Health insurance can feel like a complex maze, but understanding the regulations that govern it empowers you to make informed decisions. Here’s a breakdown of key IRDAI regulations, presented in detail for your benefit:
List of Contents
Expanded Coverage
- Pre-existing Conditions: Insurers can’t deny coverage or charge extra premiums based on pre-existing illnesses like diabetes, heart disease, or cancer. This ensures everyone has access to healthcare.
- Age Groups: All age groups, from newborns to seniors, are entitled to health insurance plans. This promotes lifelong health security.
- Treatment Options: Policies must cover various treatment settings, including hospitalization, daycare procedures, outpatient consultations (OPD), and home healthcare. This flexibility allows you to choose the treatment that best suits your needs.
- Medical Systems: Plans should cover treatments across different medical systems, including Allopathy, Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homeopathy (AYUSH). This provides you with more options for managing your health.
- Medical Providers: You have the right to choose hospitals and healthcare providers within the insurer’s network or opt for out-of-network care with some limitations. This empowers you to select providers based on your preferences and location.
- Emergency Care: No insurance company can deny coverage in a medical emergency, regardless of your policy status. This protects you from financial burden during unforeseen situations.
Read: How to choose Health Insurance for yourself and your family
Customization and Flexibility
- Add-Ons and Riders: You can personalize your health insurance plan by adding riders or endorsements that cover specific needs like maternity care, critical illness benefits, or personal accident coverage. This allows you to tailor your plan for optimal protection.
- Technological Advancements: Insurance plans should adapt to evolving medical practices. Coverage should ideally extend to new treatments and procedures as they become available, including robotic surgeries, immunotherapy, and advanced diagnostics. This ensures you have access to the latest advancements in healthcare.
Cancellation and Refunds
- Cancellation: You have the right to cancel your health insurance policy at any time by submitting a written notice to the insurer by giving 7 days notice. The Insurer shall refund proportionate premium for unexpired policy period, if the term of policy is up to one year and there is no claim (s) made during the policy period.
- You are entitled to a refund of the premium for the unexpired policy period, in respect of policies with terms more than 1 year and risk coverage for such policy years has not commenced.
- Nominations: You can designate a beneficiary (nominee) to receive the claim payout in case of your death. This ensures financial security for your loved ones. You can also change your nominee easily during the policy term.
Grace Period and Renewals
- Grace Period for Premium Payment: Life happens. You have a grace period (typically 15 or 30 days depending on the payment mode) to pay your premium before your coverage lapses. During this grace period, your renewal and accrued benefits like No Claim Bonus (NCB – discount for claim-free years) remain protected. This provides a safety net for occasional payment delays.
- Coverage During Grace Period: Even if you pay your premium in installments, your coverage continues throughout the grace period as long as you make the payment within the timeframe. This ensures uninterrupted protection.
- Policy Renewal: Your health insurance policy is generally renewable for as long as the insurer offers the product, unless there’s a valid reason for discontinuation (like fraud). Insurers cannot deny renewal based on previous claims. However, fresh underwriting (reevaluating your health) might be required only if you want to increase your sum insured (maximum coverage amount). This ensures continuous coverage as long as the policy remains in effect.
Portability and Switching Plans
- Policy Portability: You have the freedom to switch your existing health insurance policy to another insurer while retaining benefits you’ve earned, such as NCB and completed waiting periods. This empowers you to choose the plan that best suits your current needs.
- A Policyholder has the choice to port his/ her policies from one Insurer to another. The Acquiring and the Existing Insurers shall jointly, ensure that the entire underwriting details and claim history of the Policyholders are seamlessly transferred.
- The existing insurer shall provide the information sought by the Acquiring insurer immediately but not more than 72 hours of receipt of request through Insurance Information Bureau of India (IIB) https://iib.gov.in/ portal.
- The Acquiring insurer shall decide and communicate on the proposal immediately but not more than 5 days of receipt of information from Existing insurer.
- The policyholder is entitled to transfer the credits gained to the extent of the Sum Insured, No Claim Bonus, specific waiting periods, waiting period for pre-existing disease , Moratorium period etc from the Existing Insurer to the Acquiring Insurer in the previous policy.
Claim Settlement Process
- Contestability of Claims: After a specific period (typically 60 months of continuous coverage), insurers cannot deny claims based on non-disclosure or mis
No Claim Bonus (NCB)
The Insurer may reward the policyholders who do not make claim in the form of
- No Claim Bonus (NCB). Such NCB shall be paid as per the choice/ express consent of the policyholder in the following forms at the time of every renewal:
a) Cumulative Bonus: Addition in the Sum Insured without an associated increase in premium. and/or
b) Discount in renewal Premium
Policy/Claim cannot be contested
No policy and claim of health insurance shall be contestable on any grounds of non-disclosure and/or misrepresentation except for established fraud, after the completion of the Moratorium Period, i.e. 60 months of continuous coverage
Note :The accrued credits gained under the ported and migrated policies shall be counted for the purpose of calculating the Moratorium period.
Approval for Cashless facility
- Every insurer shall strive to achieve 100% cashless claim settlement in a time bound manner. The insurers shall endeavor to ensure that the instances of claims being settled through reimbursement are at bare minimum and only in exceptional circumstances.
- Insurer shall decide on the request for cashless authorization immediately but not more than one hour of receipt of request. Necessary systems and procedures shall be put in place by the Insurer immediately and not later than 31st July, 2024.
- Insurers may arrange for dedicated Help Desks in physical mode at the hospital to deal and assist with the cashless requests.
- Insurers shall also provide pre-authorization to the policyholder through Digital mode.
Final authorization for Discharge from the hospital
- Insurer shall grant final authorization within three hours of the receipt of discharge authorization request from the hospital. In no case, the policyholders shall be made to wait to be discharged from the Hospital.
- If there is any delay beyond three hours, the additional amount if any charged by the hospital shall be borne by the insurer from shareholders fund.
- In the event of the death of the policyholder during the treatment, the insurer shall:
I. immediately process the request for claim settlement.
ii. get the mortal remains (dead body) released from the hospital immediately
Consumer Protection and Transparency
- Customer Information Sheet (CIS): Upon purchasing a policy, you’ll receive a CIS in clear, concise language. This document details your coverage benefits, exclusions, sub-limits (caps on specific treatments), deductibles (your out-of-pocket amount before insurance kicks in), waiting periods (timeframe before coverage for specific illnesses applies), free look period (time to review and cancel the policy), renewal process, and grievance redressal mechanism. This empowers you to understand your policy thoroughly.
- Free Look Period: After purchasing a new policy (with a term of one year or more), you have a 30-day window to review it and cancel without penalty if you’re not satisfied. This allows you to make an informed decision before committing to the plan.
Source: IRDAI Master Circular
