IRDAI Makes Health Insurance Claims Non-contestable After 5 Years of Paying the Premium

The Insurance Regulatory and Development Authority of India (IRDAI) in its latest guidelines has prohibited insurance companies to contest health insurance claims after 5 years of receiving premiums. The insurers also have to pay an interest of 2% above the bank rate to the policyholder for a delay in claim payments, applicable from the date of receiving all the documents.

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      This new amendment does not permit the health insurance companies to contest claims if the policyholder has been paying premium continuously for a period of 5 years. The guidelines are issued in order to standardise and simplify the indemnity-based medical insurance terms and conditions. It is not applicable to personal accident and international and domestic travel insurance plans. The idea is to bring uniformity across the health insurance industry.

      It further mentions that the health insurance contracts that are not in compliance with these new sets of guidelines need to be modified when they are due for renewal on or before April 01, 2024.

      As per the guidelines issued on Standardization of General Terms and Clauses in Health Insurance Policy Contracts, this duration of 5-years is also termed as the moratorium period, which would be applicable to the sum insured of the first health insurance plan. The moratorium of 5-years would be applicable from the sum insured enhancement date only on the enhanced limits.

      After expiry of five years of moratorium period the medical insurance claims are not contestable unless it is a fraudulent act or is mentioned under the policy exclusions. However, the co-payments, sub-limits, deductibles shall follow as per the mediclaim policy contract.

      Moreover, at the time of claim settlement, IRDAI instructs the insurers to reject or settle health insurance claims within 30 days of receiving the last essential document. And if the claim settlement is delayed, then the insurance company would be liable to pay interest to the insured at a rate of 2% above the bank rate. Any misinterpretation or non-disclosure by the policyholder would call for fortification of the premium paid and the policy will be cancelled.

      And if policyholders need to port the policy as per the guidelines, they can do that and port it for all the family members and it needs to be done a minimum of 45 days before the renewal date. And if someone is insured under a health insurance policy at present and has been paying the premium continuously without any lapses, the proposed policyholder will get the accrued benefits of the waiting periods.

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      Disclaimer: The list mentioned is according to the alphabetical order of the insurance companies. Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by any insurer. For complete list of insurers in India refer to the Insurance Regulatory and Development Authority of India website www.irdai.gov.in

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      *We will respond in the first instance within 30 minutes of the customers contacting us. 30-minute claim support service is for the purpose of giving reasonable assistance to the policyholder in pursuance of the claim. Settlement of claim (including cashless claim) is the responsibility of the insurer as per policy terms and conditions. The 30- minute claim support is subject to our operations not being impacted by a system failure or force majeure event or for reasons beyond our control. For further details, 24x7 Claims Support Helpline can be reached out at 1800-258-5881.

      *Product information is authentic and solely based on the information received from the Insurer. Policybazaar is acting only as a facilitator and claims settlement shall be at the sole discretion of the Insurer. Policybazaar does not provide any medical or surgical advice or diagnosis and is not responsible for your interactions / treatment by a medical practitioner/hospital. Please consult a registered medical practitioner for any medical or surgical advice. The Information that you obtain or receive from Policybazaar, and its employees, or otherwise on the Website is for informational purposes only. As per the Insurance guidelines, you are allowed to cancel the policy with-in 30 days from the date of Issuance of policy.This option is available incase of policies with a term of one year or more.

      *All the health insurance plans cover hospitalization expenses including COVID-19 treatment cover up to the specified limits. You can also buy specific COVID-19 health insurance policies such as Corona Kavach Policy and Corona Rakshak policy.

      **All savings and online discounts are provided by insurers as per IRDAI approved insurance plans. #Tax Benefits are subject to changes in tax laws. GST Exemptions depend on fulfilment of qualification criteria and submission of relevant documents.

      *₹1748/month is the starting price for a 1 crore health insurance for an 18-year-old male, with no pre-existing diseases. Discount on renewal premium is subject to the number of wellness points earned in the health insurance policy. For more details about the plans, please read the sale brochure carefully to get upto 100% discount on renewal premium.

      *₹400/month is the starting price for ₹ 5 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

      *₹541/month is the starting price for ₹ 10 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

      *₹762/month is the starting price for ₹ 1 Crore Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

      *₹243/month(₹ 8/day) is the starting price for a 5 lakh health insurance for a 20-year-old male, non-smoker, living in Bengaluru with no pre-existing diseases

      *₹2020/month is the starting price for ₹ 1 Cr Health insurance for a 50 year old male & 50 years old female, living in Bangalore with no pre-existing diseases rounded off to nearest 10.

      *₹390/month (₹13 per day) is starting price for 1 cr. Health insurance for 25 years old male, with pre-existing diseases, residing from tier 1 city rounded off to the nearest 10.

      *No medical tests are required unless requested by the insurer’s underwriter. In-case of pre-existing diseases relevant medical proof would be required as per the terms and condition of the policy opted.

      *The values taken for effective cost calculation are indicative values and may change as per the selected plan.

      *Coverage upto double the amount of Sum Insured is available on certain covers for a minimum plan of Rs. 5 Lakh on the first claim only to an individual of upto 45 years of age with no pre-existing diseases. The benefit is available with or without extra cost depending on the plan chosen.

      *Coverage of pre-existing diseases is provided by insurer as per their underwriting policy.

      *The scope of coverage may vary from plan to plan.

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