Amendments in respect of provisions of Guidelines on Standardization of Exc

• ~I~ 'lw-il11 ~, nif.l1111i1* <1t'tt m ~ Dliiiifi INSURANCE REGULATORY AND ir.lai DEVELOPMENT AUTHORITY OF INDIA Ref: IRDAI/HL T/REG/CIR/0~6/02/2020 1 0th 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/HL T/REG/CIR/177/09/2019 and Modification Guidelines on Standardization in Health Insurance vide Ref No. IRDAI/HL T/REG/CIR/176/09/2019 dated 27th 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/HL T/REG/CIR/176/09/2019): S.no Reference Existing New 1 Definition of Pre-existing Disease Pre-existing Disease means any condition, ailment, injury or disease: Pre-Existing means any condition, Disease ailment, injury or disease: a) That is/are diagnosed by a (not applicable Overseas Travel Insurance) for a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement or b) For which medical advice or treatment was b) For which medical advice recommended by, or or treatment was received from, a recommended by, or physician within 48 received from, a physician months prior to the within 48 months prior to effective date of the the effective date of the l·ts policy issued by the policy or reinstatement. insurer or its c) A condition for which any symptoms and or signs if presented and have resulted within three months of the issuance of the policy in reinstatement (Life Insurers may define norms for applicability of PED at Reinstatement) c) (Deleted0 ~ <t. 115/1, ~ ~' ,i l<icfi<l'i '.! s I, ~-500 032 ~1 \~~ly No. 115/1, Financial Dist~guda, Hyderabad-500 032, India : +91-40-2020 4000 ~ : www.irdai.gov.in 6) : +91-40-2020 4000 Website : www.irdai.gov.in a diagnostic illness or medical condition. (Life Insurers may define norms for applicability of PED at Reinstatement) II. The following changes shall be effected in Chapter Ill of the Guidelines on Standardization of Exclusions in Health Insurance Contracts (Ref: IRDAI/HL T/REG/CIR/177/09/2019): S.no Reference Existing New 1 Exclusion (Excluded providers: K Exclusion K (Excluded Exclusion K (Excluded Code- Excl11) providers: Code- Excl11) 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.) Page 2 of 3 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: (i) Any type of contraception, Exclusion Q (Sterility and Infertility: Code- Excl17) Expenses related to sterility and infertility. This includes: (i) Any type of contraception, sterilization (ii) Assisted sterilization Reproduction (ii) Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI (iii) Gestational Surrogacy (iv) Reversal of sterilization services artificial and including insemination advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI (iii) Gestational Surrogacy (iv) Reversal of sterilization 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 Page 3 of 3