New health cover

Health insurance must be provided to people up to 65 years, and all mediclaim must be settled within a month.

In its draft norms, the Insurance Regulatory and Development Authority has also stated that an insurer must say in writing the grounds for refusing to provide a policy.

The norms come more than a year after consumer rights activist Gurang Damani filed a public interest litigation in the Bombay high court against the regulator pertaining to the settlement of medical insurance claims.

Insurers will have to provide cashless facility to policyholders undergoing treatment in a particular hospital even after it is removed from the list of preferred service providers.

Insurers should ensure that empanelled hospitals — where cashless facilities are offered — are spread across different cities and not confined only to the metros.

The draft also talks about portability, under which a policyholder can migrate to another insurer, without losing any benefit.

It has also proposed special provisions for senior citizens.

All the terms and conditions in the policy document have to be explicitly spelled out in a simple language.

Insurers will have to take into account any cumulative bonus that has accrued to the policyholder to determine the sub-limits on various expenses.

Till now, insurers used to consider only the initial sum assured to determine the sub-limits on expenses such as hospital room rents and daily ICU allowance.

Non-life insurers issuing policies will have to reimburse the policyholder 50 per cent of the medical examination cost prior to providing a cover. If the policy is issued by a life insurer, it will have to bear the entire cost of the check-up.

Insurers will also have to disclose in the policy document any loading charged on the premium through a pre-defined table.

If the individual claim experience for each of the three preceding years is more than 500 per cent of the premium at present, the insurer will load the renewal premium according to the table. A hike in premium must be mentioned in writing and properly justified.

Policies will now cover non-allopathic treatments, provided they are obtained from a government or an accredited hospital.