Ref:
IRDAI/HLT/REG/CIR/177/09/2019
27th
September, 2019
Guidelines
on Standardization of Exclusions in Health Insurance Contracts
|
Chapter
|
Item
|
Page
No.
|
|
I
|
Objective; Applicability; Legal and other
provision, Definitions
|
2-4
|
|
II
|
Exclusions not allowed in Health Insurance
Policies
|
5
|
|
III
|
Standard
Wordings for some of the exclusions in Health Insurance Policies
|
6-9
|
|
IV
|
Diseases
allowed to be permanently excluded
|
10-14
|
|
V
|
Modern
Treatment Methods and Advancement in Technologies
|
15
|
|
VI
|
Other guidelines related to exclusions
|
16-17
|
INDEX
GENERAL-
Chapter - I
1.
OBJECTIVE:
The
objective of these Guidelines are to rationalise and standardize
the exclusions in health Insurance Contracts that every Insurer shall comply
with. Health Insurance has undergone various changes and improvements over the
years. The Insurance Regulatory and Development Authority of India (Health
Insurance) Regulations as well as the TPA (Third Party Administrators)
Regulations have brought in standardization of various definitions / formats in
the health insurance industry to promote uniformity keeping the customer in
focus. The health insurance industry is keeping pace with the advancements in
technologies that are taking place in the healthcare industry.With the increase
in number of health insurance companies as well as health insurance products in
the market, it has been desired that the health insurance industry adopts a
uniform approach while incorporating exclusions in the health insurance
products. In order to have a holistic and structured approach in devising appropriate
guidelines, IRDAI, constituted a Working Group vide order Ref:
IRDAI/HLT/ORD/Misc/113/07/2018 dated 24th July,2018 to review the extantpractices
andmake appropriate recommendations to meet the above objective.Report of the
Working Group was published in IRDAI website on 02/11/2018.
2.
APPLICABILITY:
These
Guidelines are applicable to all General and Health Insurers offering indemnity
based health insurance (excluding PA and Domestic / Overseas Travel) policies
offering hospitalisation, domiciliary hospitalisation and day care treatment.
3.
LEGAL AND OTHER PROVISIONS:
3.1 Theseguidelines are issued under the
provisions of Section 34 (1) of Insurance Act, 1938 and Section 14 (2) (e) of
the IRDAI Act 1999.
3.2 In
order to enhance the health insurance coverage that is granted at the time of
issuing a policy it is considered important to rationalise the exclusions that were
hitherto prevalent in the health insurancepolicy contracts issued by all
Insurers. Certain exclusions are prohibited to be incorporated in the health
insurance policy contracts. Standardization of wordings of certain exclusions
that are incorporated in the Health Insurance Contracts is also considered
important to ensure uniformity across the industry. In order to enable the
individuals that are suffering with any existing diseases get the health
insurance coverage excluding the coverage to such existing disease, it is
considered essential to let the Insurers accept such risks, subject to
underwriting policy of the respective insurers, by permanently excluding the
coverage to such existing diseases or illnesses.
3.3 Accordingly,
these Guidelines are issued specifying (i) the exclusions that are not allowed
in the Health Insurance Policies, (ii) Standard Wordings of some of the
exclusions (iii) Existing Diseases that may be permanently excluded (iv) Modern
Treatment Methods that shall be covered (v) Other Norms on Exclusions.
3.4 Exclusions
not allowed in Health Insurance Policies are prescribed in Chapter II of these
Guidelines.No Insurer shall incorporate any exclusion specified under this
chapter as part of any of the Health InsuranceProducts. No exclusion that may
potentially circumvent these exclusions is allowed in Health Insurance
Products.
3.5 Standard
Wordings of some of the exclusions that are prevalent in Health Insurance
Policiesare prescribed in Chapter III of these Guidelines. While every Insurer
may endeavour to minimise the number of exclusions to enhance availability of
health insurance coverage, where insurers prefer to incorporate these
exclusions, they shall incorporate the same wordings in-verbatim in the policy
contracts as prescribed in this chapter.
