The Insurance Regulatory and Development Authority of India (“IRDAI”) issued a new master circular on 29th May 2024. The main focus of the new circular is to make the process of claiming health insurance both simple and beneficial to the policy holder. The changes are as follows: 

Policy Holder/Prospect/Customer: The Insurers are to extend their products, add-ons/riders to: 

1. all ages; 
2. all types of existing medical conditions; 
3. pre-existing diseases and chronic conditions; 
4. all systems of medicine and treatments including Allopathy, AYUSH, and other systems of medicine; 
5. every situation of treatment including domiciliary hospitalisation (where the policyholder is considered to be hospitalised even when getting treatment at home), outpatient treatment (OPD), Day Care and Homecare treatment; viz. all regions, all occupational categories, persons with disabilities and any other categories. 
6. all types of Hospitals and Health Care Providers to suit the affordability of the policyholders/prospects. Policyholders shall not be denied coverage in case of emergency situations. 

Products in compliance with various laws: The Insurers are to provide products in accordance with the followings laws: 

1. a) The Mental Healthcare Act, 2017; 
2. b) The Rights of Persons with Disabilities Act, 2016; 
3. c) The Surrogacy (Regulation) Act, 2021; 
4. d) The Transgender Persons (Protection of Rights) Act, 2019, and 
5. e) The HIV and AIDS (Prevention and Control) Act, 2017 

Products to cover Technological Advancement & Treatments: The insurers shall attempt to cover the latest technological advancement & treatments such as : 

1. Uterine Artery Embolization and HIFU 
2. Balloon Sinuplasty 
3. Deep Brain stimulation 
4. Oral chemotherapy
5. Immunotherapy- Monoclonal Antibody to be given as injection 
6. Intra vitreal injections 
7. Robotic surgeries 
8. Stereotactic radio surgeries 
9. Bronchial Thermoplasty 
10. Vaporisation of the prostate (Green laser treatment or holmium laser treatment) k. IONM – (Intra Operative Neuro Monitoring) 
11. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered. 
12. Any other treatment using advanced technology, as per the product design. 

Cashless Claim: The IRDAI has suggested that insurance companies must strive to facilitate 100% cashless claim settlement within a specified time frame. The time frame has been brought down to one hour for Insurance companies to decide on cashless authorization and three hours after discharge authorization request from the hospital. In no case should the policyholder be made to wait to be discharged from the hospital. 

Document Collection and TPAs: The IRDAI has stated that the policyholder will no longer be required to submit any documents for claim settlement. The collection of required documents will be carried out by the Insurance Company and Third Party Administrators (TPAs). The Performance of TPAs will have to be monitored and payments are to be made to the TPAs only upon full discharge of satisfactory service. The clawback of remuneration/charges are to be paid to TPA based on customer feedback, which shall be passed on to the policyholders. 

Contesting Claims: The circular states that except for established fraud after a moratorium period of 60 months of continuous coverage, no policy or claim of health insurance can be contested on the ground of non-disclosure and/or misrepresentation. 

No Claim Bonus: No claim bonus is provided when a policyholder doesn’t make a claim during the policy period. Customers will now be provided with flexibility to choose products, add ons and riders instead of assuring higher sum as a reward as followed previously. The Insurer can provide an option to the policy holder to choose such no claims bonus by increasing the sum assured or providing a discount in the premium amount. 

Repudiation of Claims: Every single claim repudiated is now subject to a review committee which will have to make a decision on the same. Additionally, in case of death of a policyholder during treatment, the insurer will have to release the mortals and process the claim immediately.

Renewal of Policy: On failure of renewal of policy, an insurer will have to provide a 30 days grace period for premium paid annually, half-yearly and quarterly instalment with all the credits accrued under the policy. In case of policies where premiums are paid on a monthly basis, a grace period of 15 days would be applicable. In case where the policy is renewed during grace period, all the credits (sum insured, No Claim Bonus, specific waiting periods, waiting periods for pre-existing diseases, moratorium period etc.) accrued under the policy will remain protected. The same shall be applicable for both indemnity and benefit products. Interestingly, the new circular has stated that health insurance is renewable and cannot be denied claiming that the claim was made in preceding years until a clear case of fraud or non-disclosure or misrepresentation is established. No fresh underwriting is required unless there is an increase in the sum insured. 

Refunds: Policyholders will be able to get a refund of premium/proportionate premium for unexpired policy period, if the policyholder decides to cancel his/her policy during the term. 

Ombudsman Award: The insurer will be liable to pay Rs 5,000 per day to the policy holder in case ombudsman awards are not implemented within 30 days. 

Portability: Customers are provided with a stricter time frame to port to another insurer. In the event of the insurance company withdrawing a particular product, the policyholder will have to be given options to migrate to other suitable products or a one-time option to renew the product if the renewal falls within 90 days from the date of withdrawal.