IRDAI’s Guidelines on Standardization of Critical Illness in Health Insurance

Posted on: Jul 7, 2022 | | Written by:

IRDAI’s Guidelines on Standardization of Critical Illness in Health Insurance

While we know how important health insurance is, its terms and conditions are sometimes a little complex. And we often take a policy without reading the fine print carefully. However, during the claims process, it can be frustrating to know about the exclusions you thought didn't exist. This is the reason why the Insurance Regulatory and Development Authority of India (IRDAI) regularly updates its guidelines for insurance companies. Recently, it came out with a new circular on the standardisation of critical illnesses as defined in health insurance products. Let’s discuss the modified definitions and learn how they can affect your policy terms and conditions, especially if you have critical illness insurance.

In Case of Cancers of Specified Severity

As per the IRDAI, the definition of cancer of specified severity has been modified as ``A malignant tumour characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissues. This diagnosis must be supported by histological evidence of malignancy. The term cancer includes leukaemia, lymphoma and sarcoma.”

According to the modification, these are the exclusions under cancer of specified severity:

• Tumours that are low malignant, carcinoma in situ, pre-malignant, benign, borderline malignant, non-invasive or neoplasm of unknown behaviour, including but not limited to breast carcinoma in situ, cervical dysplasia CIN-1, CIN - 2 and CIN-3.

• Non-melanoma skin carcinoma unless there is proof that it is spreading to lymph nodes or beyond;

• Malignant melanoma that has not spread beyond the epidermis

• Prostate tumours unless histologically categorised with a higher than 6 Gleason score or progressed to clinical TNM classification T2N0M0 at least

• Thyroid cancers categorised as T1N0M0 or below

• Chronic lymphocytic leukaemia below RAI stage 3

• Non-invasive papillary bladder cancer histologically described as TaN0M0 or of a lesser classification

• Gastro-intestinal stromal tumours histologically classified as T1N0M0 or below. The mitotic count should be equal to or less than 5/50 HPFs

For Multiple Sclerosis with Persisting Symptoms

As per the new definition, the diagnosis of definite multiple sclerosis must be based on investigations, including MRI findings confirming the diagnosis and the clinical impairment of motor or sensory function must have persisted for at least 6 months at a stretch.Neurological damage due to SLE is not included.

For Loss of Speech

The inability to speak due to an injury or disease of vocal cords must be total and irreparable and this loss must be for a continuous period of 12 months. The diagnosis must be furnished by an Ear, Nose, and Throat (ENT) specialist and supported by medical evidence.

About HDFC ERGO Critical Illness Insurance

The treatment for critical illnesses such as stroke, cancer, kidney disorders, paralysis, etc.is quite expensive and can drain your savings. To protect your finances, it is necessary to have critical illness insurance so that all the treatment expenses are covered. With HDFC ERGO critical illness insurance, you will get wide coverage at affordable premiums. The benefits offered by HDFC ERGO critical illness insurance are:

• Upto 15 critical illnesses are covered

• The insurer will pay a lump sum amount irrespective of the cost of treatment. This way, you don’t need to go through the hassles of raising claims for the expenses incurred

• You can purchase the plan for one or two years

Conclusion

Being diagnosed with a critical illness can be traumatic. But if you get to know that it is not covered by your critical illness insurance,it can get more frustrating. So, to ensure that you don’t face such a situation, it is advisable to read the policy wordings carefully about the inclusions and exclusions.

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

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