Introduction
The Insurance Regulatory and Development Authority of India (IRDAI) has issued Circular No. Ref: IRDAI/HLT/CIR/MISC/190/10/2023 on October 30, 2023. This circular addresses the crucial topic of revising the Customer Information Sheet (CIS) for policyholders. It emphasizes the need for policyholders to have a clear understanding of their insurance policies. In this article, we will delve into the key points of this circular and its significance.
Detailed Analysis
1. Understanding Policy Terms: The circular begins by stressing the importance of comprehending policy terms and conditions. Insurance policies can be laden with complex legal language, making it challenging for policyholders to grasp the essentials. Therefore, the circular aims to provide a simplified document that explains the basic features of the policy and offers necessary information.
2. Introduction of Customer Information Sheet: To achieve this objective, the IRDAI has introduced the Customer Information Sheet (CIS). Insurers are now mandated to provide this sheet to all policyholders. The CIS serves as a comprehensive guide, offering a straightforward explanation of the policy’s key aspects.
3. Addressing Information Asymmetry: The circular acknowledges that complaints often arise due to an information gap between insurers and policyholders. By enhancing the existing CIS, the IRDAI aims to bridge this gap and ensure that policyholders are well-informed about their policies.
4. Revised CIS Format: The circular specifies that the revised format of the CIS (Annexure-A) will be implemented from January 1, 2024. This revised format is designed to make policy information easily understandable.
5. Compliance Requirements: The circular outlines several compliance requirements for insurers, intermediaries, and agents, including the mandatory provision of the CIS to policyholders and obtaining acknowledgment. It also emphasizes making the CIS available in local languages upon the policyholder’s request.
6. Font Size and Cross Reference: The CIS must have a minimum font size of 12″ (Arial) or above, and the policy document forwarding letter should include a cross-reference to the CIS.
7. Regulation Basis: The circular is issued in accordance with Regulation 26 of IRDAI (Health Insurance) Regulations, 2016.
Conclusion
In conclusion, the IRDAI’s Circular No. Ref: IRDAI/HLT/CIR/MISC/190/10/2023 marks a significant step toward enhancing transparency and information accessibility for insurance policyholders in India. By introducing the Customer Information Sheet and implementing compliance measures, the IRDAI aims to empower policyholders with a clearer understanding of their insurance policies. This initiative is expected to reduce disputes and ensure a more informed and satisfied customer base in the insurance sector. The revised CIS format, scheduled for implementation in 2024, will play a pivotal role in achieving this goal.
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Insurance Regulatory And Development Authority Of India
Circular No. Ref: IRDAI/HLT/CIR/MISC/190/10/2023 | Dated: 30th October,2023
To
All Insurers (Except AIC & ECGC)
Sub: Revision of Customer Information Sheet
1. It is important for a policyholder to understand the terms and conditions of the policy that has been purchased. Since a policy document may be fraught with legalese, it is imperative to have a document that explains in simple words, the basic features with regard to the policy and provides necessary information.
2. With the above objective in mind, the customer information sheet (CIS) has been devised and is to be provided by insurers to all policyholders.
3. It is observed that several complaints are still emanating as a result of asymmetry of information between insurer and the policyholder.
4. In this backdrop, the existing customer information sheet has been improved and now seeks to convey basic information about the policy purchased in a manner that is easily understood.
5. The revised format of CIS (Annexure-A) shall be implemented w.e.f. 01.01.2024.
6. Compliance of the following shall be ensured:
i. Insurers, intermediaries and agents shall forward the Customer Information Sheet to all policyholders and acknowledgement, physical or digital, shall be duly obtained.
ii. Customer Information Sheet shall be made available in local language if the policyholder so desires.
iii. The CIS shall have minimum font size 12″ (Arial) or above.
iv. All details provided for in the CIS shall be duly filled in.
v. The policy document forwarding letter shall contain a cross reference to the CIS.
This circular is being issued in terms of Regulation 26 of I RDAI (Health Insurance) Regulations,2016.
Yegnapriya Bharath
Chief General Manager
Annexure-A
Scedule-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.
| SI No | Title | Description
(Please refer to applicable Policy Clause Number in next column) |
Policy Clause Number |
| 1 | Name of Insurance Product/Policy | XXXXXX | |
| 2 | Policy number | ||
| 3 | Type of Insurance Product/ Policy |
|
|
| 4 | Sum Insured (Basis) (Along with amount) |
|
|
| 5 | Policy Coverage (What the policy covers?)
(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) Undergoing 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) |
|
| 6 | Exclusions
(what the policy does not cover) |
(Note: Insurer has to ensure that all the applicable exclusions are listed here) | |
| 7 | Waiting period
|
Initial waiting Period: xx days for all illnesses (not applicable in case of continuous renewal or accidents)
Specific Waiting periods (Not applicable for claims arising due to an accident):
Pre-existing diseases: Covered after xx months |
|
| 8 | Financial limits of coverage
i. Sub-limit (It is a predefined limit and the insurance company will not pay any amount in excess of this limit) i. Co-payment (It is a specified amount i. Deductible (It is a specified amount: – up to which an – which will be 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 following Sub-limits
XXXX Deductible of Rs. XXX per claim / per year / both |
|
| 9 | Claims/Claims Procedure | Details of procedure to be followed for cashless service as well as for reimbursement of claim including pre and post hospitalization.Turn Around Time (TAT) for claims settlement:i. TAT for preauthorization of cashless facility XXXii. TAT for cashless final bill authorization: XXX Provide the details /web link for following:i. Network Hospital detailsii. Helpline number iii. Hospitals which are blacklisted or from where no claims will be accepted by insurer iv. Downloading/getting claim form |
|
| 10 | Policy Servicing | Call center number of the insurer Details of Company officials |
|
| 11 | Grievances/Complaints | Details of
– Grievance Redressal Officer of the insurer – Insurance company grievance portal/ – Ombudsman: (Please provide contact details, Toll free number and email) |
|
| 12 | Things to remember | 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 Change in Sum Insured: Sum Insured can be changed (increased/decreased) only at the time of renewal or at any time, subject to underwriting by the company. For increase in SI, the waiting period if any shall start afresh only for the enhanced portion of the sum insured. Moratorium Period: After completion of eight continuous years under the policy no look back to be applied. This period of eight years is called as moratorium period. The moratorium would be After the expiry of Moratorium Period no health insurance policy shall be contestable except for proven fraud and permanent exclusions specified in the policy contract. |
|
| 13 | 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 sheet are 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.
