As an ode to the health insurance policyholders and to make health insurance way more customer-oriented, the Insurance Regulatory and Development Authority of India (IRDAI) has issued several new guidelines defining the new laws and policies around Exclusions and Pre-existing Diseases (PED) in health insurance covers. The many revisions in the existing laws around health insurance are believed to benefit the customers to a great extent. The revisions are set to make the coverage way more comprehensive and efficient for the policyholders.
As per the modification guidelines issued in context to standardization of health insurance policies, the definition of Pre-existing Diseases (PED) has been modified to cater to the needs and requirements of different customers. In accordance with the new guidelines, any disease/s or ailment/s that is/are diagnosed by a physician 48 months prior to the issuance of the health cover will be classified under PED. Also, any disease/s or ailment/s for which any type of medical advice or treatment was recommended by a qualified doctor 48 months prior to the issuance of the policy will also be qualified under PED. Apart from this, any condition whose symptoms or signs have resulted within three months of the issuance of the policy will also be classified under Pre-existing Diseases.
To ensure that policyholders suffering from pre-existing diseases get adequate health insurance coverage, IRDAI has made it clear that insurance companies can include permanent exclusions only after due consent of the customers. Apart from a list issued by the IRDAI drafting panel, no other exclusions will be allowed in the health insurance policies. As per the guidelines, all health conditions and illnesses acquired after the issuance of policy will be covered under the policy. Some of the important and major diseases that must be added to the list include Alzheimer, Parkinson, AIDS/HIV and morbid obesity.
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Apart from these critical ailments, IRDAI has even issued a list of guidelines that specify the various ailments that will now be covered under every health insurance policy. The insurers will be now barred from excluding ailments contracted due to hazardous activity, treatment of mental illness, artificial life maintenance, age-related degeneration and internal congenital diseases. Other barred exclusions include behaviour and neurodevelopment disorders, puberty and menopause-related disorders, genetic diseases and disorders.
Further, age-related ailments including cataract surgery and knee-cap replacements would also have to be covered. Also, factory workers, working with harmful chemicals, which impact health over a long-term period, cannot be refused respiratory or skin ailments that arise as a result of workplace conditions.
The Insurance Regulatory and Development Authority (IRDAI) has also standardised the exclusions in a health insurance policy which mean if an insurer does not want to cover some specific ailments like epilepsy, chronic kidney diseases and HIV/AIDS must use specific wordings as defined by the regulatory body in the policy terms. The insurer must also specify a waiting period i.e. 30 days to 1 year after which the coverage would begin of the ailment.
As per the issued guidelines, all the suggested provisions shall be applicable in respect of all health insurance products including both individual and group health covers purchased on or after 1st October 2019. For all the existing health insurance products that are not in compliance with the issued guidelines, they will not be offered or promoted by the insurers post 1st October 2020.
(By Amit Chhabra, Head-Health Insurance, Policybazaar.com)