INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA
22nd July, 2020
All Insurers (excluding specialized insurers) and TPAs, wherever applicable
Sub: Master Circular on Standardization of Health Insurance Products
1.1 The extant IRDAI (Health Insurance) Regulations 2016 were notified on 18th July, 2016 superseding IRDA (Health Insurance) Regulations 2013.
1.2 The Guidelines on Standardization in Health Insurance were issued on 29th July, 2016.
1.3 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.
1.4 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.
2.1 This Master Circular is applicable to all insurers (excluding specialized insurers) and the TPAs wherever applicable unless otherwise specified thereunder.
3. Legal and other provisions:
3.1 This Master Circular is issued under the provisions of Section 34 (1)(a) of the Insurance Act, 1938, Regulation 14(2)(e) of the IRDAI Act 1999, Regulation 2(i)(o), 18, 31(e) and 37 of IRDAI (Health Insurance) Regulations 2016.
Sy. No. 115/1, Financial District, Nanakramguda, Gachibowli, Hyderabad – 500032
Phone: 040 20204000
4. Repeal and Savings:
4.1 This Master circular supersedes the following Guidelines/Circulars:
|Sl. No.||Circular Reference||Description|
|1.||IRDA/HLT/REG/CIR/146/07/2016 dated 29.07.2016||Guidelines on Standardization in Health Insurance|
|2.||IRDA/HLT/CI R/212/10/2016 dated 27.10.2016||Clarification to Guidelines on Standardization in Health Insurance|
|3.||IRDA/HLT/GDL/CIR/257/12/2016 dated 29.12.2016||Clarification to Guidelines on Standardization in Health Insurance|
|4.||IRDA/HLT/REG/CIR/006/01/2017 dated 10.01 .2017||Partial Modification of the provisions of Guidelines on Standardization in Health Insurance|
|5.||IRDAI/HLT/GDL/CIR/1 14/07/2018 dated 27.07.2018||Modified Guidelines on Standards and Benchmarks for hospitals in the provider network|
|6.||IRDAI/HLT/GDL/CIR/136/08/2018 dated 27.08.2018||Modified Guidelines on Items for which optional cover may be offered by insurers|
|7.||IRDAI/HLT/GDL/CIR/122/07/2019 dated 26.07.2019||Extension of timelines to comply with the Guidelines on Standards and Benchmarks for the Hospitals in the Provider Network|
|8.||I RDAI/HLT/REG/CI R/176/09/2019 dated 27.09.2019||Modification Guidelines on Standardization in Health Insurance|
|9.||IRDAI/HLT/REG/CIR/177/09/2019 dated 27.09.2019||Guidelines on Standardization of Exclusions in Health Insurance Contracts|
|10.||IRDA/HLT/REG/CIR/209/1 1/2019 dated 26.11.2019||Modified guidelines on Standardization in Health Insurance Business|
|11.||IRDAI/HLT/REG/CIR/001/01/2020 dated 01.01 .2020||Guidelines on Standard Individual Health Insurance Product|
|12.||IRDAI/HLT/REG/CIR/002/01/2020 dated 01.01 .2020||Modification guidelines on standardization in health insurance|
|13.||IRDAI/HLT/REG/CIR/ 031/01/2020 dated 24.01.2020||Modification Guidelines on Standard Individual Health Insurance Product|
|14.||IRDAI/HLT/REG/CIR/046/02/2020 dated 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|
|15.||IRDAI/H LT/REG/CI R/055/03/2020 dated 04.03.2020||Modification Guidelines on Standard Individual Health Insurance Product|
