INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA
NOTIFICATION
Hyderabad, the 19th November, 2019
Insurance Regulatory and Development Authority of India (Health Insurance) (Amendment) Regulations, 2019
F. No. IRDAI/Reg/14/165/2019.— In exercise of the powers conferred by section 114A of the Insurance Act, 1938 (4 of 1938) and sections 14 and 26 of the Insurance Regulatory and Development Authority Act, 1999 (41 of 1999), the Authority, in consultation with the Insurance Advisory Committee, hereby makes the following regulations, to amend the Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016, namely:-
1. Short title and commencement — (1) These regulations may be called the Insurance Regulatory and Development Authority of India (Health Insurance) (Amendment) Regulations, 2019.
(2) They shall come into force on the date of their publication in the Official Gazette.
2. In the Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016 –
a. Clause (m) of sub-regulation (i) of regulation 2 shall be omitted.
b. Clause (p) of sub-regulation (i) of regulation 2 shall be omitted.
c. In sub-regulation (d) of regulation 8, the words “Provided further that no discount shall be offered on any third party service or merchandise. However, discounts in premium or discounts and/or benefits on diagnostic or pharmaceuticals or consultation services of providers in the network are permitted.” shall be omitted.
d. After sub-regulation (d) of regulation 8, the following sub-regulation shall be inserted, namely:-
“e. The insured shall be informed in writing of any underwriting loading charged over and above the premium as filed and approved under the Product Filing Guidelines and specific consent of the policyholder for such loadings shall be obtained before issuance of a policy.”
e. After sub-regulation (d) of regulation 11, the following sub-regulations shall be inserted, namely: –
“e. To enable access to the basic health insurance covers, all insurers shall offer a standard health insurance product as per the guidelines as may be specified by the Authority from time to time.
f. Any of the exclusions in all health insurance policies shall be subject to the guidelines as may be specified by the Authority from time to time.”
f. In sub-regulation (iii) of regulation 13, the following proviso shall be inserted, namely: –
“Provided the renewal premium shall not be accepted more than 90 days in advance of the due date of the premium payment.”
g. For sub-regulation (i) of regulation 17, the following sub-regulation shall be substituted, namely: –
“General insurers and health insurers offering indemnity based health covers shall offer an option to the policyholders to migrate to a suitable alternative health insurance policy available at the time of modification or withdrawal of the policy. Further, indemnity based health covers offered to specific age groups, students, children under family floater policies, shall also offer an option to such lives to migrate to a suitable alternative health insurance policy available at the specific exit age. Every policy migrated shall be allowed suitable credits for all the previous policy years, provided the policy has been maintained without a break.”
h. After sub-regulation (iii) of regulation 17, the following sub-regulation shall be inserted, namely:-
“iv. Further to sub-regulation (i) to (iii), the norms on migration and portability of all policies issued by general insurers and health insurers shall be subject to the guidelines as may be specified by the Authority from time to time.”
i. For sub-regulation (a) of regulation 18, the following sub-regulation shall be substituted, namely: –
“All insurers may endeavour to provide coverage for one or more systems covered under “AYUSH treatment” provided, the treatment has been undergone in the hospitals or healthcare facilities subject to the guidelines as may be specified by the Authority from time to time.”
j. For regulation 19, the following regulation shall be substituted, namely: –
“19. Insurers may endeavour promoting wellness amongst policyholders of health insurance as per the guidelines as may be specified by the Authority from time to time.”
k. In sub-regulation (i) of regulation 23, the words “The insured shall be informed in writing of any underwriting loading charged as filed and approved under the Product Filing Guidelines over and above the premium and specific consent of the policyholder for such loadings shall be obtained before issuance of a policy. ” shall be omitted.
l. For clause (2) of sub-regulation (ii) of regulation 24, the following clause shall be substituted, namely: –
“Balance claim or claims disallowed under the earlier chosen policy/policies may be made from the other policy/policies even if the sum insured is not exhausted in the earlier chosen policy/policies. The insurer(s) in such cases shall independently settle the claim subject to the terms and conditions of other policy / policies so chosen.”
m. After sub-regulation (v) of regulation 27, the following sub-regulation shall be inserted, namely:-
“vi. Further to sub-regulation (i) to (v), in matters relating to settlement of claims, the Authority may specify guidelines from time to time.”
n. For sub-regulation (c) of regulation 30, the following sub-regulation shall be substituted, namely: –
“c. Subject to terms and conditions of the policy contract, reimbursement shall be allowed at any hospital or medical establishment. All such establishments must be licensed or registered as may be required by any Local, State or National Law as may be applicable.”
o. For sub-regulation (c) of regulation 35, the following sub-regulation shall be substituted, namely: –
“c. Authority may require insurers, third party administrators and network providers to comply with data related matters and settlement of claims through electronic means as per the guidelines as may be specified by the Authority from time to time.”
p. In clause 14 of Schedule-I, the words “loading or” shall be omitted.
q. For clause 16 of Schedule-I, the following clause shall be substituted, namely: –
“16. Portability shall be allowed subject to the guidelines as may be specified by the Authority from time to time.”
Dr. SUBHASH C. KHUNTIA, Chairman
[ADVT.-III/4/Exty./301/19]
