In a welcome move for ailing patients and their families, the Insurance Regulatory and Development Authority (IRDAI) has amended its rules to allow a lot of new disorders onto their standardized list. These rules will be applicable to all insurance companies.
Speech and language disorders, stress and mental disorders will now be covered under insurance policies.
Age-related ailments like knee cap surgery, cataract and menopause and puberty related disorders will also be covered by insurance.
However, diseases like HIV/AIDS, heart problems, epilepsy, kidney and liver diseases etc. will be permanently excluded from health insurance policies.
These new guidelines come on the heels of the recommendations that were made by the working committee that was set up in 2018.
Here is a list of the diseases that will be included:
- Diseases contracted after taking the health insurance policy.
- Injury or illness associated with hazardous activities.
- Impairment of persons' intellectual faculties by usage of drugs, stimulants or depressants as prescribed by a medical practitioner.
- Artificial life maintenance, including life support machine use, where such treatment will not result in recovery or restoration of the previous state of health under any circumstances
- Treatment of mental illness, stress or psychological disorders and neurodegenerative disorders.
- Puberty and Menopause related Disorders
- Age-Related Macular Degeneration (ARMD)
- Behavioural and Neurodevelopmental Disorders
- Disorders of adult personality including gender-related problems;
- Disorders of speech and language including stammering, dyslexia;
- Expenses related to any admission primarily for enteral feedings and other nutritional and electrolyte supplements.
- Internal congenital diseases, genetic diseases or disorders.
- If specified aetiology for the medical condition is not known.
- Failure to seek or follow medical advice or failure to follow treatment.
Representational image. Image credit: PxHere
Here is a list of diseases that are permanently excluded:
- Malignant neoplasms
- Heart ailments like congenital and vulvar heart diseases, chronic rheumatic heart diseases, stroke,
- Inflammatory bowel diseases
- Loss of hearing
- Any kind of physical disability,
- Avascular necrosis (death of bone tissue due to lack of blood supply)
- Neurodegenerative diseases like Alzheimer's and Parkinson's
- Chronic liver disease and
- Pancreatic disease
- Chronic kidney disease
- Hepatitis B,
How do these new guidelines help policyholders?
These new guidelines will help policyholders by letting them know the list of diseases that are included and excluded in their insurance policies. It will also include standard language that should be used if there is an exclusion in the insurance. There is also a specific waiting period of 30 days to one year after which the coverage will begin.
There is a side note for insurance cover for mental illnesses. The policies that are filed on or after 1 October 2019 will include the mental health cover. Policies filed before the October date will only receive cover from 1 October 2020.
Parliament has passed the HIV/AIDS Prevention and Control Act in 2017 and Section 3 of this Act says that "No person shall discriminate against the protected person on any ground including the denial of, or unfair treatment in the provision of insurance unless supported by actuarial studies". This means that the patients are not supposed to be denied insurance.
However, according to The Wire, the IRDAI says that insurance companies are still bound by Section 3 of the Act and if they have actuarial studies that support the claim of denial of health insurance coverage to people with HIV/AIDS, then they can consider extending health insurance coverage to policyholders with HIV/AIDS.
An actuarial study is a system used by insurance companies to assess, evaluate and manage the risk associated with people. They use a combination of mathematics, probability, and statistics to plan for the future.
This means that HIV/AIDS patients are at the mercy of insurance policies to give them medical coverage.
This draft also has a list of optional items that can be offered by insurers to their policyholders that include baby food, bedpans, sputum cups, gloves, nebulisation kits, etc.
You can read the entire draft here.