Section 31 in Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016
31. Health Services Agreements.
- a. Insurance companies may offer policies providing cashless services to the policyholders provided:i. The services are offered through network providers who have been enlisted to provide medical services under a direct written agreement with the insurer where there is a direct arrangement or by a tripartite agreement amongst health services provider, the TPA and the insurer where it is through a TPA. Where an insurer wishes to utilise the services of a TPA, it shall ensure that the written agreement is entered into for defined services with a TPA holding a valid Certificate of Registration issued in accordance with the IRDAI (Third Party Administrators - Health Services) Regulations, 2016 as may be amended from time to time.b. The Agreements which shall be entered into between / amongst insurers, network providers or TPAs shall cover the following amongst others:i. The tariff applicable with respect to various kinds of healthcare services being provided by the network provider.ii. A clause empowering the insurer to cancel or modify the agreement in case of any fraud, misrepresentation, inadequacy of service or other non-compliance or default on the part of TPA or network provider;.iii. A standard clause as may be agreed upon providing for continuance of services by a network provider to the insurance company if the TPA is changed or the agreement with TPA is terminated.iv. A clause providing for opting out of network provider from a given TPA or disempanelment of a network provider by a TPA subject to Guidelines specified by the Authority, if any, for reasons of inadequacy of service rendered by the TPA to the network provider.v. A clause specifically fixing the onus on the Insurer to deny or repudiate a claim vi. A clause enabling insurer to inspect the premises of the Network Provider at any time without prior intimation.c. Insurers and TPAs shall comply with standard clauses to be incorporated in all such agreements as specified by the Authority by way of guidelines.d. The insurance company shall endeavour to enter into Agreements with adequate number of both public and private sector network providers across the geographical spread. The copy of the agreement shall be maintained by the Insurer for a period of not less than five years from the date of the expiry or termination of the agreement.e. The Authority may specify, through Guidelines, certain standards, benchmarks and protocols for Network Providers from time to time. The Insurers and TPAs shall ensure that only those Providers who meet with such standards, benchmarks and protocols are enrolled into the network.
