Blog, Health Insurance Concepts

FAQs of Health Insurance As Per IRDAI

What are the Insurance Companies that offer Health Insurance in India?

Health Insurance policies are offered by all Life, General and Health Insurance companies that are registered with IRDAI. The names of the Insurance companies that are registered with IRDAI are available in IRDAI website Standalone Health Insurance Companies also offer Personal Accident Policies, Domestic Travel Policies and Overseas Travel Policies.

What is Health Insurance Business?

Section 2 (6C) of Insurance Act, 1938 defines Health Insurance Business as under:

“health insurance business” means the effecting of contracts which provide for sickness benefits or medical, surgical or hospital expense benefits, whether in-patient or out-patient travel cover and personal accident cover “

What is the maximum age at entry for taking a Health Insurance policy? Whether Health Insurance is available lifelong once taken a policy?

The Authority, as part of its administration of Health Insurance Business notified IRDAI (Health Insurance) Regulations, 2016 (hereafter referred as Health Insurance Regulations, 2016). In accordance to the provisions of Regulation 12(i) titled “Entry and Exit Age” all health insurance policies shall ordinarily provide for an entry age of at least up to 65 years. There are also Health Insurance Products that offer Health Insurance Coverage beyond age 65 years. In accordance to the provisions of Regulation 12(ii) once a proposal is accepted in respect of a health insurance policy (except Personal Accident and Travel Policies) and a policy is issued which is thereafter renewed periodically without any break, further renewal shall not be denied on grounds of the age of the Insured. Thus, health insurance policies are lifelong renewable.

Whether pre-existing diseases are covered under a health insurance policy?

Offering health insurance coverage to any person who was already suffered / has been suffering from any disease / illness is subject to underwriting policy of an insurer. It is also to be informed that providing coverage for those persons who were cured of any specific illness / disease is subject to product design of the Insurers. Insurers design products keeping in view certain factors such as viability and self-sustainability of products and the needs of the intended target market segment.

What is pre-existing disease?

As part of Guidelines on Standardization IRDAI has already defined Pre-Existing Disease. A Pre-existing disease is defined as under (reproduced verbatim).

Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and I or were diagnosed, and I or for which medical advice I treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter. (Life Insurers may define norms for applicability of PED at reinstatement).

Are there any principles for charging premiums for Health Insurance coverage?

Health Insurance Regulations, 2016 specified certain principles of pricing of Health Insurance Products offered by Life General and Health Insurers. These principles are placed hereunder (in verbatim).

a. Regulation (10): Principles of Pricing of Health Insurance Products offered by Life, General and Health Insurers:

b. Insurers shall ensure that the premium for a health insurance policy shall be based on,

  i. Age: for individual policies and group policies.

  ii. Other relevant risk factors as applicable

c. For provision of cover under family floater, the impact of the multiple incidence of rates of all family members proposed to be covered shall be considered.

d. The premiums filed shall ordinarily be not changed for a period of three years after a product has been cleared in accordance to the product filing guidelines specified by the Authority. Thereafter the insurer may revise the premium rates depending on the experience subject to (d) (e) and (I) hereunder. However, such revised rates shall not be changed for a further period of at least one year from the date of launching the revision.

Whether Premium rates are unchanged?

The Policy Premium rate shall be unchanged for all group products for the term of the policy and for all individual and family floater products, other than travel insurance products offered by General and Health Insurers for a period of one year or three years as per the tenure of the policy. For further information, Regulation 10 (d) (e) and (f) may be referred.

What is Cashless facility? Whether cashless facility is offered at all hospitals?

Cashless facility means a facility extended by the Insurer or TPA on behalf of the Insurer to the insured, where the payments for the costs of treatment undergone by the Insured in accordance with the policy terms and conditions, are directly made to the network provider by the Insurer to the extent pre-authorization is approved. Cashless facility shall be offered only at Network Providers which have entered into an agreement with the insurer to extend such services.

What is A YUSH Treatment? Whether A YUSH Treatment is allowed in all Health Insurance Policies?

AYUSH Treatment refers to the medical and / or hospitalization treatments given under ‘Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems’. Whether or not AYUSH treatment is allowed in a Health Insurance Policy is subject to the product features offered by the insurers.

What are the Regulatory provisions for settlement of Health Insurance claims by TPAs/lnsurers?

