From passive claimant to empowered policyholder – Money News | The Financial Express

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With India’s health insurance premiums crossing ₹1.2 lakh crore, claim delays are a growing concern. Learn about the IRDAI’s 1-hour and 3-hour rules, penal interest on delays, and how to use the Bima Bharosa portal.

Know Your Rights: How to Tackle Delayed Health Insurance Claims

INDIA’S HEALTH INSURANCE landscape has reached a significant milestone, with premiums crossing the Rs 1.2 lakh crore mark. However, for a policyholder, the actual utility of insurance is tested only at the time of a claim.

Unfortunately, a rising number of complaints today are not about rejection, but about exhaustion—specifically, the exhaustion caused by delayed settlements. However, help is at hand. 

The power of the one- and three-hour rules

The Insurance Regulatory and Development Authority of India (Irdai) has established strict timelines to prevent families from being held hostage by hospital billing desks. For cashless claims, insurers are legally required to respond to pre-authorisation requests within one hour.

Even more critical is the discharge process. Once a hospital submits the final bill, the insurer must provide the final authorisation within three hours. If you are being made to wait beyond this window, you have the right to hold the insurer accountable. These are not merely suggestions; they are mandates designed to ensure that the “protection” you paid for is delivered when it matters most.

Interest on delayed payments

For reimbursement claims, the standard timeline for settlement is 30 days from the receipt of all necessary documents. If a claim requires a deeper investigation, this can be extended to 45 days, but the insurer cannot keep a claim in limbo indefinitely.

If an insurer delays payment beyond the stipulated 30 or 45-day window, it is liable to pay interest to the policyholder. This interest is 2% above the prevailing bank rate. 

Documentation is your responsibility

To protect your rights, always ensure you have a complete trail. This includes original hospital bills, discharge summaries, diagnostic reports, and pharmacy invoices. It is a good practice to take your doctor’s help when responding to queries from the insurer. 

Escalating complaints 

Grievance redressal officer (GRO): Every insurer must have a dedicated GRO. Once you file a formal complaint, it has 14 days to resolve the issue.

Bima Bharosa Portal: If the insurer’s response is unsatisfactory or absent, you can escalate the matter to the Irdai through thenBima Bharosa portal. This puts the complaint on the regulator’s radar.

Insurance ombudsman: For disputes up to Rs 50 lakh, the ombudsman offers a quasi-judicial, cost-free platform for resolution. Their award is binding on the insurer.

Knowing your rights, from the one-hour authorisation rule to the right to penal interest, transforms you from a passive claimant into an empowered consumer. 

The writer is co-founder and COO, Insurance Samadhan

Disclaimer: The views expressed are the author’s own and do not reflect the official policy or position of Financial Express.