5. The Master Circular is divided into three sections.
5.1 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
6. Effective date : This Master circular shall come into force with immediate effect.
D V S Ramesh
General Manager (Health)
|Section 1: Guidelines on Standardization in Health Insurance|
|Chapter I||Standard Definitions of terminology to be used in Health Insurance Policies||05|
|Chapter II||Standard Nomenclature and Procedure for Critical Illnesses||14|
|Chapter III||Items for which optional cover may be offered by insurers||22|
|Chapter IV||Standards and benchmarks for hospitals in the provider network||23|
|Chapter V||Health Insurance Returns||25|
|Annexure I||List of the Items for which optional cover may be offered by Insurers/List of the Items that are to be subsumed into Room Charges/ List of the Items that are to be subsumed into Procedure Charges/ List of the Items that are to be subsumed into costs of treatment||26|
|Annexure II||List/Formats of Health Insurance Regulatory Returns||32|
|Section 2: Guidelines on Standardization of Exclusions in Health Insurance Contracts|
|Chapter II||Exclusions not allowed in Health Insurance Policies||95|
|Chapter III||Standard Wordings for some of the exclusions in Health Insurance Policies||96|
|Chapter IV||Existing Diseases allowed to be permanently excluded||100|
|Chapter V||Modern Treatment Methods and Advancement in Technologies||105|
|Chapter VI||Other guidelines related to exclusions||106|
|Section 3: Guidelines on Standard Individual Health Insurance Product|
|Annexure 1||Format for the Policy Terms and Conditions of the Standard Product||115|
|List of the items for which coverage not available/ Items that are to be subsumed into Room Charges/ Items that are to be subsumed into Procedure Charges/ Items that are to be subsumed into costs of treatment||136|
|Annexure B||Contact details of the Insurance Ombudsman offices||140|
|Annexure 2||Format for Customer Information Sheet||142|
|Annexure 3||Form IRDAI-UNF-HISP||145|
Section 1: Guidelines on Standardization in Health Insurance
Chapter I: Standard Definitions of terminology to be used in Health Insurance Policies
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.
An accident means sudden, unforeseen and involuntary event caused by external, visible and violent means.
2. Any one illness: (not applicable for Travel and Personal Accident Insurance) Any one illness means continuous period of illness and includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment was taken.
3. Cashless facility:
Cashless facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization is approved.
4. Condition Precedent:
Condition Precedent means a policy term or condition upon which the Insurer’s liability under the policy is conditional upon.
5. Congenital Anomaly:
Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure or position.
a) Internal Congenital Anomaly
Congenital anomaly which is not in the visible and accessible parts of the body.
b) External Congenital Anomaly
Congenital anomaly which is in the visible and accessible parts of the body
Co-payment means a cost sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.
7. Cumulative Bonus:
Cumulative Bonus means any increase or addition in the Sum Insured granted by the insurer without an associated increase in premium.
8. Day Care Centre:
A day care centre means any institution established for day care treatment of illness and/or injuries or a medical setup with a hospital and which has been registered with the local authorities, wherever applicable, and is under supervision of a registered and qualified medical practitioner AND must comply with all minimum criterion as under ±
i) has qualified nursing staff under its employment;
ii) has qualified medical practitioner/s in charge;
iii) has fully equipped operation theatre of its own where surgical procedures are carried out;
iv) maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.
9. Day Care Treatment:
Day care treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and
ii. which would have otherwise required hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
(Insurers may, in addition, restrict coverage to a specified list).
Deductible means a cost sharing requirement under a health insurance policy that provides that the insurer will not be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the insurer. A deductible does not reduce the Sum Insured.
(Insurers to define whether the deductible is applicable per year, per life or per event and the manner of applicability of the specific deductible)
11. Dental Treatment:
Dental treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery.
12. Disclosure to information norm:
The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure of any material fact.
13. Domiciliary Hospitalization:
Domiciliary hospitalization means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:
i) the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
ii) the patient takes treatment at home on account of non-availability of room in a
14. Emergency Care:
Emergency care means management for an illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the insured person s health
15. Grace Period:
Grace period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no premium is received.
16. Hospital (not applicable for Overseas Travel Insurance):
A hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under Clinical Establishments (Registration and Regulation) Act 2010 or under enactments specified under the Schedule of Section 56(1) of the said act Or complies with all minimum criteria as under:
i) has qualified nursing staff under its employment round the clock;
ii) has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;
iii) has qualified medical practitioner(s) in charge round the clock;
iv) has a fully equipped operation theatre of its own where surgical procedures are carried out;
v) maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel;
17. Hospitalization (not applicable for Overseas Travel Insurance): Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‘In–patient Care’ hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours.
Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.
(a) Acute condition – Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery
(b) Chronic condition – A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:
1. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
2. it needs ongoing or long-term control or relief of symptoms
3. it requires rehabilitation for the patient or for the patient to be specially trained to cope with it
4. it continues indefinitely
5. it recurs or is likely to recur
Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent, visible and evident means which is verified and certified by a Medical Practitioner.
