INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA

To All Insurers and TPAs, wherever applicable

Ref. No: IRDAI/HLT/REG/CIR/046/02/2020

Date: 10-02-2020

Amendments in respect of provisions of Guidelines on Standardization of Exclusions in Health Insurance Contracts and Modification Guidelines on Standardization in Health Insurance

Reference is invited to the provisions of Guidelines on Standardization of Exclusions in Health Insurance Contracts vide Ref No. IRDAI/HLT/REG/CIR/177/09/2019 and Modification Guidelines on Standardization in Health Insurance vide Ref No. IRDAI/HLT/REG/CIR/176/09/2019 dated 27th September 2019. Under the powers vested in Section 34(1) of the Insurance Act,1938 and Section 14(2) (e) of the IRDAI Act 1999, following Amendments are issued.

I. The following changes shall be effected in Clause 1 of the   Modification Guidelines on Standardization in Health Insurance  (Ref: IRDAI/HLT/REG/CIR/176/09/2019):

S.no Reference Existing New
  1 Definition of Pre-Existing Disease 

(not applicable for Overseas Travel Insurance)

Pre-existing Disease means any condition, ailment, injury or disease:

a)  That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or

b)  For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement.

c)  A condition for which any symptoms and or signs if presented and have resulted within three months of the issuance of the policy in a diagnostic illness or medical condition.

(Life Insurers may define norms for applicability of PED at Reinstatement)

Pre-existing Disease means any condition, ailment, injury or disease:

a)    That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement

or

b)    For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement

(Life Insurers may define norms for applicability of PED at Reinstatement)

c) (Deleted)

II.    The following changes shall be effected in Chapter III of the Guidelines on Standardization of Exclusions in Health Insurance Contracts (Ref: IRDAI/HLT/REG/CIR/177/09/2019):

S.no Reference Existing New
1 Exclusion K (Excluded providers: Code- Excl11) Exclusion K (Excluded providers: Code- Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible.  However, in case of life threatening situations following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

 (Explanation: Details of excluded providers shall be provided with the policy document. Insurers to use various means of communication to notify the policyholders, such as e-mail, SMS about the updated list being uploaded in the website.)

Exclusion K (Excluded providers: Code- Excl11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible.  However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

(Explanation: Details of excluded providers shall be provided with the policy document. Insurers to use various means of communication to notify the policyholders, such as e-mail, SMS about the updated list being uploaded in the website.)

2 Exclusion Q (Birth control, Sterility and Infertility: Code- Excl17) Exclusion Q (Birth control, Sterility and Infertility: Code- Excl17)

Expenses related to Birth Control, sterility and infertility. This includes:

(i)    Any type of contraception, sterilization

(ii)  Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI

(iii) Gestational Surrogacy

(iv) Reversal of sterilization

Exclusion Q (Sterility and Infertility: Code- Excl17)

Expenses related to sterility and infertility. This includes:

(i)    Any type of contraception, sterilization

(ii)  Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI

(iii) Gestational Surrogacy

(iv) Reversal of sterilization

Insurers and Third Party Administrators, wherever applicable, are advised to make a note of the above changes and ensure compliance.

This has the approval of the competent authority.

(Suresh Mathur)
Executive Director

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