Irdai's Master Circular: Empowering Health Insurance

The Insurance Regulatory and Development Authority of India (IRDAI) has issued a comprehensive master circular on health insurance products, consolidating information previously spread across 55 separate circulars. It provides policyholders and potential customers with a clear and user-friendly resource to understand their rights and the features they can expect from health insurance plans.

The master circular mentions the following points for policyholders. 

Wider Choice for Diverse Needs
Insurers must offer a variety of health insurance products, add-ons, and riders catering to various demographics, medical conditions, and healthcare preferences. This ensures affordability and coverage that suits your specific needs.

Understanding Your Policy
The Customer Information Sheet (CIS) explains your policy clearly. It details the type of insurance, sum insured, coverage, exclusions, waiting periods, and other crucial aspects in simple language.

Flexibility in Choosing Coverage:
You have the freedom to choose products, add-ons, and riders that best address your medical conditions and healthcare requirements. This allows for a customised approach to health insurance.

Simplified Multi-Policy Claims:
If you have multiple health insurance policies, you can choose which one to use first. The primary insurer will then coordinate with the others to settle the remaining balance.

Rewards for Responsible Behaviour:
Insurers can offer 'No Claim Bonuses' for not making claims during the policy period. These bonuses can come in the form of increased sum insured or discounted premiums, incentivisng preventive healthcare.

Freedom to Cancel and Renew:
You have the right to cancel your policy anytime and receive a refund for the remaining period's premium. Additionally, health insurance policies are guaranteed for renewal, and previous claims (except for fraud) won't prevent it. Fresh medical underwriting is only required for increased sum insured. This provides peace of mind and ensures continued coverage.
The master circular also lays down the following regarding compliance by insurers. 

End-to-End Technological Solutions
Insurers should efficiently onboard policyholders, manage renewals, provide seamless policy servicing, and address grievances through comprehensive technology solutions, ensuring a smooth and hassle-free experience.

Cashless Claim Settlement
They should strive for 100 per cent cashless claim settlement within defined timelines, facilitating quick and hassle-free reimbursements for policyholders.

Empanelment of Healthcare Providers
Insurers should empanel all categories of hospitals and healthcare service providers, considering the financial accessibility of diverse population segments.

Transparent Information Display
Insurers should display prominently on the insurer's website the list of hospitals/healthcare service providers for cashless claim settlement, along with clarification on reimbursement procedures for services outside empanelled facilities and detailed instructions for claim settlement processes under both cashless and reimbursement modes.

Efficient Authorization Processes
Insurers should commit to prompt processing of cashless authorisation requests, with immediate decisions and final authorisations within strict timelines to ensure timely treatment.

Swift Handling of Mortal Remains
In the unfortunate event of death during treatment, hospitals to release mortal remains promptly to the concerned parties.

Fair Claim Repudiation Procedures
No claim can be repudiated without the approval of the claims review committee. This will ensure fair and thorough assessment of all claims.

Simplified Document Submission
Policyholders are to be relieved from the burden of submitting claim documents; insurers and Third-Party Administrators (TPAs) will collect necessary documentation directly from hospitals, streamlining the claim settlement process.

Anagh Pal

BW Reporters