20. Inpatient Care (not applicable for Overseas Travel Insurance): Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.
21. Intensive Care Unit:
Intensive care unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
22. ICU Charges:
ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.
23. Maternity expenses: Maternity expenses means;
a) medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization);
b) expenses towards lawful medical termination of pregnancy during the policy
24. Medical Advice:
Medical Advice means any consultation or advice from a Medical Practitioner including the issuance of any prescription or follow-up prescription.
25. Medical Expenses:
Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.
26. Medical Practitioner (not applicable for Overseas Travel Insurance): Medical Practitioner means a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within its scope and jurisdiction of license.
(Insurance companies may specify additional or restrictive criteria to the above e.g. that the registered practitioner should not be the insured or close member of the family. Insurance Companies may also specify definition suitable to overseas jurisdictions where Indian policyholders are getting treatment outside India as per the terms and conditions of a health insurance policy issued in India)
27. Medically Necessary Treatment (not applicable for Overseas Travel Insurance):
Medically necessary treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:
i) is required for the medical management of the illness or injury suffered by the insured;
ii) must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
iii) must have been prescribed by a medical practitioner;
iv) must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
28. Network Provider (not applicable for Overseas Travel Insurance): Network Provider means hospitals or health care providers enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by a cashless facility.
29. New Born Baby: Newborn baby means baby born during the Policy Period and is aged upto90 days.
Non- Network Provider:
Non-Network means any hospital, day care centre or other provider that is not part of the network.
31. Notification of Claim:
Notification of claim means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.
32. OPD treatment:
OPD treatment means the one in which the Insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.
33. 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.
(Life Insurers may define norms for applicability of PED at reinstatement).
(Note: All existing health insurance products that are not in compliance with this definition shall not be offered and promoted from 01st October, 2020 onwards)
34. Pre-hospitalization Medical Expenses
Pre-hospitalization Medical Expenses means medical expenses incurred during pre-defined number of days preceding the hospitalization of the Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
35. Post-hospitalization Medical Expenses:
Post-hospitalization Medical Expenses means medical expenses incurred during pre-defined number of days immediately after the insured person is discharged from the hospital provided that:
i. Such Medical Expenses are for the same condition for which the insured person’s hospitalization was required, and
ii. The inpatient hospitalization claim for such hospitalization is admissible by the insurance company.
36. Qualified Nurse (not applicable for Overseas Travel Insurance):
Qualified nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
37. Reasonable and Customary Charges (not applicable for Overseas Travel Insurance):
Reasonable and Customary charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness / injury involved.
Renewal means the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all waiting periods.
39. Room Rent:
Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated medical expenses.
40. Subrogation (Applicable to other than Health Policies and health sections of Travel and PA policies):
Subrogation means the right of the insurer to assume the rights of the insured person to recover expenses paid out under the policy that may be recovered from any other source.
41. Surgery or Surgical Procedure:
Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief from suffering and prolongation of life, performed in a hospital or day care centre by a medical practitioner.
42. Unproven/Experimental treatment:
Unproven/Experimental treatment means the treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven.
43. AYUSH Hospital:
An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:
a. Central or State Government AYUSH Hospital; or
b. Teaching hospital attached to AYUSH College recognized by the Central Government/Central Council of Indian Medicine/Central Council for Homeopathy; or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine, registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the following criterion:
i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.
44. AYUSH Day Care Centre:
AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having facilities for carrying out treatment procedures and medical or surgical/para-surgical interventions or both under the supervision of registered AYUSH Medical Practitioner (s) on day care basis without in-patient services and must comply with all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;
iii. Maintaining daily records of the patients and making them accessible
to the insurance company’s authorized representative.
(Explanaton: Medical Practitoner referred in the definition of “AYUSH Hospital” and “AYUSH Day Care Centre” shall carry the same meaning as defined in the defnition of “Medical Practitioner” under Chapter I of Guidelines)
“Migration” meansthe right accorded to heath nsurance policyholders (including all members under family cover and members of group health insurance policy), to transfer the credit gained for pre-existing conditions and time bound exclusions, with the same insurer.
“Portability” means, the right accorded to individual health insurance policyholders (including all members under family cover), to transfer the credit gained for preexisting conditions and time bound exclusions, from one insurer to another insurer.
