IRDAI Consolidates Health Insurance Guidelines
May 18, 2020
Health insurance is an insurance policy that protects the policyholder and his/her family against the medical costs that arise due to an accident, illness or on the diagnosis of any serious disease. Today, several companies offer health insurance plans to their customers that provide various benefits such as cashless treatment at network hospitals, tax benefits, etc.
Today, quality healthcare treatment is expensive. A decent hospital has the potential to finish up your savings in a few days. Instead of worrying about the hospital bills, you need to concentrate your entire energy on the recovery. A health insurance policy can help you with that. You can approach any of the network hospitals which has a tie-up with your insurance provider and recover peacefully.
|Plan Name||Entry Age||Renewability||Sum Assured||Network Hospitals|
|Religare Care||Min - 91 days |
Max - No limit
|Lifetime||Upto 6 crore||5420+|
|Star Family Health Optima||Min - 16 days |
Max - 65 years
|Lifetime||(Rs. 12 Lacs - Rs. 25 Lacs)||9800+|
|My: health Suraksha Silver Smart||Min - No limit |
Max - No limit
|-||(Rs. 3 Lacs - Rs. 1 crore)||10000+|
|Aditya Birla Activ Assure Diamond||Min - 91 days |
Max - No Limit
|Lifetime||(Rs. 3 Lacs - Rs. 50 Lacs)||5700+|
|HDFC Ergo Health Optima Restore (formerly known as Apollo Munich Optima Restore)||Min - 91 days |
Max - 65 years
|Lifetime||(Rs. 3 Lacs - 50 Lacs)||5000+|
Table Data updated on 22-05-2020
Apart from the above-stated plans, we have prepared a detailed list of the top 10 health insurance plans in India 2020.
It allows the insured to get the required treatment in network hospitals without paying a single penny during hospitalization up to the sum assured limit. The insurance company pays on your behalf and allows you to have a complete focus on your treatment.
The expenses prior to hospitalization and after discharge from the hospital up to a specific period are covered by health insurance policy only if the expenses are associated with the illness subject to terms and conditions of the insurance company.
On buying a health insurance policy, you will be liable to receive tax advantages for the premiums paid under Section 80D of the Income Tax Act, 1961. One can avail tax benefits up to a certain limit depending upon the age of the policyholder and his/her parents (if any).
This benefit is very useful during hospitalization as this will provide daily cash to a certain limit to take care of the additional expenses in the hospital like food, traveling, etc. Usually, the benefit amount is up to Rs.2,000 per day but it may vary in case of accidents and ICU procedures.
The costs for the transplantation of an organ are bearable by the insurance company. Health insurance covers the surgery expenses related to organ donation. However, the costs for complications after surgery, organ donor expenses, and medical tests are not covered under the same.
It is a discount that you will receive from the insurer for every claimless year. NCB comes as a discount on the payable premium at the time of the renewing policy or whenever you want to increase the Sum Assured amount. At the time of renewal, you must check for No Claim Bonus benefit.
To motivate the policyholders towards a healthy life, insurance companies offer free occasional medical check-ups. Depending on the company and the type of policy, you will be eligible for a master health check-up.
This keeps you insured for the long term. Most of us try to follow a healthy lifestyle but illness or accidents could take us by shock. Therefore, having a health insurance policy acts as a blessing in hard times.
Once the sum assured amount is completely used, the insurance company will restore the amount automatically and you don't have to pay any additional cost for the benefit. The plans with restoration benefits are expensive as compared to normal health/medical insurance policies and are applicable as per the clauses of the policy.
To deal with the different needs of customers, there are multiple forms of health insurance plans available. Such plans are mentioned below:-
Critical Illness plan offers a fixed benefit/payout in case of any critical illnesses specified under the policy. With the lump sum benefit, you will be able to pay the huge hospitalization costs and get the treatment on time. Learn More
Senior Citizen Health Plan is designed especially for the old age people who are above 60 years of age. This plan is to fight against all medical contingencies during old age. As per the Insurance Regulatory and Development Authority of India (IRDA) regulations, every insurance company must insure people up to the age of 65 years. Learn More
Maternity health insurance is offered by almost every health insurance company that covers pre and post-natal care, child deliveries, and sometimes vaccination expenses of newborn babies.
