Exclusions under health insurance set to reduce with new IRDAI guidelines

Rajalakshmi Nirmal BL Research Bureau | Updated on October 08, 2019 Published on October 08, 2019

Premium would be higher by 10-15 per cent compared to older policies   -  istockphoto.com

Products compliant with the new Guidelines on Standardisation of Exclusions in health insurance contracts will be in the market in the next three months


There is good news for health insurance buyers. IRDAI – the insurance market watchdog, has introduced a set of new guidelines that is set to make health insurance policies more comprehensive and policyholder friendly.

Insurance companies are allowed to sell their existing policies for one more year (till October 1, 2020). But any new health product for the retail segment that insurers file with the regulator here on, has to comply with the new guidelines. Existing holders of health policy need not stress out. At the time of the renewal, your existing policy will be revamped to adhere to the new regulations.

Health products compliant with the new Guidelines on Standardisation of Exclusions in Health Insurance contracts would be in the market in the next three months, say insurance companies. Premium would be higher by 10-15 per cent compared to older policies, as they will be offering wider coverage, they add.

1 Cover extended for more diseases

All along health insurance companies had excluded many lifestyle disorders and those relating to genetic problems. Now, all of these have to be covered. Women can also heave a sigh of relief as health insurance hereon will cover gynaecology problems relating to menopause. According to the new regulation, health insurance policy cannot exclude– treatment of mental illness, stress or psychological disorders; puberty and menopause related disorders; genetic disorders, internal congenital diseases; speech disorders and injury or illness associated with hazardous activity. Yashish Dahiya, CEO & Co-Founder, Poliybazaar.com adds that insurance companies are now required to also cover age related ailments such as cataract surgery and knee-cap replacements. Insurers also cannot exclude diseases contracted after taking the policy. So, say in case a person is diagnosed with a chronic kidney disease after a few months of issuance of the policy and the condition was not under permanent exclusion at the time of issuing the policy, the insurance company has to cover it.

2 Existing diseases allowed to be permanent exclusions

Insurance companies have been allowed to exclude diseases that are disclosed by a prospective policyholder as permanent exclusion under the policy with his consent. This will help those people who would have otherwise been rejected a policy also get covered. Currently, for instance, anyone with a Parkinson’s or Alzheimer’s disease stands very little chance of getting a health cover. But with new regulations, insurers may come forward to cover such patients as there is option to list the specific disease as a permanent exclusion and cover the individual for other illnesses. The regulator has also listed illnesses that an insurance company can incorporate as permanent exclusions. This checks insurers from putting ‘all and sundry’ claims under permanent exclusions for a policyholder. The list includes – epilepsy, congenital heart disease, cerebrovascular disease (stroke), chronic liver diseases (includes fibrosis, cirrhosis of liver and alcoholic cirrhosis of liver among others), pancreatic diseases, chronic kidney diseases (including renal failure and hypertensive renal disease), loss of hearing, Hepatitis B, Alzheimer’s and Parkinson’s disease and HIV among others. Note that permanent exclusions can be incorporated only at the time of signing up for the policy; it cannot be done at the time of renewal.

3 Standard wordings of exclusions brings transparency

There has always been a lot ambiguity over what is covered and what is not, owing to lack of clarity around definitions of certain terminologies used in health insurance, as they vary from insurer to insurer. This leads to problems for policyholders at the time of claim. This is now set to change. The regulator has given a precise definition to various jargons that include – specified disease waiting period, 30-day waiting period, and ‘excluded providers’. Certain illnesses have also been more clearly defined such as obesity, refractive error, sterility and infertility and maternity to bring uniformity across policies. The new guidelines also now defines hazardous or adventure sports include para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing, scuba diving, hand gliding, sky diving and deep-sea diving, though the regulator adds that the list is not exhaustive. The injuries resulting from these sports will be excluded from cover .

4 After eight years, no claims shall be contestable

If eight years have passed by after issuance of the policy, the insurance company cannot reject any claim of the policyholder on grounds other than fraud says the new regulation. Hence the insurer cannot use vague pretexts or excuses for rejecting a claim as in the past. This is a big positive for a policyholder. Now, the question that arises is, will this new piece of regulation help only if the policyholder had renewed the policy with the same insurance company? Not necessarily, says, Subramanyam Brahmajosyula, Head - Underwriting & Reinsurance, SBI General Insurance. “So, as long as you are renewing the policy continuously for 8 years, the policyholder would be given the benefit of doubt”.

5 Coverage for new treatment methods

To ensure that health insurance policyholders get the benefit of modern treatment methodologies, the regulator has listed some procedures that all insurers should cover. This includes – Balloon Sinuplasty, Deep brain stimulation, oral chemotherapy, immunotherapy, intra vitreal injections, robotic surgeries and stem cell therapy, among others. IRDAI, however, gives freedom to insurers to impose sub-limits on these treatments.


Published on October 08, 2019
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