Chapter II: Standard Nomenclature and Procedure for Critical Illnesses
The following nomenclature and procedure are being prescribed for 22 critical illnesses that could form part of a health insurance policy. All Insurers shall use the definitions without exception wherever the products offer coverage to any of the Critical Illnesses specified herein.
1. 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 T1 N0M0 (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.
2. MYOCARDIAL INFARCTION
(First Heart Attack of specific severity)
I. The first occurrence of heart attack or myocardial infarction, which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for Myocardial Infarction should be evidenced by all of the following criteria:
i. A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g. typical chest pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
II. The following are excluded:
i. Other acute Coronary Syndromes
ii. Any type of angina pectoris
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic heart disease OR following an intra-arterial cardiac procedure.
3. OPEN CHEST CABG
I. The actual undergoing of heart surgery to correct blockage or narrowing in one or more coronary artery(s), by coronary artery bypass grafting done via a sternotomy (cutting through the breast bone) or minimally invasive keyhole coronary artery bypass procedures. The diagnosis must be supported by a coronary angiography and the realization of surgery has to be confirmed by a
II. The following are excluded:
i. Angioplasty and/or any other intra-arterial procedures
4. OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES
I. The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an echocardiography and the realization of surgery has to be confirmed by a specialist medical practitioner. Catheter based techniques including but not limited to, balloon valvotomy/valvuloplasty are excluded.
5. COMA OF SPECIFIED SEVERITY
I. A state of unconsciousness with no reaction or response to external stimuli or internal needs. This diagnosis must be supported by evidence of all of the following:
i. no response to external stimuli continuously for at least 96 hours;
ii. life support measures are necessary to sustain life; and
iii. permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.
II. The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly from alcohol or drug abuse is excluded.
6. KIDNEY FAILURE REQUIRING REGULAR DIALYSIS
I. End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (haemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed by a specialist medical practitioner.
7. STROKE RESULTING IN PERMANENT SYMPTOMS
I. Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage and embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist medical practitioner and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at least 3 months has to be produced.
II. The following are excluded:
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions.
8. MAJOR ORGAN /BONE MARROW TRANSPLANT
I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a transplant has to be confirmed by a specialist medical practitioner.
II. The following are excluded:
i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted
9. PERMANENT PARALYSIS OF LIMBS
I. Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or spinal cord. A specialist medical practitioner must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for more than 3 months.
10. MOTOR NEURON DISEASE WITH PERMANENT SYMPTOMS
I. Motor neuron disease diagnosed by a specialist medical practitioner as spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis. There must be progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons. There must be current significant and permanent functional neurological impairment with objective evidence of motor dysfunction that has persisted for a continuous period of at least 3 months.
11. 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.
I. Coronary Angioplasty is defined as percutaneous coronary intervention by way of balloon angioplasty with or without stenting for treatment of the narrowing or blockage of minimum 50 % of one or more major coronary arteries. The intervention must be determined to be medically necessary by a cardiologist and supported by a coronary angiogram (CAG).
II. Coronary arteries herein refer to left main stem, left anterior descending, circumflex and right coronary artery.
III. Diagnostic angiography or investigation procedures without angioplasty/stent insertion are excluded.
13. BENIGN BRAIN TUMOR
I. Benign brain tumor is defined as a life threatening, non-cancerous tumor in the brain, cranial nerves or meninges within the skull. The presence of the underlying tumor must be confirmed by imaging studies such as CT scan or
II. This brain tumor must result in at least one of the following and must be confirmed by the relevant medical specialist.
i. Permanent Neurological deficit with persisting clinical symptoms for a continuous period of at least 90 consecutive days or
ii. Undergone surgical resection or radiation therapy to treat the brain
III. The following conditions are excluded:
Cysts, Granulomas, malformations in the arteries or veins of the brain, hematomas, abscesses, pituitary tumors, tumors of skull bones and tumors of the spinal cord.
I. Total, permanent and irreversible loss of all vision in both eyes as a result of illness or accident.
II. The Blindness is evidenced by:
i. corrected visual acuity being 3/60 or less in both eyes or ;
ii. the field of vision being less than 10 degrees in both eyes.
III. The diagnosis of blindness must be confirmed and must not be correctable by aids or surgical procedure.
I. Total and irreversible loss of hearing in both ears as a result of illness or accident. This diagnosis must be supported by pure tone audiogram test and certified by an Ear, Nose and Throat (ENT) speciaist. Totameans “the loss of hearing to the extent that the loss is greater than 90decibels across all frequencies of hearing” in both ears.
