IRDAI Guidelines for Health Insurance Claim Settlement

Posted on: Jul 5, 2024 | 3 mins | Written by: HDFC ERGO Team

IRDAI Guidelines for Health Insurance Claim Settlement

IRDA Guidelines For Health Insurance Claim Settlement

Thanks to unhealthy lifestyle habits and high pollution levels, health conditions are increasing among people of all ages. Therefore, it has become increasingly important for individuals and families to stay covered under health insurance. A health plan covers a range of medical expenses and keeps away financial worries, especially during expensive procedures.

Keeping the importance of quality healthcare in mind, the Insurance Regulatory and Development Authority of India, or IRDAI, has made major changes to health insurance claim settlement rules for pre-existing conditions, specified diseases, and moratorium periods. These changes have been effective from 1st April 2024. Read on to know about these IRDAI guidelines for health insurance claim settlement in detail.

Changes in Health Insurance Claim Rules

The IRDAI has made the following changes to health insurance claim rules —

1. Waiting period for pre-existing conditions:

The IRDAI has reduced the maximum waiting period for pre-existing conditions from 4 years to 3 years.

Here’s how coverage for pre-existing conditions works in health insurance:

• When you are buying insurance, the insurer will ask you to fill out the application form with the correct details. They will also ask you if you are suffering from a pre-existing medical condition.

• If you are diagnosed with a medical condition and the same falls under pre-existing conditions as per the terms and conditions of your health plan, you will have to wait for a specified period before the insurer starts covering your medical expenses related to the pre-existing condition or PED.

• If you avail of treatment for a pre-existing condition when your policy is still in the waiting period, the insurer will not cover the bills.

Therefore, the reduction in the waiting period for pre-existing conditions from 4 years to 3 years will ease your worries. After 3 years, you can opt for cashless treatment at any network hospital of your insurance provider or file a reimbursement claim.

2. Moratorium period:

The Insurance Regulatory and Development Authority of India has also asked health insurance providers to reduce the moratorium period from 8 years to 5 years.

The following are some points to keep in mind:

• Once the moratorium period of your health plan ends, your insurance provider cannot deny your health insurance claims, including for pre-existing conditions, except for fraud.

• The IRDAI has also told insurance providers that if a policyholder has paid health insurance premiums continuously for 5 years or 60 months, the insurer cannot deny claims, even for reasons such as non-disclosure or misrepresentation.

• If you enhance or increase the sum insured of your health plan, you will have to wait another 5 years to make a claim on the increased or enhanced amount.

For example, suppose you take a health insurance policy for INR 5 lakh. After 3 years, you decide to increase the sum insured by your health plan for better financial security during medical emergencies. Therefore, you increase the sum insured of your health plan by INR 2 lakh. In this case, you will have to serve a total moratorium period of 5 years for the increased sum insured of INR 2 lakh.

3. Waiting period for specified diseases:

As per the new rules, the waiting period for specified diseases has been reduced from 4 years to 3 years. Some examples of specified diseases are dementia, osteoporosis, Parkinson’s disease, cardiac ailments, etc.

The coverage for specified diseases in health insurance works in the following ways:

• Once the specified waiting period is over, the insurance provider will cover treatment for specified diseases mentioned in your health insurance document.

• The insurer will cover specified diseases after the waiting period of 3 years only if you renew your health plan on time and keep it active continuously for 36 months.

An Important Point to Keep in Mind

The reduced waiting period for health insurance will apply to new as well as old healthcare plans.

For example, you bought health insurance 2 years ago. In this case, you will have to serve a waiting period of 1 more year for pre-existing conditions and specified diseases instead of 2. Similarly, the remaining moratorium period will also be reduced from 6 years to 3 years.

Suppose you are buying health insurance for the first time or a new healthcare plan. In that case, you must serve a waiting period of 3 years for pre-existing conditions and specified diseases and a moratorium period of 5 years.

Conclusion

These are the latest IRDAI guidelines for health insurance claim settlement. Since these changes reduce the moratorium period and waiting period for pre-existing diseases and specified conditions, policyholders stand to benefit in the long run. The shorter waiting period can also benefit insurance companies as this may encourage more people to purchase health insurance to avail of its benefits during medical emergencies.

Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.

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