INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA

Ref: IRDAI/HLT/REG/CIR/176/09/2019

Date: 27th September, 2019

To

All Insurers and TPAs, wherever applicable,

Re: Modification Guidelines on Standardization in Health Insurance:

1. Reference is invited to Clause 33 of Chapter — I of Guidelines on Standardization in Health Insurance Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29th July, 2016 where pre-existing disease is defined. The definition of Pre-existing Disease stands modified as under and the following definition is substituted at Clause 33 of the within referred Guidelines:

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)

2. Reference is invited to Chapter — Ill of Guidelines on Standardization in Health Insurance Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29th July, 2016 where items for which optional cover may be offered by insurers are specified in Annexure — I. In substitution of the items specified in the within referred Guidelines, the revised items are specified in Annexure — I of these modified Guidelines.

3. The provisions of these Guidelines shall be applicable in respect of all health insurance products (both Individual and Group) filed on or after 1st October 2019. All existing health insurance products that are not in compliance with these Guidelines shall not be offered and promoted from 01st October, 2020 onwards.

4. This has the approval of the competent authority.

(DVS Ramesh)
General Manager (Health)

Annexure — I

Items for which optional cover may be offered by Insurers

1. Reference is invited to Chapter III of Guidelines on Standardization in Health Insurance vide Circular Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29th July, 2016 where items for which optional cover may be offered by Insurers were specified. On a review of the list of items it is decided to classify the existing ‘Optional Items’ into the following categories.

i. LIST — I :: Items that may be retained ‘as it is’ as optional items — Items specified in the list are the Optional Items to which Insurers may offer coverage.

ii. LIST — II :: Costs that are to be subsumed into the Room Charges — Items specified in the list shall form part of room charges

iii. LIST — III:: Costs that are to be subsumed into the specific (say surgical) procedure charges — Items specified in the list shall be considered as part of procedure charges.

iv. LIST — IV:: Costs that are to be subsumed into the costs of treatment —Items specified in the list shall be considered as part of costs of treatment.

2. Where the costs are to be subsumed into the room charges specified in List — II or procedure charges specified in List III or costs of treatment (including costs of diagnostics) specified in List IV all claims shall be settled in accordance to the terms and conditions of the policy contract. Insurers shall put in place measures to ensure that items which are part of room / surgical procedure / treatment (including diagnostics) as referred in the lists herein shall not be billed to the policyholders by the hospitals and every insurer shall inform or notify the same to the hospitals and the policyholders suitably. Accordingly, all insurers are advised to make it part of their service level agreement with the network providers (hospitals) in case of cashless cases. In case of reimbursements (with other than network providers) Insurers shall settle the claims as per the terms and conditions of the policy contract

List I — Optional Items

SI No Item
1 BABY FOOD
2 BABY UTILITIES CHARGES
3 BEAUTY SERVICES
4 BELTS/ BRACES
5 BUDS
6 COLD PACK/HOT PACK
7 CARRY BAGS
8 EMAIL / INTERNET CHARGES
9 FOOD CHARGES (OTHER THAN PATIENT’s DIET PROVIDED BY HOSPITAL)
10 LEGGINGS
11 LAUNDRY CHARGES
12 MINERAL WATER
13 SANITARY PAD
14 TELEPHONE CHARGES
15 GUEST SERVICES
16 CREPE BANDAGE
17 DIAPER OF ANY TYPE
18 EYELET COLLAR
19 SLINGS
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED
22 Television Charges
23 SURCHARGES
24 ATTENDANT CHARGES
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED CHARGE)
26 BIRTH CERTIFICATE
27 CERTIFICATE CHARGES
28 COURIER CHARGES
29 CONVEYANCE CHARGES
30 MEDICAL CERTIFICATE
31 MEDICAL RECORDS
32 PHOTOCOPIES CHARGES
33 MORTUARY CHARGES
34 WALKING AIDS CHARGES
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)
36 SPACER
37 SPIROMETRE
38 NEBULIZER KIT
39 STEAM INHALER
40 ARMSLING
41 THERMOMETER
42 CERVICAL COLLAR
43 SPLINT
44 DIABETIC FOOT WEAR
45 KNEE BRACES (LONG/ SHORT/ HINGED)
46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
47 LUMBO SACRAL BELT
48 NIMBUS BED OR WATER OR AIR BED CHARGES
49 AMBULANCE COLLAR
50 AMBULANCE EQUIPMENT
51 ABDOMINAL BINDER
52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
53 SUGAR FREE Tablets
54 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals payable)
55 ECG ELECTRODES
56 GLOVES
57 NEBULISATION KIT
58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC]
59 KIDNEY TRAY
60 MASK
61 OUNCE GLASS
62 OXYGEN MASK
63 PELVIC TRACTION BELT
64 PAN CAN
65 TROLLY COVER
66 UROMETER, URINE JUG
67 AMBULANCE
68 VASOFIX SAFETY

List II — Items that are to be subsumed into Room Charges

SI No Item
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
2 HAND WASH
3 SHOE COVER
4 CAPS
5 CRADLE CHARGES
6 COMB
7 EAU-DE-COLOGNE / ROOM FRESHNERS
8 FOOT COVER
9 GOWN
10 SLIPPERS
11 TISSUE PAPER
12 TOOTH PASTE
13 TOOTH BRUSH
14 BED PAN
15 FACE MASK
16 FLEXI MASK
17 HAND HOLDER
18 SPUTUM CUP
19 DISINFECTANT LOTIONS
20 LUXURY TAX
21 HVAC
22 HOUSE KEEPING CHARGES
23 AIR CONDITIONER CHARGES
24 IM IV INJECTION CHARGES
25 CLEAN SHEET
26 BLANKET/WARMER BLANKET
27 ADMISSION KIT
28 DIABETIC CHART CHARGES
29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
30 DISCHARGE PROCEDURE CHARGES
31 DAILY CHART CHARGES
32 ENTRANCE PASS / VISITORS PASS CHARGES
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
34 FILE OPENING CHARGES
35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
36 PATIENT IDENTIFICATION BAND / NAME TAG
37 PULSEOXYMETER CHARGES

List III — Items that are to be subsumed into Procedure Charges

SI
No.
Item
1 HAIR REMOVAL CREAM
2 DISPOSABLES RAZORS CHARGES (for site preparations)
3 EYE PAD
4 EYE SHEILD
5 CAMERA COVER
6 DVD, CD CHARGES
7 GAUSE SOFT
8 GAUZE
9 WARD AND THEATRE BOOKING CHARGES
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
11 MICROSCOPE COVER
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
13 SURGICAL DRILL
14 EYE KIT
15 EYE DRAPE
16 X-RAY FILM
17 BOYLES APPARATUS CHARGES
18 COTTON
19 COTTON BANDAGE
20 SURGICAL TAPE
21 APRON
22 TORNIQUET
23 ORTHOBUNDLE, GYNAEC BUNDLE

List IV — Items that are to be subsumed into costs of treatment

SI No. Item
1 ADMISSION/REGISTRATION CHARGES
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE
3 URINE CONTAINER
4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES
5 BIPAP MACHINE
6 CPAP/ CAPD EQUIPMENTS
7 INFUSION PUMP— COST
8 HYDROGEN PEROXIDDSPIRIT1 DISINFECTANTS ETC
9 NUTRITION PLANNING CHARGES – DIETICIAN CHARGES- DIET CHARGES
10 HIV KIT
11 ANTISEPTIC MOUTHWASH
12 LOZENGES
13 MOUTH PAINT
14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTIONISTERILLIUM
17 Glucometer & Strips
18 URINE BAG

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