IRDA Makes Health Insurance Claims Easier

Recently, IRDA introduced many changes in Health Insurance to ensure that standardization can be achieved and the terms & conditions can be made clearer. These were more related to enhancement of some definitions, defining common terms clearly and inclusion of higher disclosure by the companies. As many as 46 common terms and 11 critical procedures are made to be define clearly by the insurers. All these changes were done with an objective to have higher transparency, increase scope of coverage and ease the claim process by making the fine prints bolder.

Here are few of those changes which will impact your health insurance policy claim going forward:

1. Portability: Launched in October 2010 it was considered to be a big relief for health insurance policy holders who were not satisfied with their existing insurer. However, portability was much used by the companies to allow their existing policyholders to even switch to their new products. This, IRDA has disallowed and so portability will be applicable within companies but not products within a company.
2. Room Rent: Many companies have limitations on various hospitalization expenses such as room rent, doctor fees, nursing expenses etc. All these sub-limits were implemented separately. But now room rent expenses will include nursing and medication expenses also. This will change the way sub-limits are charged now.
3. Hospitals: All companies have a list of hospital network where you can claim cashless treatment. In case you took treatment outside this network you can claim reimbursement. IRDA has defined the category of approved hospitals from which reimbursement can be claimed for health insurance. As per this definition such hospital should have min 15 beds, an operation theatre etc. This has been relaxed and now hospitals which come under Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act are also included in the list without any inpatient bed requirement. The condition will be applicable only on unregistered hospitals. This increases the number of hospitals from where reimbursement can be claimed thus benefiting public at large.
4. Deductibles:  In certain policies there are deductibles which you have to pay first and then the health insurance claim from the policy becomes payables. These deductibles can also come from other health insurance policies. It’s more of sharing your claim with the company. Top up and super top-up policies are products with deductible clauses. Now companies will have to clarify how the deductible will be applicable. Will it be once in a year or for every claim? If it is once in a year then the company will have to pay all the claims in the respective year while for every claim it will be applicable accordingly. Also, the insurance company will not be liable for a specific amount in case of indemnity policies and for specified number of days/hours in hospital cash policies.
5. Coverage for New Born: IRDA has changed the definition of new born also. Till now only baby born to the person were covered in a health policy. But now onwards adopted children’s born between 1-90 days during the policy period will also be covered. This is certainly a welcome move for parents who adopt new born and wants to have a sufficient health protection for them.
6. Maternity Expenses: In majority of health insurance policies maternity expenses can be claimed up to two deliveries or abortion in a lifetime or during the policy term. This condition has been relaxed and now maternity expenses will include medical treatment or expense traceable to childbirth, including caesarean sections during hospitalization and lawful abortions during the policy period. But pre natal and post natal expenses are still not included in the coverage.

Apart from this there are changes such as registered homeopathic practitioners have been included in the list of medical practitioners and many others definitions has been enhanced/deleted. All these changes in health insurance will bring standardization in the industry and will make claim process smother for policyholders. Take note of these changes to ensure you are well aware while making your claim or buying a health insurance.