An Irdai constituted panel has proposed several changes to health insurance exclusion rules.
The revisions would make the coverage more comprehensive for policyholders.
Shorter waiting periods for lifestyle diseases
Now, insurers will not be able to prescribe waiting periodsā time span when you canāt claim benefit for an ailmentāof one to four years for those suffering from hypertension, diabetes and cardiac conditions. The committee has recommended a cap of 30 days on the waiting period, unless these ailments are pre-existing.
Policy to be incontestable after eight renewals
The panel has suggested that insurers will not be allowed to question claims on the grounds of nondisclosures at the time of taking the first policy after eight years of continuous renewals, except in the case of frauds. This will ease policyholdersā concerns about possible rejection after years of paying premiums diligently. The policies would, however, be subject to all sub-limits, co-payment clauses and deductibles mentioned in the policy contract.
Mandatory coverage for illnesses developed after policy purchase
All health conditions acquired after policy issuance, other than those that are not covered under the policy contract (like infertility and maternity), should be covered under the policy and cannot be permanently excluded, the report suggests. It adds that exclusion of ailments like Alzheimerās disease, Parkinsonās disease, AIDS/HIV and morbid obesity should not be permitted.
Standard, clearer definition of pre-existing diseases
The panel has recommended a simpler definition of pre-existing diseases to prevent any disputes over interpretation. The suggested definition is: any condition, ailment, injury or disease that is diagnosed before buying the first policy, for which medical advice or treatment was recommended by, or received from, a physician.
This apart, the report prescribes lenient options for insurers if a pre-existing ailment is discovered later. āThe insurer can put a waiting period for such illnesses instead of cancelling the policy on grounds of non-disclosure,ā says Nikhil Apte, Chief Product Officer, Product Factory (Health Insurance), Royal Sundaram General Insurance. However, this option will be available only during the moratorium period recommended by the panel.
Coverage for people with severe health conditions
Cancer survivors, epilepsy patients and those with physical disabilities are often denied coverage due to their health conditions, even for completely unrelated ailments. The panel has now suggested that insurers should offer health covers to such individuals, with the condition that specific pre-existing diseases will not be covered throughout the policy tenure.
The report lists 17 conditions that will qualify under this clause. These include congenital and valvular heart disease, chronic liver and kidney diseases, HIV/AIDS, epilepsy, among others. For instance, if you have a history of heart-related ailments, insurers may not extend the cover, even for unrelated procedures like knee replacement. If the suggestion is put into effect, you can buy a policy that excludes heart ailments but can be used for a knee replacement surgery.
Advanced medical treatments to be covered
The regulator has mooted the formation of a Health Technology Assessment committee that will recommend the inclusion of modern treatment procedures and drugs introduced in the Indian market. āIt will act as a self-regulatory body. Policyholders will be able to undergo treatment under advanced procedures without worrying about the financial implications,ā says Mahavir Chopra, Director, Health, Life and Strategic Initiatives, Coverfox.com. Insurers will not be able to exclude any procedure in the list approved by the committee, which will review the listed procedures annually. The panel has also advised insurers not to reject claims of oral chemotherapy and peritoneal dialysis.