16. END STAGE LUNG FAILURE
I. End stage lung disease, causing chronic respiratory failure, as confirmed and evidenced by all of the following:
i. FEV1 test results consistently less than 1 litre measured on 3 occasions 3 months apart; and
ii. Requiring continuous permanent supplementary oxygen therapy for hypoxemia; and
iii. Arterial blood gas analysis with partial oxygen pressure of 55mmHg or less (PaO2 < 55mmHg); and
iv. Dyspnea at rest.
17. END STAGE LIVER FAILURE
I. Permanent and irreversible failure of liver function that has resulted in all three of the following:
Permanent jaundice; and Ascites; and
II. Liver failure secondary to drug or alcohol abuse is excluded.
18. 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.
19. LOSS OF LIMBS
I. The physical separation of two or more limbs, at or above the wrist or ankle level limbs as a result of injury or disease. This will include medically necessary amputation necessitated by injury or disease. The separation has to be permanent without any chance of surgical correction. Loss of Limbs resulting directly or indirectly from self-inflicted injury, alcohol or drug abuse is excluded.
20. MAJOR HEAD TRAUMA
I. Accidental head injury resulting in permanent Neurological deficit to be assessed no sooner than 3 months from the date of the accident. This diagnosis must be supported by unequivocal findings on Magnetic Resonance Imaging, Computerized Tomography, or other reliable imaging techniques. The accident must be caused solely and directly by accidental, violent, external and visible means and independently of all other causes.
II. The Accidental Head injury must result in an inability to perform at least three (3) of the following Activities of Daily Living either with or without the use of mechanical equipment, special devices or other aids and adaptations in use for disabled persons. For the purpose of th s benefit, the word “permanent” shall mean beyond the scope of recovery with current medical knowledge and technology.
III. The Activities of Daily Living are:
i. Washing: the ability to wash in the bath or shower (including getting into and out of the bath or shower) or wash satisfactorily by other means;
ii. Dressing: the ability to put on, take off, secure and unfasten all garments and, as appropriate, any braces, artificial limbs or other surgical appliances;
iii. Transferring: the ability to move from a bed to an upright chair or wheelchair and vice versa;
iv. Mobility: the ability to move indoors from room to room on level surfaces;
v. Toileting: the ability to use the lavatory or otherwise manage bowel and bladder functions so as to maintain a satisfactory level of personal hygiene;
vi. Feeding: the ability to feed oneself once food has been prepared and made available.
IV. The following are excluded:
i. Spinal cord injury;
21. PRIMARY (IDIOPATHIC) PULMONARY HYPERTENSION
I. An unequivocal diagnosis of Primary (Idiopathic) Pulmonary Hypertension by a Cardiologist or specialist in respiratory medicine with evidence of right ventricular enlargement and the pulmonary artery pressure above 30 mm of Hg on Cardiac Cauterization. There must be permanent irreversible physical impairment to the degree of at least Class IV of the New York Heart Association Classification of cardiac impairment.
II. The NYHA Classification of Cardiac Impairment are as follows:
i. Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms.
ii. Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present even at rest.
III. Pulmonary hypertension associated with lung disease, chronic hypoventilation, pulmonary thromboembolic disease, drugs and toxins, diseases of the left side of the heart, congenital heart disease and any secondary cause are specifically excluded.
22. THIRD DEGREE BURNS
I. There must be third-degree burns with scarring that cover at least 20% of the body’s surface area. The diagnosis must confirm the total area involved using standardized, clinically accepted, body surface area charts covering 20% of the body surface area.
Chapter III: Items for which optional cover may be offered by insurers
a. Details of items for which optional cover may be offered by insurers and details of the items that are to be subsumed into costs of room charges, cost of specific procedure charges and cost of treatment are specified under Annexure I. Insurers, however, may endeavour to cover all or some of optional items specified at List I of Annexure – I or design add-ons or optional covers for them.
(Note: All existing health insurance products that are not in compliance with this shall not be offered and promoted from 01st October, 2020 onwards.)
b. Where the insurer has a list of expenses not covered under the policy, the same has to be mentioned in the policy and the detailed list needs to be put up on the website of the insurer to enable the policyholder to refer to the details as and when
c. The instructions given in this Chapter are applicable to Indemnity policies only.
