Health insurance: Stopping arbitrary hikes in premium
IRDAI steps in at a time when Arbitrary hikes premium In Insurance of health insurance policies regulations for wider coverage of exclusions.
General & standalone health insurance companies will not be allow to increase the premium.
A policy by modifying the existing benefits & adding new benefits in the existing products.
However, insurers can offer addition of new benefits upgradation of existing benefits as add-on covers.
Optional covers with a standalone premium rate to ensure an inform choice to the policyholders.
Pricing of products
(IRDAI) ensure that the financial viability of every health insurance product at the end of every financial year.
The report of such review should be submits to their board along with the analysis of favorable or unfavorable experience of product.
Ensure sustainability of the product & to protect the interests of policyholders of the underlying product.
The circular from the regulator comes at a time when several insurers have hike the premium.
Health insurance policies citing regulations for wider coverage and standardization of exclusions.
Last year, the regulator had standardize the nomenclature and procedure for 22 critical illnesses that form part of a health insurance policy.
All health insurers will have to use the definitions without exception wherever the products are offered for coverage.
Insurers have also hike the premium because of the rising Covid- 19 relate claims & increasing medical inflation.
The regulator had clarify that the increase in premium due to the change in norms would not be more than 5% of the originally approve premium rates.
Moreover, in order to enable all sections of policyholders to easily understand the contents of policy contracts.
The policy contracts of all health insurance products must have a clear heading such as standard definitions.
Specific definitions, benefits cover under the policy, exclusions. to draw the attention of policyholders.
The wordings of all the standard exclusions, standard terms & clauses and standard definitions use in the policy contract will have to comply with the wordings as specified by the regulator.
This new format will have to do for all health insurance policies issue from October 1, 2021.
The regulator has underline that policyholders must get clear & transparent communication at various stages of claim processing.
Insurers in place systems to enable policyholders track the status of cashless claims file with the Insurer through the website.
The status will cover from the time of receipt of request to the time of disposal of the claim along with the decision taken.
In cases where the claims are processed through TPAs, the insurers can let their TPAs operationalize.
The claim tracking mechanism and the policyholders will be notified in all the communications.
Insurers will have to ensure that the repudiation of the claim is not based on “presumptions and conjectures”.
If the claim is denied or repudiated, the communication about the denial or the repudiation has to be made only by the insurer by specifically stating the reasons for the denial or repudiation.
The insurer will also furnish the grievance redressal procedures available with the insurance company.
The insurance ombudsman along with the detailed addresses of the respective offices.