To
All
General and Health Insurers (except ECGC & AIC)
Guidelines
on Covid Standard Health Policy
A.
Preamble:
1.
In view of the global pandemic Covid 19, the
Authority has decided to mandate all general and health insurers to offer Individual
Covid Standard Health Policy with the following objectives:
·
To have a Covid specific product addressing basic
health insurance needs of insuring public related to Covid.
·
To have a standard product with common policy
wordings across the industry
2.
Towards this, the following Guidelines on Covid
Standard Health Policy are issued under the provisions of Section 34 (1) (a) of
Insurance Act, 1938.
3.
All general and health insurers shall offer the
Covid Standard Health Policy by duly complying with the following guidelines.
4.
The Covid Standard Health Policy shall have One
Basic mandatory cover as specified in these Guidelines which shall be uniform
across all General and Health Insurers.
5.
One Optional Cover specified in these
Guidelines, shall be offered along with the Covid Standard Health Policy within
the sum insured. The total amount payable in respect of Covers B (I) (11) (12)
(13) (14) (15) and B(II) (18) shall not exceed 100% of the Sum Insured during a
policy period. The premium payable towards this Optional Cover shall be
specified separately so as to enable policyholders to choose and pay based on
the need.
6.
The insurer may determine the price keeping in
view the covers proposed to be offered subject to complying with the norms
specified in the IRDAI (Health Insurance) Regulations, 2016 and Guidelines
notified there under.
7.
The Base Cover of Covid Standard Health Policy shall
be offered on Indemnity basis whereas Optional Cover shall be made available on
Benefit Basis.
8.
The Covid Standard Health Policy shall offer a policy
tenure of three and half months (3 ½ months), six and half months (6 ½ months),
and nine and half months (9 ½ months) including waiting period.
9. Every General and Standalone Health Insurer, who has been issued a
Certificate of Registration to transact General and/or Health Insurance
Business, shall mandatorily offer this product. However,
if any insurer is currently not offering health insurance products at all, the
above stipulation will not apply to those.
10.
The Covid Standard Health Policy shall comply
with all the provisions of Insurance Regulatory and Development Authority of
India (IRDAI) (Health Insurance) Regulations, 2016, all other applicable
Regulations, Guidelines on Standardization in Health Insurance (Ref:
IRDA/HLT/REG/CIR/146/07/2016) dated 29th July, 2016, Guidelines on Product
Filing in Health Insurance Business (Ref: IRDA/HLT/REG/CIR/150/07/2016) dated
29th July, 2016, Guidelines on Standardization of Exclusions in Health
Insurance Contracts (Ref: IRDAI/HLT/REG/CIR/177/09/2019) dated 27thSeptember,
2019 and other applicable Guidelines as amended from time to time.
B.
Construct of Covid Standard Health Policy: The Covid
Standard Health Policy shall offer the following:
I.
Base cover:
11. COVID Hospitalization Expenses: The Hospitalization expenses
incurred by the insured person for the treatment of Covid on Positive diagnosis
of Covid in a government authorized diagnostic centre. This section shall cover
the following:
a)
Room, Boarding, Nursing Expenses as provided by
the Hospital / Nursing Home.
b)
Surgeon, Anesthetist, Medical Practitioner,
Consultants, Specialist Fees (including consultation through telemedicine as per
Telemedicine Practice Guideline of 25th March 2020) whether paid
directly to the treating doctor / surgeon or to the hospital.
c)
Anesthesia, blood, oxygen, operation theatre
charges, surgical appliances, ventilator charges, medicines and drugs, costs
towards diagnostics, diagnostic imaging modalities, PPE Kit, gloves, mask and
such other similar expenses
(Expenses on Hospitalization for a minimum
period of 24 hours are admissible.)
d) Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU)
expenses.
e) Expenses
incurred on road Ambulance subject to a maximum of Rs.2000/- per hospitalization.