3.6 Existing
Diseases allowed to be permanently excluded are prescribed in Chapter IV of these
Guidelines.Every insurer may endeavour to extend health insurance coverage to all
the persons to be insured who disclosed pre-existing disease at the point of
underwriting in accordance to Regulation (8) of IRDAI (Health Insurance)
Regulations, 2016. Insurers while granting health insurance coverage to the
persons with the existingdiseases referred in Chapter IV may levy suitable
health loading based on objective criteria as laid down in the board approved
underwriting policy. Where underwriting policy of the Insurer does not enable
the Insurer to offer the Health Insurance Coverage for the given existing disease
disclosed even after levying the loading, Insurers are allowed to permanently
exclude the Health Insurance coverage to the existing disease specified in the within
referred Chapter. Other than the diseases listed in Table –
1 of Chapter – IV, any other pre-existing disease disclosed by the person to be
insured shall be covered subject to the norms applicable for preexisting diseases.
3.7 In
order to ensure that the policyholders of health insurance policies are not
denied getting access to the technologically and medically advanced treatment
procedures, Insurers shall not exclude the treatment procedures specified in
Chapter V.
3.8 Other
norms related to exclusions are prescribed in Chapter VI of these Guidelines.
4.
Definitions: The words used herein and defined in the Insurance Act, 1938, Insurance
Regulatory and Development Authority Act, 1999 and Regulations notified
thereunder shall have the same meaning as assigned to them respectively.
5. EFFECTIVE
DATE:
The
provisions of these Guidelines shall be applicable in respect of all health
insurance products (Other than Personal Accident, Domestic and Overseas Travel
Policies) (both Individual and Group)referred in Clause (2) above filed on or
after 01stOctober,2019. All existing health insurance products that
are not in compliance with these Guidelines shall not be offered and promoted
from 01stOctober, 2020 onwards.
This
has the approval of the competent authority.
(DVS
Ramesh)
General
Manager (Health)
CHAPTER
II
Exclusions
not allowed in Health InsurancePolicies:
1.
On
examining the extant wordings in the health insurance policy contracts and the
prevailing exclusions, it is directed that the following exclusions shall not
be allowed in health insurance (Other than PA & Travel) policies. No
Health Insurance Policy shall incorporate the following exclusions in the terms
and conditions of the policy contract.
a.
Diseases
contracted after taking the health insurance policy, except for the conditions excluded
for which standard wordings are prescribed in Chapter III.
b. Injury or illness
associated with hazardous activities. (Explanation: However, only treatment
necessitated due to participation in adventure or hazardous sports is permitted
as exclusion.)
c. Impairment of
Persons’ intellectual faculties by usage of drugs, stimulants or depressantsas prescribed
by a medical practitioner.
d. Artificial life
maintenance, including life support machine use, where such treatment will not
result in recovery or restoration of the previous state of health under any
circumstances unless in a vegetative state as certified by the treating medical
practitioner. (Explanation: Expenses up to the date of confirmation by the
treating doctor that the patient is in vegetative state shall be covered as per
the terms and conditions of the policy contract).
e. Treatment of mental
illness, stress or psychological disorders and neurodegenerative disorders.
f. Puberty and Menopause
related Disorders:Treatment for any symptoms, Illness, complications arising
due to physiological conditions associated with Puberty, Menopause such as
menopausal bleeding or flushing.
g. Age Related Macular
Degeneration (ARMD)
h. Behavioural andNeurodevelopmental
Disorders:
i. Disorders of adult
personality ;
ii. Disorders of speech
and language including stammering, dyslexia;
i. Expenses related to
any admission primarily for enteral feedings.
j. Internal congenital diseases,
genetic diseases or disorders.
k. If specified aetiology for themedical
condition is not known.
l.
Failure
to seek or follow medical adviceor failure to follow treatment.
CHAPTER
III
Standard
Wordings for some of the exclusions in Health Insurance Policies:
1. To make the wordings
of exclusions uniform and specific across the Industry, the wordings of the following
exclusions are standardized. Where these exclusions or exclusions similar to
the ones specified hereunder are used, Insurers shall incorporate the same
wordings in verbatim in the health insurance policy contracts.
2. Against each
exclusion a code number is specified. Insurers are directed to put in place
operational and system procedures to capture exclusion code specific claim
repudiations for the purpose of deriving data/information relating to exclusion
wise repudiation of health insurance claims.
A. Exclusion Name:
Pre-Existing Diseases - Code- Excl01
a) Expenses related to
the treatment of a pre-existing Disease (PED) and its direct complications
shall be excluded until the expiry of #### months of continuous coverage after
the date of inception of the first policy with insurer.
b) In case of
enhancement of sum insured the exclusion shall apply afresh to the extent of sum
insured increase.
c) If the Insured Person
is continuously covered without any break as defined under the portability
norms of the extant IRDAI (Health Insurance) Regulations, then waiting period
for the same would be reduced to the extent of prior coverage.
d) Coverage under the
policy after the expiry of ##### months for any pre-existing disease is subject
to the same being declared at the time of application and accepted byInsurer.
