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All You Need to Know About IRDAI's New Health Insurance Rules

Published On Jan 15, 2020 5:30 AM By Sakshi Aggarwal

There is only one thing which has huge potential to create hindrance in one’s career, money and success pyramid of life, that is ’poor health’. We all have witnessed the pressure faced when our loved ones get hospitalised. From that long wait in the hospital, till the silent prayers for our loved ones to recover, we try doing all that it takes to see our loved ones healthy soon. Which is why today a huge number of people are running towards buying a good health insurance plan for themselves and their loved ones. Related to which is good news mentioned further in the article. Find out! 

All thanks to the insurance regulator IRDAI that India is going witnessing a radical transformation in the health insurance sector. It has introduced new regulations which will benefit the policyholders in many ways. They will now get enhanced coverage, clear definitions and less confusion in policy fine print. Because all the highlights related to regulations are positive for the policyholders, they are expected to witness a lesser number of claim rejection now.    

Also Read: New Provisions by IRDAI: Here's What You Need to Know

The health insurance providers in the market will now have to comply with IRDAI’s new norms. And as far as existing policies are concerned, they must also imply them by October 2020.  

Let us now understand the key aspects of health insurance regulations. 

1. Exclusions not allowed 

IRDAI has issued a list of 12 features which the insurers cannot include in the exclusions list of health insurance plans. This is sure to make the policyholders really happy. This is because until now, on the basis of these features, the customers used to get their claim requests or even the policies denied. 

But now that the IRDAI has said no or such exclusions, people suffering from let’s say, mental illnesses, psychological disorders, or types of neurodegenerative ailments, menopause or puberty related illness won’t be denied health insurance plans. 

An insurer now will also have to pay for illness or injury pertaining to hazardous activities. Which means, the policyholders can now not be denied health insurance plans simply because they work in a hazardous environment like a coal mine or a nuclear power plant. The insurer will pay for any expense incurred in such an environment. But this exclusion will not include engagement in adventure sport. 

Other exclusions that the IRDAI has disallowed include age-related macular degeneration, birth disorders, genetic ailments, and congenital diseases. 

2. Standard policy document

As per new regulations, the policy fine print has been standardised. IRDAI has issued 18 codes for 18 policy exclusions. An insurer can only reject a claim referring to exclusion from these 18 codes only. It is another good news for the policyholders as they can now experience transparent claim settlement process. 

Some standard exclusions include pre-existing diseases, adventure sports, expenses incurred due to cosmetic surgery, treatment for drug abuse or alcoholism, infertility, maternity, and refractive error. 

A health insurance company can consider these exclusions for the basis of rejection and can state them in the policy contract. And on the good side,  the insurers cannot reject claims giving invalid reasons like for example, obesity. 

The new regulations are so specific that even after listing out obesity in the list of exclusions, they specify that claims pertaining to surgical treatment of obesity is included if the surgery is conducted on doctor’s advice. Also, if the BMI of the patient is equal or greater than 40 or if it is more than 35 and the patient is suffering from heart disease, or type II Diabetes. 

3. Specified permanent exclusions

The insurance regulator has also issued a list of 16 permanent exclusions that comprises of illnesses like Hepatitis B, kidney disease, epilepsy, and chronic liver disease. Any insurer is allowed to offer a health insurance product without covering these ailments. 

With this, the joy of policyholders will have no bounds as until now patients suffering from these diseases were denied health insurance plans completely. But now, instead of facing blanket rejection for these illnesses along with others as well, they will be offered selective coverage i.e. for other illnesses. 

If taken this in the right spirit by the health insurance companies, then this regulation will definitely prove to be beneficial by offering partial coverage to those suffering from pre-existing disease, let us say, which is one of the 16 exclusions.  

Other general guidelines

As per IRDAI’s new regulations, no health insurance policy can have a waiting period of more than 4 years. The insurance regulator has banned using open-ended words like ‘such as’, ‘etc.’, or ‘related to’ in waiting periods and exclusions in the policy contract. This will ensure that claims are not rejected on an unfair basis.  

For lifestyle diseases like diabetes, hypertension, and cardiac conditions, the waiting period cannot be for more than 90 days from now. In case the policyholder buys a policy without any pre-existing conditions, the insurer will honour claims if the condition is developed after 90 days from date of policy inception.     

Not to ignore, is another vital aspect that is the definition of pre-existing disease. As per the insurance regulator, a pre-existing disease can be defined as the one which is diagnosed or has been treated for 4 years before the policy was issued. If it has not been diagnosed, then any disease with symptoms occurring within 3 months after the issuance of policy will be taken as a pre-existing disease. 

Also Read

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The new health insurance regulations are going to make the concept of health insurance easy for its customers. Another good news is that it is sure to increase health insurance penetration as well in India. This is because people who were earlier denied health insurance plans altogether because of specific conditions will now be provided (with partial coverage). 

On the other hand, the fact that these regulations will enhance coverage benefits may increase health insurance premiums a little bit from next year onward. But will benefit the policyholders in the long run. 

So, one must not think about increased premiums in the near future, but focus on enhanced benefits in the long run and grab on the best health insurance option soon. 

To choose the best health insurance plan online, you can get in touch with the experienced customer care executives at Insurancedekho on the toll-free number 1800 1205 698. The team will understand your requirements and shortlist a few plans for you as per your budget and current health conditions. Once you decide on which policy to buy, you can make the policy yours by following a few steps. 

Stay healthy, stay insured! 

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