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Regulations Regarding Health Insurance That Every Policyholder Should Be Aware Of

Updated On Apr 18, 2022

When a medical emergency occurs, a person's health becomes a concern. It might be equally overwhelming for the patient and loved ones in terms of enough financial assistance and emotional support. If the patient is covered by comprehensive coverage, a health insurance company may give financial assistance. Because purchasing health insurance is not a legal obligation, a potential policyholder has unlimited flexibility in selecting a coverage. But how can a policyholder have faith in an insurance company? There are several guidelines provided by IRDA which is a statutory body for framing rules and regulations in the Indian Insurance Sector,  that every policyholder should be aware of such rules and regulations.

What Are the Health Insurance Regulations?

The IRDA has methodically drafted a slew of rules that must be followed. These regulations assist both the insurer and the insured in providing and receiving a fair deal on health insurance and linked services. The following is a list of some of the most important rules established by the IRDA.

  • Exclusions - A health insurance policy will not cover all illnesses and conditions. A standard health insurance plan does not cover smoking-related diseases, drinking-related diseases, sexually transmitted diseases, cosmetic procedures/plastic surgery, and other lifestyle-related disorders. While lifestyle-related concerns, sexually transmitted illnesses, and cosmetic procedures will remain prohibited, many critical issues such as genetic diseases, psychiatric disorders, mental health problems, Depression, and neurodevelopment disorders will no longer be prohibited. This will not only help to reduce the stigma attached to mental health issues, but it will also provide much-needed coverage to the millions of individuals impacted by them.
  • Alternative medicine - Alternative medicines such as Ayurveda and Unani procedures were formerly excluded from most health insurance policies. However, under the new IRDAI rules, a policyholder can now claim coverage for any alternative procedures, often known as Ayush. Inquire with your insurance provider about coverage benefits for Ayush treatments if you're looking for non-restrictive health insurance for your family and yourself. AYUSH coverage is frequently included in all of the insurance offered by providers such as Niva Bupa.
  • Additional information - A maternity plan is meant to cover a specific event, whereas a typical health insurance plan covers unanticipated health concerns. As a result, most standard health insurance policies exclude pregnancy coverage. If you and your spouse want to start a family, you should enroll as soon as possible in a health insurance plan that includes maternity coverage or in a separate maternity insurance plan, because maternity benefits are only available after a three to the six-year waiting period, depending on the insurer. Finally, regardless of age, everyone from a newborn child to senior citizens should be able to access health insurance benefits, and luckily, insurance firms are now recognizing and satisfying these expectations. 
  • Claim denial - A health insurance company cannot deny a claim if the coverage has been renewed continuously for the previous eight years. The moratorium will be in effect for eight years. Except for fraud and/or a claim lodged after the moratorium period against the policy's exclusion, the insurance company cannot petition the IRDA even against settlement of such a claim. A claim cannot be refused because of the insurance company's deceit or failure to disclose. The IRDAI has given the insurance company an eight-year period in which to verify the information presented by the policyholder, so a claim cannot be refused on that basis.


These are some of the most significant terms and conditions of the IRDAI that everyone should be aware of. When looking for a health insurance plan, keep these terms in mind and be aware of the requirements.

Also read - What Can You Do To Make Your Current Health Insurance Plan Better?


This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

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