IRDAI Health Guidelines,2016

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Major points:

All health insurance policies issued by general and health insurers are portable. Policies issued by life insurers cannot be ported. Any insured wanting to port his/her policy has to apply to the new insurer between 45 to 60 days before the renewal date. The existing insurer has to furnish the insured's data within seven days. The new insurer has to communicate with the insured within 15 days of receipt of the data.

If an insured has a sum insured of Rs. 5 lakhs in his/her existing policy and an accrued bonus of say Rs.1 lakh, the new insurer has to offer a sum insured of at least Rs. 6 lakhs. 

Renewability of health policies is life long. This does not apply to benefit policies where lump sum is paid to the insured and policy terminated. 

Life insurers cannot offer indemnity based products. Health policies issued by life insurers must have a  tenure of five years or more. Premium of such policies cannot be altered for a block of three years.

Unit linked policies cannot offer single premium health products.

General and health insurers can offer health plans for a minimum tenure of one year and a maximum tenure of 3 years. Group policies can be offered for one year.

General and health insurers may reward policyholders for

• early entry
• continued renewals
• favourable claims
• preventive and wellness habits

These awards can be in the form of discounts in premium or accretion to sum insured through bonus.

All health policies shall ordinarily provide for an entry age of 65 years.

An existing health policy cannot be terminated on grounds of age or poor claim experience. But it can be terminated on the grounds of fraud, moral hazard, misrepresentation or non-cooperation by the insured.

At least 50 per cent of the pre-insurance health check up costs has to be borne by the insurer, once the proposal is accepted. This is applicable to policies issued for one year or less. Therefore health policies issued by life insurers do not have this facility of reimbursement.

IRDAI has encouraged insurers to offer pilot projects for up to five years. These may be brought out with innovative features.

General and health insurers can provide cover for Ayush treatment which comprises of Ayurveda, Siddha, Unani and Homeopathy.

Written consent has to be taken from senior citizens if any loading is charged at the time of the renewal. A separate channel has to be established by insurers to address the grievances of senior citizens. 

In case the insured has multiple benefit policies, he/she is entitled to receive claim amounts from all of them. But if the insured has multiple indemnity based policies, he/she can receive the claim amount, from insurer of his/her choice. In the event of sum insured being exhausted from one policy, the other policy can be utilised.

An insurer shall settle or reject a claim within 30 days of the receipt of the last necessary document.

To avail the benefit of cashless facility, insurers shall issue an Identification Card to the insured within 15 days from the date of issuance of a policy either directly or through a TPA.

A TPA cannot reject or repudiate a claim. Also, A TPA cannot make a payment to the policyholders, claimants or network providers.