(Explanation:
Subject to product design the number of months, not exceeding 48 months, shall
be specified or a reference may be given to the policy schedule)
B. Exclusion Name:
Specified disease/procedure waiting period- Code- Excl02
a) Expenses related to
the treatment of the listed Conditions, surgeries/treatments shall be excluded
until the expiry of <####> months of continuous coverage after the date
of inception of the first policy with us. This exclusion shall not be
applicable for claims arising due to an accident.(Explanation: Subject to product
design the number of months, not exceeding 48 months, shall be specified)
b) In case of
enhancement of sum insured the exclusion shall apply afresh to the extent of
sum insured increase.
c) If any of the
specified disease/procedure falls under the waiting period specified for
pre-Existing diseases, then the longer of the two waiting periods shall apply.
d) The waiting period
for listed conditions shall apply even if contracted after the policy or declared
and accepted without a specific exclusion.
e) If the Insured Person
is continuously covered without any break as defined under the applicable norms
on portability stipulated by IRDAI, then waiting period for the same would be
reduced to the extent of prior coverage.
f) List of specific
diseases/procedures(Explanation: “List of specific diseases / Procedures in
respect of which waiting period is imposed shall be specified here or reference
to be furnished”.)
C. 30-day waiting period- Code- Excl03
a) Expenses related to
the treatment of any illness within 30 days from the first policy commencement
date shall be excluded except claims arising due to an accident, provided the
same are covered.
b) This exclusion shall
not, however, apply if the Insured Person has Continuous Coverage for more than
twelve months.
c) The within referred
waiting period is made applicable to the enhanced sum insured in the event of
granting higher sum insured subsequently.
D. Investigation &
Evaluation- Code- Excl04
a) Expenses related to
any admission primarily for diagnostics and evaluation purposes only are
excluded.
b) Any diagnostic
expenses which are not related or not incidental to the current diagnosis and
treatment are excluded.
E. Exclusion Name: Rest
Cure, rehabilitation and respite care- Code- Excl05
a) Expenses related to
any admission primarily for enforced bed rest and not for receiving treatment.This
also includes:
i. Custodial care either
at home or in a nursing facility for personal care such as help with activities
of daily living such as bathing, dressing, moving around either by skilled
nurses or assistant or non-skilled persons.
ii. Any services for
people who are terminally ill to address physical, social, emotional and
spiritual needs.
(Note: However,
Insurers may endeavour to develop add-on riders to offer respite care and home
care, especially, the coverage that kicks in at age 65 onwards, provided the
coverage under base policy is continued without break.)
F. Obesity/ Weight
Control:Code-
Excl06
Expenses related to the surgical treatment of
obesity that does not fulfil all the below conditions:
1) Surgery to be
conducted is upon the advice of the Doctor
2) The surgery/Procedure
conducted should be supported by clinical protocols
3) The member has to be
18 years of age or older and
4) Body Mass Index (BMI);
a) greater than or equal
to 40 or
b) greater than or equal
to 35 in conjunction with any of the following severe co-morbidities following
failure of less invasive methods of weight loss:
i.
Obesity-related
cardiomyopathy
ii.
Coronary
heart disease
iii.
Severe
Sleep Apnea
iv.
Uncontrolled
Type2 Diabetes
G. Change-of-Gendertreatments:Code- Excl07
Expenses
related to any treatment, including surgical management, to change
characteristics of the body to those of the opposite sex.
H. Cosmetic or plastic
Surgery:Code- Excl08
Expenses
for cosmetic or plastic surgery or any treatment to change appearance unless
for reconstruction following an Accident, Burn(s) or Cancer or as part of
medically necessary treatment to remove a direct and immediate health risk to
the insured. For this to be considered a medical necessity, it must be
certified by the attending Medical Practitioner.
I.
Hazardous
or Adventure sports:Code- Excl09
Expenses
related to any treatment necessitated due to participation as a professional in
hazardous or adventure sports, including but not limited to, para-jumping, rock
climbing, mountaineering, rafting, motor racing, horse racing or scuba diving,
hand gliding, sky diving, deep-sea diving.
