Section 30 in Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016
30. Administration of Health Policies.
- a. Subject to the terms of a policy, General Insurers and Health insurers shall extend to all policy holders a cashless facility for treatment at specific establishments or the reimbursement of the costs of medical and health treatments or services availed at any medical establishment.b. Cashless facility shall be offered only at establishments which have entered into an Agreement with the insurer to extend such services. Such establishments will be termed as Network Providers.[c. Subject to terms and conditions of the policy contract, reimbursement shall be allowed at any hospital or medical establishment. All such establishments must be licensed or registered as may be required by any Local, State or National Law as may be applicable.] [Substituted by Notification No. F.No. IRDAI/Reg/14/165/2019, dated 19.11.2019 (w.e.f 12.7.2016).]d. The administration of all health plus life-combi products shall be in accordance with the provisions of Schedule II of this Regulation.e. Except in emergencies a cashless facility may require a Pre-Authorisation to be issued by the Insurer or an appointed TPA to the Network Provider where the treatment is to be undergone. The Authority may prescribe a Standard Pre-Authorisation form and standard reimbursement claims forms which shall be used for this purpose, as applicable.f. To avail the benefit of cashless facility, insurers shall issue an Identification Card to the insured within 15 days from the date of issuance of a policy, either through a TPA or directly.Provided where there is no mention of the expiry date on the card, the Insurer may provide a permanent card which is valid as long as the policy is renewed with the company.g. The identification card shall, at the minimum, carry details of the policyholder and the logo of the insurer. Insurers shall endeavour to issue Smart Cards with features such as cards with Quick Response Code, Magnetic reader to enable the TPAs and Network Providers offer health services seamlessly.h. Where a policyholder has been issued a pre-authorisation for the conduct of a given procedure in a given hospital or if the policyholder is already undergoing such treatment at a hospital, and such hospital is proposed to be removed from the list of Network Provider before the final settlement of the claim, then insurers shall provide the benefits of cashless facility to such policy holder as if such hospital continues to be on the Network Provider list.i. An insurance company may enter into an arrangement with other insurance companies for sharing of Network Providers, transfer of claim and transactional data arising in areas beyond their service.