Individual health insurance covers the health expenditure of a single person or an individual, but there's always flexibility of availing the bigger sum assured. The premium that we pay annually depends on the amount of sum assured.
Family Floater Health Insurance allows to insure all family members under a single policy. All the family members can enjoy the benefit of the entire sum assured. The amount of the premium paid is less as compared to individual plans. The policyholder along with the spouse, dependent children and the parents can be included in the plan. Learn More
Unit Linked Health Plan (ULHP) is a combination of health insurance and investment. Along with the health protection, ULHPs will help you in building a corpus that can be used by the investor to meet expenditures that do not get covered under medical insurance plans.
To choose the best health insurance plan, there are a few factors that should be kept in mind before finalizing your decision. They are as follows:
Different insurers provide a variety of facilities and covers to the policyholder. It is vital to check all the facilities and the coverage provided so as to fulfill the requirements for treatment. Compare policies and make a checklist for your needs and choose the best plan accordingly.
Reliability of the Company
The policyholder should go through the insurance company's website and its details before choosing a medical insurance plan. The profile and the history of the company should be checked along with the customer reviews to make the right choice.
Sum Assured Amount
The principal point to be noticed while buying medical insurance is the amount of Sum Assured offered by the insurer to the insured. If you or your family members are suffering from any specific disease, you might have a fair idea of the amount to be chosen for future health costs. Hence, it is important to choose the sum assured wisely.
Co-pay & Deductible
You should keep an eye out for the clause of co-pay & deductible which insurance companies attach with some of their plans. Just to be clear, It is a predefined amount (in %) which the insured agrees to pay for medical services. For example, if the co-pay is 10% and the claim amount is 2 Lakhs, 20,000 will be paid by the insured and the rest will be taken care of by the company.
On the other hand, a deductible is the fixed amount which the policyholder has to pay each year before his/her plan begins to pay for covered expenses. For example, a person's deductible is Rs.1,00,000. In March, the person has a viral infection and the doctor's bill is Rs.10,000. Since this is the first payment of the year, the entire amount will be paid by the person (insured). In June, the person runs into an accident and has minor surgery. The total bill comes out to be Rs.1,50,000. Here the person will pay Rs.90,000 and the rest is paid by the company. In October, the person has 2 fractures and the bill is Rs.40,000. Since the person has paid the yearly deductible, the entire expense will be paid by the company. Learn More
Add-On Benefits & Plans
Companies offer numerous riders and additional benefits to the customer that actually boosts the coverage, scope and advantage of the policy resulting in a complete health cover protection shield. You may also add a top-up plan with the respective coverage by paying an extra premium.
Option For Cashless Claim
Check whether the insurance company is providing the cashless claim facility as it is an important feature of the policy that will help in times of emergency hospitalization.
PolicyX.com is a one-stop shop for all your insurance related needs. PolicyX is Insurance Regulatory and Development Authority of India (IRDAI) certified web insurance aggregator company (License Number: IRDA/WBA17/14).
You can Compare health insurance plans from top insurance companies with PolicyX and buy the best health insurance plan as per your needs. The team of PolicyX makes sure that you are getting the best deal within your budget; away from fake promises and products. We try to provide the easiest buying process. Our systems and teams are well-equipped to help you with the buying procedure from starting till the end. Let us look at the following key highlights about PolicyX:
The team of PolicyX.com will instantly share policy documents over email. (*Note: Medical tests would be done according to the plan features and insurance company's norms and conditions).
With the available health insurance companies in the market, a lot of research is required to select the best among them. That research mainly depends on a few factors which are listed below:
Reputation of the Company: The reputation of the company plays an important role. It is advisable to go for a company that carries a good brand image. Sound research will be required that will help you to choose the right health insurance provider.
Financial Stability: You must check the financial stability of the company. You can check the Credit Rating Information Services of India Limited (CRISIL) rating. Go for a company with AAA Rating as it is considered to have the highest financial strength to meet its obligations.
