What has IRDA changed health cover holders in new rule?

The insurance regulator IRDAI has given a big relief to health insurance policyholders. Now they will not have to go through the hassle of dealing with the insurance company for claim settlements. IRDAI has issued a master circular on May 29. It is considered a big step in the interest of policyholders. Let’s find out about the 10 major steps taken by IRDAI.

1) Under the new rules, the insurance company will have to decide on cashless treatment within one hour of receiving a request from the customer. Similarly, the hospital will have to grant discharge permission within three hours of receiving the patient’s request. If there is a delay of more than three hours, and if the hospital charges any amount, the insurance company will have to pay it from the shareholder fund. It has been observed in cashless treatment that people have to wait for over 10 hours for discharge because there is a delay in claim settlement by the insurance company.

2) In the case of claim settlement, policyholders will not need to submit any documents. The insurance company and TPA will collect necessary documents from the hospital.

3) IRDAI has said that insurance companies should offer different insurance products via add-ons, or riders to cover all ages, areas, professions, religions, medical conditions, or treatments. Also, all types of hospitals and healthcare providers should be included so that policyholders can choose according to their affordability.

4) Along with the policy document, the policyholder will be given a Customer Information Sheet (CIS). Which will explain in simple language the basic features of the insurance policy such as insurance type, sum insured, coverage details, exclusions in the policy, deductibles, sub-limits and waiting periods.

5) The regulator has said in the circular that customers should be provided the facility to choose products, add-ons, or riders based on their medical conditions or special needs.

6) If the policyholder does not make any claims during the policy period, the insurance company should reward it. Options such as increasing the sum insured or giving discounts in premiums can be given as ‘no claim bonus’.

7) In case of having multiple health insurance policies, the policyholder can claim settlement in any policy of their choice. The insurance company whose policy is chosen will be considered the primary insurer. If the available insurance cover on the chosen policy is less than the acceptable claim amount, the primary insurer will ask for details of the policyholder’s other policies and will negotiate with other insurance companies for the settlement of the balance amount.

8) If the policyholder chooses to cancel the policy at any time during the policy term, then they will receive a refund of the premium or proportionate premium for the unexpired policy period.

9) According to the new rules, renewal of health insurance policy cannot be denied on the basis that claims were made in previous policy years. If the policyholder deceives the insurance company, provides false information or conceals anything, renewal can be denied only on these grounds.

10) Without the approval of the claim review committee, the insurance company cannot reject any claim. Also, the reason for not approving the claim must be provided. Similarly, in case of death during treatment, the body will be immediately removed from the hospital.

Considering the interests of policyholders, most of the rules of the master circular are effective immediately. IRDAI has asked insurance companies to strive for 100% cashless claim settlement. Policyholders will also be given a grace period for paying premiums. Monthly premium payers will have a grace period of 15 days from the due date, while quarterly, half-yearly, and yearly premium payers will have a grace period of 30 days. During the grace period, benefits such as sum insured, no claim bonus, waiting period for pre-existing diseases and so on, will remain secured upon policy renewal.