Hospital not according to IRDAI norms

Can a claim be repudiated on the basis of a hospital not meeting the norms of IRDAI?

What are the IRDAI norms regarding a hospital?

Some of these are:

  • must be registered with local authorities under Clinical Establishments Registration & Regulation Act,2010

  • must have qualified nursing staff

  • must have at least 10 inpatient beds in towns having population than 10 lakhs

  • has fully equipped operation theatre

In Rajesh Kumar vs. United Insurance[1], the insured’s wife was admitted in a hospital at Patiala. The insurer denied the claim on the ground that Patiala’s population was more than 18 lakhs (2011). And this particular hospital had only 10 beds.

The Ombudsman ruled in the insured’s favor pointing out that Patiala city’s population was less than 5 lakhs. The insurer had taken the entire district’s population which was erroneous.

Therefore we must consider whether a hospital meets the IRDAI norms before getting admitted. Empanelled hospitals would definitely meet the criteria but if the hospital is not on the list of the insurer, you do need to check the credentials.

 


[1] CHD-G-051-1718-0491; http://ecoi.co.in/synopsis.html

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