Sample: Changes in Health Insurance Rules that You Should Know About

The Insurance Regulatory and Development Authority (IRDA) has come up with several changes in health insurance guidelines. These changes will make it easier for you to understand the terms and conditions while buying a health insurance policy. 

In this article, we have summed up what these changes entail. We have also simplified the technical terms for your convenience. Do read this article if you already have a health insurance policy or are willing to buy one soon. 

No more ambiguity

IRDA has made the guidelines more specific and exhaustive. You do not need to struggle with the ambiguity of sentences and technical jargon anymore. 

Earlier, it had said obesity and diseases related to obesity would not be covered. Now, it will specify the diseases that will not be covered. This will help make the law uniform for everyone. It will also help in reducing the hassle of finding out whether a particular disease is actually the result of obesity. It will help keep a fraud check in this regard as well. 

Wider coverage

The scope of health insurance has now become more expansive. IRDA has included many diseases in the list of covered illnesses. Many of the diseases excluded earlier have now been included within the purview of health insurance guidelines. 

Mental illnesses will also be covered and you can claim the charges in case of hospitalization. It is a major step towards promotion and awareness about mental health in the country.

Some examples of other diseases included are behavioral and neuro-related disorders, genetic diseases, menopause, puberty-related problems and injuries due to hazards. 

Pre-existing diseases – defined

The term, pre-existing illness, had been a major source of confusion till now. There was no clear definition of the term. Earlier, it was your responsibility to revisit the symptoms and prescriptions of your pre-existing illness. In case you forgot something while buying the policy, your claim for the same used to get rejected. Now, IRDA has defined the term as any illness for which you have been advised treatment by a doctor or a diagnosis has been made. 

Uniformity in definition

Earlier, there was no uniformity in the technical terms used by IRDA and they varied from policy to policy. The same terms had different meanings in different policies, which led to widespread confusion. For example, pre-existing illness, obesity, maternity and a 30-day waiting period were some ambiguous terms. IRDA has now standardized the definitions of all the terms and exclusions. 

Claim settlement after eight years

This change has come as a big relief. Now the insurance company will have to settle a genuine claim after holding the policy continuously for eight years. The claim can be rejected by the insurance company only if a case of fraud is proven. 

Serious illnesses covered

Earlier, you could not get yourself a health insurance policy if you had serious illnesses like Alzheimer’s, chronic kidney disease, epilepsy and cancer. Now, these illnesses have been added to permanent exclusions. You can now buy a health cover for diseases other than the serious illnesses mentioned in the exclusions list. 

Coverage of modern treatments

IRDA has included some of the modern treatments within the scope of health coverage. Balloon sinuplast, deep brain stimulation, oral chemotherapy, immunotherapy, robotic surgeries, bronchial thermoplasty and stem cell therapy are some examples in this regard.

A maximum four-year waiting period

Earlier, the waiting period varied for different illnesses. It ranged between two and four years in most of the cases. Some policies also had a waiting period of more than four years. Now, IRDA has made it clear that the waiting period cannot be more than four years in any case. 

Reduced waiting period for lifestyle diseases

Earlier, the waiting period for lifestyle diseases ranged between two and four years. IRDA has now specified the maximum waiting period for such diseases – 90 days. This will not be applicable if you already have a lifestyle disease when taking the policy. It will be classified as a pre-existing illness. 

Domiciliary hospitalization included

IRDA has included domiciliary hospitalization, i.e. treatment at home due to the unavailability of beds. In such a case, the pre- and post-hospitalization expenses will be covered.