July 22, 2021

Insurance Regulatory and Development Authority of India (IRDAI) has recently come up with the new guidelines to standardize exclusions in health insurance products.

The Mental Healthcare Act 2017 makes mandatory for every insurer to ensure medical coverage for mental health ailments.

Specific Excluded Illnesses will now Be Covered

The regulator has asked insurers not to exclude eleven illnesses like mental illnesses, genetic disorders, stress/psychological disorders, behavioral and neuro-developmental disorders, hazardous activities, puberty and menopause-related disorders from the exclusions list of health insurance policies.

IRDAI has issued the new rules and now, insurers can’t decline to cover the people who have used opioids or anti-depressants and also, can’t exclude instances with a history of clinical depression, sociopathy, psychopathy, personality or neurodegenerative disorders.

Insurance companies can’t exclude coverage towards the treatment cost incurred for children in treatment of development disorders, cerebral palsy, autism, speech disorders and dyslexia. In India, nearly 1 in 8 children is suffering from neurodevelopmental condition as per 2018 study by INCLEN Trust International. Considering this scenario, a move to provide coverage for this health condition proves a quite significant development.

No Rejection after 8 Years of Coverage

Another major decision will have the wide impact on the insurance industry. As per the guidelines issued, insurers cannot reject claims of those found to be a smoker or suffering from a disease or pre-existing disease, if the insured person has been availing insurance cover for continuous eight years.

IRDAI further added that insurer can no longer exclude coverage, in case the policyholder failed to get or follow medical advice or treatment.

Cheer to Sports Enthusiasts

As per new rules drafted by IRDAI, insurance companies now have to provide the coverage for risky sports pursuits including dirt biking, paragliding, whitewater rafting, go-karting and F1 racing. Coverage is also available for ethnic sports like jallikattu and kambala. Moreover, insurers can’t discriminate on gender and identity basis.

Insurers can’t reject to provide cover when an insured person is on life support, however they can reject claims when he/she is in a minimally conscious state. Insurers will have to pay for the expenses incurred, if the patient is certified by competent authorities. Insurers can put waiting periods for any specific illnesses up to the maximum of four years.

IRDAI also asked insurers to comply with the new health insurance guidelines, else they have to withdraw the non-compliant health insurance products by 1st April 2020.

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