NEW DELHI: This month has seen a large scale revamp of the Indian health insurance sector, resulting in, among other things, higher premiums due to mandatory coverage for conditions excluded earlier, EMI-based premium payments, and a major change to the pre-existing conditions clause.
The Insurance Regulatory and Development Authority of India (IRDAI) has over the past few months, announced several tweaks to health insurance guidelines, a process accelerated by the outbreak of the Covid-19 pandemic. All these changes have gone into force beginning October 1 on all new and existing health insurance policies.
Among the more significant changes is the one where previously uncovered conditions are now mandatory under a general health insurance cover. Insurers are now barred from excluding conditions such as those arising due to hazardous activity, treatment for mental illnesses, age-related conditions such as cataracts, internal congenital diseases, artificial life maintenance, etc.
A comprehensive health insurance plan has to cover all these, besides others such as behaviour and neurodevelopment disorders. The flipside, of course, is that this has resulted in health premiums rising sharply-upto 45 per cent in some cases. Industry analysts say that the average price rise is likely to be around 15-20 per cent across products.
But, the tweaks have also standardised exclusion policies. Insurers now have to spell out specifically the conditions that are not covered under the insurance policy to the customers, with detailed guidelines on specific words laid out by the regulator. No insurers will be able to reject claims on an insurance policy that has completed eight years where the customer has paid premiums continuously, except in cases of proven fraud and permanent exclusions.
The definition of pre-existing disease/conditions (PED) have also been modified. Now, any condition diagnosed by a physician 48 months before the policy is issued will be classified as a PED. As will any condition for which any medical advice or treatment was recommended by a qualified doctor 48 months before issuance. Conditions whose symptoms have resulted within three months of the issuance are also PEDs. However, the regulator has also issued a list of exclusions that will be allowed, and insurers are not allowed to exclude any condition which does not feature on this list.
EMI premium payments