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To All Insurance Companies and TPAs
Ref. No: IRDA/HLT/REG/CIR/209/11/2019 Date: 27-11-2019
Modified guidelines on Standardization in Health Insurance Business

1.    Reference is invited to Chapter – I of the Guidelines on Standardization in Health Insurance issued vide Circular no. IRDA/HLT/REG/CIR/146/07/2016 dated 29th July, 2016 (Guidelines), where Standard Definitions for 42 commonly used terms in health insurance policies are defined.

 

2.    In addition to the definitions notified in Chapter – I of the above referred Guidelines, the following two definitions are inserted as clause 43 and 44 with immediate effect:

 

43. AYUSH Hospital:

 

An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:

 

a.    Central or State Government AYUSH Hospital; or

b.    Teaching hospital attached to AYUSH College recognized by the Central Government/Central Council of Indian Medicine/Central Council for Homeopathy; or

c.    AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine, registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH Medical Practitioner and must comply with all the following criterion:

 

i.              Having at least 5 in-patient beds;

 

ii.            Having qualified AYUSH Medical Practitioner in charge round the clock;

 

iii.           Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;

 

iv.           Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.

 

44. AYUSH Day Care Centre:

AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having facilities for carrying out treatment procedures and medical or surgical/para-surgical interventions or both under the supervision of registered AYUSH Medical Practitioner (s) on day care basis without in-patient services and must comply with all the following criterion:

i.              Having qualified registered AYUSH Medical Practitioner(s) in charge;

 

ii.            Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures are to be carried out;

 

iii.           Maintaining daily records of the patients and making them accessible to the insurance company’s authorized representative.

[Explanation: Medical Practitioner referred in the definition of “AYUSH Hospital” and “AYUSH Day Care Centre” shall carry the same meaning as defined in the definition of “Medical Practitioner” under Chapter I of Guidelines]

3.    AYUSH Hospitals and AYUSH Day Care Centres referred above shall also obtain either pre-entry level certificate (or higher level of certificate) issued by National Accreditation Board for Hospitals and Healthcare Providers (NABH) or State Level Certificate (or higher level of certificate) under National Quality Assurance Standards (NQAS), issued by National Health Systems Resources Centre (NHSRC).

 

4.    All the existing AYUSH Hospitals and AYUSH Day Care Centres shall comply with the requirements referred under Clause (3) above within a period of twelve months from the date of issue of this Circular, if the said certificate is not already obtained.

 

5.    This Circular supersedes clause 4(xvi) of Chapter II of the Guidelines on Product filing in Health Insurance issued vide IRDAI Circular no. IRDA/HLT/REG/CIR/005/01/2017 dated 10th January, 2017.

 

6.    These Guidelines are issued under the powers vested with Regulation 18 of IRDAI (Health Insurance) Regulations, 2016 read with Section 34 (1) of Insurance Act, 1938. The provisions of this Circular shall be applicable from immediate effect.

 

7.    The instructions referred at Clause (3) and (4) above are subject to the directions of the Hon'ble Delhi High Court in its order dated 29th May 2019 / 31st May, 2019 in respect of W.P(C) 6237 of 2019, which needs to be complied with till further orders of the Hon'ble Court.

 

8.    This has the approval of the competent authority.

 

 

 

General Manager (Health)

  
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