Modification Guidelines on Standardization in Health Insurance

INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA

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

Date: 27^th 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 29^th 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 29^th 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 1^st October 2019. All existing health insurance products that are not in compliance with these Guidelines shall not be offered and promoted from 01^st 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

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

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

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