Hyderabad:
In a bid to rationalise and standardise the exclusions in health Insurance covers IRDAI on Thursday has proposed a new set of norms for all the health insurance products excluding personal accident, domestic and overseas travel policies.
All existing health insurance products that are not in compliance with these guidelines will not be offered and promoted by the insurers from 01st April, 2020 onwards, said IRDAI.
Every health insurance product has to cover all pre existing diseases disclosed by the persons to be insured immediately after the expiry of the forty-eight months waiting period or such lower period as stipulated in the product, said the IRDA’s draft exposure draft.
After completion of eight continuous years under the policy no look back to be applied. This period of eight years is called as moratorium period.The moratorium would be applicable for the sums insured of the first policy and subsequently completion of eight 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.
The draft exposure has further said that the waiting period for life style conditions namely, Hypertension, Diabetes, Cardiac conditions is not allowed for more than 30 days except if these diseases are pre-existing and disclosed at the time of underwriting.
The insurance regulator has said that no health insurance policy can incorporate the following exclusions in the terms and conditions of the policy contract. They are:diseases contracted after taking the health insurance policy, injury or illness associated with hazardous activities, impairment of persons’ intellectual faculties by usage of drugs, stimulants or depressantsas prescribed by a 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, Disorders of adult personality including gender related problems, disorders of speech and language including stammering, dyslexia;
Insurers also can't deny coverage for claims of Oral Chemo therapy, where Chemo therapy is allowed and Peritoneal Dialysis, where dialysis is allowed.
Insurers are allowed to incorporate the following existing diseases disclosed by the person to be insured at the time of underwriting as permanent exclusions with due consent of the proposer or person to be insured.The permanent exclusion would be specific for the 17 listed conditions. However, these permanent exclusions shall be allowed only in cases where the policyholder may be denied coverage as per the underwriting policy of the Insurer for the existing diseases disclosed at the time of underwriting. They are:Sarcoidosis, Malignant Neoplasms, Epilepsy, Heart Ailment Congenital heart disease and valvular heart disease, Cerebrovascular disease (Stroke), Chronic Liver diseases, Pancreatic diseases, Chronic Kidney disease, Hepatitis B, Alzheimer's Disease, Parkinson's Disease, Demyelinating disease, HIV & AIDS, Loss of Hearing, Any Physical Disability, Papulosquamous disorder of the skin, Avascular necrosis (osteonecrosis)
To ensure that the policyholders are not denied availability of health insurance coverage to modern treatment methods, insurers have to ensure that the some of the treatment procedures should not be excluded in the health insurance policy contracts. These 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.They are:Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered,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.
All stakeholders are requested to offer their comments on the proposed guidelines by 31st May.