J.
Breach
of law:Code- Excl10
Expenses
for treatment directly arising from or consequent upon any Insured Person committing
or attempting to commit a breach of law with criminal intent.
K.
Excluded
Providers:Code- Excl11
Expenses
incurred towards treatment in any hospital or by any Medical Practitioner or
any other provider specifically excluded by the Insurer and disclosed in its
website / notified to the policyholders are not admissible. However, in case
of life threatening situations following an accident, expenses up to the stage
of stabilization are payable but not the complete claim.
(Explanation:
Details of excluded providers shall be provided with the policy document. Insurers
to use various means of communication to notify the policyholders, such as
e-mail, SMS about the updated list being uploaded in the website.)
L.
Treatment
for, Alcoholism, drug or substance abuse or any addictive condition and
consequences thereof.Code- Excl12
M. Treatments received
in heath hydros, nature cure clinics, spas or similar establishments or private
beds registered as a nursing home attached to such establishments or where
admission is arranged wholly or partly for domestic reasons.Code- Excl13
N. Dietary supplements
and substances that can be purchased without prescription, including but not
limited to Vitamins, minerals and organic substances unless prescribed by a
medical practitioner as part of hospitalization claim or day care procedure.Code-
Excl14
O. Refractive Error:Code- Excl15
Expenses related to the treatment for correction of eye sight
due to refractive error less than 7.5 dioptres.
P. Unproven Treatments: Code- Excl16
Expenses
related to any unproven treatment, services and supplies for or in connection
with any treatment. Unproven treatments are treatments, procedures or supplies
that lack significant medical documentation to support their effectiveness.
Q. Birth control,
Sterility and Infertility:Code- Excl17
Expenses related to Birth Control, sterility and infertility.
This includes:
(i) Any
type of contraception, sterilization
(ii) Assisted
Reproduction services including artificial insemination and advanced
reproductive technologies such as IVF, ZIFT, GIFT, ICSI
(iii) Gestational
Surrogacy
(iv) Reversal
of sterilization
R. Maternity: Code Excl18
i.
Medical
treatment expenses traceable to childbirth (including complicated deliveries
and caesarean sections incurred during hospitalization) except ectopic
pregnancy;
ii.
Expenses
towards miscarriage (unless due to an accident) and lawful medical termination
of pregnancy during the policy period.
CHAPTER
IV
Existing
Diseases allowed to be permanently excluded:
1.
Notwithstanding
the provisions of Clause (1) of Chapter- II, Insurers are allowed to incorporate
the following existing diseases disclosed by the person to be insured at the
time of underwriting as permanent exclusions with due consent of the proposer
or person to be insured, where underwriting policy of the Insurer does not
enable the Insurer to offer the Health Insurance Coverage for the given
existing disease disclosed even after levying the loading.The permanent
exclusion would be specific for the following listed conditions. However, it is
emphasized that these permanent exclusions shall be allowed only in cases where
the policyholder may be denied coverage as per the underwriting policy of the
Insurer for the existing diseases disclosed at the time of underwriting.
TABLE
- 1
|
Sr. No.
|
Disease
|
ICD Code
|
|
1
|
Sarcoidosis
|
D86.0-D86.9
|
|
2
|
Malignant Neoplasms
|
C00-C14 Malignant neoplasms of lip,
oral cavity and pharynx, • C15-C26 Malignant neoplasms of digestive organs,
• C30-C39 Malignant neoplasms of respiratory and intrathoracic organs•
C40-C41 Malignant neoplasms of bone and articular cartilage• C43-C44 Melanoma
and other malignant neoplasms of skin • C45-C49 Malignant neoplasms of
mesothelial and soft tissue • C50-C50 Malignant neoplasms of breast •
C51-C58 Malignant neoplasms of female genital organs • C60-C63 Malignant
neoplasms of male genital organs • C64-C68 Malignant neoplasms of urinary
tract • C69-C72 Malignant neoplasms of eye, brain and other parts of central
