The New IRDAI Health Insurance Regulations

If you don't really understand health insurance, you are not alone. To make health insurance simpler and more transparent for customers like you, the IRDAI (Insurance Regulatory and Development Authority) has issued a new set of guidelines and taken some important steps that will affect the kind of coverage you and your loved ones can get, including the inclusion of modern treatment methods, and the standardisation of health insurance exclusions.

Let's take a quick look at what these guidelines

1. The IRDAI has issued a list of treatments that need to be mandatorily covered by all insurers, thereby increasing the scope of coverage of all health insurance policies.

While these treatments cannot be permanently excluded, the insurer can add a waiting period for any of these diseases up to a maximum of 48 months.

Despite the waiting period, this new regulation is a victory in itself because up until now, these treatments would typically form a part of the permanent exclusions of most health insurance policies. This is also another reason to buy health insurance at an earlier stage in life.

2. The list of diseases and treatments that can no longer form a part of any health insurance policy is as follows:

a. Any disease contracted after the health insurance policy was purchased, other than the ones provided for in “Standard Wordings” issued by the IRDAI
b. Injury or illness resulting from participation in a hazardous activity, other than adventure or hazardous sports. This means, for example, coverage cannot be denied to an industrial worker who works in close proximity to harmful chemicals.
c. Any impairment to the insured’s intellectual facilities resulting from drugs etc. prescribed by a medical doctor
d. Artificial life maintenance until the doctor confirms the vegetative state of the patient
e. Treatment of mental illness, psychological disorders, neurodegenerative disorders, and behavioural and neurodevelopmental disorders
f. Treatment of puberty- or menopause-related disorders
g. Age-related macular degenerations
h. Internal congenital diseases, genetic diseases or disorders.

3. If your least favourite part in policy wordings is the exclusions section, you're not alone. However, that’s also one of the most important sections to be aware of when it comes to any health insurance policy.

This won’t be a problem anymore because the IRDAI has provided standard wording for exclusions and all insurers have to use this verbatim. This ensures that you can easily compare exclusions across various policies and do not have to worry about ambiguously worded exclusions.

4. As per IRDAI’s new guidelines, pre-existing diseases and any other specified diseases/procedures cannot have a waiting period of longer than 48 months. A pre-existing disease is any medical condition that a person is already suffering from before the benefits of their health insurance policy kick in.

5. IRDAI has provided a standard list of 16 pre-existing diseases that insurers can permanently exclude. Other than these 16, no other pre-existing diseases can be permanently excluded:**

a. Malignant Neoplasms
b. Sarcoidosis
c. Epilepsy
d. Heart ailment including congenital and valvular heart disease
e. Stroke
f. Inflammatory bowel diseases
g. Chronic liver diseases
h. Pancreatic diseases
i. Chronic kidney diseases
j. Hepatitis B
k. Alzheimer’s and Parkinson’s disease
l. Demyelinating disease
m. HIV & AIDS
n. Loss of hearing
o. Papulosquamous disorder of the skin
p. Osteonecrosis

6. To ensure that the insured has access to modern treatment methods, the IRDAI mandates that no health insurance policy shall exclude the following treatments. These treatments can be taken either as an in-patient or as part of domiciliary hospitalization.

a. Balloon Sinuplasty
b. Uterine Artery Embolization and HIFU
c. Deep Brain stimulation
d. Oral chemotherapy
e. Immunotherapy- Monoclonal Antibody to be given as an injection
f. Intra vitreal injections
g. Robotic surgeries
h. Stereotactic radio surgeries
i. Bronchial Thermoplasty
j. The vaporization of the prostate (Green laser treatment or holmium laser treatment)
k. Intra Operative NeuroMonitoring
l. Hematopoietic stem cells for bone marrow transplant.

7. Once the insured has had continuous coverage of eight years, no condition/disease other than the ones permanently excluded can be denied coverage. This applies even to undisclosed pre-existing diseases.

From covering mental illness to capping waiting period for pre-existing diseases, IRDAI is recognizing the need of the hour. So, #ThinkAhead and take advantage of these new norms. Review your health insurance policy and remember these new changes.