Insurance Regulatory and Development Authority

10.01.2017

Insurance

Clarifications in respect of the provisions of IRDAI (Health Insurance) Regulations 2016 and Guidelines on Product Filing in Health Insurance

MANU/IRDA/0002/2017

Reference is invited to the provisions of Guidelines on Product Filing in Health Insurance notified vide ref: IRDA/HLT/REG/CIR/150/07/2016 dated 29th July, 2016 (hereafter referred as the Guidelines). Under the powers vested in Regulation 2 (i) (o) read with Regulation 39 of IRDAI (Health Insurance) Regulations, 2016, the following clarifications are issued.

I. The following clarifications / further provisions shall be effected in CHAPTER - II of the Guidelines.

1. Reference to Clause (2) (I) (j) in Clause (3)(II)(iii) shall be replaced with Clause (3) (I) (j). On replacing, the first sentence of Clause (3) (II) (iii) shall be read as under;

"Insurers shall comply with Clause (3) (I) (d), Clause (3) (I) (e), Clause (3) (I) (i) and Clause (3) (I) (j) referred above,"

2. After Clause (4) (xiv) the following additional sub-clauses are incorporated.

(xv) "Any revision or modification including a revision in the price of a policy which is approved by the Authority shall be notified to policyholders at least ninety days prior to the date when such revision or modification comes into effect. The notice shall set out the revisions or modifications affected, and the changes in premium, if any. The possibility of a revision or modification of the terms of the policy including the premium must be disclosed in the prospectus and policy wordings.

(xvi) "Norms for AYUSH Coverage: In addition to the hospitals specified in Regulation 18-'AYUSH Coverage' of IRDAI (Health Insurance) Regulations 2016, General and Health Insurers may also provide coverage for one or more systems covered under 'AYUSH treatment, provided the treatment has been undergone in:

i. Teaching hospitals of AYUSH colleges recognised by Central Council of Indian Medicine (CCIM) and Central Council of Homeopathy (CCH)

ii. AYUSH Hospitals having registration with a Government authority under appropriate Act in the State/UT and complies with the following as minimum criteria:

a) has at least fifteen in-patient beds;

b) has minimum five qualified and registered AYUSH doctors;

c) has qualified paramedical staff under its employment round the clock;

d) has dedicated AYUSH therapy sections;

e) maintains daily records of patients and makes these accessible to the insurance company's authorized personnel

(xvii) "Norms for settlement of claims under multiple policies: On the norms prescribed in Regulation 24(ii)(2) (Multiple Policies) of IRDAI (Health Insurance) Regulations, 2016, it is further clarified that the policyholder having multiple policies shall also have the right to prefer claims from other policy / policies for the amounts disallowed under the earlier chosen policy / policies, even if the sum insured is not exhausted. Then the Insurer(s) shall settle the claim subject to the terms and conditions of the other policy / policies so chosen.

II. The following further provisions shall be effected in CHAPTER - IV of the Guidelines.

1) Clause III (2) shall be substituted with the following provision and shall be read as under:

"No changes shall be effected in respect of any group insurance product filed under the Use and File. However, where a modification is to be made to such Group Health product, the iteration mentioned under Use and File procedure shall be followed afresh.

III. Annexure-I, Section II, 2.8.9 shall be replaced with the following and shall be read as under: "Maximum renewal Age"

Insurers and, Third Party Administrators wherever applicable, are advised to make a note of the above clarifications and ensure compliance.

Tags : Clarifications provisions IRDAI

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