The Insurance Regulatory and Development Authority of India (IRDAI) has taken a significant step towards empowering policyholders and promoting inclusive health insurance with its new Master Circular on Health Insurance Products dated 29.05.2024
Key Highlights for Policyholders:
Diverse Product Offerings: Insurers must provide a wide range of products, add-ons, and riders catering to various ages, regions, occupations, and medical conditions, ensuring affordability and suitability for all policyholders.
Customer Information Sheet (CIS): Simplifies insurance details, including coverage, exclusions, deductibles, and waiting periods, for easy understanding.
Flexible Choices: Policyholders can select products and riders based on specific medical needs.
Multiple Policy Claims: Allows choosing which policy to claim from, with coordination from the primary insurer for any balance amount.
No Claim Bonus Options: Rewards for no claims can be in the form of increased sum insured or premium discounts.
Premium Refunds: Pro-rata premium refunds available for policy cancellations.
Guaranteed Renewability: Policies are renewable without new underwriting, except in cases of fraud or misrepresentation.
Compliance for Insurers:
Technology Integration: Insurers must provide seamless onboarding, renewals, and policy servicing with end-to-end technology solutions.
Cashless Claims: Aim for 100% cashless claim settlements promptly.
Hospital Empanelment: Include diverse healthcare providers to ensure affordability.
Transparency on Website: Display hospital networks, claim procedures, and timelines.
Quick Claim Processing: Immediate decisions on cashless requests and swift final authorizations on hospital discharge.
Claims Review Committee: No claim repudiations without committee approval.
Document Collection: Insurers and TPAs must collect required documents directly from hospitals.
Additional Provisions:
Portability Requests: Stricter timelines for handling portability requests.
Ombudsman Awards: Insurers must implement awards within 30 days or pay Rs. 5000 per day.
AYUSH Treatment: Equal treatment options for AYUSH therapies.
TPA Performance: Regular monitoring and payment based on satisfactory service.
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