Product Portfolio: Don't forget that insurance is a vast industry and keeps on changing by time. It does not remain the same all the time and so does your needs. That's why it is important to go for a company that offers a wide range of helpful insurance policies caters to the different needs of customers.
Smooth & Quick Claim Settlement Process: It is advisable to search for an insurance company that follows a simple and easy claim settlement process. During emergencies, it is crucial to settle the claims on time so as to seek proper healthcare facilities.
Customer Support Service: Pay attention to the quality of customer services of an insurance company, for that you need to check for the ratings and reviews of the customers for the services provided. Choose the company that offers online chat, email assistance, and phone assistance.
Insurance Advisor: Insurance is tough to understand by a common person. But now many insurance companies appoint insurance advisors who will help you in choosing an appropriate insurance plan according to your needs.
Feedback and Reviews: One of the most important and common aspects are customer ratings and feedback received by an insurance company. You can go through the Insurance Regulatory and Development Authority of India (IRDAI) website to check the number of complaints and resolutions against the insurance company.
The most important part of an insurance policy is the claim settlement process. People often worry about the claim settlements. Some insurance companies offer direct claim settlement process and some take the help of TPAs (Third Party Administrators) for claim settlement. The claim settlement process takes place in two forms which are mentioned below:
You can avail cashless treatment facilities only in the network hospitals of the insurance company. The TPA must be notified beforehand in case of planned hospitalization, or within a specified timeframe in case of an emergency. The hospital's insurance desk helps with all the paperwork. The TPA has to approve the mediclaim amount, and the hospital will settle it with the insurer. There are likely to be exclusions i.e., expenses that the TPA won't pay. Such expenses must be settled by the patient directly at the hospital's cash counter.
The insurer can avail of the reimbursement facility both at networked and non-networked hospitals. Here, you can avail of treatment facilities and settle the bill directly with the hospital. You can then claim reimbursement of the expenses from the TPA by submitting relevant bills and receipts of treatment.
Claim Settlement Ratio (CSR) is the ratio of the total number of claims to the total number of death claims received by the insurance company.
It is considered as an important factor because it shows the number of claims that an insurer has settled versus the rejected ones. With this ratio, you will be clear in choosing the right insurance company for your health plan. Always ensure that you are going for a high claim settlement ratio of an insurance company.
|Insurance Companies||Incurred Claim Ratio (2018-2019)|
|HDFC Ergo Health Insurance Company (formerly known as Apollo Munich Health Insurance Company)||63%|
|Bajaj Allianz General Insurance Co Ltd||85%|
|Bharti AXA General Insurance Company||89%|
|Cholamandalam Health Insurance Company||35%|
|Manipalcigna Health Insurance Company||62%|
|Future Generali Insurance Company||73%|
|HDFC ERGO Health Insurance||62%|
|Iffco Tokio General Insurance Company||102%|
|Liberty Videocon General Insurance Company||82%|
|Magma HDI General Insurance Company||90%|
|Max Bupa Health Insurance||54%|
|National Insurance Company||107.64%|
|New India Assurance Company||103.74%|
|Oriental General Insurance Company||108.80%|
|Raheja QBE General Insurance Company||33%|
|Reliance General Insurance Company||94%|
|Religare Health Insurance Company||55%|
|Royal Sundaram General Insurance Company||61%|
|SBI General Insurance Company||52%|
|Shriram General Insurance Company||53%|
|Star Health Insurance Company||63%|
|TATA AIG General Insurance Company||78%|
|United India Insurance Company||110.51%|
|Universal Sompo General Insurance Company||92%|
Table Data updated on 22-05-2020
*Source IRDAI (Insurance Regulatory and Development Authority of India)
May 18, 2020
On Tuesday, IRDAI has issued a consolidated list of all the health insurance guidelines amended up to 12th May 2020. The list includes-
Before and during this pandemic, the IRDAI has come out with several changes and guidelines to make health insurance plans more customer-centric. And the recent guideline is basically a consolidated list that has been introduced with a motive of avoiding any type of confusion regarding all the changes announced earlier.
By offering a single list of all the amendments, IRDAI has made it easier and beneficial for all and the same will provide clarity to both - insurance companies and customers. We can also consider this consolidated list as a reference document for future use. This is really a wonderful move by IRDAI and the regulatory has taken great initiatives to transform the health insurance industry in India. This consolidated list is the compilation of such great steps.
