IRDAI Updates Health Insurers’ Norms For Furnishing Policy Details To Customers

Starting January 1, insurance companies are mandated to furnish policyholders with essential details in a specified format, encompassing sum assured, coverage inclusions and exclusions, and the claims procedure, according to a recent update by the Insurance Regulatory & Development Authority (IRDAI). The IRDAI has revamped the customer information sheet to ensure clear communication of fundamental policy information, facilitating easy comprehension of terms and conditions associated with the purchased policy.

"Since a policy document may be fraught with legalese, it is imperative to have a document that explains, in simple words, the basic features concerning the policy and provides necessary information. With the above objective in mind, the customer information sheet (CIS) has been devised. It will be provided by insurers to all policyholders," according to the IRDAI circular released on October 30.

"It is observed that several complaints are still emanating as a result of asymmetry of information between the insurer and the policyholder. Against that backdrop, the existing customer information sheet has been improved and now seeks to convey basic information about the policy purchased in a manner that is easily understood. The revised format of CIS (annexure A) shall be implemented with effect to January 1, 2024," the circular adds.

According to the updated CIS, insurers must furnish policyholders with essential details, including the 'name of the insurance product/policy,' 'policy number,' 'type of insurance product/policy,' and the 'sum insured.' Additionally, policyholders will receive information about policy coverage (such as hospital expenses), exclusions (items not covered by the policy), waiting periods, financial limits of coverage, claims procedures, and specifics regarding the mechanism for addressing grievances and complaints. The circular also specifies that insurers, intermediaries, and agents must distribute the CIC to all policyholders and obtain an acknowledgement accordingly. Additionally, if the policyholder prefers, the CIC should be provided in the local language.

Insurers, intermediaries, and agents are mandated to send the CIS to every policyholder and obtain acknowledgement, either physically or digitally. If the policyholder prefers, the CIS should be accessible in the local language. The CIS must adhere to a minimum font size of 12" (Arial) or above, and all specified details should be accurately filled in. The letter accompanying the policy document must reference the CIS. This circular is issued following Regulation 26 of the IRDAI (health insurance) regulations, 2016.

Revised Customer Information Sheet: Know Your Policy

This document presents essential information about your policy; it is advisable to review your policy document for a comprehensive understanding.

Title Description Policy

There is no reference to the applicable policy clause number in the next column (please refer to the appropriate policy clause number in the number column).

Name Of Insurance Product/Policy: XXXXXX

Policy NumberType Of Insurance Product/Policy:

· Indemnity (Covers insured losses up to the sum insured)

· Benefit (Provides a fixed amount on the occurrence of a covered event)

· Both Indemnity And Benefit (Combines elements of both)

· Sum Insured (Basis):

· Individual Sum Insured (Separate sum for each member)

· Floater Sum Insured (Single sum for all members)

· (Along with the amount)

Policy Coverage (What The Policy Covers?): Expenses Related To

· Hospital admission beyond xx hours

· Pre-hospitalization (treatment before admission) of xx days

· Post-hospitalization within xx days

· Specified day-care procedures

· Critical illnesses

· Diagnosis of specified severity illness

· Daily cash benefit during hospitalization

· OPD/Dental/Maternity coverage

· Emergency or Travel Medical Assistance

· Personal Accident Cover

· Travel Cover

(Note: This list is indicative; ensure all policy benefits are included.)

· Exclusions (What the policy does not cover):

(Note: Insurer must list all applicable exclusions.)

Waiting Period:

· Initial Waiting Period: xx days for all illnesses (not applicable for continuous renewal or accidents)

· Specific waiting periods for certain diseases/procedures

Financial Limits Of Coverage:

· Sub-limits specified for certain diseases/procedures

· Co-payment and Deductible details

· Any other applicable limit

Claims/Claims Procedure:

Details on cashless and reimbursement claim procedures, including pre and post-hospitalization.

Turnaround Time (TAT) for claims settlement:

i. TAT for preauthorization of cashless facility: XXX

ii. TAT for cashless final bill authorization: XXX

Provide Details/Web Links For:

i. Network Hospital details

ii. Helpline number

iii. Blacklisted hospitals

iv. Downloading/getting the claim form

Policy Servicing:

Call center number and details of company officials.

Grievances/Complaints:

Details of grievance redressal officer, insurance company grievance portal/department, and ombudsman.

(Please provide contact details, toll-free number, and email)

Important Considerations

Free Look Cancellation: You can cancel the insurance policy within xx days from its inception if you no longer wish to continue. The insurer will specify the process for free look cancellation.

Policy Renewal: Your policy shall not be denied renewal except for fraud, moral hazard, misrepresentation, or non-cooperation, as long as the policy is not withdrawn.

Migration And Portability: At the time of renewal, you can choose to migrate to another policy with the same insurer or port your policy to a different insurer. The insurer will provide details on the process for migration and portability.

Change In Sum Insured: Changes to the sum insured (increase/decrease) can only be made at the time of renewal or at any time, subject to underwriting by the company. For an increase, the waiting period shall restart only for the enhanced portion of the sum insured.

Moratorium Period: After eight continuous years under the policy, no look-back will be applied. This moratorium period applies to the sums insured of the first policy, and the subsequent eight continuous years apply from the date of enhancement of sums insured only on the enhanced limits. After the moratorium expires, the health insurance policy shall not be contestable except for proven fraud and permanent exclusions specified in the policy contract.

Your Responsibilities

Please openly declare all pre-existing diseases or conditions before purchasing a policy. Non-disclosure may impact claim settlement. Also, disclose any other material information during the policy period, as specified by the insurer.

Insurer's Specification

The insurer will outline material information that requires disclosure.

Policy Holder Declaration

I have read the above and confirm my understanding of the details.

Place

Date: (Signature of the policyholder)

Note

i. The insurer will provide a web link where product-related documents, including the Customer Information Sheet, are available on their website.

ii. In case of any conflict, the terms and conditions in the policy document prevail.

iii. The insurer will confirm the policyholder's receipt of the CIS.