KNOW THE NEW GUIDELINES ON YOUR MEDICAL INSURANCE
GST ON HEALTH INSURANCE: GST COUNCIL DEFERS DECISION
Dated 09.09.2024 : The 54th GST Council meeting was held as scheduled today in New Delhi. The meeting was chaired by Union Finance Minister Nirmala Sitharaman.
There was much anticipation about the reduction of GST rates for purchase of life and health insurance policies in today's council meeting , especially for the senior citizens . The existing rate for the Health insurance is 18% and it was rumoured that the rate might be reduced to 0% / 5 % especially for the senior citizens .
In the meeting ,the council members had a broad consensus to reduce the GST rate on health insurance premiums, providing relief to individuals and senior citizens . But no final decision was taken today . GST Council recommended to constitute a Group of Ministers (GoM) to holistically look into the issues pertaining to GST on the life insurance and health insurance. The GoM members are Bihar, UP, West Bengal, Karnataka, Kerala, Rajasthan, Andhra Pradesh, Meghalaya, Goa, Telangana, Tamil Nadu, Punjab, and Gujarat. The GoM is to submit the report by end of October 2024.
The final decision is expected to be taken in the next meeting which might take place in the month of November 2024 .
Master Circular on Protection of Policyholders' interests 2024 :
Dated 06.09.2024: A master circular is issued by the IRDAI under the Insurance Act, 1938, on 05.09.2024 for the Protection of Policyholders' Interests .
The master circular contains two sections as under:
2.1. Section 1: It contains summary of important and relevant information at various stages of an insurance contract for the prospects / policyholders / customers. A prospect or policyholder to know his/ her rights and obligations at various stages of an insurance policy may visit this Section.
Important and relevant information at various stages of Life Insurance Policies are in Part A, , Health Insurance Policies are in Part B, and Retail General Insurance Policies are In Part C. Separate Master Circulars on certain relevant and important aspects of insurance business are also issued on Life Insurance Business; Health Insurance Business and General Insurance Business .
2.2. Section 2: It contains broad requirements to be complied with by an insurer under the Regulations.
SOME IMPORTANT CLAUSES ON SETTLEMENT OF CLAIMS :
i. The policyholder or the claimant, as applicable, is required to intimate the insurer, about the happening of a claim under the insurance policy, at the earliest possible time either in person or through: a) Online mode; b) distribution channel; c) Third Party Administrator (TPA); d) Hospital /Health care Provider where such facility is provided; e) authorized call center of the insurer; f) any other mode as may be specified in the policy document.
ii. No claim shall be rejected or closed for want of documents or for delayed intimation of the claim
Processing of claim
i. Claim intimation received by the insurers shall be processed and settled within timelines specified.
ii. In case the claim is not settled within the specified timelines, then the claimant is entitled for interest at bank rate plus 2 percent from the date of receipt of intimation
to till the date of payment. Such interest shall be suo-moto paid by the insurers.
TIME LIMITS for Cashless facility for health insurance
1.. Approval for Cashless facility: Insurer shall decide on the request for cashless authorization immediately but not more than one hour of receipt of request.
2. Final authorization for Discharge from the hospital i. Insurer shall grant final authorization within three hours of the receipt of discharge authorization request from the hospital. In no case, the policyholder shall be made to wait to be discharged from the Hospital. ii. If there is any delay beyond three hours, the additional amount if any charged by the hospital shall be borne by the insurer from shareholder's fund.
3. Settlement of health insurance Claims
1. . Insurer shall ensure that the claims registered are attended to at speed and the claims are settled at the earliest possible time.
2. Pursuant to intimation of the claim, Insurers and Third-Party Administrators (TPAs), shall collect the required documents from the Hospitals. Policyholder shall not be required to submit the documents.
3. No claim shall be repudiated without the approval of Product Management Committee (PMC) or a three-member sub-group of PMC called the Claims Review Committee (CRC).
4. In case, the claim is repudiated or rejected or disallowed partially, details shall be communicated to the claimant along with full details giving reference to the specific terms and conditions of the policy document.
