The Insurance Regulatory and Development Authority of India (IRDAI) has introduced significant amendments to the existing regulations governing health insurance, mentioned below are details;
1. Reduction in Pre-existing Disease (PED) Waiting Period
IRDAI has reduced the maximum waiting period for covering pre-existing diseases in health insurance from 4 years to 3 years. Policyholders can now claim treatment costs for pre-existing conditions, such as diabetes and hypertension, after a waiting period of 3 years. This regulation aims to prevent insurance companies from rejecting PED claims after this specified period, providing greater assurance to policyholders.
2. Elimination of Sub-Limits on AYUSH Treatment
IRDAI has removed sub-limits on AYUSH (Ayurveda, Yoga, Naturopathy, Siddha, Unani, and Homeopathy) treatments. Policyholders can now claim the full cost of treatments under these alternative medicine systems up to the sum insured limit. Insurers must establish Board-approved policies to ensure parity between AYUSH treatments and other forms of healthcare within their offerings.
Standard Operating Procedures (SOP) Implementation
Insurers are mandated to establish adequate controls and SOPs for various aspects, including enrolling hospitals into their network, incorporating necessary clauses in health service agreements with AYUSH facilities, defining standard treatment protocols, and addressing potential instances of fraud or system abuse.
3. Removal of Age Limit for Health Insurance Purchase
IRDAI has abolished the maximum age limit for purchasing health insurance policies in India, previously capped at 65 years. This revision allows individuals of all ages, particularly senior citizens, to acquire comprehensive medical insurance coverage without age-related restrictions.
4. Inclusivity for Individuals with Severe Medical Conditions
Health insurance companies are prohibited from denying policies to individuals with severe pre-existing conditions such as heart disease, cancer, renal failure, and AIDS. This inclusivity measure aims to expand the reach of medical insurance coverage across diverse demographic segments.
5. Reduction in Waiting Period for Specific Diseases/Procedures
IRDAI has decreased the maximum waiting period for specific diseases/procedures, such as joint replacement surgery, from 4 years to 3 years. This adjustment facilitates earlier access to health insurance claims for listed conditions/procedures after a waiting period of up to 3 years.
6. Reduction in Moratorium Period
The moratorium period in health insurance has been reduced from 8 years to 5 years. This revision prohibits insurance companies from rejecting claims due to non-disclosure or misinterpretation after 5 years of continuous coverage, except in cases of fraud.
These updated guidelines signify a proactive approach by IRDAI towards enhancing the accessibility, inclusivity, and efficiency of health insurance services in India.