IRDA Guidelines on Standardisation of Health Insurance

IRDA had come out with a set of guidelines on standardisation of health insurance policies.

These guidelines are effective from Oct 1, 2020

What does it mean for Policy Holders ?

[A Thread]

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These guidelines pertain to following areas

1. Exclusions which are not permitted

2. Standard Wordings for Some Exclusions

3. Existing Diseases that may be permanently excluded

4. Modern Treatments that were earlier excluded and can now be covered

5. Other Norms

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Many Exclusions are now not allowed now such as:

i) Costs for Treatment of Mental Illnesses or Psychological Disorders which were earlier excluded from the Insurance Policies will now have to be covered

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ii) Similarly Exclusions for Genetic Diseases, Behavioral or Neuro Developmental Disorders such as Stammering or Dyslexia also cannot be excluded

ii) Internal Congenital Diseases or Genetic Diseases cannot be excluded

Another major change relates to standardised wordings for some exclusions.

The wordings for common exclusions such as Pre-Existing Diseases, Specific Diseases, 30 Day Waiting Period etc. have been made uniform across the industry

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The third change relates to Existing Diseases that are allowed to be Permanently excluded from Policy Coverage

Ppl with serious ailments can now avail insurance cover with the existing serious ailments excluded

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Earlier ppl with serious ailments like Epilepsy, Congenital Heart Disease, Alzheimer's or Parkinson's Disease, Chronic Liver & Kidney Diseases were unable to get insurance cover at all.

Now such ppl will be able to get insurance with permanent exclusion of such illnesses!

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Another Change relates to Modern Treatment Methods

Earlier Health Insurance Policies would not cover claims for patients who were treated using modern treatment methods or Advanced Technologies.

IRDA has now made it compulsory for all health insurance policies to cover

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Some Examples of Advanced Treatment methods that have to be now covered included

Oral Chemotherapy
Stem Cell Therapy
Robotic Surgeries
Intra Vitreal Injections

etc

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Other Imp Changes in the guidelines are as follows:

(i) The maximum waiting period for any specific diseases in the insurance policy will be limited to a maximum of 4 years

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(ii) Claims cannot be denied after 8 years of Policy Coverage except in cases where fraud has been proven or for diseases which are permanently excluded in the insurance policy.

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Lifestyle Diseases

The waiting period for people suffering from lifestyle diseases namely Hypertension, Diabetes, Cardiac Condition cannot be more than 90 days except if these diseases are Pre-Existing

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Pre and Post-Hospitalisation Expenses

Pre and Post-Hospitalisation Expenses will be covered in case of Domiciliary Hospitalisation as well

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The other aspects of guidelines relate to Clauses in Health Insurance Policy Contracts

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Claim Settlement

The Insurance Company has to now settle claims within 30 days of receipt of the last necessary document except in circumstances where the insurance company feels that an investigation is required

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In Case an investigation is required, the Insurance Company has to settle claims within 45 days of receipt of the last necessary document

This means that Policyholders will benefit from time bound claims settlement

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Penalty in Case of Delay in Claims Settlement

In case of delay in claim settlement, the Insurance Company will have to pay Interest to the Policyholder at a rate of 2% above the Bank Rate

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Multiple Policies

In case of multiple health insurance policies taken by the policyholder, the insured can choose the Insurance Company which shall settle his/her claim

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Will these changes be incorporated in health insurance policies of existing Policyholders?

Yes, These changes will be applicable to all the existing health insurance policyholders upon subsequent renewal of their policies

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