Cashless Claim Within An Hour! How Can Customers Take Full Benefit Of IRDAI's New Update?

Cashless claim settlements are a cornerstone of the modern insurance landscape, offering numerous benefits to policyholders and the industry alike. Irdai in a master circular released on Wednesday alerted all insurance providers to authorise customers’ requests for cashless claims immediately but not exceeding ‘one hour’ of receipt of the request. Irdai’s new guidelines also set a 3-hour limit to clear the cashless claim which is a much-needed customer-centric approach to streamline the quick claim process for the insured. Medical emergencies often come with significant emotional and financial stress. “Cashless claim settlements eliminate the need for policyholders to arrange large sums of money upfront, allowing them to focus entirely on their recovery,” Sharad Bajaj, COO of InsuranceDekho, an insurtech platform said.

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Cashless Network: “Most insurers have a digital claims process that allows customers to initiate a claim, register a claim, as well as track the claim through portal/mobile application,” Manish Dodeja, Head – Claims & Underwriting, Care Health Insurance said.

'Recently, we witnessed the provisional inclusion of non-network hospitals as a part of the cashless network subject to the association between hospital and insurer, which led to a transformation in cashless claim settlements,' Bajaj noted.

Tapping the convenience with AI: Insurers can significantly enhance customer convenience through advanced technology and end-to-end digital solutions. “Many insurance companies have been able to implement artificial intelligence (AI) based rule engines that allow for standard decisions to be taken faster without human intervention,” Dodeja stated.

“Providing user-friendly mobile apps and online portals allows customers to manage policies, initiate claims, and track claim statuses seamlessly,” Rakesh Goyal, Director of Probus Insurance, an insurtech platform based in Mumbai affirmed.

Beyond transactions, there is an ardent need for automating and risk underwriting and claim processing within the industry. “Irdai’s aim to achieve 100 per cent cashless claim settlements and claim settlements within three hours of the hospital’s discharge request will significantly address the claim settlement challenges in the industry,” Balachander Sekhar, Co-founder of RenewBuy said.

How can customers take full benefit of cashless claims?

Cashless claims offer significant advantages, allowing policyholders to receive treatment at network hospitals without needing upfront payments, as the insurer settles bills directly with the hospital. Customers should keep these key factors in mind to ensure they can take full benefit of cashless claims:

Network of hospitals: “To fully benefit from cashless claims, customers should start by familiarizing themselves with the network hospitals associated with their insurer,” Goyal said. Once that is done they should check if the hospital will provide pre-authorization on the treatment cost for a smoother cashless claim. For customers, it is crucial to have a check on their nearby hospital category, if it lies in the blacklisted category then the insurer is not bound to pay any claim.

Intimation at the earliest: “Insurers are working on the Cashless Anywhere process now, where, in case of intimation of a claim from the customer, insurance companies attempt to convert the reimbursement to cashless if the hospital is also fine with the same. Hence, an intimation of claim allows customers to take full advantage of cashless claims,” Manish Dodeja, Head – Claims & Underwriting, Care Health Insurance said.

Know your policy: ‘Before availing any medical services, customers should thoroughly understand what their insurance policy covers,’ Bajaj stated. This includes knowing the diseases, treatments, and procedures included, as well as any exclusions or waiting periods. Being informed about policy specifics helps avoid surprises during the claim process.

Additional charges: In case of delays hospitals may charge additional half-day room charges or sometimes even if the discharge is in the late hours customers may have to stay overnight, which is an added expense and burden. A policyholder should be mindful of the additional hospital charges including the policy limits, and sub-limits on specific treatments. Customers must maintain clear communication at all times with the insurer as well as the hospital authorities.

Essential documents: Keeping all relevant documents, such as the health insurance card, policy details, and identification, readily available is essential for swift processing, Goyal states.

This immediate financial relief is crucial during emergencies, ensuring medical treatment can commence without delay and getting caught up in paperwork. A quick and efficient claim process builds trust between the insurer and the insured.

Health insurance in India has been growing rapidly in the last couple of years. “However, penetration remains low, indicating significant room for growth,” says Ravi Bhadani, Partner, SNG & Partners, Advocates & Solicitors. Bhadani notes that the new reforms, particularly the time-bound settlement of claims and end-to-end technology solutions, will increase transparency, prevent financial distress, and simplify the consumer journey.

‘Going forward a hassle-free cashless claim process will encourage more individuals to invest in health insurance,’ Bajaj says.