The insurance regulator IRDAI, on Thursday, has laid down norms to standardize the general terms and clauses incorporated in indemnity based health insurance [excluding Personal Accident and Domestic / Overseas Travel] products by simplifying the wordings of general terms and clauses of the policy contracts and ensure uniformity across the industry.
In case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, the insured person will have the right to require a settlement of his/herclaim in terms of any of his/her policies. In all such cases the insurer chosen by the insured person are obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy, said the IRDAI..
Insured person having multiple policies will also have the right to prefer claims under this policy for the amounts disallowed under any other policy / policies even if the sum insured is not exhausted.Then the insurer has to independently settle the claim subject to the terms and conditions of this policy.
If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support , or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid will be forfeited.
The insurer will not repudiate the claim and / or forfeit the policy benefits on the ground of fraud, if the insured person / beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such misstatement of or suppression of material fact are within the knowledge of the insurer.
Any amount already paid against claims made under this policy but which are found fraudulent later has to be repaid by all recipient(s)/policyholder(s), who has made that particular claim,who shall be jointly and severally liable for such repayment to the insurer.
No loading shall apply on renewals based on individual claims experience, said the IRDAI..
Further, 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 claim will be contestable except for proven fraud and permanent exclusions specified in the policy contract. The policies would however be subject to all limits, sub limits, co-payments, deductibles as per the policy contract.