Naval Goel (CEO & Founder of PolicyX.com), "I appreciate IRDAI for coming out with this consolidated list of recently amended health insurance guidelines. This has cleared several queries of customers and insurance companies. Now customers can easily compare what they are missing out. With this move, IRDAI has made it clear how it is making health insurance products more customer-centric."
As a part of amendments, IRDAI has also asked insurance companies to provide provisions for senior citizens. As per the IRDAI, life insurance companies, general insurance companies, and TPAs should create a separate channel to address the health insurance-related claims. They should focus more on the grievances of senior citizens.
April 17, 2020
COVID-19 outbreak following by nationwide lockdown has put the country on a break. During this situation, banks and other money lending companies are coming out with a lot of relief by rescheduling the EMI's and other bills that are helping people in maintaining their expenses. Likewise, insurance companies in India have planned to support their customers during this outbreak by extending the health insurance renewal dates.
The centre has planned the whole thing to extend the renewal deadline for health insurance policyholders. All such existing policies which are due for renewal because of lockdown can be renewed by the mid of the next month. The finance minister of India confirmed that the renewal dates associated with health insurance policies that fall during the period of 25th March to 3rd May are now extended till 15th May.
Normally, under health insurance, if you fail to pay a premium on time, the insurance plan ceases to be in force. Health insurance companies provide one month extra from the renewal date to make the premium payment which is known as the grace period. The plan can be renewed if you pay a premium during the grace period but the insured will not be covered during this tenure.
Now, if the insured makes the payment on or before 15th May, the health insurance policy will continue to remain active.
This move brings a lot of relief to the customers as they might be able to get the required assistance on time. Now people can stay relax and follow the rules of lockdown which keep them safe from this deadly virus, Naval Goel (CEO & Founder of PolicyX.com).
March 6, 2020
The coronavirus is spreading very fast globally and many cases have been reported in India as well. Those who are insured under the health insurance plan have a question- whether their claims related to coronavirus will get settled or not? Insurance companies confirm that all cases related to coronavirus will be treated/covered as any other illness only. Such claims will be processed as per the regular norms.
Recently, IRDAI has issued a set of guidelines to be followed by the insurance companies when it comes to handling claims associated with coronavirus.
The IRDAI has also asked insurance companies to come out with a product that will exclusively cover the treatment of coronavirus and multiple specific diseases that includes vector-borne diseases. Many health insurance plans do not offer cover against a pandemic disease. However, to date, WHO has not declared Coronavirus as pandemic disease, but the risks exist. Right now, coronavirus can get the complete cover as it is not even considered as a pre-existing disease. Hence, there is no waiting period in such ailments.
February 17, 2020
Pre-existing diseases have always been an easy excuse for insurance providers to reject the claims of their customers. Even after being fully-insured, the policyholders lose to insurance providers. Finally, IRDAI has changed the rules of the game and now, the ball is in the court of policyholders. In the latest circular, the Insurance Regulator And Development Authority Of India has deleted the 'modified/additional clause' from the definition of pre-existing diseases. Examples of such diseases include anxiety, diabetes, lupus, etc.
As per the definition of pre-existing diseases in September 2019 circular, if any critical illness is diagnosed within 3 months of purchasing the health insurance policy, it would fall under the category of pre-existing diseases and will be covered under the insurance policy. However, as per the latest circular, no illness will be a part of pre-existing diseases, even if, it is diagnosed after 3 months of purchasing the medical insurance policy. This modification will soon be updated in the standardisation of health policies.
This move by IRDAI is a step in the right direction. It will help in reducing the claim rejection rates in health policies. As far as insurance providers are considered, they have to abide by this modification on an immediate basis.
January 31, 2020
Today, the cost of a basic operation is like buying a budget four wheeler car. To protect investments, people prefer to buy health insurance. But they face a mammoth task of selecting one provider among the 100s. Different names/terms & conditions can mess with your head. To counter the problem, IRDAI has introduced a standard health policy- Arogya Sanjeevi. It will look after your essential health needs without adding many changes to policy's wordings.
