Modifications in Definition of Critical Illnesses Prescribed In Guidelines on Standardization in Health Insurance Products

Reference: IRDAI/HLT/REG/CIR/104/5/2022 27.5.2022 Date: 27/05/2022

The extant IRDAI (Health Insurance) Regulations 2016 were notified on 18th July, 2016 superseding IRDA (Health Insurance) Regulations 2013. The Guidelines on Standardization in Health Insurance were issued on 29th July, 2016. Subsequently Modification Guidelines have been issued from time to time amending aforementioned Guidelines. Further, some new Guidelines have been issued under the provisions of the Insurance Act, 1938 and IRDAI (Health Insurance) Regulations 2016. In consolidation of all the Guidelines issued up to 31st March, 2020 and in force as on date, this Master Circular on Standardization of Health Insurance Products is issued. This Master Circular is applicable to all insurers (excluding specialized insurers) and the TPAs wherever applicable unless otherwise specified thereunder.

In order to ensure uniformity across the industry certain basic terminology being used in Health Insurance policies are given standard definitions so that prospects and insureds are able to understand them without ambiguity. All insurers shall adhere to the following standard definitions for the terminology listed hereunder, for all insurance products filed hereafter falling under the definition of ‘Health Insurance Business’ wherever the said terms are referred to in the terms and conditions. Where a particular terminology is not applicable to one or more types of policies, it is indicated against it in brackets.

The Master Circular is divided into three sections.

Section 1 – Guidelines on Standardization in Health Insurance,

Section 2 – Guidelines on Standardization of Exclusions in Health Insurance Contracts; and

Section 3 – Guidelines on Standard Individual Health Insurance Product

Modifications in the definition of Critical Illnesses prescribed in Guidelines on Standardization in Health Insurance Products.

1. Reference is invited to the Chapter II of Section 1 of Master Circular on Standardization of Health Insurance Products Ref: IRDAI/HLT/REG/CIR/193/07/2020 dated 22.07.2020 prescribing nomenclature and procedure for 22 critical illnesses that may form part of health insurance policies. Insurers were mandated to use the definitions without exception wherever the products cover any of the Critical Illnesses specified in the guidelines.

2. In partial modification of clause 1, 11 & 18 aforementioned circular, the definitions specified hereunder are substituted:

S.no

Critical Illness Modified Definition Old Definitions
1 CANCER OF SPECIFIED SEVERITY CANCER OF SPECIFIED SEVERITY

I. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissues. This diagnosis must be supported by histological evidence of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.

II. The following are excluded –

i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant, borderline malignant, low malignant potential, neoplasm of unknown behavior, or non-invasive, including but not limited to:

Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN – 2 and CIN-3.

ii.  Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;

iii. Malignant melanoma that has not caused invasion beyond the epidermis;

iv. All tumors of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least clinical TNM classification T2N0M0;

v. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;

vi. Chronic lymphocytic leukaemia less than RAI stage 3

vii.   Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser classification;

viii. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification) or below and with mitotic count of less than or equal to 5/50 HPFs;

CANCER OF SPECIFIED SEVERITY

I. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissues. This diagnosis must be supported by histological evidence of malignancy. The term cancer includes leukemia, lymphoma and sarcoma.

II. The following are excluded –

i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant, borderline malignant, low malignant potential, neoplasm of unknown behavior, or non-invasive, including but not limited to: Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -2 and CIN-3.

ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;

iii. Malignant melanoma that has not caused invasion beyond the epidermis;

iv. All tumors of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least clinical TNM classification T2N0M0;

v. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or below;

vi. Chronic lymphocytic leukaemia less than RAI stage 3

vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0 or of a lesser classification,

viii. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification) or below and with mitotic count of less than or equal to 5/50 HPFs;

ix. All tumors in the presence of HIV infection.

11 MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS

I. The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of the following: 

i. investigations including typical MRI findings which unequivocally confirm the diagnosis to be multiple sclerosis and

ii. there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months.

II.  Neurological damage due to SLE is excluded.

MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS

I. The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of the following:

i. investigations including typical MRI findings which unequivocally confirm the diagnosis to be multiple sclerosis and

ii. there must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of at least 6 months.

II. Other causes of neurological damage such as SLE and HIV are excluded.

18 LOSS OF SPEECH  LOSS OF SPEECH

I. Total and irrecoverable loss of the ability to speak as a result of injury or disease to the vocal cords. The inability to speak must be established for a continuous period of 12 months. This diagnosis must be supported by medical evidence furnished by an Ear, Nose, Throat (ENT) specialist. 

LOSS OF SPEECH

I. Total and irrecoverable loss of the ability to speak as a result of injury or disease to the vocal cords. The inability to speak must be established for a continuous period of 12 months. This diagnosis must be supported by medical evidence furnished by an Ear, Nose, Throat (ENT) specialist.

II. All psychiatric related causes are excluded.

3. These modifications shall come into force with immediate effect.

4. All other terms and conditions referred in the within referred master circular dated 22.07.2020 shall remain unchanged.

DISCLAIMER: the article presented here is only for sharing information and knowledge with readers. The views expressed are personal and in case of necessity do consult with insurance advisors for more clarity and understanding on subject matter.

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