Chapter IV: Standards and benchmarks for hospitals in the provider network
1. Insurers and TPAs, wherever applicable, shall ensure that Network Providers or Hospitals which meet with the definition of Hospital provided in Chapter I of these Guidelines shall meet with the following minimum requirements:
a. All the Network Providers as at 27th July, 2018 shall, comply with the following by 26th July, 2020:
i. Register with Registry of Hospitals in the Network of insurers (ROHINI) maintained by insurance information Bureau (llB). [https://rohini.iib.gov.in].
ii. Obtain either “NABH Entry Level Certification” (or higher level of certificate) issued by National Accreditation Board for Hospitals and Healthcare Providers (NABH) or State Level Certificate (or higher level of certificate) under National Quality Assurance Standards (NOAS), issued by National Health Systems Resources Centre (NHSRC).
iii. In respect of all the new entrants (after 27th July 2018), only those hospitals that are compliant with the requirements specified at Clause (a) (i) above shall be enlisted as network providers. These network providers shall comply with the requirements stipulated at Clause (a) (ii) above within one year from the date of enlisting as a Network Provider and this shall be one of the conditions of Health Services Agreement.
iv. Insurers and TPAs may also endeavour to get hospitals (other than Network Providers) involved in reimbursement claims to meet the requirements stipulated at Clause (a) (i) and (a) (ii) above.
b. AYUSH Hospitals and AYUSH Day Care Centres which meet the definition of AYUSH Hospitals and AYUSH Day Care Centres defined under Chapter I of these Guidelines shall also obtain:
i. Either “NABH Entry Level Certification” (or higher level of certificate) issued by National Accreditation Board for Hospitals and Healthcare Providers (NABH) or State Level Certificate (or higher level of certificate) under National Quality Assurance Standards (NQAS), issued by National Health Systems Resources Centre (NHSRC).
ii. All the existing AYUSH Hospitals and AYUSH Day Care Centres shall comply with the requirements referred above within a period of twelve months from 26th November, 2019, if the said certificate is not already obtained.
(Note: The above instructions at a and b are subject to the directions of the Hon’ble Delhi High Court in its order dated 29th May 2019 / 31st May 2019, in respect of W.P(C) 6237 of 2019, which needs to be complied with till further orders of the Hon’ble Court.)
c. The providers shall comply with the minimum standard clauses in the agreement amongst Insurers, Network Providers and TPAs applicable to providers listed in Annexure 22 of Master Circular Ref. IRDAI/TPA/REG/CIR/130/06/2020 dated 03.06.2020 and as amended from time to time.
d. Providers shall be bound by the Provider ServicesCashless facility admission procedure laid down in Schedule A of Master Circular Ref. IRDAI/TPA/REG/CIR/1 30/06/2020 dated 03.06.2020 and as amended from time to time.
e. Providers shall be bound by the process of de-empanelment of providers laid down in Schedule B of Master Circular Ref. IRDAI/TPA/REG/CIR/130/06/2020 dated 03.06.2020 as amended from time to time.
f. Providers shall follow the standard discharge summary format prescribed under Schedule C of Master Circular Ref. IRDAI/TPA/REG/CIR/130/06/2020 dated 03.06.2020 and as amended from time to time.
g. Providers shall follow the standard format for provider bills prescribed under Schedule D of Master Circular Ref. IRDAI/TPA/REG/CIR/130/06/2020 dated 06.2020 and as amended from time to time.
h. Providers shall ensure that the standard claim form and form for request for cashless hospitalization for Health Insurance Policy provided for under Annexure 30 of Master Circular Ref. IRDAI/TPA/REG/CIR/130/06/2020 dated 06.2020 and as amended from time to time are adhered to in respect of all claims.
Chapter V: Health Insurance Returns
a. The periodical returns to be submitted by all the Insurers are specified in Annexure II of these Guidelines.
b. All the returns as specified under Annexure II shall be furnished for data pertaining to Financial Year 2017-18 onwards.
c. The timeline for submission of the returns is specified as under.
1. All Yearly returns shall be furnished within 90 days from the close of the Financial Year.
2. All Half Yearly returns shall be furnished within 45 days from the close of every Half – Year.
3. All Quarterly returns shall be furnished within 30 days from the close of the Quarter.