The insurance claim settlement process often feels like entering a maze—daunting,

confusing, and seemingly endless. This is where the Insurance Regulatory and Development

Authority of India (IRDAI) steps in.



But how well do you know the rules that govern your claims? 



From standardized timelines to grievance redressal, IRDAI's regulations aren't just about

policyholders following procedures—they're about empowering you with the right tools to

navigate challenges like claim rejection and delays in claim process. 



1. Decoding IRDAI: Your Rights, Simplified 



The IRDAI isn't just another regulatory body—it's the backbone of India's insurance

framework. Its claim settlement guidelines ensure that insurers maintain accountability and

transparency while giving policyholders a fair shot at accessing the benefits they're entitled

to. 



Here's why they matter:



● Timely Claim Settlement: During a medical emergency, no one should have to wait

endlessly for funds. IRDAI has mandated timelines to eliminate unnecessary delays.

● Clarity on Claim Rejections: Insurers must explain every rejection with valid

reasons, minimising ambiguity and unfair practices.

● Policyholder-Centric Approach: From digital claims processing to grievance

redressal, every guideline prioritizes the policyholder's convenience and rights. 



So, as a policyholder, what are your rights? Here's a brief list for your convenience



1. Right to Information: Access clear details about policy terms, conditions, benefits,

and exclusions.

2. Right to Fair Treatment: Expect transparency and honesty in all insurer dealings.

3. Right to Timely Services: Receive prompt policy issuance, endorsements, and claim

settlements.

4. Right to Grievance Redressal: File complaints and escalate unresolved issues to

IRDAI or the Insurance Ombudsman.

5. Right to Policy Portability: Switch insurers without losing accrued benefits.

6. Right to Privacy: Personal and medical data must remain confidential.

7. Right to Free Look Period: Cancel life insurance policies within 30 days if

unsatisfied.

8. Right to Nomination: Assign policy benefits to a nominee or transfer policy

ownership.

9. Right to Policy Document: Receive the policy document promptly after payment.

10. Right to Claim Settlement: Fair and timely settlement of valid claims is guaranteed.



2. IRDAI's Guidelines for Claim Settlement Timelines 



Time is often of the essence when it comes to health insurance claims, and the IRDAI

recognizes this.



“The Company shall settle or reject a claim, as the case may be, within 30 days from the date

of receipt of last necessary document.” - states the official website of IRDAI.



However, some circumstances require further investigation, in case of false claims, frauds

etc. for such cases the IRDAI states -



“However, where the circumstances of a claim warrant an investigation in the opinion of the

Company, it shall initiate and complete such investigation at the earliest, in any case not later

than 30 days from the date of receipt of last necessary document. In such cases, the Company

shall settle or reject the claim within 45 days from the date of receipt of last necessary

document.” 



To ensure efficiency, the following timelines are mandated:



● Cashless Claims: Approvals must be given within three hours of receiving a request.

● Reimbursement Claims: Insurers must settle the claim within 30 days of receiving

complete documentation.

● Delay in Claim process: If there's a delay beyond 30 days (45 under investigation),

insurers are required to pay interest (at a rate of 2% above the bank rate) on the claim

amount for the delay period.



Conclusion



The IRDAI framework grants policyholders important rights and protections, but applying

these rights can often be a difficult task. From interpreting confusing clauses to ensuring

accurate documentation, even small mistakes can lead to delays or claim rejections.



Thankfully, subject matter experts are available to assist with the entire claims process,

ensuring accuracy and efficiency—from documentation preparation to claim submission.



Should there be any delays or claim rejections, these experts provide invaluable support in

resolving such issues seamlessly