Saturday, June 2, 2012

IRDA - Landmark draft Health Insurance Regulations

Given below is an article from Moneylife in full. I thank sri KV Cary for alerting me on this. Comments are welcome. Vyasamoorthy

IRDA comes up with landmark draft health insurance regulations
May 31, 2012 07:14 PM 
Raj Pradhan

IRDA has come up with momentous regulations which will change the health insurance industry workings if the draft is implemented without watering it down. TPAs' role will get marginalized and hence they may try to scuttle the implementation in its current form

Insurance Regulatory and Development Authority (IRDA) has finally issued draft health insurance regulations addressing several areas of concern which were raised in a public interest litigation (PIL) by social activist Gaurang Damani. The draft covers product design, renewability, portability, file and use procedures, protection of policyholders' interest, servicing ofhealth insurance policythird party administrators (TPA), contract between insurer and hospitals and so on.

According to Mr Damani, "They have accepted 80%-90% of what I had demanded in the court. A few minor things remain, some of which are already there in their other circulars, but just need to be added to the policy document. I would mention the same in the next court hearing. One point that is missing in the draft guidelines is need for a doctor's signature in case of claims denial."

The important points in IRDA guidelines are related to following:

  • Entry and exit age - All health insurance policies shall provide for entry age at least up to 65 years. All health insurance policies shall not have an exit age for renewal of the policies, once the proposal is accepted, provided the policy is continuously renewed without a break.
  • Cumulative bonus to be mentioned in the policy document
  • Mediclaim denial grounds to be given in writing
  • Reward a favourable claim ratio
  • Refund on pre-insurance med check-ups - A proposal resulting into a policy shall reimburse at least 50% of the medical exam cost.
  • Separate grievance cell for senior citizens
  • Increase in premium must be in writing and must be justified
  • Claims independent of multiple fixed benefit policies - The insurer shall make the claim payments independent of payments received under other similar polices.
  • If two or more policies are taken by  an insured during a period from one or  more  insurers,  where the  purpose  of  such  policies  is  to  indemnify  the  treatment costs, the insurer shall not apply the contribution clause but the  policyholder shall have an option to chose insurer with whom the claim is to  be settled. In all such cases, the insurer shall be obliged to settle the claim without insisting for contribution clause.
  • Insurers  may  provide  coverage  to  non-allopathic  treatments  provided  the treatment has been undergone in a government hospital or in any institute recognized  by  the government.
  • Any  product  that  is  being  offered  in  the  market  by  insurance  companies shall not be allowed to be withdrawn  in respect of the existing customers of  the  product,  unless,  the  existing  customers  are  given  an  option  to switch to a similar product under specific written consent.
  • Uncomplicated one page customer information sheet to cover key benefits, exclusions and grievance mechanisms.
  • Renewal cannot be denied randomly
  • Waiting period for pre-existing diseases (PED) be clearly specified
  • Claim settlement within 30 days
  • Insurer to make direct payment to the hospital and policyholder (not through TPA). Cheques will have to be written by the insurance company and send to hospital (for cashless) and policyholder (for reimbursement). It means that cheques cannot be held by TPAs as a float.
  • ID card to have logo of the insurance company. In  case  the  policy  is  renewed,  provisions  to  be  established  by the  insurer  to  ensure  there  shall  not  be  any  need  for  re-issue  of  fresh cards provided there is no change in the details of the policyholder. It means auto-renewal of same ID cards.
  • Agreement between the TPA and insurance company to be registered with IRDA
  • Seamless transfer of policies services by an existing TPA to the new TPA
  • Claim settlement - Specific ground of settlement and denial of claim must be mentioned
  • All insurers shall have an agreement directly with the hospitals to establish the list of network providers. The insurer  shall  be  responsible  for  carrying  out  an empanelment  process  of  hospitals  or  health  care  providers  to  provide  cashless facility to the policyholder. The TPA role is effectively 

Complete draft may be downloaded from IRDA site at:

No comments:

Post a Comment