Health Insurance Guidelines by IRDA

by Vanessa Jones on Feb 15 2013 11:57 AM

 Health Insurance Guidelines by IRDA
The Insurance regulatory and Development Authority (IRDA) drafted some health insurance guidelines on 31st May 2012. These will restrain the role of the TPA to process claims. There are still some issues which have to be addressed.
The IRDA agreed to address various important issues like, settlement of claims within 30 days of receiving documents, lifelong renewals, refund on pre-insurance medical check-ups and a separate grievance cell for senior citizens.
On the 16th of May 2012, a memorandum had been submitted by Moneylife foundation, to J. Hari Narayan, chairman of IRDA.

According to the memorandum:

Senior Citizens could not increase their Sum Insured, also survivors of serious illnesses like cancer were not allowed to increase the sum assured. The insurance company manages to do this under the guise of “Right to Underwrite” It should be mandatory to allow increases due to inflations, irrespective of past claims.

Prosthetics and Artificial limbs for the disabled were not covered. ‘The Challenging Ones’ – an NGO in a memo to the IRDA Chairman on the 16th of May requested him to make it mandatory for insurance companies to cover the cost of prosthetics to the beneficiaries without an artificial cap. Many insurance companies don’t have regulations for this.

Even after the chairman’s assurance there has no response from the IRDA and neither have reminders elicited any response.

Most Insurance companies reject insurance for procedures which do not require a 24 hour stay at the hospital. IRDA needs to include day care procedures as the technology has advanced and don’t necessitate an overnight hospital stay.

Many insurance companies want a 24 – 48 hour advance intimation of hospitalization and a 7 day claim submission. Many a time TPA’s are not equipped with a 24 hour helpline, nor do they work on holidays and weekends, or are short staffed, many a time they deny having received any intimation from the beneficiary. This prevents hospitalization and claims get rejected. IRDA needs to be firm about all insurers installing toll free, 24/7 numbers, fax, email and SMS facilities.

The cashless facility is limited to preferred-provider network; this does not involve the majority. When cashless is offered to corporate, it should be made available to retail mediclaim beneficiaries.

At the Bombay High Court hearing of the 12th February 2013, of a public interest litigation filed by social activist Gaurang Damani, IRDA legal representative stated that health insurance draft regulations have been approved by its board.


Hannah Punitha (IRDA Licence Number: 2710062)

Raj Pradhan, Feb 2013