Insurance Regulatory and Development Authority of India
Date: 07-11-2019
In order to enhance the scope of services offered under wellness and preventive features/benefits of health insurance products, it is proposed to issue comprehensive guidelines on wellness and preventive features/benefits.
Under the provisions of Sec 34(1) of the Insurance Act 1938, it is proposed that Guidelines be issued, specifying the rewards that can be offered as wellness benefits in the health insurance products, the requirement of disclosing in the policy contract about the manner in which the accrued benefits can be offered / utilized by the policyholders and other necessary disclosures that the insurers have to carry out for enabling informed choice to the policyholders keeping in view protection of the policyholders’ interests.
Towards this, an exposure draft is herewith issued seeking comments of the stakeholders by 18th November 2019.
Comments may please be forwarded to email id [email protected] in the attached format (in MS excel) within the date specified as above.
Suresh Mathur
Executive Director
Exposure Draft
Ref: IRDAI/HLT/REG/CIR/XXX/ 10/2019
7th November, 2019
To all Insurance Companies
Re: Draft Guidelines on Wellness and Preventive Features/Benefits
1. Reference is invited to Chapter VII of the Guidelines on Product Filing Health Insurance Business issued vide Circular Ref: IRDA/HLT/REG/CIR/150/07/2016 dated 29th July, 2016 specifying norms on Wellness features/benefits. In supersession of these norms on wellness features/benefits, under the provisions of Sec 34(1) of the Insurance Act 1938, the following norms are prescribed:
a. Any wellness and preventive feature shall be designed only with the objective of maintaining good health and improving it.
b. No Wellness feature/benefit shall be offered without it being filed or incorporated as part of the product in terms of the Product Filing Guidelines.
c. There shall be no discrimination in providing any of the wellness features/benefits offered to the same or similarly placed categories of policyholders of the underlying health insurance product.
d. Every Insurer shall assess the pricing impact of wellness and preventive features offered, if any, and the same shall be disclosed upfront in the File and Use or Use and File application, as may be the case, prescribed in the Product Filing Guidelines or applicable File and Use norms.
e. Based on fitness and wellness criteria stipulated and disclosed, insurers may endeavour promoting wellness amongst health insurance policyholders by offering:
i) health specific services provided by Network providers or other empanelled hospitals / service providers for the following:
a) Outpatient consultations or treatments
b) Pharmaceuticals
c) Health check-ups/diagnostics
Including discounts on all the above by redeemable vouchers.
ii) redeemable vouchers to obtain protein supplements and other consumable health boosters / supplements.
iii) redeemable vouchers for membership in yoga centres or gymnasiums for participating in fitness activities.
iv) discounts on premiums and/or increase in sum insured at the time of renewals based on wellness regime followed by policyholders in the preceding policy period. Provided increase in sum insured shall be independent and shall not be linked to the cumulative bonus offered, if any.
v) Coverage to non-payable/non-admissible items of cost of treatment.
f. Insurers shall not publish the trade names or trade logos of third party merchandize in any of the insurance advertisements, but may refer the product or service offered in generic term. However, Insurers shall disclose the specific items of products and services offered in their website with complete granularity and may provide a link to this in their insurance advertisement and policy contracts.
Provided insurers shall not promote products or services of any particular third party service provider.
g. Insurers shall not accept any liability towards quality of the products or services offered by third parties and shall specify upfront that the said third party is responsible for providing the products or services stipulated under the wellness features of the product and insurer is not liable for any defects or deficiencies on the part of the service provider.
h. Insurers shall also ensure that the service providers under wellness / preventive programs have put in place appropriate mechanism to discharge their obligations by offering the agreed services or products under wellness program of every health insurance product.
i. Other than the monetized value of the rewards points redeemed by the policyholders, no payments shall be made by insurers to the third party merchants.
j. Insurers shall not receive any consideration amount for offering the third party products/services.
k. Third party merchant wise, product wise pay-outs made shall be disclosed in the annual public disclosures by insurers.
l. The costs towards the wellness services shall be factored into the pricing of the underlying health insurance product and price factored shall be disclosed in all insurance advertisements wherever wellness features are disclosed and promoted.
m. In case of Family Floater Plans, Insurers should clearly define and disclose in policy document and all insurance advertisements wherever wellness features are disclosed and promoted, the manner in which accrual and redemption of benefits is considered in respect of all members covered.
n. Insurer shall clearly specify in the policy contract as to whether the accrued benefits can be carried forward or not when the policy is renewed with the Insurer and the period of validity of the accrued benefits under both the scenarios.
o. The benefit accrued shall be at periodic intervals at rates/amounts declared upfront at the commencement of the policy and shall not be linked to any dynamic factor such as interest rate etc. The same shall be specified in the Policy Document.
p. Insurer shall notify the benefits accrued to the credit of a Policyholder and entitlements of the policyholders under the said feature at periodic intervals –at least once in a year.
q. Insurer shall specify in the Policy Wordings and Prospectus, the mode of communication that the Insurer adopts for notification of various activities offered or allowed under the Wellness feature.
r. Insurers shall specify the manner of redeeming the benefits allowed under the said feature in the prospectus, policy wordings and shall disclose in their website updated information, if any.
s. Insurer shall be responsible for any errors or omission in calculation of accrued benefits and shall address the same through their in-house Grievance Redressal Mechanism.
t. Information gathered during the process of offering the wellness benefits, if any, shall be kept confidential and shall not be used for purposes other than what it is meant for.
2. The Authority has the right to reject wellness features proposed by the insurer if they are against policyholders’ interests and are not in line with fair market conduct notwithstanding the fact that they may broadly meet with the above guidelines.
3. The Authority reserves the right to instruct the insurers to withdraw any Wellness feature which is not in compliance with any regulations or guidelines issued by the Authority or which is found to be prejudicial to the interests of the policyholders or not in line with fair market conduct. The Authority also reserves the right in such cases to take appropriate action as deemed fit.
4. These Guidelines shall come into force from immediate effect and are applicable to all health insurance products offered by all Insurers.
5. This has the approval of the competent authority
DVS Ramesh
General Manager (Health)
Format for suggestions on exposure draft – Guidelines on wellness and preventive features/benefits
| Change suggested by – Name / Organisation | Sl. | Page no. | Clause / Sub-Clause | Comments / Changes suggested | Rationale |
It is suggested that one row may be used for one change/comment.