All insurance providers have to roll out this policy from 1st April 2020. To distinguish themselves, they have to add the wording (Arogya Sanjeevni) before their name. For example, Arogya Sanjeevani Policy Birla Sun Life Insurance. It's not just the name that this policy will attend. It will bring key features that are stated below:-
Apart from them, the providers can be generous and offer additional benefits such as higher sum assured & wellness. It will certainly make their customer happy.
Before buying a health insurance plan, we are sure you must be having a lot many questions in your mind. Don't worry PolicyX.com is here to figure out the queries at its best. Let's go through some common queries:
Yes, there's no limit to the number of claims in a single year unless there is a specific cap laid down in the policy. The sum insured, however, is the maximum claimable limit under the mediclaim policy.
According to statistics, Rs 5 lakh family floater policy will cover self, spouse and one child will cost anywhere between Rs 10,000 and Rs 17,000 on an annual basis whereas Rs. 5 lakh individual health plan will cost a 35 year old Rs. 4,000-7,000 a year.
The difference between a mediclaim and health insurance policy is all about the coverage provided. Mediclaim is confined to hospitalization expenses and domiciliary care costs whereas health insurance provides full protection against the treatment, hospitalization, surgery expenses.
Therefore, health insurance is a better decision to secure your and your loved ones' future.
During Emergency Hospitalization you can claim for cashless treatment in the following ways:
A health insurance plan is for the future security and a smart investment financial plan. If you buy it early premiums will be low and can cover the diseases coming up in life. It is an absolute necessary and important but not mandatory plan in India.
As we have discussed above, it is important to buy health insurance at an early stage of life. If you are 25 years of age you should buy a health insurance plan to safeguard your health from future medical expenses.
Yes, it is possible to utilize your health insurance immediately after all the paperwork and documentation is done from the insurance company's end along with the payments. However, most companies offer the facilities after a certain waiting period.
Yes, every insurance company has a network of hospitals in which cashless treatment facilities are available to the policyholders.
It varies from insurer to insurer, most of the companies do not provide cover for pre-existing diseases but on the other hand, many companies cover the same after a waiting period of 4 years.
The policy can be renewed later if you pay your premium on time or within the grace period, which is usually 15 days from the date of expiry of the policy for most insurance companies. However, you will not be entitled to any coverage for the period during which the insurance company did not receive any premium. Also, the policy would lapse if the premium is not paid within the grace period.
Yes, according to a circular issued by the Insurance Regulatory and Development Authority (IRDA), with effect from 1 October, 2011, the insured can transfer a policy from one insurer to another, and also from one plan to another. The insured will lose no renewal credit for pre-existing health conditions which he/she enjoyed in the incumbent policy. But the credit would be limited to the sum insured and the bonus eligible under the present policy. Check with your insurance company for the detailed clauses in this regard.
Some insurance companies reimburse general health checkup expenses usually once every 4 years.
Smoking has an adverse effect on health insurance premiums. This means that if you are a smoker, you end up paying higher premiums as you are subjected to greater medical risks.
In case you forget to pay your health insurance premiums, the provider gives you a grace period that usually varies from one to three months. However, if you fail to pay the premiums during this time as well, your insurance policy lapses and you are no longer entitled to the health insurance benefits of the policy.
Yes, health insurance provides cover to diabetes patients and related complications. However, it may vary from insurer to insurer, most of the companies provide the same after a waiting period of 4 years.
Yes, health insurance covers the medical tests and scans for the inpatient treatment, i.e., during hospitalization for at least 24 hours. For outpatient treatment, out of the hospital cover for the same is not applicable.
A waiting period of 48 months is applicable to avail the maternity insurance benefits and cover. A cover of Rs. 25,000 in caesarean delivery and Rs. 15,000 is provided usually from a maternity health insurance plan.
These days, most insurers have arrangements with various hospitals spread across the country as part of a network. An individual, if policyholder under a policy which offers the cashless facility, can get treated in any hospital of the network without paying hospital bills because the same is paid directly by a third party administrator (TPA), on behalf of the insurer. However, all expenses beyond the sum insured or the ones not covered under the policy, have to be paid by the policyholder directly to the hospital. Cashless facility is not available if the hospital is not included in the network. In such cases, payment by the insurance company to the hospital is usually carried out on a reimbursement basis.