5. Settlement of claims (other than cashless) shall be settled within fifteen days from submission of claim.
NEW GUIDELINES ON ISSUE ON HEALTH INSURANCE POLICIES
Note : A new Master circular dated 29.05.2024 has been issued by IRDAI which overrides the below notification . For details , CLICK HERE
Dated 21.04.2024 : IRDAI has issued notification to insurance companies issuing new guidelines for the issue of health insurance policies and the notification is operative from 01.04.2024 . Two types of policies can be issued :
2.1.1 Indemnity based health insurance policy means an insurance policy that compensates an insured for the loss due to occurrence of an insured event as specified in the policy.
2.1.2 Benefit based health insurance policy means an insurance policy that pays fixed amount on the occurrence of an insured event as specified in the policy.
SALIENT FEATURES OF THE GUIDELINES
:
1. Insurers shall ensure that they offer health insurance products to cater to all the age groups.
2. Insurers may design products specifically for senior citizens, students, children, maternity and any other group as specified by the Competent Authority
3. Waiting period for pre-existing diseases disclosed by the persons to be insured, shall be maximum up to 36 months of continuous coverage under the Health Insurance policy.
4. Moratorium Period : After completion of sixty continuous months of coverage (including portability and migration) in health insurance policy, no policy and claim shall be contestable by the insurer on grounds of non-disclosure, misrepresentation, except on grounds of established fraud.
5. Renewal : A health insurance policy shall be renewable except on grounds of established fraud or non-disclosure or misrepresentation by the insured . An insurer shall not deny the renewal of a health insurance policy on the ground that the insured had made a claim or claims in the preceding policy years, except for benefit based policies where the policy terminates following payment of the benefit covered under the policy like critical illness policy.
6. General insurers and health insurers offering indemnity based health insurance policy shall provide an option of migration to an alternative health insurance product to the extent of the sum insured and the benefits available in the previous policy.
7. Special provisions for senior citizens: All insurers shall establish a separate channel to address the health insurance related claims and grievances of senior citizens. The details of such channel shall be available in the website of the insurers.
THE NOTIFICATION :
2. Classification of products: For the purpose of these regulations, health insurance products shall be classified into either indemnity or benefit based products and may be offered to individual or families or groups.
2.1. Types of policies:
2.1.1 Indemnity based health insurance policy means an insurance policy that compensates an insured for the loss due to occurrence of an insured event as specified in the policy.
2.1.2 Benefit based health insurance policy means an insurance policy that pays fixed amount on the occurrence of an insured event as specified in the policy.
3. Scope of health insurance business:
3.1. General insurers and health insurers may offer individual and group health insurance products on either indemnity and/or benefit basis. 3.2. Life insurers may offer individual and group health insurance products on benefit basis. Life insurers may also offer health insurance product under unit linked platform. Provided that a life insurer shall not offer indemnity based products either individual or group.
3.3. Credit linked products can be offered up to the loan period not exceeding five years.
3.4. Overseas or domestic travel insurance policies may only be offered by general insurers and health insurers.
3.5. Health insurance products of life insurers shall also be subject to the provisions in the Schedule I of these regulations, wherever applicable.
4. Pricing:
4.1Premium shall remain unchanged for the policy term. Insurers may offer facility of premium payment in instalment.
4.2Insurers may devise mechanism(s) or incentive(s) to reward policyholders for early entry, continued renewals, favourable claims experience, preventive and wellness habits and disclose upfront such mechanism or incentives in the prospectus and the policy document. Provided that what is proposed to be covered as part of wellness and preventive habits be clearly defined in each and every product.
5. AYUSH coverage: Insurers shall have a Board approved policy for providing AYUSH coverage, which interalia, shall include their approach towards placing AYUSH treatments at par with other treatments for the purpose of health insurance so as to provide an option for the policyholders to choose treatment of their choice.
6. Product design:
6.1Insurers shall ensure that they offer health insurance products to cater to all the age groups.
6.2Insurers may design products specifically for senior citizens, students, children, maternity and any other group as specified by the Competent Authority.
6.3Insurers shall endeavor to offer coverage for persons with all types of existing medical conditions.
