Irdai: Master Circular On Health Insurance Business

The Insurance Regulatory and Development Authority of India (Irdai) has issued a master circular on health insurance products, as a major regulatory revamp, to empower the policyholders and strengthen inclusive health insurance. The master circular has all the entitlements in a health insurance policy available to a policyholder. It also stressed measures towards providing a seamless, faster, and hassle-free claims experience to a policyholder with a health insurance policy and ensuring ethical service standards across the health insurance sector.

“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,” according to a press release issued by Irdai.

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The Irdai's major norms require insurers to offer a diverse range of insurance products, add-ons, and riders. These products are for people across all ages, regions, occupational categories, medical conditions, treatments, and all types of hospitals and health care providers. The aim is to provide suitability and affordability. Along with every policy document, the insurers will also need to provide a Customer Information Sheet (CIS).

In simple terms, it explains the basic features of insurance policies such as insurance type, sum insured, coverage details, exclusions, sub-limits, deductibles, and waiting periods. Customers also need to have the flexibility to choose products, add-ons, and riders, according to their medical conditions or specific needs.

Only a policyholder with multiple health insurance policies has the option to choose the policy that can be used for admissible claim amounts.

If there are no claims during the policy period, the insurers may reward the policyholders by providing an option to choose such No Claim Bonus, which can either increase the sum insured or reduce the premium amount.

In case a policyholder cancels their policy during the policy term, he would receive a refund for the premium for the remaining period.

According to Irdai, a health insurance policy is renewable and shall not be denied on the ground that claim (s) was made in the preceding policy years, apart from cases such as proven fraud, non-disclosure, or misrepresentation by the insured.

Compliance Required By The Insurers

• Provide end-to-end technology solutions for effective, efficient, and seamless onboarding of policyholders, renewal of policy, policy servicing, and grievance redressal.

• Strive towards achieving the facilitation of 100 per cent cashless claim settlement in a time-bound manner.

• Empanelment of all categories of hospitals /health service providers considering the affordability of different segments of the population.

• Display prominently on the insurer’s website.

• list of hospitals/healthcare service providers with whom they have tied up for cashless claim settlement;

• Specify that a policyholder has to file for claim reimbursement in case services are availed in other than empanelled hospitals/healthcare service providers;

• Procedures to be followed for claim settlement under the cashless facility and reimbursement of claims.

• To decide on cashless authorization requests immediately and within one hour and final authorization on discharge from the 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.