nervous system • C73-C75 Malignant neoplasms of thyroid and other endocrine
glands • C76-C80 Malignant neoplasms of ill-defined, other secondary and
unspecified sites • C7A-C7A Malignant neuroendocrine tumours • C7B-C7B
Secondary neuroendocrine tumours • C81-C96 Malignant neoplasms of lymphoid,
hematopoietic and related tissue• D00-D09 In situ neoplasms • D10-D36 Benign
neoplasms, except benign neuroendocrine tumours • D37-D48 Neoplasms of
uncertain behaviour, polycythaemia vera and myelodysplastic syndromes •
D3A-D3A Benign neuroendocrine tumours • D49-D49 Neoplasms of unspecified
behaviour
|
|
3
|
Epilepsy
|
G40 Epilepsy
|
|
4
|
Heart Ailment Congenital heart disease
and valvular heart disease
|
I49 Other cardiac
arrhythmias, (I20-I25)
Ischemic heart diseases, I50 Heart failure, I42
Cardiomyopathy; I05-I09 - Chronic rheumatic
heart diseases. • Q20 Congenital malformations of cardiac chambers and
connections • Q21 Congenital malformations of cardiac septa • Q22 Congenital
malformations of pulmonary and tricuspid valves • Q23 Congenital
malformations of aortic and mitral valves • Q24 Other congenital
malformations of heart • Q25 Congenital malformations of great arteries • Q26
Congenital malformations of great veins • Q27 Other congenital malformations
of peripheral vascular system• Q28 Other congenital malformations of
circulatory system • I00-I02 Acute rheumatic fever • I05-I09 • Chronic
rheumatic heart diseases Nonrheumatic mitral valve disorders mitral (valve):
• disease (I05.9) • failure (I05.8) • stenosis (I05.0). When of unspecified
cause but with mention of: • diseases of aortic valve (I08.0), • mitral
stenosis or obstruction (I05.0) when specified as congenital (Q23.2, Q23.3)
when specified as rheumatic (I05), I34.0Mitral (valve) insufficiency • Mitral
(valve): incompetence / regurgitation - • NOS or of specified cause, except
rheumatic, I 34.1to I34.9 - Valvular heart disease.
|
|
5
|
Cerebrovascular
disease (Stroke)
|
I67 Other
cerebrovascular diseases, (I60-I69) Cerebrovascular diseases
|
|
6
|
Inflammatory Bowel
Diseases
|
K 50.0 to K 50.9
(including Crohn's and Ulcerative colitis)
K50.0 - Crohn's
disease of small intestine; K50.1 -Crohn's disease of large intestine; K50.8
- Other Crohn's disease; K50.9 - Crohn'sdisease,
unspecified. K51.0 - Ulcerative (chronic) enterocolitis; K51.8 -Other
ulcerative colitis; K51.9 - Ulcerative colitis,unspecified.
|
|
7
|
Chronic Liver
diseases
|
K70.0 To K74.6
Fibrosis and cirrhosis of liver; K71.7 - Toxic liver disease with fibrosis
and
cirrhosis of liver; K70.3 - Alcoholic cirrhosis of liver; I98.2 -
K70.-Alcoholic liver disease; Oesophageal varices in diseases
classifiedelsewhere. K 70 to K 74.6 (Fibrosis, cirrhosis, alcoholic liver
disease, CLD)
|
|
8
|
Pancreatic diseases
|
K85-Acute
pancreatitis; (Q 45.0 to Q 45.1) Congenital conditions of pancreas, K 86.1 to
K 86.8 - Chronic pancreatitis
|
|
9
|
Chronic Kidney
disease
|
N17-N19) Renal
failure; I12.0 - Hypertensive renal disease with renal failure; I12.9
Hypertensive renal disease without renal failure; I13.1 - Hypertensive heart
and renal disease with renal failure; I13.2 - Hypertensive heart and renal
disease with both (congestive) heart failure and renal failure; N99.0 - Post
procedural renal failure; O08.4 - Renal failure following abortion and
ectopic and molar pregnancy; O90.4 - Postpartum acute renal failure; P96.0 - Congenital
renal failure. Congenital malformations of the urinary system (Q 60 to Q64),
diabetic nephropathy E14.2, N.083
|
|
10
|
Hepatitis B
|
B16.0 - Acute
hepatitis B with delta-agent
(coinfection) with hepatic coma; B16.1 – Acute hepatitis B with delta-agent (coinfection)
without hepatic coma; B16.2 - Acute hepatitis B without delta-agent with
hepatic coma; B16.9 –Acute hepatitis B without delta-agent and without
hepatic coma; B17.0 –Acute delta-
(super)infection of hepatitis B carrier; B18.0 -Chronic viral hepatitis B
with delta-agent; B18.1 -Chronic viral hepatitis B without delta-agent;
|
|
11
|
Alzheimer's
Disease, Parkinson's Disease -
|
G30.9 - Alzheimer's
disease, unspecified; F00.9 -
G30.9Dementia in Alzheimer's disease,
unspecified, G20 - Parkinson's disease.
