Introduction: The Insurance Regulatory & Development Authority (IRDAI) has recently announced a revision in its consolidated guidelines regarding the Customer Information Sheet for Health Insurance products. This comes as a part of the ongoing efforts to ensure transparency and simplicity for policyholders.
Revision of Customer Information Sheet: In light of Regulation 26 of IRDAI (Health Insurance) Regulations,2016, every health insurance policyholder is entitled to a Customer Information Sheet (CIS). This provision aims at:
- Providing crucial information to the policyholder.
- Ensuring that the information is presented in a language that’s easy to grasp.
Engaging Stakeholders: IRDAI has always emphasized the importance of stakeholder engagement. With the exposure draft now available, all stakeholders are encouraged to offer their feedback by the 13th of September, 2023.
Decoding the Customer Information Sheet:
- Name & Type of Insurance Product/Policy: It is crucial to understand the name and the type of insurance you’re opting for – whether it’s indemnity-based, a benefit policy, or a combination.
- Sum Insured: This segment provides clarity on whether each member has a separate insured sum or if there’s a collective floater sum insured for all members.
- Policy Coverage: Gain insights into what the policy covers, including aspects like hospitalization, pre & post-hospitalization, critical illness procedures, and other benefits.
- Exclusions: Knowing what your policy doesn’t cover is as important as knowing what it does. This section lists out the exclusions.
- Waiting Period: Details about the initial waiting period and specific waiting periods for certain diseases or treatments are highlighted.
- Financial Limits of Coverage: Understand the sub-limits, co-payments, deductibles, and other financial constraints of the policy.
- Claims/Claims Procedure: A guide to the claims procedure, both for cashless treatments and reimbursements. Details include TAT for claim settlements and other crucial links.
- Policy Servicing & Grievances/Complaints: To ensure seamless communication, details of helpline numbers, grievance redressal officers, and ombudsman details are provided.
- Key Takeaways: This segment delves into aspects like free look cancellation, policy renewal terms, migration, and portability options.
- Your Obligations: Policyholders have certain obligations, including declaring pre-existing diseases. Non-disclosure can lead to challenges during claim settlement.
Conclusion: The IRDAI’s move to revisit and revise the Customer Information Sheet is a commendable step towards fostering transparency and trust among policyholders. As a consumer, it’s vital to thoroughly understand and familiarize oneself with these guidelines to make informed decisions about health insurance.
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Insurance Regulatory & Development Authority
Reference No.: IRDAI/HLT/REG/CIR/194/07/2020 Date: 30/08/2023
Customer Information Sheet/Know Your Policy
PROLOGUE:
I. Revision of Customer Information sheet- Consolidated Guidelines on Product filing in Health Insurance Business dated 22nd July, 2020
a) Regulation 26 of IRDAI (Health Insurance) Regulations, 2016 mandates that every policyholder shall be provided with a Customer Information Sheet(herein after referred to as CIS) as specified by the Authority in the captioned Guidelines.
b) To ensure that the health insurance policy information is provided in a simple and easily understandable language, it is proposed to revisit the customer information sheet.
II. An exposure draft on the above is hereby issued seeking comments of all stakeholders.
All stakeholders are requested to review the attached exposure draft and provide their views / comments in the prescribed format to [email protected] email id on or before 13.09.2023.
Format for furnishing comments
| Sl.No. | Sl. No and title of the CIS | Comments/Change suggested | Rationale for Comment/Suggestion |
Yegnapriya Bharath
Chief General Manager (Health)
Exposure Draft
Annexure-2 of Consolidated Guidelines on Product filing in Health Insurance Business Ref: IRDAI/HLT/REG/CIR/194/07/2020 dated 22nd July, 2020is modified as under: –
CUSTOMER INFORMATION SHEET/KNOW YOUR POLICY
This document provides key information about your policy. You are also advised to go through your policy document.
|
Sl No |
Title | Description
(Please refer to applicable Policy Clause Number in next column) |
Policy Clause Number |
| 1 | Name of Insurance Product/Policy | XXXXXX | |
| 2 | Type of Insurance Product/ Policy |
|
|
| 3 | Sum Insured (Basis) (Along with amount) |
or
|
|
| 4 | Policy Coverage (What am I covered for?)
