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The Insurance Regulatory and Development Authority of India issues amendments to the guidelines on health insurance standardization and exclusions. The update revises the definition of a pre-existing disease by removing the clause related to symptoms presenting within three months of policy issuance and adds reinstatement references. The update also revises hospital exclusion terms to include life-threatening situations alongside accidents for stabilization expenses and renames Exclusion Q to remove birth control from the heading. All insurers and Third Party Administrators must comply with these changes.
What you must do
Key dates
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Exceptions
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भारतीय बीमा विनियामक और विकास प्राधिकरण INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA
Ref: IRDAI/HLT/REG/CIR/046/02/2020
10th February, 2020
To
All Insurers and TPAs, wherever applicable
Re: Amendments in respect of provisions of Guidelines on Standardization of Exclusions in Health Insurance Contracts and Modification Guidelines on Standardization in Health Insurance
Reference is invited to the provisions of Guidelines on Standardization of Exclusions in Health Insurance Contracts vide Ref No. IRDAI/HLT/REG/CIR/177/09/2019 and Modification Guidelines on Standardization in Health Insurance vide Ref No. IRDAI/HLT/REG/CIR/176/09/2019 dated $27^{\text{th}}$ September 2019. Under the powers vested in Section 34(1) of the Insurance Act, 1938 and Section 14(2) (e) of the IRDAI Act 1999, following Amendments are issued.
I. The following changes shall be effected in Clause 1 of the Modification Guidelines on Standardization in Health Insurance (Ref: IRDAI/HLT/REG/CIR/176/09/2019):
| S.no | Reference | Existing | New |
|---|---|---|---|
| 1 | Definition of Pre-Existing Disease
(not applicable for Overseas Travel Insurance) | Pre-existing Disease means any condition, ailment, injury or disease:
(Life Insurers may define norms for applicability of PED at Reinstatement) | Pre-existing Disease means any condition, ailment, injury or disease:
(Life Insurers may define norms for applicability of PED at Reinstatement)
|
II. The following changes shall be effected in Chapter III of the Guidelines on Standardization of Exclusions in Health Insurance Contracts (Ref: IRDAI/HLT/REG/CIR/177/09/2019):
| S.no | Reference | Existing | New |
|---|---|---|---|
| 1 | Exclusion K (Excluded providers: Code- Excl11) | Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations following an accident, expenses up to the stage of stabilization are payable but not the complete claim.
(Explanation: Details of excluded providers shall be provided with the policy document. Insurers to use various means of communication to notify the policyholders, such as e-mail, SMS about the updated list being uploaded in the website.) | Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.
(Explanation: Details of excluded providers shall be provided with the policy document. Insurers to use various means of communication to notify the policyholders, such as e-mail, SMS about the updated list being uploaded in the website.) |
| 2 | Exclusion Q (Birth control, Sterility and Infertility: Code- Excl17) | Exclusion Q (Birth control, Sterility and Infertility: Code- Excl17)
Expenses related to Birth Control, sterility and infertility. This includes:
| Exclusion Q (Sterility and Infertility: Code- Excl17)
Expenses related to sterility and infertility. This includes:
|
Insurers and Third Party Administrators, wherever applicable, are advised to make a note of the above changes and ensure compliance.
This has the approval of the competent authority.
(Suresh Mathur)
Executive Director
