Tag Archives: cashless medical

health insurance claims – covid

IRDAI circular dated 23rd april, 2021 advising health insurance companies to honour cashless covid claims.

1.  There are reports of certain network providers (hospitals) charging high rates and insisting on cash payments from the policyholders for providing treatment to COVID-19 infected patients despite having cashless arrangement with Insurers.

2.  In compliance with the provisions of Regulation 31of IRDAI ( Health Insurance ) Regulations, 2016, the Insurers, in case of “cashless claim” under a health insurance policy, are advised to ensure expeditious settlement of such claims on cashless basis in accordance to the Service Level Agreements ( SLAs) entered with hospitals.

3.  While reviewing cashless requests the Insurers are also advised to ensure that the policyholders are charged as per the rates agreed to by network providers wherever applicable. Insurers are also advised to ensure that hospitals do not levy any additional charges for the same treatment other than those rates that are agreed with the insurers.

4.  In order to ensure that all network providers extend cashless services to policyholders and to address any issues causing inconvenience to policyholders while availing cashless service, the Insurers are advised to put in place an effective communication channel with all the network providers for prompt resolution of grievances of policyholders. Insurers are advised to report levying of excess charges or denial of cashless facility to the respective State Governments for appropriate action.

5.  All Insurers are directed to ensure that the “reimbursement claims “under a health insurance policy shall be settled as per the terms and conditions of the respective policy contract expeditiously. Insurers are advised to issue suitable guidelines on this to all TPAs.

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extension of ESI scheme to Arunachal Pradesh

https://pib.gov.in/PressReleasePage.aspx?PRID=1667020

n its continuous endeavor to cover more workers under ESI Scheme, Govt. of India has now extended the Employees’StateInsurance (ESI) Scheme for the first time to Arunachal Pradesh, with effect from 1st November, 2020. A notification to this effect has been issued by the Central Government for notifying the district of Papum Pare,under ESI Scheme.

All factories located in the district of Papum Pare of Arunachal Pradesh employing 10 or more persons shall become eligible for coverage under ESI Act 1948. The facility of online registration under ESI Scheme is available on the website www.esic.in and also on the “Shram Suvidha Portal” of the Ministry of Labour and Employment, Government of India. No physical documents are required to be submitted for registration under ESI Act. The employees working in these factories, earning wages up to Rs. 21,000/- per month (Rs. 25 thousand per month for persons with disability) shall be eligible for coverage under the ESI Scheme.

The covered employees and their dependants shall become eligible for host of benefits including Cashless Medical Care Services, Sickness Benefit, Maternity Benefit, Employment Injury Benefit and Dependant Benefit in case of death due to employment injury, Unemployment Benefit etc. Arrangements for medical care are being made through a newly opened Dispensary Cum Branch Office (DCBO) at Itanagar.

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