Insurance Regulatory and Development Authority

22.04.2021

Insurance

Facilitation by the Insurers for cashless services at network hospitals

MANU/IRDA/0049/2021

1. It has been brought to the notice of the Authority that some hospitals are denying cashless facility to policyholders for treatment of COVID-19 treatment despite having cashless arrangement with the Insurers.

2. Attention is drawn to the Authority's circular Ref. No.: IRDAI/HLT/MISC/CIR/189/07/2020 dated 14.7.2020 on Provision of cashless facility to the policyholders where in it was specified that the Insurers shall ensure that where the policyholder is notified about availability of cashless facility at the empanelled network provider, the cashless facility at such network provider shall be made available to the policyholders in accordance to the terms and conditions of the policy contract and as per the terms agreed in Service Level Agreement (SLA).

3. Therefore, general and health Insurers shall ensure that all such network provider hospitals extend cashless facility for any treatment to the policyholder including COVID-19 treatment in accordance with agreed provisions of SLA and terms and conditions of the policy contract.

4. 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 in addition to taking up appropriate action as specified in the aforesaid circular.

5. The Insurers have also been directed to ensure smooth availability of cashless facility with all network providers empanelled with them by putting in place continuous communication channel with all the network providers for prompt cashless services and for resolution of grievances of policyholders if any.

6. This has the approval of the competent authority.

Tags : Insurers Cashless services Network hospitals

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