“Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016” provide a comprehensive framework for health insurance operations, ensuring the protection of policyholders’ interests and promoting effective management of health insurance products. Here’s a detailed summary of the regulations:
Title and Commencement:
The regulations are titled as such and came into force upon their publication in the Official Gazette.
Scope and Applicability:
Applies to all insurers (life, general, health) conducting health insurance business in India, including Third Party Administrators (TPAs).
Definitions:
Detailed definitions of terms such as “Act”, “Health insurance business”, “AYUSH treatment”, “Cashless facility”, and others are provided to clarify their use within the regulations.
Health Insurance Products:
Insurers must ensure that health insurance products are filed and approved by the IRDAI as per Product Filing Guidelines before being marketed.
Specific guidelines for the withdrawal and review of health insurance products ensure they remain financially viable and compliant.
Group Insurance:
Group health insurance policies should not be issued solely for the purpose of insurance benefits; there must be a clear relationship between group members and the policyholder.
Underwriting and Premiums:
Insurers are required to establish a health insurance underwriting policy approved by their Board. Premiums should be based on age and other relevant factors and remain unchanged for a certain period.
Claims and Renewal:
Guidelines for claims processing emphasize timeliness and fairness. Health insurance policies should generally be renewable except on grounds like fraud or misrepresentation.
Portability:
Provisions allow for the portability of health insurance policies, giving policyholders the right to transfer their coverage to a different insurer with credit for pre-existing conditions.
AYUSH Coverage:]
Insurers are encouraged to cover treatments under Ayurveda, Yoga, Unani, Siddha, and Homeopathy, subject to specific guidelines.
Wellness and Preventive Aspects:
Insurers may promote wellness and preventive care amongst policyholders according to guidelines specified by the Authority.
Standardization:
Standard definitions and nomenclature for critical illnesses and other health conditions ensure consistency across policies.
Senior Citizens:
Special provisions are included to protect senior citizens, ensuring fair premiums and addressing their specific health claims and grievances efficiently.
Miscellaneous Provisions:
Additional regulations cover areas like health services agreements, engagement of TPAs, settlement of claims, and administration of health insurance policies to ensure comprehensive management and operational clarity.
These regulations establish robust guidelines for the health insurance sector, aiming to enhance transparency, protect policyholders, and ensure the delivery of quality health insurance services.