|
|
12
|
Demyelinating
disease
|
G.35 to G 37
|
|
13
|
HIV & AIDS
|
B20.0 - HIV disease
resulting in mycobacterial infection; B20.1 - HIV disease resulting in other
bacterial infections; B20.2 - HIV disease resulting in cytomegaloviral
disease; B20.3 - HIV disease resulting in other viral infections; B20.4 - HIV
disease resulting in candidiasis; B20.5 - HIV disease resulting in other
mycoses; B20.6 - HIV disease resulting in Pneumocystis carinii pneumonia;
B20.7 - HIV disease resulting in multiple infections; B20.8 - HIV disease
resulting in other infectious and parasitic diseases; B20.9 - HIV disease
resulting in unspecified infectious or parasitic disease; B23.0 - Acute HIV
infection syndrome; B24 - Unspecified human immunodeficiency virus [HIV]
disease
|
|
14
|
Loss of Hearing
|
H90.0 - Conductive
hearing loss, bilateral; H90.1 - Conductive hearing loss, unilateral with
unrestricted hearing on the contralateral side; H90.2 - Conductive hearing
loss, unspecified; H90.3 - Sensorineural hearing loss, bilateral; H90.4 -
Sensorineural hearing loss, unilateral with unrestricted hearing on the
contralateral side; H90.6 - Mixed conductive and sensorineural hearing loss,
bilateral; H90.7 - Mixed conductive and sensorineural hearing loss,
unilateral with unrestricted hearing on the contralateral side; H90.8 - Mixed
conductive and sensorineural hearing loss, unspecified; H91.0 - Ototoxic
hearing loss; H91.9 - Hearing loss, unspecified
|
|
15.
|
Papulosquamous
disorder of the skin
|
L40 - L45
Papulosquamous disorder of the skin including psoriasis lichen planus
|
|
16.
|
Avascular necrosis
(osteonecrosis)
|
M 87 to M 87.9
|
2. With reference to Sl
No. 13 of the above table, it is clarified that Insurers shall comply with the
provisions of Section 3 (j) of the Human Immunodeficiency Virus and Acquired
Immune Deficiency Syndrome (Prevention and Control) Act 2017 which specifies
that no person shall discriminate against the protected person on any ground
including the denial of, or unfair treatment in the provision of insurance
unless supported by actuarial studies. While complying with the provisions
of the HIV and AIDS (Prevention and Control) Act 2017, Insurers shall be bound
by these provisions, where the Actuarial studies support the denial of the health
insurance coverage, the above approach of allowing to incorporate HIV / AIDS
(refer Sl No. 13) as the permanent exclusion at the time of underwriting, maybe
considered by the Insurers in order to enable these sections of policyholders
to get the health insurance coverage for conditions other than the conditions
referred in Sl No. 13 above.
3. Exclusion of coverage
in respect of the existing diseases referred in Table – 1 of this chapter shall
be limited to the ICD Codes of the respective diseases. No claim which does not
relate to the ICD codes referred herein shall be denied by attributing to the
diseases referred herein. The policyholders shall be entitled to costs of
treatment in respect of any other treatments, other than, the treatment
directly attributable to ICD Codes referred in Table – I above subject to terms
and conditions of the policy contract.
CHAPTER V
Modern
Treatment Methods and Advancement in Technologies:
1.
To
ensure that the policyholders are not denied availability of health insurance
coverage to Modern Treatment Methods Insurers shall ensure that the following
treatment procedures shall not be excluded in the health insurance policy
contracts. These Procedures shall be covered (wherever medically indicated)either
as in-patient or as part of domiciliary hospitalization oras day care treatment
in a hospital.
A. Uterine Artery Embolization
and HIFU
B. Balloon Sinuplasty
C. Deep Brain
stimulation
D. Oral chemotherapy
E. Immunotherapy-
Monoclonal Antibody to be given as injection
F. Intra vitreal
injections
G. Robotic surgeries
H. Stereotactic radio
surgeries
I. BronchicalThermoplasty
J. Vaporisation of the
prostrate (Green laser treatment or holmium laser treatment)
K. IONM - (Intra
Operative Neuro Monitoring)
L. Stem cell therapy: Hematopoietic stem
cells for bone marrow transplant for haematological conditions to be covered.
