The Government has clarified that health insurance claims in India will continue to be decided by insurers in accordance with the terms and conditions of the insurance policy, and there is currently no proposal to require insurers to accept the opinion of healthcare providers while deciding claims. (Asia Insurance Review)
The clarification is significant amid continuing debate over the respective roles of hospitals and insurers in health insurance claim settlement. While doctors and hospitals determine the medical treatment required by a patient, the admissibility and extent of an insurance claim depend on whether the treatment and associated expenses fall within the coverage provided under the policy.
This means that a healthcare provider’s medical recommendation or assessment will not automatically determine whether an insurer must approve or pay a claim. The insurer will continue to examine claims against policy provisions such as coverage, exclusions, waiting periods, sub-limits, deductibles and other applicable conditions. (Asia Insurance Review)
IRDAI’s existing framework also places responsibility on insurers for processing health claims within prescribed timelines. According to the regulator, decisions on cashless pre-authorisation are generally required within one hour, while final authorisation after receiving a discharge request is to be provided within three hours. Reimbursement claims are generally required to be settled within 15 days. (IRDAI)
At the same time, policyholders are expected to carefully understand the scope of their health insurance cover. IRDAI advises customers to examine exclusions, waiting periods, room-rent restrictions, co-payments, deductibles and treatment-related sub-limits, as these provisions can directly influence claim admissibility and the amount ultimately payable. (IRDAI)
The clarification reinforces the principle that health insurance remains a contractual arrangement, with claims determined according to the coverage agreed between the insurer and policyholder rather than solely on the opinion of the treating hospital.
For consumers, the development also underlines the importance of understanding policy conditions before purchasing health insurance and maintaining proper documentation when making a claim.
