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भारतीय बीमा विनियामक और विकास प्राधिकरण INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA
Ref: IRDAI/HLT/REG/CIR/ $117$ /09/2019
$27^{\text{th}}$ September, 2019
Guidelines on Standardization of Exclusions in Health Insurance Contracts
INDEX
| Chapter | Item | Page No. |
|---|---|---|
| I | Objective; Applicability; Legal and other provision, Definitions | 2-4 |
| II | Exclusions not allowed in Health Insurance Policies | 5 |
| III | Standard Wordings for some of the exclusions in Health Insurance Policies | 6-9 |
| IV | Diseases allowed to be permanently excluded | 10-14 |
| V | Modern Treatment Methods and Advancement in Technologies | 15 |
| VI | Other guidelines related to exclusions | 16-17 |
Page 1 of 17 सर्वे नं. 115/1, फाइनेंशियल डिस्ट्रिक्ट, नानकरामगुडा, हैदराबाद-500 032, भारत Survey No. 115/1, Financial District, Nanakramguda, Hyderabad-500 032, India (5) : +91-40-2020 4000,फैक्स : +91-40-2020 4555 (5) : +91-40-2020 4000, Fax : +91-40-2020 4555 वेबसाइट : www.irdai.gov.in Website : www.irdai.gov.in
GENERAL - Chapter - I
The objective of these Guidelines are to rationalise and standardize the exclusions in health Insurance Contracts that every Insurer shall comply with. Health Insurance has undergone various changes and improvements over the years. The Insurance Regulatory and Development Authority of India (Health Insurance) Regulations as well as the TPA (Third Party Administrators) Regulations have brought in standardization of various definitions / formats in the health insurance industry to promote uniformity keeping the customer in focus. The health insurance industry is keeping pace with the advancements in technologies that are taking place in the healthcare industry. With the increase in number of health insurance companies as well as health insurance products in the market, it has been desired that the health insurance industry adopts a uniform approach while incorporating exclusions in the health insurance products. In order to have a holistic and structured approach in devising appropriate guidelines, IRDAI, constituted a Working Group vide order Ref: IRDAI/HLT/ORD/Misc/113/07/2018 dated 24th July, 2018 to review the extant practices and make appropriate recommendations to meet the above objective. Report of the Working Group was published in IRDAI website on 02/11/2018.
These Guidelines are applicable to all General and Health Insurers offering indemnity based health insurance (excluding PA and Domestic / Overseas Travel) policies offering hospitalisation, domiciliary hospitalisation and day care treatment.
3.1 These guidelines are issued under the provisions of Section 34 (1) of Insurance Act, 1938 and Section 14 (2) (e) of the IRDAI Act 1999.
3.2 In order to enhance the health insurance coverage that is granted at the time of issuing a policy it is considered important to rationalise the exclusions that were hitherto prevalent in the health insurance policy contracts issued by all Insurers. Certain exclusions are prohibited to be incorporated in the health insurance policy contracts. Standardization of wordings of certain exclusions that are incorporated in the Health Insurance Contracts is also considered important to ensure uniformity across the industry. In order to enable the individuals that are suffering with any existing diseases get the health insurance coverage excluding the coverage to such existing disease, it is considered essential to let the Insurers accept such risks, subject to underwriting policy of the respective insurers, by permanently excluding the coverage to such existing diseases or illnesses.
Page 2 of 17
3.3 Accordingly, these Guidelines are issued specifying (i) the exclusions that are not allowed in the Health Insurance Policies, (ii) Standard Wordings of some of the exclusions (iii) Existing Diseases that may be permanently excluded (iv) Modern Treatment Methods that shall be covered (v) Other Norms on Exclusions.
3.4 Exclusions not allowed in Health Insurance Policies are prescribed in Chapter II of these Guidelines. No Insurer shall incorporate any exclusion specified under this chapter as part of any of the Health Insurance Products. No exclusion that may potentially circumvent these exclusions is allowed in Health Insurance Products.
3.5 Standard Wordings of some of the exclusions that are prevalent in Health Insurance Policies are prescribed in Chapter III of these Guidelines. While every Insurer may endeavour to minimise the number of exclusions to enhance availability of health insurance coverage, where insurers prefer to incorporate these exclusions, they shall incorporate the same wordings in-verbatim in the policy contracts as prescribed in this chapter.
3.6 Existing Diseases allowed to be permanently excluded are prescribed in Chapter IV of these Guidelines. Every insurer may endeavour to extend health insurance coverage to all the persons to be insured who disclosed pre-existing disease at the point of underwriting in accordance to Regulation (8) of IRDAI (Health Insurance) Regulations, 2016. Insurers while granting health insurance coverage to the persons with the existing diseases referred in Chapter IV may levy suitable health loading based on objective criteria as laid down in the board approved underwriting policy. Where underwriting policy of the Insurer does not enable the Insurer to offer the Health Insurance Coverage for the given existing disease disclosed even after levying the loading, Insurers are allowed to permanently exclude the Health Insurance coverage to the existing disease specified in the within referred Chapter. Other than the diseases listed in Table - 1 of Chapter - IV, any other pre-existing disease disclosed by the person to be insured shall be covered subject to the norms applicable for preexisting diseases.
3.7 In order to ensure that the policyholders of health insurance policies are not denied getting access to the technologically and medically advanced treatment procedures, Insurers shall not exclude the treatment procedures specified in Chapter V.
3.8 Other norms related to exclusions are prescribed in Chapter VI of these Guidelines.
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The provisions of these Guidelines shall be applicable in respect of all health insurance products (Other than Personal Accident, Domestic and Overseas Travel Policies) (both Individual and Group) referred in Clause (2) above filed on or after $01^{\text {st }}$ October, 2019. All existing health insurance products that are not in compliance with these Guidelines shall not be offered and promoted from $01^{\text {st }}$ October, 2020 onwards.
This has the approval of the competent authority.
(D V S Ramesh) General Manager (Health)
Page 4 of 17
CHAPTER II
Exclusions not allowed in Health Insurance Policies:
