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Important Changes in Health Insurance Norms & Benefits

  • Akarshita Yaji
  • Feb 17 2022
  • 5 minutes
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The insurance penetration in the country is very low. The Government of India and all insurance companies have taken numerous initiatives in order to change the status quo, especially in the health insurance sector. The Insurance Regulatory and Development Authority of India (IRDAI) has issued guidelines and specifications for the health insurance sector that have come into effect from 01.10.2020. the important changes that have been brought about by the policy is as follows – 

Changes in health insurance norms

1. The new policy guidelines covers new ailments

Under these new guidelines, the treatment for mental illness, age-related degeneration, behaviour and neurodevelopmental disorders, genetic diseases, puberty and menopause-related disorders, internal congenital diseases and artificial life maintenance will be covered under a comprehensive plan. Additionally, insurers cannot exclude illnesses contracted from hazardous activities. Also, age-related illnesses such as knee-replacement surgeries or cataracts will be covered under the policy cover.

2. New definition for Pre-existing diseases

The new guidelines state that any disease or ailment that is diagnosed 48 months prior to the issuance of the health insurance cover will be considered a pre-existing disease. Also, age-related illnesses Further, any condition whose symptoms or signs have come about within a period of three months of the date of issuance of the policy, then it will also be classified under pre-existing Diseases. This ensures that people suffering from pre-existing diseases do not suffer from a lack of proper health coverage.

3. The insurance coverage has increased

The insurance coverage has increased to telemedicine too accounting for increasing physical distance. The guidelines issued by MCI enables Registered Medical Practitioners to provide healthcare using telemedicine, and so insurers have now been advised to allow claim settlement for telemedicine consultation as per the terms and conditions of the policy contract.

4. Standardisation 

The policy has sought for standardisation of important product clauses such as disclosure of material facts, settlement of claims, policy cancellation, etc. in their policies so that customers can understand these clauses in the insurance policy easily and can compare products across insurers. There is an option to add additional terms and clauses to allow for more informed choice from the customer.

5.Payment of health insurance premiums through EMIs

There is a new option for the insured to make premium payments in the form of EMIs giving them more flexibility in payments. However, this is subject to the application by each health insurer.

6. Norms on proportionate deductions

The guidelines issued on proportionate deductions of claims is especially useful for policy holders who choose a higher category of hospital room than what is allowed by the capping of insurance policy, as consultation fees and the like proportionately increase with a higher category room.

Associate medical expenses are to be clarified in the contract itself as per the new guidelines. This might result in disallowing the costs of consumables and pharmacy, implants and medical devices, and diagnostics under this category.

Additionally, insurers are not allowed to add any proportionate deduction for ICU charges in lieu of the fact that ICUs cannot be further categorised.

7. Claims cannot be rejected after 8 years

If the health insurance policy holder has been consistently paying his premium for a period of 8 years or more, then claims cannot be rejected by the insurer except in the case of fraud or permanent exclusion. The 8 year period is the moratorium period.

8. Wellness benefits 

In order to incentivise healthy lives, the recent guidelines stress on rewarding policy holders on the basis of preventive and wellness habits. This is done by disclosing upfront, mechanisms or incentives in the prospectus and the policy document, that incentivize individuals to monitor and improve their health.

9. Launch of several pilot products

The IRDAI has encouraged insurance companies to launch several health insurance products to cover risks that were outside the ambit of health insurance policies all these years. There are several continuity benefits being introduced and the insurers are also encouraged to try and test new products.

10. Shorter turnaround time

As per the new guidelines, the insurer has to settle/ reject health insurance claims within a period of 30 days from the date the claim is received. Any delays will incur penalties for the insurance company.

Conclusion 

An adequate health insurance cover, for not just oneself but his or her family too, has become the need of the times. The government recognizing the importance of this has incentivized and made the insurance process simpler and more cost effective. It is best that one takes advantage of these new guidelines and secures the lives and future of his or her family.

Frequently asked questions

  1. Can claims made by a policyholder who has insurance for 10 years be rejected?
    No, the new guidelines have clearly stated that any claims made by policyholders after crossing the moratorium period of 8 years cannot be rejected.
  1. What is the penalty that the insurance company has to pay if the claims are not settled on time?
    The reimbursement of the claim has to happen within 30 days failing which a penalty of 2% above the applicable bank rate must be paid on the claim amount.
  1. Will mental illness be covered under health insurance policies?
    Yes, indeed, mental illnesses will be covered.

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