IRDA has recently come up with some major changes in health insurance effective from 1^st October 2020 and issued guidelines to reduce confusion and facilitate ease of understanding for the customers.

1. Exclusions: Standard Definitions

There are various exclusions in a health insurance policy and wordings for them differ from policy to policy. This confuses the policyholders. IRDA has standardized the definitions and wordings for many types of exclusions. Now all policies will have the same wordings and code for exclusions which will eliminate grey areas.

2. No ambiguous wordings in Policy

 IRDA has also said that there should not be any ambiguity in the wordings of the policy which can create confusion in the future.

 3. Greater coverage: Many Exclusions are disallowed

Many exclusions that were disallowed earlier have to be covered under the policy now. Some of them are;

Treatment of mental illness

Behavioral and Neurodevelopmental Disorders

Genetic diseases or disorders

Puberty and Menopause Related Disorders

Injury or illness associated with hazardous activities

This is good news for policyholders having a mental illness related to hospitalization.

4. Standardization of “Pre-existing” diseases

This is one area that was quite confusing for customers. Now, the IRDA has made it clear that a pre-existing illness is an illness for which,

• A doctor has advised you a treatment
• Or Doctor has diagnosed a disease

Only in these two cases, it will be treated as pre-existing illness, else not.

5. No claim rejection after 8 yrs. of premium payment

Now health insurance companies will have to settle all the claims once a policy has been active for a continuous period of 8 yrs.

 6. People with serious illnesses to get cover with permanent exclusions

A lot of people who had some serious illnesses like cancer, epilepsy, Chronic Kidney disease, Alzheimer’s Disease were denied any kind of health insurance. They were not even provided cover for other things with these things put as permanent exclusions. However, this has changed.

IRDA has said that now people with the above kinds of illnesses also have a right for getting health insurance for other illnesses.

7. Modern treatments to be covered in health insurance

Here is a full list of modern treatments which IRDA has specified to be covered under Health Insurance;

• Uterine Artery Embolization and HIFU
• Balloon Sinuplasty
• Deep Brain stimulation
• Oral chemotherapy
• Immunotherapy- Monoclonal Antibody to be given as an injection
• Intra vitreal injections
• Robotic surgeries
• Stereotactic radio surgeries
• Bronchial Thermoplasty
• Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
• IONM – (Intra Operative Neuro Monitoring)
• Stem cell therapy

8. Waiting period for specified illnesses can’t be more than 4 yrs.

So earlier there was clarity on how much can be the waiting period for various illnesses like cataract, knee surgery, and many other kinds of illnesses. Most of the time it was in the range of 2-4 yrs. and some older policies may have a higher than 4 yrs of the waiting period. But IRDA has now made it clear that in no case, it can be more than 4 yrs. of the waiting period.

9. Waiting period for lifestyle diseases only up to 90 days

Currently the insurer classify life style diseases as” pre existing illness” at the time of underwriting and waiting period for lifestyle diseases is kept up to 2-4 yrs.But in case of renewed policies, the waiting period for lifestyle illnesses like diabetes, hypertension, and Cardiac conditions can be only up to 90 days and not beyond that . .

10. Pre and Post hospitalization expenses to be covered for domiciliary hospitalization

Another change is that now in case of domiciliary hospitalization, the pre- and post-hospitalization expenses will also be covered which was not the case earlier.

You can surely expect that the premiums will rise in the future for these policies

If you already have the health insurance policy, you can expect the premiums to rise on your next renewal. Health Insurance companies are also bound to incorporate these changes treating the instructions as an order from IRDA.

Source: IRDA Circular ( attached)