1) In terms of Regulation 27 (i) an insurer shall settle or reject a claim, within thirty days of the receipt of the last ‘necessary’ document.

2) Regulation 27 (ii) specified that except in cases where a fraud is suspected, ordinarily no document not listed in the policy terms and conditions shall be deemed ‘necessary’. The insurer shall also ensure that all the documents required for claims processing are called for at one time and that the documents are not called for in a piece-meal manner.

3) Regulation 27 (iv) stipulated that every Insurer may stipulate a period within which all necessary claim documents should be furnished by the policyholder/insured to make a claim. However, claims filed even beyond such period should be considered if there are valid reasons for any delay.

4) In terms of Regulation 27 (v) every Insurance Claim shall be disposed of in accordance to the Terms and Conditions of the policy contract and the extant Regulations governing the settlement of Claims.

What is Portability of Health Insurance policies

“Portability” means the right accorded to an individual health insurance policyholder (including family cover), to transfer the credit gained for pre-existing conditions and time bound exclusions, from one insurer to another or from one plan to another plan of the same insurer.

Clause No. 12 of Schedule – I of IRDAI (Health Insurance) Regulations 2016 specifies that on receipt of the data from the existing insurance company, the new insurance company may underwrite the proposal and convey its decision to the policyholder in accordance to the applicable regulatory framework relating Protection of Policyholders’ Interest Regulations.

Clause 18 of Schedule – I of IRDAI (Health Insurance) Regulations 2016 specifies that the portability shall be applicable to the sum insured under the previous policy and also to an enhanced sum insured, if requested for by the insured, to the extent of cumulative bonus acquired from the previous insurer(s) under the previous policies.

When to apply for Portability?

A policyholder desirous of porting his/her policy to another insurance company shall apply to such insurance company to port the entire policy along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days from the premium renewal date of his/ her existing policy.

Who is Third Party Administrator (TPA)?

Third Party Administrator means any person who is registered under the IRDAI (Third Party Administrators – Health Services) Regulations, 2016 notified by the Authority, and is engaged, for a fee or remuneration by an insurance company for the purposes of providing health services.

How Cost of pre-insurance health checkup is treated by Life, General and Health Insurers:

The cost of any pre-insurance medical examination shall generally form part of the expenses allowed in arriving at the premium. However, in case of products with term of one year and less, if such cost is to be incurred by the insured, not less than 50% of such cost shall be borne by the insurer once the proposal is accepted, except in travel insurance policies.

If a person is having multiple policies are there any norms that specify the manner of settlement of claim?

The norms on multiple policies are as under:

i. In case of multiple policies which provide fixed benefits, on the occurrence of the insured event in accordance with the terms and conditions of the policies, each insurer shall make the claim payments independent of payments received under other similar polices.

ii. If two or more policies are taken by an insured during a period from one or more insurers to indemnify treatment costs, the policyholder shall have the right to require a settlement of his/her claim in terms of any of his/her policies.

  1. In all such cases the insurer who has issued the chosen policy shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.
  2. the policyholder having multiple policies shall also have the right to prefer claims from other policy I policies for the amounts disallowed under the earlier chosen policy I policies, even if the sum insured is not exhausted. Then the lnsurer(s) shall settle the claim subject to the terms and conditions of the other policy I policies so chosen
  3. If the amount to be claimed exceeds the sum insured under a single policy after considering the deductibles or co-pay, the policyholder shall have the right to choose insurers from whom he/she wants to claim the balance amount.
  4. Where an insured has policies from more than one insurer to cover the same risk on indemnity basis, the insured shall only be indemnified the hospitalization costs in accordance with the terms and conditions of the chosen policy.

Whether any proposal or medical examination is required at renewal stage?

No Insurer shall resort to fresh underwriting by calling for medical examination, fresh proposal form etc. at renewal stage where there is no change in Sum Insured offered.

What is Co payment?

Co-payment means a cost sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.

What is Cumulative Bonus?

Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.

What is deductible?

Deductible means a cost sharing requirement under a health insurance policy that provides that the insurer will not be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the insurer. A deductible does not reduce the Sum Insured. (Insurers to define whether the deductible is applicable per year, per life or per event and the manner of applicability of the specific deductible)

What is Grace Period?

Grace period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of preexisting diseases. Coverage is not available for the period for which no premium is received.

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