Refer: “Bond, Administration Bond.”

***

UK: A bond issued to the Principal Probate Registrar against defaults by the person (i.e. the administrator) appointed to administer the estate of another.

Costs of running a business other than acquisition cost and settling claims.

Subject to the terms of a policy, General Insurers and Health insurers shall extend to all policy holders a cashless facility for treatment at specific establishments or the reimbursement of the costs of medical and health treatments or services availed at any medical establishment.Cashless facility shall be offered only at establishments which have entered into an Agreement with the insurer to extend such services. Such establishments will be termed as Network Providers.Reimbursement shall be allowed at any medical establishment. All such establishments must be licensed or registered as may be required by any Local, State or National Law as applicable.The administration of all health plus life-combi products shall be in accordance with the provisions of Schedule II of this Regulation.Except in emergencies a cashless facility may require a Pre-Authorisation to be issued by the Insurer or an appointed TPA to the Network Provider where the treatment is to be undergone. The Authority may prescribe a Standard Pre-Authorisation form and standard reimbursement claims forms which shall be used for this purpose, as applicable.To avail the benefit of cashless facility, insurers shall issue an Identification Card to the insured within 15 days from the date of issuance of a policy, either through a TPA or directly. Provided where there is no mention of the expiry date on the card, the Insurer may provide a permanent card which is valid as long as the policy is renewed with the company.The identification card shall, at the minimum, carry details of the policyholder and the logo of the insurer. Insurers shall endeavour to issue Smart Cards with features such as cards with Quick Response Code, Magnetic reader to enable the TPAs and Network Providers offer health services seamlessly.Where a policyholder has been issued a pre-authorisation for the conduct of a given procedure in a given hospital or if the policyholder is already undergoing such treatment at a hospital, and such hospital is proposed to be removed from the list of Network Provider before the final settlement of the claim, then insurers shall provide the benefits of cashless facility to such policy holder as if such hospital continues to be on the Network Provider list.An insurance company may enter into an arrangement with other insurance companies for sharing of Network Providers, transfer of claim and transactional data arising in areas beyond their service.Health Insurance, Administration of Health Policies, Health Insurance Claim Payments as per Health Insurance Regulations (HIR), 2016: Settlement/Rejection of claim by insurer : An insurer shall settle or reject a claim, as may be the case, within thirty days of the receipt of the last ‘necessary’ document.Except in cases where a fraud is suspected, ordinarily no document not listed in the policy terms and conditions shall be deemed ‘necessary’. The insurer shall ensure that all the documents required for claims processing are called for at one time and that the documents are not called for in a piece-meal manner.The information that the insurer has captured in the proposal form at the time of accepting the proposal, the terms & conditions offered under the policy, the medical history as revealed by earlier claims, if any, and the prior claims experience shall all be maintained by the insurer as an electronic record and shall not be called for again from the policyholder/insured at the time of subsequent claim settlements.Insurer may stipulate a period within which all necessary claim documents should be furnished by the policyholder/insured to make a claim. However, claims filed even beyond such period should be considered if there are valid reasons for any delay.Every Insurance Claim shall be disposed of in accordance to the Terms and Conditions of the policy contract and the extant Regulations governing the settlement of Claims. No Claim shall be closed in the books of the Insurers.Health Insurance, Co-Payment: Co-Pay means that a certain percentage or a certain fixed amount of the claim has to be borne by the policyholder. If co-pay is 15%, then whatever is the hospital bill you will have to pay the 15% and balance 85% only will be paid by the Insurance Company.For multiple policies, claims under other policy can be made after exhaustion of Sum Insured in the earlier policy, as per Sec 24 (ii)2 of HIR 2016. The option to choose will remain with the insuredHealth Insurance, Administration of Health Policies, Health Insurance Claims, Precautions to be taken by Claimant : Best option is to obtain Cashless facility i.e. the Insurance Company pays the bills directly to the hospital. But the hospital must be part of their preferred network (PPN), which list should be available on the insurance company website.If insured person wished to take treatment in a hospital, which is not on the PPN cashless list, then the claim must intimate to the Insurance company/TPA within 24 hours of