which customers are mistreated by insurance companies.