29.05.2024

Press Release

Reforms in Health Insurance

–-towards healthier insurance landscape

In a significant stride towards reinforcing empowerment of policy holders and bolstering inclusive health insurance, the Insurance Regulatory and Development Authority of India (IRDAI) has issued a comprehensive Master Circular on Health Insurance Products repealing 55 circulars.

The Master Circular has brought in one place the entitlements in a health insurance policy available to a Policyholder/prospects for their easy reference and also emphasizes measures towards providing seamless, faster and hassle-free claims experience to a policyholder procuring health insurance policy and ensuring enhanced service standards across the health insurance sector.

Salient features of the Master Circular are:

For Policyholders/Prospects/Customers

• Wider choice to be provided by the Insurers by making available products/add- ons/riders by offering diverse insurance products catering to all ages, regions, occupational categories, medical conditions/ treatments, all types of Hospitals and Health Care Providers to suit the affordability of the policyholders/prospects.
• Customer Information Sheet(CIS) which is provided by the Insurer along with every policy document. It explains the basic features of insurance policies in simple words like type of insurance, sum insured, coverage details, exclusions, sub-limits, deductibles, and waiting periods
• Customer to be provided with the flexibility to choose products/add-ons/riders as per his/her medical conditions/specific needs.
• A Policyholder with multiple health insurance policies gets to choose the policy under which he/she can get the admissible claim amount. The primary insurer with whom claim is first submitted shall coordinate and facilitate settlement of balance amount from the other insurers
• In case of no claims during the policy period, the insurers may reward the policyholders by providing an option to choose such No Claim Bonus either by increasing the sum insured or discounting the premium amount.
• Policyholder to get refund of premium/proportionate premium
  for unexpired policy period, if he chooses to cancel his/her policy at any time during the policy term
• A health insurance policy is renewable and shall not be denied
  on the ground that claim (s) was made in the preceding policy years, except in case of established fraud or non-disclosure or misrepresentation by the Insured. An Insurer shall not resort to fresh underwriting unless there is an increase in sum insured

Compliance required by the Insurers

• Provide end to end technology solutions
  for effective, efficient and a seamless on boarding of policyholders, renewal of policy, policy servicing, grievance redressal
• Strive towards achieving facilitation of 100% cashless claim settlement in a time bound manner
• Empanelment of all categories of hospitals /health service providers considering the affordability of different segments of population.
• Display prominently on insurer’s website:
• a. List of hospitals/health care service providers with whom they have tie up for cashless claim settlement;
• b. Specify that a policyholder has to file for claim reimbursement in case services are availed in other than empanelled hospitals / healthcare service providers;
• c. Procedures to be followed for claim settlement under cashless facility and reimbursement of claims 
• To decide on cashless authorization requests immediately and within one hour and final authorization on discharge from hospital within three hours of request from the hospital.
• In the event of death during the treatment, mortal remains to be released From the Hospital immediately
  .
• No claim can be repudiated without the approval of the Claims Review Committee which is required to take decision on repudiation of every claim
• For claim settlements, the policyholder shall not be required to submit any documents. Insurers and TPAs shall collect the required documents from the Hospitals.
• For portability requests on Insurance Information Bureau of India(IIB) https://iib.gov.in/portal, stricter timelines being imposed for the existing insurer and the acquiring insurers to act
• Insurer is liable to pay Rs. 5000/- per day to the policyholder in case ombudsman awards are not implemented within 30 days
• Underwriting policy to ensure Ayush treatment at par with the other treatments. Policyholders to be given an option to choose treatment of their choice.
• Performance of TPAs to be monitored. Payments to be made to the TPAs only upon full discharge of satisfactory service. Claw back of remuneration/charges paid to TPA basis customer feedback, which shall be passed on to the policyholders.
• In case of withdrawal of products suitable option(s) to be given to policyholder to migrate to any other suitable product (existing or modified version of the withdrawn product) or one-time option to renew the products (if renewal falls within 90 days from the date of withdrawal)

This Master Circular represents a landmark effort to empower the policyholders, ensuring they receive the highest standards of care and service; fostering an environment of trust and transparency in the health insurance sector.

The detailed Master Circular is placed at IRDAI website at Document Detail-IRDAI

Source (IRDA press release – 29-05-2024)

(LINK).