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IRDAI Rules for Health Insurance

Due to the rapidly rising healthcare costs, health insurance has become a necessity for the average person if they want to have a high standard of healthcare. With modern insurance plans offered by health insurance companies, policyholders can get treatments at the best hospitals through the ‘network hospitals’ benefit. To protect the interests of the customers, an oversight authority called the ‘Insurance Regulatory and Development Authority of India’, or IRDAI/IRDA was formed in 1999. The IRDAI oversees the operations of public and private insurance companies in India to ensure fairness and transparency as well as sets rules that all insurers have to abide by.

 

Some of the most important IRDAI guidelines for health insurance that have been set for insurance companies are:

 

  • Group health insurance policies will only be valid for one year.

  • Insurance companies are obliged to inform their policyholders about all the terms and conditions of a health insurance policy that are related to getting treatment at medical institutions and hospitals across India.

  • If the insurance company has denied a potential customer’s application, they must provide a genuine and logical reason in writing.

  • If a policyholder continues to renew their policy on time and has held the policy since an early age, the insurer must provide them with some rewards, which must be specifically mentioned on the policy document.

  • The insurer must provide the policyholder with a list of hospitals and medical institutions from where the medical bills and receipts will be accepted for an insurance claim.

  • The level of health insurance premiums charged to the policyholders, more specifically the elderly, must be affordable and reasonable. The exact details of the insurance cost must be communicated to the customers.

New Updated IRDAI Health Insurance Guidelines

The IRDAI introduced several new guidelines for health insurance companies in 2020, to better help insurers and policyholders deal with the COVID-19 pandemic conditions. You can take a look at these new IRDAI guidelines below:

 

  • An insurer cannot reject a health insurance claim from a policyholder if they have been continually renewing their policy for at least 8 years. This 8-year time frame will be called the Moratorium period and the insurance company cannot appeal for the rejection of any such claims unless there is fraud involved or the reason for the claim is an exclusion under the health insurance policy.

  • As the COVID-19 pandemic forced millions of people to stay home and seek medical consultation online or through the telephone, IRDAI has instructed insurers to provide coverage to the customers to seek remote doctor consultations. As the fees for even private online consultations can be extremely high, the IRDAI has enforced this rule to protect the financial interests of the policyholders. As a result, the policyholders can seek online treatment from qualified doctors without worrying about the cost of consultations.

  • If there is a delay in the release of the approved insurance claim amount, the insurance company will have to pay interest to the policyholder at a rate which is 2% higher than the rates offered by banks. The insurance company should settle the claim within 30-45 days of the policyholder submitting all the required documents for making a claim.

 

Note: These new rules have come into effect for all new plans issued from October 1, 2020, and all older plans that have been renewed after April 1, 2021.

Benefits of IRDAI Guidelines for Policyholders

There are multiple benefits that policyholders can enjoy due to the guidelines set by the IRDAI:

 

  • Policyholders can choose to buy multiple health insurance plans and apply for a health insurance claim on more than one policy if the claim amount for one of them reaches the maximum sum insured.

  • Policyholders can choose to switch their insurers if they are not satisfied with the services provided by their existing insurance company.

  • Policyholders can also choose to upgrade their insurance plan with the same insurance provider if they feel the need for enhanced coverage.

  • Policyholders can get the highest level of medical treatment by using the ‘network hospitals’ that are offered by their insurance providers.

To Conclude

The IRDAI guidelines on health insurance have made it easy for potential customers to buy health policies from reputed insurance providers without worrying too much about their insurance claim being rejected for no genuine reasons. Moreover, policyholders can appeal to the IRDAI insurance ombudsman if they feel their insurer has not been following the insurance guidelines or has rejected their claims without a valid cause.

 

If you do not yet have health insurance, you should get one immediately to secure yourself and your family against expensive hospital bills arising due to medical emergencies. You can check out the health insurance plans available at Bajaj MARKETS and choose one that suits your needs. 

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FAQs on IRDAI Health Insurance Guidelines

  • ✔️What are the new IRDAI guidelines on health insurance?

    The new IRDAI guidelines on health insurance are: Insurers cannot reject a claim from a policyholder who has continuously renewed their policy for at least 8 years., Insurers must allow coverage for telephonic medical consultations., If there is a delay in the payment of insurance claims, the insurer must pay interest to the policyholder on the approved claim amount. 

  • ✔️What is the purpose of IRDAI?

    The IRDAI was formed to carry out the following functions: To register new insurance companies, renew their permits or cancel their registration., To oversee and approve any new insurance products offered by insurers., Protect the interest of the policyholders and the insurers, as well as promote transparency and fair practices in the industry. 

  • ✔️What is the difference between IRDA and IRDAI?

    They are the same organisation referred to by two different acronyms. 

  • ✔️How can I appeal to the IRDAI if my insurance claim is rejected?

    If your insurance claim has been rejected, you will have to write to the insurance ombudsman. 

  • ✔️Are there any tax benefits of purchasing health insurance?

    Yes, there are several benefits of purchasing health insurance, as mentioned under Section 80D of the Income Tax Act, 1961.