Insurers can’t reject claims primarily based on presumptions and conjectures: Irdai

The insurance coverage regulator on Friday mentioned that normal and medical insurance firms can’t reject claims primarily based on “presumptions and conjectures” and should specify the rationale for denial or rejection of claims by referring to the corresponding coverage situations.

In a round addressed to the insurers, the regulator mentioned, “Claims shall be processed in a clear, seamless and environment friendly method inside the prescribed timelines”.

And, within the case of rejection or denial of a declare, the insurance coverage firm has to offer the policyholders with the grievance redressal procedures of the corporate in addition to the insurance coverage ombudsman, together with the detailed addresses of the respective places of work.

Moreover, insurers have to determine sure procedures by advantage of which policyholders get clear communication from the businesses at numerous levels of declare processing. Insurers should put in place programs to allow policyholders to trace the standing of cashless requests/claims filed with the insurer/TPA by the web site/portal/app or some other authorised digital means on an ongoing foundation.

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