These things Health Policyholders need to know: Take a look at updated IRDA rules

Insurance companies are under obligation to provide a Customer Information Sheet (CIS) to their policyholders according to the Insurance Development Authority of India (IRDAI) guidelines. The document will furnish complex policy details and offer policyholders a clear understanding of their insurance coverage concerning sum assured, coverage specifics, exclusions, and claims procedure.

30 days free-look period:

The free-look period for reviewing policies is mandatorily extended to 30 days from the date of receiving the policy document, regardless of the mode of acquisition (online, physical, etc.). This additional time enables policyholders, to compare policies from different companies and make well-informed decisions after meticulously assessing the policy details, encompassing coverage, exclusions, terms, and conditions, before arriving at a final decision.

An insurance company cannot reject a claim citing non-disclosure of illness after 60 months:

The IRDAI has tweaked the product rules in policy holders’ favour. A health insurance company cannot reject a claim of a policyholder citing non-disclosure of pre-existing illnesses, except in cases of proven fraud, after 60 months of continuous coverage. That is, if you have paid five annual premiums, your claim will not be rejected on the grounds of suppression of health status or misrepresentation unless that insurer can prove fraud. Earlier, this waiting period was 96 months called the moratorium period. The insurance company cannot appeal to the IRDA against the settlement of such claim except for fraud and/or a claim raised against the exclusion of the policy after the moratorium period.

Mandated maximum waiting period for pre-existing illness:

The mandated maximum waiting period for pre-existing conditions or illnesses has been shortened from four years to three years. A medical illness or injury that you have before you start a new health care plan may be considered a pre-existing condition. Conditions like diabetes, asthma, high cholesterol, or a long-term back condition may be examples of pre-existing health conditions. They tend to be chronic or long-term. That is, if a policyholder is suffering from, above health conditions, your insurer will pay hospitalisation claims after you have paid at least three premiums (down from four earlier). A mandatory shorter waiting period of three years will make the process easier for policyholders. However, if insurers offer shorter waiting periods than the mandatory shorter waiting period mandated it is left to the policyholders to do homework and zero in on such policies.

Online consultation included in the coverage:

The fee paid for online consultations can amount to a large sum that would be proven to be a financial loss to the insured person. IRDA has asked health insurance companies to include telemedicine in the coverage where applicable. This move has allowed medical practitioners and patients to freely avail medical opinions.  

Delayed claim settlement:

In case of a delayed claim settlement by the insurer, the company is liable to pay the interest on the claim amount at the rate of 2% more than the bank rate. The claim should be settled within 30 to 45 days from the date of communicating the last required document to the policyholder. The time duration for claim settlement will depend upon the nature of the claim and investigation required.

Multiple health policies:

If a policyholder has multiple health policies, he/she can choose to raise a claim at a preferred insurance company and the insurer will be liable to settle the claim as per the terms and conditions of the policy. The policyholder is entitled to choose a claim from another insurer for an amount disapproved by the first insurer, by raising a claim for the balance amount with another insurer in case of multiple policies. This rule applies when the sum insured is exhausted under the first policy.

Health Insurance Portability:

A health insurance policyholder is free to shift his/her policy to another insurance company with a new plan of a similar nature in case he/she is not satisfied with the services provided by the insurance company. IRDA has created a web-based facility to get and maintain data about all health insurance policies issued by insurance companies to individuals so that it can be accessed by the new company to which a policyholder wishes to port his policy. This enables the new insurer to obtain data on the history of health insurance of the policyholder wishing to port his policy.

Portability of policy only during the renewal of the policy:

You can port the policy only at the juncture of renewal. That is, the new insurance period will be with the new insurance company. When you change your health insurance policy from one insurance company to another, you don’t have to lose the benefits you have accumulated. The new insurer “shall allow for credit gained by the insured for a pre-existing condition(s) in terms of waiting period”. In the past in health insurance policies, such a move resulted in your losing benefits like the waiting period for covering “Pre-existing Diseases”. This applies not only when you move from one insurer to another but also from one plan to another with the same insurer. Your new insurer has to insure you at least up to the sum insured under the old policy.

A policyholder may migrate to another plan offered by the current insurance company or migrate to a new plan with another insurance company only at the juncture of renewal. Apart from the waiting period credit, all other terms of the new policy including the premium are at the discretion of the new insurance company. At least 45 days before your renewal is due you have to write to your old insurance company requesting a shift your policy to a specific company to which you want to shift the policy Renew your policy without a break (there is a 30-day grace period if porting is under process).

Age restriction to purchase new policy removed:

Until now, individuals were limited to purchasing a new insurance policy only until the age of 65. However, with the recent changes that have come into effect from April 01, 2024, anyone, regardless of age, is eligible to purchase a new health insurance