12. Home Care Treatment Expenses: Insurer shall cover the costs
of treatment of COVID incurred by the Insured person on availing treatment at
home maximum up to 14 days per incident provided that:
a)
The Medical practitioner advices
the Insured person to undergo treatment at home.
b)
There is a continuous active line
of treatment with monitoring of the health status by a medical practitioner for
each day through the duration of the home care treatment.
c) Daily monitoring chart including records of treatment administered
duly signed by the treating doctor is maintained.
d) Insured shall be permitted to avail the services as prescribed by
the medical practitioner. Cashless or reimbursement facility are offered under
homecare expenses subject to claim settlement policy disclosed in the website
of the Insurer.
e) In case the insured intends to avail the services of non-network
provider, claim shall be subject to reimbursement, a prior approval from the
Insurer needs to be taken before availing such services. Insurer shall respond
to approval request within 2 hrs of receiving the last necessary requirement.
In this benefit, the following
shall be covered if prescribed by the treating medical
practitioner and is related to
treatment of COVID,
a. Diagnostic tests
undergone at home or at diagnostics centre
b. Medicines
prescribed in writing
c. Consultation
charges of the medical practitioner
d. Nursing
charges related to medical staff
e. Medical
procedures limited to parenteral administration of medicines
f. Cost of Pulse oximeter, Oxygen cylinder and Nebulizer
Subject to other terms, conditions and exclusions of the policy,
expenses payable during the Policy period shall not in aggregate exceed the
maximum Sum Insured as specified in the Policy Schedule against this Benefit.
13. AYUSH Treatment: The Medical
expenses incurred on hospitalization under AYUSH (as defined in IRDAI (Health Insurance) Regulations, 2016)
systems of medicine for the treatment of Covid on Positive diagnosis of Covid
in a government authorized diagnostic centre shall be covered up to the Sum
Insured without any sub-limits.
14. Pre-Hospitalization medical
expenses incurred for a period of 15days prior to the date of hospitalization/home
care treatment following an admissible claim under this policy shall be covered.
Pre hospitalization expenses shall also cover the costs of diagnostics towards Covid.
15. Post-Hospitalization medical
expenses incurred for a period of 30days from the date of discharge from the
hospital/completion of home care treatment, following an admissible claim under
this policy shall be covered.
16. No deductibles are permitted in this product.
17. The Policy shall include the cost of treatment for any comorbid
condition including pre-existing comorbid condition (s)along with the treatment
for Covid.
II.Optional cover:
18. Hospital Daily Cash: The Company
will pay 0.5% of sum insured per day for each 24 hours of continuous hospitalization
for treatment of Covid following an admissible hospitalization claim under this
policy.
The benefit shall be payable maximum
up to 15 days during a policy period in respect of every
insured person.
C. Other Norms applicable:
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Sl.No
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Particulars
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Norms Applicable
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1.
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Plan Variants
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No plan variants are
allowed.
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2.
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Distributions Channels
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Covid Standard Health
Policy may be distributed across all distribution channels including Micro
Insurance Agents, Point of sale persons and Common Public Service Centres.
Distribution of Covid
Standard Health Policy shall be governed by the regulations of concerned
distribution channels.
In addition to the number
of products allowed to be marketed as per IRDAI circular ref: IRDAI/ INT/
CIR/ PSP/ 019/01/2020 dated 13thJanuary, 2020 "Covid Standard
Health Policy" is also allowed to be marketed by Point of Sale.
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3.
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Family Floater
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Covid Standard Health
Policy shall be offered on family floater basis also.
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4.
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Definition of family
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Family consists of the proposer and
any one or more of the family members as mentioned below:
(i)
legally
wedded spouse.
(ii)
Parents
and Parents-in-law.
(iii)
dependent
Children (i.e. natural or legally adopted) between the day 1 of age to 25
years. If the child above 18 years of age is financially independent, he or
she shall be ineligible for coverage.
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5.
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Category of Cover
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The Base Cover of Covid
Standard Health Policy shall be offered on indemnity basis whereas Optional Cover
shall be made available on Benefit Basis.
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6.
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Minimum and Maximum Sum Insured
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The minimum sum insured
under Covid Standard Health Policy shall be Rs 50,000/- (Fifty Thousand only)
Maximum limit shall be Rs 5,00,000/-(5
Lakh) (in the multiples of fifty thousand)
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7
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Policy Period
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Covid Standard Health
Policy shall be offered with a policy term of three and half months (3 ½
months), six and half months (6 ½ months) and nine and half months (9 ½
months) including waiting period.
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8
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Modes of premium payment
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Single premium
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9.
