Guidelines that has improvised your Mediclaim Policy
IRDAI issued a remarkable circular on 27th September 2019, Ref. No: IRDAI/HLT/REG/CIR/177/09/2019 that got effective from 01.10.2020 onwards which was termed as Guidelines on Standardization of Exclusions in Health Insurance Contracts. The purpose of the circular is mainly as under:
To enhance health insurance coverage
Prohibit certain exclusions
Ensure uniformity across the industry
In order to enable the individuals suffering with any existing diseases to get health insurance coverage excluding the coverage to such existing disease, by permanently excluding the coverage to such existing diseases or illnesses.
Salient Features:
Exlusions Not Allowed by any Insurer:
It is directed that the following exclusions shall not be allowed in health insurance (Other than PA & Travel) policies.
Diseases contracted after taking the health insurance policy.
Injury or illness associated with hazardous activities. However, only treatment necessitated due to participation in adventure or hazardous sports is permitted as exclusion.
Impairment of Persons’ intellectual faculties by usage of drugs, stimulants or depressants as prescribed by a medical practitioner.
Artificial life maintenance, including life support machine use, where such treatment will not result in recovery or restoration of the previous state of health under any circumstances unless in a vegetative state as certified by the treating medical practitioner.
Treatment of mental illness, stress or psychological disorders and neurodegenerative disorders.
Puberty and Menopause related Disorders: Treatment for any symptoms, Illness, complications arising due to physiological conditions associated with Puberty, Menopause such as menopausal bleeding or flushing.
Age Related Macular Degeneration (ARMD)
Behavioural and Neurodevelopmental Disorders:
(i) Disorders of adult personality;
(ii) Disorders of speech and language including stammering, dyslexia;
Internal congenital diseases, genetic diseases or disorders.
Expenses related to any admission primarily for enteral feedings.
If specified aetiology for the medical condition is not known.
Failure to seek or follow medical advice or failure to follow treatment.
Rationale for Existing Disease to be Permanently Excluded:
Every Insurance Company has a right to know any pre-existing disease of the proposer before underwriting the proposal, therefore the insured should disclose any pre-existing disease at the time of signing the proposal form. However, it is a prerogative of insurer that while approving health insurance coverage of the proposer with the existing diseases to levy suitable loading over the normal premium, if underwriter accepts the same. All diseases other than those allowed to be permanently excluded shall be covered subject to the norms applicable for pre-existing diseases (i.e. up to 48 months waiting period).
Only 16 diseases and their subcategories as given in the circular are allowed to be permanently excluded.
Sarcoidosis
Malignant Neoplasms
Epilepsy
Heart Ailment Congenital heart disease and valvular heart disease
Cerebrovascular disease (Stroke)
Inflammatory Bowel Diseases
Chronic Liver diseases
Pancreatic diseases
Chronic Kidney disease
Hepatitis B
Alzheimer's Disease, Parkinson's Disease
Demyelinating disease
HIV & AIDS
Loss of Hearing
Papulosquamous disorder of the skin
Avascular necrosis (osteonecrosis)
It is made clear by IRDAI that only those existing diseases as referred above be limited to the ICD Codes of the respective diseases. No claim which does not relate to the ICD codes referred in the circular can be denied.
Modern Treatment Methods and Advancement in Technologies:
IRDAI wants to ensure that the policyholders are not denied availability of health insurance coverage to Modern Treatment Methods. The following Procedures shall be covered (wherever medically indicated) either as in-patient or as part of domiciliary hospitalization or as day care treatment in a hospital.
Uterine Artery Embolization and HIFU
Balloon Sinuplasty
Deep Brain stimulation
Oral chemotherapy
Immunotherapy- Monoclonal Antibody to be given as injection
Intra vitreal injections
Robotic surgeries Stereotactic radio surgeries
Bronchial Thermoplasty
Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
IONM - (Intra Operative Neuro Monitoring)
Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.
However, insurers can make suitable sub-limits for the above treatments. It has been further reiterated that Insurers may endeavour to cover any other modern treatment methods, which means that future treatments also need to be considered as and when they are used.
Issue of Non-declaration/Misrepresentation of Material Facts:
The guidelines have given clarity to a major discrepancy which lot of policy holders used to face, that was cancellation of policy due to non-disclosure/misrepresentation. Such cancellation used to not only result in repudiation of the claim but also in effect shut out all future insurance coverage as any other insurer refuses to extend cover, if an earlier insurer had cancelled the policy on the above grounds. In order to prevent this situation, the IRDAI offers either the Insurance Company exclude the disease permanently and continue with policy or charge extra premium henceforth after the detection of the disease. Lastly, the insurance company can incorporate waiting period of another 48 months to cover the disease with aforesaid three options for insurers.
Moratorium Period Clause:
A great and necessary innovation is the moratorium clause. It states that after completion of eight continuous years under the policy no look back to be applied. The moratorium would be applicable for the sums insured of the first policy and subsequently completion of 8 continuous years would be applicable from date of enhancement of sums insured only on the enhanced limits. After the expiry of Moratorium Period no health insurance policy shall be contestable except for proven fraud and permanent exclusions specified in the policy contract.
Pre & Post Hospitalisation Benefit Allowed under Domiciliary Treatment Benefit Covid-19 has brought home the need for treatment at home due to unavoidable circumstances and hence the IRDAI has stated that Pre/Post hospitalization cover under Domiciliary Treatment benefit shall not be excluded where pre/post hospitalization cover is offered in case of in-patient hospitalization under the product and the underlying product covers domiciliary hospitalization.
Additional Covers and Clarity on what is covered:
The Exclusion Clauses made compulsory and uniform has also brought in certain welcome beneficial covers with clarity.
1) The most important is the coverage for Surgical Treatment of Obesity only if prescribed by doctors. The following severe co-morbidities following failure of less invasive methods of weight loss:
Obesity-related cardiomyopathy
Coronary heart disease
Severe Sleep Apnoea
Uncontrolled Type 2 Diabetes
2) Plastic Surgery Treatment Allowed for: Reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.
3) Hazardous Activities cannot be excluded but only Hazardous or Adventure sports.
4) Excluded Hospitals can Treat Emergency Cases and the Insured can get the claim. However, in case of life-threatening situations following an accident, expenses up to the stage of stabilization are payable but not the complete claim.
5) Ectopic Pregnancy and miscarriage due to accident will be covered. Thus expenses towards miscarriage due to an accident are also covered.
The above might be technical for many, please get in touch with your advisor for better understanding and clarity on the policy you renew now onwards.