Section 27 in Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016
27. Settlement/Rejection of claim by insurer.
- i. An insurer shall settle or reject a claim, as may be the case, within thirty days of the receipt of the last 'necessary' document.ii. Except in cases where a fraud is suspected, ordinarily no document not listed in the policy terms and conditions shall be deemed 'necessary'. The insurer shall ensure that all the documents required for claims processing are called for at one time and that the documents are not called for in a piece-meal manner.iii. The information that the insurer has captured in the proposal form at the time of accepting the proposal, the terms & conditions offered under the policy, the medical history as revealed by earlier claims, if any, and the prior claims experience shall all be maintained by the insurer as an electronic record and shall not be called for again from the policyholder/insured at the time of subsequent claim settlements.iv. Insurer may stipulate a period within which all necessary claim documents should be furnished by the policyholder/insured to make a claim. However, claims filed even beyond such period should be considered if there are valid reasons for any delay.v. Every Insurance Claim shall be disposed of in accordance to the Terms and Conditions of the policy contract and the extant Regulations governing the settlement of Claims. No Claim shall be closed in the books of the Insurers.[vi. Further to sub-regulation (i) to (v), in matters relating to settlement of claims, the Authority may specify guidelines from time to time.] [Inserted by Notification No. F.No. IRDAI/Reg/14/165/2019, dated 19.11.2019 (w.e.f 12.7.2016).]