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Entry age
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Minimum entry age shall be
18 years for principal insured and maximum age at entry shall not be less than
65 years for all the insured members including principal insured.
Dependent Child / children
shall be covered from Day 1 of age to 25 years subject to the definition of
‘Family’.
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10.
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Benefit Structure
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The benefit pay out should
be explicitly disclosed in the format of application (Form – IRDAI-UNF-SCHP)
along with other relevant documents.
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11.
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Underwriting
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The insurer shall specify
the non-medical limit and relevant details explicitly in the format
specified.
5% discount in premium
shall be provided to health care workers.
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12.
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Renewal, Portability and Migration
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Lifelong renewability,
migration and portability stipulated under Regulation 13 and 17 of IRDAI
(Health Insurance) Regulations, 2016 respectively are not applicable.
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13.
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Pricing
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The premium under this
product shall be pan India basis and no geographic location / zone based
pricing is allowed.
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14.
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Comorbid Conditions
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The Policy shall include
the cost of treatment for any comorbid condition including pre-existing
comorbid condition(s) along with the
treatment for Covid.
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D: Construct of Terms and Conditions for Covid Standard Health
Policy:
19. The Policy Terms and Conditions of the Covid Standard Health
Policy shall be in the format specified in Annexure – 1. Insurer may suitably
modify the definitions and other clauses of the policy contract prospectively
based on the Regulations or Guidelines that may be issued by the Authority from
time to time.
E: Other Norms:
20. The nomenclature of the product shall be Corona Kavach Policy,
succeeded by name of insurance company, (Corona Kavach Policy, ). No other name is allowed in any of the documents.
21. The Proposal Form used for the product shall be subject to the
norms specified under the Guidelines on Product Filing in Health Insurance.
22. Insurers shall mandatorily issue Customer Information Sheet as per
the format specified in Annexure-2.
23. The Covid Standard Health Policy may be offered as MICRO Insurance
Product subject to Sum Insured limits specified in IRDAI (Micro Insurance)
Regulations, 2015, and other circulars / guidelines issued in this regard by
the Authority from time to time.
24. The Covid Standard Health Policy shall be launched without prior
approval of the Authority subject to complying with the following conditions.
a. The product shall be approved by the Product Management Committee.
b. Insurers shall obtain UIN for the Covid Standard Health Policy by
filing the relevant particulars in Form – IRDAI-UNF-SCHP (as specified in
Annexure – 3 of these Guidelines) along with a certificate from Chief
Compliance Officer that the product filed is in compliance with the norms
specified under these guidelines.
c. On review of the application, the Authority may call for such
further information as may be required and may issue suitable directions which
shall be retrospectively effected in respect of all contracts issued under this
product.
25. General and Health Insurers shall ensure that this product is
compulsorily offered on or before 10th July, 2020.
26.
In terms of the provisions of Regulation
4(iii) of IRDAI (Issuance of e-Insurance Policies) Regulations, 2016 providing
policy document in physical form is mandatory when policies are issued in
electronic form directly to the policyholders. Since features of Corona
Kavach Policy shall be common across the
industry and as the terms and conditions of the policy are specified by the
Authority, with the objective of reducing the operating costs
and to pass on this benefit of reduced operational cost to the policyholders by
way of affordable premiums, insurers are allowed to issue
the policy contract of Corona Kavach Policy in electronic
/ digital format. The digital form of the policy contract may be
forwaded through email or a link shall be provided in the certificate of
insurance.However, where policyholder specifically seeks the physical form of
the policy contract, the same shall be provided by the insurer.
27.
Every insurer offering Corona Kavach Policy shall provide a certificate of insurance to the policyholder indicating the
availability of health insuarnce coverage.The certificate shall have a reference to access detailed terms and conditions of the policy
contract. Insurers shall also clearly mention policy period (Policy Start Date
to Policy End Date), effective policy period (from end of waiting period to end
of policy period), waiting period (policy start date to end of policy period)
in the Certificate of Insurance.
28. In terms of
Clause 5 of Guidelines on short term health insurance policies Ref:
IRDAI/HLT/REG/CIR/156/05/2020 dated 23rd June, 2020, the policies issued
under these guidelines will remain valid till 31st March, 2021.
29. This has the approval of Competent Authority.
(DVS Ramesh)
General Manager