Insurance Regulatory and Development Authority of India

Circular No. Ref: IRDAI/HLT/REG/CIR/104/5/2022 | Date: 27-05-2022

To
All Insurers

Re: Modifications in definition of Critical Illnesses prescribed in Guidelines on Standardization in Health Insurance

1. Reference is invited to the Chapter II of Section 1 of Master Circular on Standardization of Health Insurance Products Ref: IRDAI/HLT/REG/CIR/193/07/2020 dated 22.07.2020 prescribing nomenclature and procedure for 22 critical illnesses that may form part of health insurance policies. Insurers were mandated to use the definitions without exception wherever the products cover any of the Critical Illnesses specified in the guidelines.

2.  In partial modification of clause 1, 11 & 18 aforementioned circular, the definitions specified hereunder are substituted:

S.no

Critical Illness Modified Definition
1 CANCER OF SPECIFIED SEVERITY 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 T1N0M0 (TNM Classification) or below and with mitotic count of less than or equal to 5/50 HPFs;

11 MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS 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.  Neurological damage due to SLE is excluded.

18 LOSS OF SPEECH 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. 

3. These modifications shall come into force with immediate effect.

4.  All other terms and conditions referred in the within referred master circular dated 22.07.2020 shall remain unchanged.

This has the approval of the competent authority.

(DVS Ramesh)

Chief General Manager (Health)

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