admission in any hospital.In case of a pre-planned surgery, it is better to inform the Insurance Company/TPA much earlier.As per IRDA’s guidelines to the Insurance companies, “the consumer cannot be forced to sign the discharge or Settlement Intimation voucher”. Signing the discharge voucher does not mean that the Insurer’s liability is over.Health Insurance, Administration of Health Policies , Health Insurance Claims, Role of TPA and Insurer : *TPA is not permitted to settle/reject/repudiate claims*, as per Sec 33(c) of HIR 2016The claims settlement (rejection) letter should mention the specific *grounds for denial/rejection of claim*, as per Sec 33(d)(iv) of HIR 2016Consumer will *get interest of 2% over the prevailing bank rates, on claims payment delayed beyond 30 days* and will have to mentioned in the policy document, as per Sec 28(iv) of HIR 2016The *claims payment* will be made from the Insurer’s bank account and *not the TPA’s*, as per Sec 32 of HIR 2016 Earlier claim cheques were issued to the customer by the TPA (Third party Administrator), but now the insurance company would have to write a claim cheque or ECS directly to the customer. This would eliminate the float that some of the TPAs were enjoying. Also, there was never any public audit of the claims funds sanctioned by the Insurance company v/s actual amount disbursed by the TPA.TPA has to electronically transfer the claims document to Insurer for a decision as per Sec 35(a) of HIR 2016The TPA will ask for claims related *papers in one time only*, and not in a piece meal manner as per Sec 27(ii) of HIR 2016Non-allopathic (AYUSH) treatments may be covered, as per Sec 18 of HIR 2016Fees to the TPA shall not be related to reduction of claims costs as per Sec 20(6) of Health Services Regulations for TPA, 2016Discounts offered by hospitals have to passed on to the policyholders, as per Sec 20(9) of Health Services Regulations for TPA, 2016Change of TPA will be intimated to the consumer in writing 30 days before hand as per Sec 34(a) of HIR 2016.Health Insurance, Bed Charges: Generally *bed charges are 1-2%* of the sum assured, depending on your Insurance carrier. All other charges like doctor visit etc. are often related to this bed charge, so it is important to be within these limits.For multiple policies, claims under other policy can be made after exhaustion of Sum Insured in the earlier policy, as per Sec 24 (ii)2 of HIR 2016. The option to choose will remain with the insuredHealth Insurance, Administration of Health Policies, Health Insurance Disputes resolution, especially Claims processing : For claims-related complaints, consumers can write to the Grievance cell of the Insurance Company. As per IRDA guidelines, grievances must be acknowledged by the Insurance company in 3 working days and it must be *resolved in 15 working days*. If there is no response to the letter, you can file a Right to Information (RTI) application with the Grievance Officer.The *IRDA Call Centre (toll-free at 155255*) also offers an alternative channel for policyholders, serving from 8 AM to 8 PM, Monday to Saturday in Hindi, English and various Indian languages.Customer can also write to *complaints@irda.gov.in* or online or through post at: Consumer Affairs Department, Insurance Regulatory and Development Authority (IRDA), 3rd floor, Parishram Bhavan, Basheer Bagh, HyderabadFor still unresolved disputes of *less than Rs 20 lakhs* pertaining to claims settlement or regarding premiums paid/payable and non-issue of insurance documents, the *Insurance Ombudsman* can be approached. The written complaint with the relevant claim papers can be send by the customer himself (*no lawyer is required*), within 1 year of dispute. After registering with the Ombudsman office, attach this application document.Health Insurance, Bhavishya Arogya Policy : This was a deferred Mediclaim Policy introduced on 1.12.1990 to cater to the medical care of retired persons. The policy reimburses medical, surgical expenses following illness/accidental injury incurred by the insured person during his “retirement” age a defined in the Policy. The Policy could be taken at any age from 25 years onwards up to 55 years. Retirement age to be selected by insured at the time of taking the policy to be between 55 and 60 years. The amount of maximum total benefit available under the basic policy was Rs. 50,000 during lifetime of the insured commencing from the policy retirement age and shall not exceed Rs. 20,000 per any one illness or injury. Policy similar to Mediclaim with deletion of 30 days waiting period, 1st year exclusion, pre-existing diseases, circumcision, pregnancy and cost of health checkup. It is no longer in use in the market.

Descriptive of a contract under which an Insurer, Insurance broker or other organization provides a client with administration services (such as rating, expenses allocation or claims settlement) with respect to loss exposures and losses that the client retains rather than insures. Also, an arrangement under which an insurer or another third-party administrator contracts to provide specific record-keeping and claim payment functions to a self-funded group insurance plan or a particular class of insurance of an insurer.