IRDAI Issued Guidelines to Standardize Health Insurance Exclusions

Insurance Regulatory and Development Authority of India (IRDAI) has recently come up with new guidelines to standardize exclusions in health insurance products.

The Mental Healthcare Act 2017 makes it mandatory for every insurer to ensure medical coverage for mental health ailments.

Specific Excluded Illnesses will now Be Covered

The regulator has asked insurers not to exclude eleven illnesses like mental illnesses, genetic disorders, stress/psychological disorders, behavioral and neurodevelopmental disorders, hazardous activities, puberty, and menopause-related disorders from the exclusions list of health insurance policies.

IRDAI has issued the new rules and now, insurers can’t decline to cover the people who have used opioids or anti-depressants and also, can’t exclude instances with a history of clinical depression, sociopathy, psychopathy, personality, or neurodegenerative disorders.

Insurance companies can’t exclude coverage towards the treatment cost incurred for children in the treatment of developmental disorders, cerebral palsy, autism, speech disorders, and dyslexia. In India, nearly 1 in 8 children is suffering from neurodevelopmental conditions as per a 2018 study by INCLEN Trust International. Considering this scenario, a move to provide coverage for this health condition proves a quite significant development.

No Rejection after 8 Years of Coverage

Another major decision will have a wide impact on the insurance industry. As per the guidelines issued, insurers cannot reject claims of those found to be a smoker or suffering from a disease or pre-existing disease, if the insured person has been availing of Insurance cover for continuous eight years.

IRDAI further added that insurers can no longer exclude coverage, in case the policyholder failed to get or follow medical advice or treatment.

Cheer to Sports Enthusiasts

As per new rules drafted by IRDAI, insurance companies now have to provide coverage for risky sports pursuits including dirt biking, paragliding, whitewater rafting, go-karting, and F1 racing. Coverage is also available for ethnic sports like Jallikattu and Kambala. Moreover, insurers can’t discriminate on a gender and identity basis.

Insurers can’t reject to provide cover when an insured person is on life support, however, they can reject claims when he/she is in a minimally conscious state. Insurers will have to pay for the expenses incurred if the patient is certified by competent authorities. Insurers can put waiting periods for any specific illnesses up to a maximum of four years.

Pre-Existing Disease

Talking about the pre-existing diseases, amendment in health policy this time covers a lot of options. As PED is the most demanded and most asked the question before buying a policy because we all know that till yesterday, no insurance company used to give the option of Pre-Existing Disease with its policy, but this time IRDAI has made a lot of changes in the rules and now on pre-existing diseases will also be covered under some criteria.

If anyone wants to buy a health policy and he is suffering from any disease, in such a condition pre-existing disease will cover only one condition then he must have to wait 48 months after insuring himself. After 48 months, the pre-existing disease will also get covered. The time period of 48 months is known as the waiting period.

Guidelines for Health Insurance Inclusions

In June 2020, IRDA released three specific new guidelines regarding the policy and coverage of the plan. Keeping the customer in mind, IRDA always comes up with significant innovations.

Standardizations of important product clauses in their policies to understand them easily and compare products across insurers.

As per IRDA’s new norms, the insurance company should mention the critical products clauses in standard terms; the reason behind it is “customer will understand the policy, what policy offering him”. Look, standardizations and simplification can make policy’s wordings, so easy that he anyone can easily understand the offers of product. 

Ensuring insurance coverage for telemedicine is essential in these times of physical distancing.

We all face the brutality of Covid-19 year after year, and in this scenario, the Medical Council of India released a guideline in March 2020. As per the medical council, every medical practitioner should provide a telemedicine service. Apart from medical practitioners, every insurance company also has to settle telemedicine consultation claims. 

To provide more rational and customer-friendly claim deductions.

The third guideline is that if a customer claims for the settlement, then being an insurance company, you need to take care of deductions that you will deduct. It should not happen that you are deducting any amount as you want, the deduction should be proportionate, and it should be as per norms. 

IRDAI also asked insurers to comply with the new health insurance guidelines, else they have to withdraw the non-compliant health insurance products by 1^st April 2020.