2. Subject to product
design sub-limits may be imposed for any of the above treatments.
3. Insurers may
endeavour to cover any other modern treatment methods
CHAPTER
VI
Other
guidelines related to exclusions:
1. Notwithstanding
the provisions of Clause (1) of Chapter – II, Insurers are allowed to
incorporate waiting periods for any specific disease condition(s) however to a
maximum of 4 years. Subject to product design Insurers are also allowed to
impose sub limits or annual policy limits for specific diseases / conditions; be
it in terms of amount, percentage of sums insured or number of days of
hospitalisation/ treatment in the policy.However, Insurers shall adopt an
objective criterion while incorporating any of these limitations and shall be
based on sound actuarial principles.
2.
Insurers
are advised to consider the following options to handle the cases of
Non-declaration/Misrepresentation of material facts that are surfaced during
the course of the policy contract. The options specified hereunder for the
purpose of continuing the health insurance coverage to the policyholders and
the underlying claim, if any, shall be subject to terms and conditions of the
applicable policy contract.
a) If the non-disclosed
condition or disease is from the list of the Permanent exclusions specified in Chapter
IV above the insurer can take consent from the policyholder or insured person
and permanently exclude the existing disease and continue with the policy.
b) If the non-disclosed
condition is other than from the list of permanent exclusions, then the insurer
can incorporate additional waiting period of not exceeding 4 years for thesaid
undisclosed disease or condition from the date the non-disclosed condition was
detected and continue with the policy subject to obtaining the prior consent of
the policyholder or the insured person. The within referred additional waiting
period that may be imposed for the undisclosed conditions is allowed notwithstanding
the moratorium period referred in Clause no. 3 hereunder. However, the
additional waiting period referred herein, shall be imposed, only in those
cases where had the medical condition / disease been disclosed by the
policyholder or the Insured person at the point of underwriting, the insurer
would have imposed the waiting period not exceeding forty-eight months at the
time of underwriting.
c) Where the
non-disclosed condition allows the Insurer to continue the coverage by levying
extra premium or loading based on the objective criteria laid down in the Board
approved underwriting policy, the Insurer may levy the same prospectively from
the date of noticing the non-disclosed condition. However, in respect of policy
contracts for a duration exceeding one year, if the undisclosed condition is
surfaced before expiry of the policy term, the Insurer may charge the extra
premium or loading referred herein retrospectively from the first year of
issuance of policy or renewal, whichever is later.
d) The above threeoptions
will not prejudice the rights of the insurer to invoke the cancellation clause of
‘Disclosure to Information norm’ under the policy for non-disclosure
/misrepresentation subject to its underwriting policy.
3. After completion of eight
continuous years under the policy no look back to be applied. This period of eight
years is called as moratorium period.The moratorium would be applicable for the
sums insured of the first policy and subsequently completion of 8 continuous
years would be applicable from date of enhancement of sums insured only on the
enhanced limits. After the expiry of Moratorium Period no health insurance
policy shall be contestable except for proven fraud and permanent exclusions
specified in the policy contract. The policies would however be subject to all
limits, sub limits, co-payments, deductibles as per the policy.The moratorium period
is applicable for health insurance policies issued by General and Health
Insurers.
4. The wordings of the
exclusions or waiting periods shall be specific and unambiguous. No open-ended
exclusions like“Indirectly related to”, “such as”, “etc.” are allowed while incorporating
the exclusions and in the waiting periods.
5.
Waiting
period for life style conditions namely, Hypertension, Diabetes, Cardiac
conditions is not allowed for more than90 days except if these diseases are
pre-existing and disclosed at the time of underwriting.
6.
Insurers
should not deny coverage for claims of Oral Chemo therapy, where Chemo therapy
is allowed and Peritoneal Dialysis, where dialysis is allowed subject to
product design.
7.
Pre/Post
hospitalization cover under Domiciliary Treatment benefit shall not be excluded
where pre/post hospitalization cover is offered in case of in-patient
hospitalization under the product and the underlying product covers domiciliary
hospitalization. (Explanation: On a review of the definition given to
domiciliary treatment, it is evident that this treatment is taken only under
certain unavoidable circumstances that may be beyond the control of the
policyholder. Hence, in fitness of things it is important that the policyholder
can have pre / post hospitalization expenses as are otherwise made available in
case of in-patient hospitalization.)