You can claim several tax benefits if you subscribe to a health insurance scheme. Such benefits are extended by section 80D of the Income Tax Act. Presently, subscribers to health insurance, who purchased the policy by a payment mode other than cash, are eligible for Rs 15,000 annual deduction from their taxable income for the payment of health insurance premium for self, dependent children, or spouse. The deduction is higher for senior citizens at Rs 20,000. Also, since the 2008-09 financial year, an additional deduction of Rs 15,000 can be claimed for mediclaim premium paid for parents. It's Rs 20,000 if parents are senior citizens.
Age is the biggest factor which determines the premium payable. The older you are, the higher will be your premium, because you'll be more prone to illness. Your medical history is another factor that will go into determining the premium. If you don't have any medical history, the premium would be naturally lower. You are eligible for a discount on the further premium payable for the years for which there has been no claim of the insurance money. Some insurance companies cover add-on benefits like free medical checkups and/or diagnostic tests in case of no claim.
Read the offer document/prospectus and understand it fully before signing on the dotted lines. What's not included will be clearly written in the prospectus. Any pre-existing illness, usually, is not covered under a policy. But read the offer document to understand what the insurer means by pre-existing illness. Also, the majority of the policies generally exclude certain types of diseases in the first year of coverage. A waiting period is also often imposed on such diseases. Some expenses not covered under most health insurance policies include cost of contact lenses, spectacles and hearing aids, dental surgery (unless it requires hospitalization), general debility, convalescence, venereal disease, congenital external defects, use of drugs and alcohol, intentional self-injury, expenses for diagnosis, AIDS, X-ray and/or laboratory tests not connected with the illness requiring hospitalization, treatment related to pregnancy or childbirth, including C-section, naturopathy treatment and others as deemed exclusive by the insurer.
As already said, there is usually a 30-day waiting period when you buy a new policy, starting from the day you enrolled in the health insurance scheme. During this period, the insurance company won't pay any hospitalization charges. But this is not applicable in case of an emergency hospitalization arising out of an accident. The waiting period is not applicable for renewal of the policy for subsequent years.
It's a medical condition or ailment that existed before you took the health insurance policy. This is a significant point in all policies because insurers don't cover such conditions within 48 months prior to taking the first policy. It means a pre-existing condition may be considered for payment, only after the completion of 48 months of continuous insurance cover.
Once an insurance claim is filed and settled, the coverage gets reduced by the amount paid on settlement. For instance, if you take an Rs5 lakh mediclaim policy in January, and in April, the insurance company pays? 3 lakhs towards your hospitalization and treatment, then you will be eligible for the balance Rs 2 lakhs as coverage for the remaining duration i.e., May to December
In a family floater scheme, a single policy covers the hospitalization expenses of the entire family. Such a policy has only one sum insured which can be utilized by a single or all members collectively in the family. The limit of coverage is capped at the sum assured. Family floater plans are considered better than buying a separate health policy for each member of the family. It takes care of all medical expenses, including surgeries, sudden illness, and accidents.
Women of all walks of life are now progressing and trying to maintain the fine balance between their personal and professional commitments. Hence, it is important that their medical needs are catered to. Various health insurance providers have now come up with unique health insurance plans that specifically cater to female medical conditions such as breast cancer, ovarian cancer, cervical cancer, complications during pregnancy, childbirth or other forms of critical illnesses. Some of the top companies that provide these kinds of health insurance plans are TATA AIG, Bajaj Allianz, etc.
Goods and Services Tax (GST) - implemented in 2017 - is an indirect tax levied on the sale of goods and services in India. It has replaced many indirect taxes imposed on goods and services by State and Central Government. Tax slabs under GST have been fixed at 0%, 5%, 12% and 28%.
Before the new tax regime, the service tax rate applicable on health insurance was 15%. However, with the implementation of GST, the tax rate has been raised by 3%- placing health insurance in the 18% tax bracket.
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Last updated on 22-05-2020