7. Pre-existing diseases and specific waiting period: Waiting period for pre-existing diseases disclosed by the persons to be insured, shall be maximum up to 36 months of continuous coverage under the Health Insurance policy. Insurers may endeavor to have lesser preexisting disease waiting period and specific waiting period in the health insurance products. Provided that the above waiting period norm of pre-existing disease shall not be applicable for Overseas Travel Policies.
8. Moratorium (applicable for health insurance policies issued by general and health insurers): After completion of sixty continuous months of coverage (including portability and migration) in health insurance policy, no policy and claim shall be contestable by the insurer on grounds of non-disclosure, misrepresentation, except on grounds of established fraud. This period of sixty continuous months is called as moratorium period. The moratorium would be applicable for the sums insured of the first policy. Wherever the sum insured is enhanced, completion of sixty continuous months would be applicable from the date of enhancement of sums insured only on the enhanced limits.
9. Renewal of health policies issued by general insurers and health insurers (not applicable for travel and personal accident policies):
9.1 A health insurance policy shall be renewable except on grounds of established fraud or non-disclosure or misrepresentation by the insured, provided the policy is not withdrawn and also subject to conditions stated at clause 8 of this schedule.
9.2 An insurer shall not deny the renewal of a health insurance policy on the ground that the insured had made a claim or claims in the preceding policy years, except for benefit based policies where the policy terminates following payment of the benefit covered under the policy like critical illness policy.
9.3 The insurer shall condone a delay in renewal up to the grace period from the due date of renewal without considering such condonation as a break in policy.
9.4 For individual products, the loadings on renewal premium shall be at portfolio and not based upon any individual policy claim experience. However, discount in premium may be provided by insurers to individual policyholders for good claims experience.
9.5 No insurer shall resort to fresh underwriting by calling for medical examination, fresh proposal form etc. at renewal stage where there is no change in sum insured offered. Provided that where there is an improvement in the risk profile, the insurer may endeavour to recognize that for removal of loadings at the point of renewal.
10. Migration and portability of health insurance policy:
10.1 General insurers and health insurers offering indemnity based health insurance policy except Personal Accident and Travel Policies, shall provide an option of migration to an alternative health insurance product to the extent of the sum insured and the benefits available in the previous policy. The insurer may underwrite the proposal in case of migration, if the insured is not continuously covered for 36 months.
10.2 All indemnity based health insurance policies issued by general and health insurers except Personal Accident and Travel Policies, shall allow the portability of policies to the extent of the sum insured and the benefits available in the previous policy, irrespective of individual or group policy subject to the Board approved underwriting policy of the insurers.
10.3 Life insurers may allow portability, wherever possible, as per the policy terms.
11. Special provisions for senior citizens: All insurers shall establish a separate channel to address the health insurance related claims and grievances of senior citizens. The details of such channel shall be available in the website of the insurers.
To read the Gazette notification of IRDAI , CLICK HERE
NATIONAL HEALTH CLAIMS EXCHANGE :
National Health Claims Exchange : A Single window Insurance claims settlement on Hospitalization
Are you worried about the shoddy claim processing by your present TPA ? Delayed settlements ?
Now a common claim settlement platform in the offing to speed up the claim settlement , based on the initiative by National health Authority .
Dated 24.05.2024 : The National Health Claim Exchange (NHCX) is a digital platform being developed in India to streamline health insurance claims processing. It's a joint initiative between the National Health Authority (NHA) and the Insurance Regulatory and Development Authority of India (IRDAI) . The platform will be a single agency to process claims on the member health insurance companies.
The platform will
1. Check Coverage eligibility
2. . Preauth Request Submission
3. Predetermination Request Submission
4. Claim Submission
5. Payment Status
6. Communication Request
7. Reprocess Request
NHCX is expected to launch soon (reportedly within the next 2-3 months). Insurers and healthcare providers are being advised to onboard the platform. Government of India has initiated the development of the system to enable standardized and faster claims processing for better patient experience with reduced operations costs .
The expected benefits of the new system of claim settlements for the policy holders include Reduced wait time , Faster preauthorization and discharge approvals from insurance companies , • Reduced cost of insurance premiums , More types of claims coverage in future including, OPD, Pharmacy Bills etc.