(Policy Clause Number/s) |
Expenses in respect of:
Admission in Hospital beyond xx hrs Pre-hospitalisation (treatment prior to admission in hospital) of xx days amounting to x% of claim Post-hospitalisation (treatment after discharge from hospital) within xx days from date of discharge amounting to x% of claim. Specified / Listed procedures requiring less than xx hours of hospitalization (day care) Uundergoing specified procedure in case of xx Critical illnesses Diagnosis of an illness of specified severity Daily cash benefit of Rs___per day during admission in hospital OPD / Dental/ Maternity coverage Emergency or Travel Medical Assistance Personal Accident Cover Travel Cover (Note: This is an indicative list. Insurer must ensure that all the benefits of the policy are listed above) |
|
| 5 | Exclusions (what the policy does not cover) | (Note: Insurer has to ensure that all the applicable exclusions are listed here) | |
| 6 | Waiting period
|
Initial waiting Period: xx days for all illnesses (not
applicable in case of continuousrenewal or Specific Waiting periods (Not applicable for claims arising due to an accident): o xx months for xx diseases/procedures o yy months for yy diseases/procedures Pre-existing diseases: Covered after xx months |
|
| 7 | Financial limits of coverage
i. Sub-limit (It is a pre-defined limit and the insurance company will not pay any amount in excess of this limit) ii. Co-payment (It is a specified amount iii. Deductible (It is a – upto which an will not pay any – which will be claim amount (if claim amount is more than the iv. Any other limit (as applicable) |
The policy will pay only up to the limits specified hereunder for the following diseases/procedures:
XX XX In case of a claim, this policy requires you to share the following costs: Expenses exceeding the
XXXX Deductible of Rs. XXX per claim / per year / both |
|
| 8 | Claims/Claims Procedure | Details of procedure to be followed for cashless
service as well as for reimbursement of Turn Around Time (TAT) for claims settlement: XX Provide the details /web link for following: i. Network Hospital details ii. Helpline number iii. Downloading / getting claim form |
|
| 9 | Policy Servicing | Call center number of the insurer Details of Company officials |
|
| 10 | Grievances/Complaints | Details of
– Grievance Redressal Officer of the insurer – Insurance company grievance portal/ – Ombudsman: (Please provide contact details, Toll free number/email) |
|
| 11 | Things you need to know | Free Look cancellation: You may cancel the insurance policy if you do not want it, within xx days from the beginning of the policy.
Insurer to specify the process for free look cancellation Policy renewal: Except on grounds of fraud, moral hazard or misrepresentation or non-cooperation, renewal of your policy shall not be denied, provided the policy is not withdrawn. Migration and Portability: When your policy is due for renewal, you may migrate to another policy with us or port your policy to another insurer. Insurer to specify the process for migration and portability |
|
| 12 | Your Obligations | Please disclose all pre-existing disease/s or condition/s before buying a policy. Non-disclosure may affect the claim settlement.
Disclosure of other material information during the policy period.) Insurer to specify the material information |
Declaration by the Policy Holder;
I have read the above and confirm having noted the details.
Place:
Date:
(Signature of the Policy)
Note:
i. Insurer shall provide web-link where the product related documents including the Customer Information sheetare available on the website of the insurer.
ii. In case of any conflict, the terms and conditions mentioned in the policy document shall prevail.
iii. Insurer to take confirmation of the policyholder regarding receiving of the Customer Information Sheet.
Good initiative by IRDAI. However, what would be the deadline to implement these reforms, if accepted by all Insurers remains to be seen. The Qn also arises is what happens to existing customers who have been misinformed till now by gullible agents for the sake of fulfilling monthly targets? Can existing customers change their policy once they understand the coverage and scope of the purchased policy? Remains to be seen.