Section 20(9) in Insurance Regulatory and Development Authority of India (Third Party Administrators - Health Services) Regulations, 2016
(9)Discounts on Bills offered by Network Providers. - The insurers and the TPAs shall ensure that discounts, if any, received or agreed to be received from the hospital towards health services are passed on to the policyholder or the claimant. Subject to this,a. Where discounts are obtained from any of the Network Providers or from any other Hospitals outside the network, either by TPAs or by the Insurers, it shall be ensured that the discounts, if any, so obtained from the network providers / hospitals, are passed on to the policyholders or the claimants of the concerned health insurance policy.b. Where, by virtue of any agreement, discounts are agreed to be received on the aggregated bills raised by the hospitals, every insurer or TPA shall appropriately identify and apportion the eligible amount of the discount to the underlying health insurance policy in respect of which the claim is settled so as to pass on the benefit of the discount to the concerned policyholder or the claimant, as the case may be.c. In order to implement the above Regulations, every Insurer and the TPA shall put in place the following procedures:i. The insurers and TPAs shall mandate the hospitals to reflect such agreed discounts in the final hospitalization bill of each claim, by which the policyholder or the claimant can also be aware of the actual bill raised by the hospital.ii. Where the admissible claim amount is more than the Sum Insured, the agreed discount shall be effected on the Gross amount raised in the bill, before letting the policyholder or the claimant bear the costs over and above the eligible claim amounts.iii. Where the underlying health insurance policies have co-payment or the deductible conditions, the insurer or TPA shall ensure that the said co-payment or deductible is effected only after netting off the discounts offered by the hospital, if any.d. Every Insurer shall make these procedures as part of the detailed guidelines on claim settlement to be provided to the TPAs, in accordance with the provisions of [sub-regulation (b) of regulation 33 of Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016] [Substituted 'Reg. 12 (b) (i) of IRDA (Health Insurance) Regulations, 2013' by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).] as amended from time to time.e. The above procedures shall be applicable to both cashless services and reimbursements of all the claims of health insurance policies.
