Health insurance customers may soon get relief in the form of coverage for certain diseases and medical procedures that were earlier excluded.

Working group set up

The Insurance Regulatory and Development Authority (IRDAI) has set up a working group to be chaired by Suresh Mathur, ED (Health), IRDAI, to examine the exclusions prevalent in health insurance and rationalise them by minimising the number to enhance the scope of health insurance coverage.

Lifestyle changes

According to Puneet Sahni, Head-Product Development, SBI General Insurance, certain procedures which were earlier excluded, could now find their way into coverage due to changes in lifestyle and advancement in medical technology.

“Peritoneal dialysis, for instance, was excluded as it did not entail hospitalisation, but for chronic patients, it is better when compared to the normal dialysis.

“Even bariatric is excluded, but if you see obesity is no more a lifestyle disease. These things may be reviewed comprehensively to ensure better coverage to a customer,” Sahni told BusinessLine .

Significantly, the working group has been asked to rationalise the exclusions that disallow coverage with respect to new modalities of treatments and technologically-advanced medical treatments.

“Rationalisation of exclusions will help improve penetration of health insurance in the country,” said S Prakash, Chief Operating Officer (COO), Star Health and Allied Insurance.

“The number of exclusions, both for diseases and procedures, have gone up in recent times, and the wordings vary from company to company, making it a little confusing for customers,” said Sanjay Datta, Chief-Underwriting and Claims, ICICI Lombard General Insurance.

“Some of the congenital and pre-existing diseases should be seen in the light of recent developments in healthcare, and the same is true for procedural exclusions. The discussions (of the working group) could be centered around how to position these and some of the new ones that are coming up in the context of health insurance,” said Datta.

A source of dispute

According to P Nandagopal, Founder and CEO, Insurance Inbox, exclusions and the way they are worded are the biggest source of dispute between the insurer and the insured.

“The standardisation and rationalisation of exclusions will help customers get better understanding of their health insurance policy, and will also ensure uniformity in the claims process across the health insurance industry, thereby reducing customer grievances,” said Anurag Rastogi, Member of Executive Management, HDFC ERGO.

“However, it is important to be careful as ‘over standardisation’ may curb ‘innovation’,” said Rajive Kumaraswami, MD and CEO, Magma HDI.