Health Insurance Norms to be more Customer-friendly 2022

Coverage for New Ailments

The regulator has issued specific guidelines related to illnesses like genetic diseases and disorders, behaviour and neurodevelopment disorders, puberty and menopause-related disorders, etc. that will now be included under regular health insurance plans.

Hereafter, insurers will be barred from not covering illnesses related to hazardous activities. Comprehensive health insurance plans will further include treatment cost for internal congenital diseases, mental illnesses, age-related degeneration, and artificial life maintenance.

In addition to these, coverage for age-related illnesses like knee-cap replacements, and cataract surgeries will also become a part of the inclusions. Also, people working with harmful chemicals that may impose long term health complications shall be covered for skin and respiratory ailments that may arise due to their working conditions.

Standardization of the Exclusions

The Insurance Regulator has also standardized the limitations in health insurance plans that if an insurer does not want to cover specific ailments like chronic kidney diseases, HIV/AIDS, and epilepsy, they must use specific wordings as demarcated by the IRDAI in the policy terms.

It has also notified the insurers to make the range of waiting period for 30 days to one year, and after that, the coverage will be provided for the illness.

New Definition of Pre-existing-Diseases

To ensure adequate insurance coverage to the policyholders suffering from pre-existing diseases, the regulator has mandated the insurers to include permanent exclusions only after taking consent from the customers. No exclusion is allowed apart from those listed by the IRDAI.  As per the new guidelines, all the medical issues suffered after the policy commencement can be claimed by the insured.

So, the regulator has laid down guidelines regarding the standardization of medical insurance policies; and it has suggested changing the definition of pre-existing diseases (PED) to cater to the customers’ requirements. As per the issued guidelines, any illness that has been diagnosed or medical advice was taken by a doctor 48 months before policy issuance will be classified as Pre-existing Diseases.

Pre-existing Disease refers to any injury, ailment or medical condition, for which there were symptoms, or was diagnosed, or medical treatment/advice was taken within 48 months prior to the first health insurance policy purchased by the insured and then renewed thereafter.

Some of the major illnesses that need to be included are AIDS/HIV, Alzheimer, morbid obesity, and Parkinson.

No Rejection of Claim after 8 Years

IRDAI stated in June 2019 that if the policyholder has been paying the premium for a medical insurance policy for consecutive eight years, then the insurer cannot reject the claim except for permanent exclusions or any proven fraudulent act.

This move has been crucial for the honest medical insurance buyers who had to face rejection for certain claims even after paying the premium for a decade. Those 8-years in the proposal are referred to as the ‘Moratorium period.’ In case there is any sub-limit, deductible, and co-payment in the policy, they need to be followed as per the valid policy terms and conditions.

Paying Medical Insurance Premiums in EMIs

Amidst the ongoing Coronavirus pandemic, the IRDAI introduced a circular in Jan 2022 suggesting minor modifications in policies filed by both standalone health insurers and general insurers. Furthermore, the circular by the regulator also permitted to pay the health insurance premiums in instalments. However, it is entirely up to the insurers if they want to offer this facility or not.

The instalments can be paid half-yearly, quarterly, and monthly as decided by the insurance company. So, from now on customers who cannot pay the entire premium in one go, have the choice to pay it in equal instalments over regular intervals during a policy year.

These were some of the important modifications in terms of health insurance cover that would ensure extensive medical insurance cover to those who are already insured and also the new applicants from Jan 2022.