India repeals 55 health insurance documents

On a good note, policyholders gain more product choices.

The Insurance Regulatory and Development Authority of India (IRDAI) released a circular which repealed 55 health insurance-related documents.

The IRDAI hopes this development is a step towards enhancing policyholder empowerment and inclusive health insurance.

The text below comes from a document filed last 29 May:

For Policyholders/Prospects/Customers

• Insurers are required to offer a wider choice of products/add-ons/riders catering to all ages, regions, occupational categories, medical conditions/treatments, and types of hospitals and healthcare providers.
• The Customer Information Sheet (CIS) provided by insurers along with every policy document explains the basic features of insurance policies in simple terms.
• Policyholders have flexibility in choosing products/add-ons/riders based on their medical conditions and specific needs.
• Policyholders with multiple health insurance policies can choose the policy under which they wish to claim the admissible amount, with the primary insurer facilitating coordination with other insurers for settlement.
• No Claim Bonus options are provided to policyholders in case of no claims during the policy period, either by increasing the sum insured or discounting the premium.
• Policyholders have the right to receive a refund of premium for the unexpired policy period if they choose to cancel their policy at any time during the policy term.
• Health insurance policies are renewable and cannot be denied on the grounds of previous claims, except in cases of established fraud, non-disclosure, or misrepresentation.

Compliance Required by Insurers

• Insurers must provide end-to-end technology solutions for effective onboarding, renewal, policy servicing, and grievance redressal.
• Strive towards achieving 100% cashless claim settlement in a time-bound manner.
• Empanel all categories of hospitals/health service providers, considering the affordability of different population segments.
• Display a list of hospitals/healthcare service providers with whom cashless claim settlement tie-ups are in place on their website.
• Ensure that procedures for claim settlement under cashless facilities and reimbursement are transparent and clearly communicated.
• Decide on cashless authorisation requests immediately and within one hour, with final authorisation on discharge from the hospital within three hours.
• Release mortal remains immediately in the event of death during treatment.
• No claim can be repudiated without approval from the Claims Review Committee, which must make a decision on the repudiation of every claim.
• Insurers and TPAs (Third Party Administrators) are responsible for collecting required documents from hospitals; policyholders are not required to submit any documents.
• Stricter timelines are imposed for existing and acquiring insurers to act on portability requests via the Insurance Information Bureau of India (IIB) portal.
• Insurers must pay Rs. 5000/per day to policyholders if ombudsman awards are not implemented within 30 days.
• Ensure Ayush treatment is treated on par with other treatments; policyholders have the option to choose the treatment of their choice.
• Monitor TPA performance, with payments made only upon full discharge of satisfactory service; claw back remuneration/charges paid to TPAs based on customer feedback.
• Provide suitable options to policyholders in case of product withdrawal, including migration to another suitable product or one-time renewal option.

This Master Circular aims to empower policyholders by ensuring they receive high standards of care and service, promoting trust and transparency in the health insurance sector in India.

It consolidates entitlements in health insurance policies for easy reference, emphasising measures for seamless, faster, and hassle-free claims experiences.