The expected benefits to the hospitals include Single Payer Network , • Universal claims format • Faster payments by the insurannce companies , Improved patient experience , Better visibility of claims status and Paperless operations .
Insurance companies will have reduction in overhead operational costs , • Enabling new processes/rules for auto adjudication, control
fraud and abuse prevention , • Reduction in claims processing cost per each claim , Paperless operations and Better quality of data for
Industry and regulators
For further details , visit NHCX Website
MAXIMUM WAITING PERIOD REDUCED FOR PRE EXISTING DISEASES :
Dated 14.04.2024 : As per the latest IRDAI notification dated 20.03.2024 , Health insurance companies cannot stipulate a period of more than 36 months for the Waiting period for pre-existing diseases disclosed by the persons to be insured . Insurers may prescribe lesser pre existing disease waiting period and specific waiting period in the health insurance products. The new regulation is effective from the 1st , April 2024 .
Further the new regulation also removes the burden on the policyholders to declare pre-existing diseases for which they have not taken any treatment within the last 3 years or ailments diagnosed beyond 3 years.
As per the new notification , “Pre-existing disease (PED)” means any condition, ailment, injury or disease:
a) that is/are diagnosed by a physician not more than 36 months prior to the date of commencement of the policy issued by the insurer; or
b) for which medical advice or treatment was recommended by, or received from, a physician, not more than 36 months prior to the date of commencement of the policy.
Earlier insurers were allowed waiting period up 4 years and many insurers stipulate a waiting period of 24 months normally
This rule is not applicable to the overseas travel policies .
To read the notification , CLICK HERE
Galaxy Health and Allied Insurance company :
IRDAI GRANTS ONE MORE HEALTH INSURANCE LICENCE
Dated 31.03.2024 : Insurance Regulatory & Development Authority of India (IRDAI) in its 125th meeting held on 19 March, 2024 has granted Certificate of Registration to a new health insurer namely, Galaxy Health and Allied Insurance Company Limited to carry health insurance business in India. With this the number of insurers operating in health insurance segment has gone up to 7.
M/s Galaxy Health and Allied Insurance Company Limited is a Chennai head quartered insurance company
Medical insurance for visitors to India :
MEDICALS FOR NOMADS : International Medical insurance providers
Dated 30.03.2024 : We have been told by the USA based medical insurance company Medical For Nomads, that they are the distributor of international health & medical insurance policies underwritten by Regency Assurance . They serve the expatriates in over 120 countries worldwide including India . The insurance cover provided via Medical For Nomads is worldwide, EXCEPT the USA. They provide short term or regular medical insurance .
The overseas nationals visiting India , who may require medical insurance in India , may visit their website to know the services available with them . The services include cashless treatment for the policy holders .
PS : We have not independently verified the authenticity for the claims made by the company in their website or quality of their services and we do not take any responsibility what so ever for any transactions one undertakes with the company .
AYUSH TREATMENTS TO BE COVERED IN ALL HEALTH INSURANCE POLICIES :
AYUSH TO BE AT PAR WITH OTHER TREATMENTS
Dated 06.02.2024 : In view of growing popularity of AYUSH treatments , Insurance Regulatory & Development Authority of India ( IRDAI ) has asked all General and Health Insurers to consider AYUSH treatments at par with other treatments .
IRDAI has now directed the Insurers to have a Board approved policy for providing AYUSH coverage, which interalia, shall include their approach towards placing AYUSH Treatments at par with other treatments for the purpose of health insurance so as to provide an option for the policyholders to choose treatment of their choice. The policy shall also contain the quality parameters as well as procedure for enrolling AYUSH Hospitals/Day Care Centers as network providers for the purpose of providing cashless facility .
IRDAI has also asked the Insurers to modify their existing products that contain limitations for AYUSH Treatments and ensure compliance with above directions.
NOTE : AYUSH is a name devised from the names of the alternative healthcare systems covered by the ministry of Ayush : Ayurveda, Yoga & Naturopathy, Unani, Siddha, Sowa Rigpa, and Homeopathy.
To read IRDAI circular dated 31.01.2024 , CLICK HERE