भारतीयबीमाविनियामकऔर  विकासप्राधिकरण

Insurance Regulatoryand Development Authority of India

To

All General and Health Insurers (except ECGCand AIC),

and

All Third Party Administrators,

Re:Guidelines on Public Disclosures by Insurers on the qualitative andquantitative parameters of the health services rendered to policyholders

1.   All general and health insurers registered withIRDAI rendering health services both through TPA and/or in-house shall make thecaptioned TPA wise public disclosures in the format specified at Annexure -1. Thedata in the specified format shall be duly signed by either CEO or one of theWhole Time Directors of the Insurer.

2.   The information shall be published within aperiod of ninety days after the close of every financial year.

3.   All TPAs shall provide the link of everyinsurance company where the said information is available. The link shall bemade available in respect of the insurers with whom the TPA had a service levelagreement.

4.   All TPAs shall also provide the requisite dataor information to the Insurers, wherever called for, in order to enableinsurers publish the above information in their respective websites.

5.   The policyholders desirous of knowing thedetails referred in annexure-1 shall be able to access all the aboveinformation on visiting the website of respective Insurer or the TPA.

6.   In case of termination of services of a TPA,the Insurer shall publish the same in its website along with the reasons fortermination within three days from the effective date of termination.

7.   The above directions shall come into force withimmediate effect and data as at 31st March, 2020 shall be published by 30^thSeptember, 2020.

8.   Theseguidelines are issued under the powers vested with Section 34(1) of theInsurance Act, 1938 read with Regulation 3 (5) of Insurance Regulatory andDevelopment Authority of India (Third Party Administrators - Health Services)Regulations, 2016.

9.   Thisis issued with the approval of Competent Authority.

(DVS Ramesh)

General Manager (Health)

Annexure-1

PUBLIC DISCLOSURES ON QUANTITATIVE ANDQUALITATIVE PARAMETERS OF HEALTH SERVICES RENDERED

(INFORMATION AS AT -----)

NAME OF THE INSURANCE COMPANY: --------

a.    Specifyin-house claim settlement (if, data is in respect of in-house claim settlement)/ Specify name of the TPA with whom insurer entered into service level agreement(if data relates to the health services rendered by TPA) as may be the case.

Note:Data shall be consolidated at insurer level in case of in house claimsettlements and at the level of the concerned TPA in case of services renderedby TPA.

(i)Validity of agreement with the TPA: from dd/mm/yyyy to dd/mm/yyyy

b.    Numberof policies and lives serviced in respect of which public disclosures are made:

c.    Informationwith regards to the geographical area in which services are rendered by theTPAs/insurer (States Names-District names shall be provided) in respect ofwhich public disclosures are made.

d.    Dataof number of claims processed:

                     i.       Outstanding number of claims at the beginningof the year: --

                   ii.       Number of claims received during the year ----

                  iii.       Number of claims paid during the year: ---- (alsoto specify % in brackets)

                  iv.       Number of Claims repudiated during the year:--- (also to specify % in brackets)

                   v.       Number of claims outstanding at the end of theyear: ---

e.    TurnAround Time (TAT) for cashless claims (in respect of number of claims):

*Percentage to be calculatedon total of the respective column.

**reckoned from the time lastnecessary document is received by insurer /TPA (whichever is earlier) and tillfinal pre-auth is issued to the hospitals

***reckoned as final dischargesummary sent to hospital from the time discharge bill is received by TPA

f.     TurnAround Time in case of payment/repudiation of claims:

*Percentageshall be calculated on total of the respective column

g.    Dataof grievances received against the TPA:

Place:

Date:

Signatureof CEO / Whole Time Director

Nameof the Insurer: