Guidelines
on
Standardization of
General Terms and Clauses in Health Insurance Policy Contracts
1. OBJECTIVE:
The
Objective of these guidelines is to standardize the general terms and clauses
incorporated in indemnity based Health Insurance [excluding Personal Accident
(hereinafter called as PA) and Domestic / Overseas Travel] products by
simplifying the wordings of general terms and clauses
of the policy contracts and ensure uniformity across the industry.
These
Guidelines are issued under the provisions of Section 34(1) of the Insurance
Act, 1938 read with Regulation 20 and Schedule III of IRDAI (Health Insurance)
Regulations, 2016.
2. APPLICABILITY:
These Guidelines are
applicable to all General and Health Insurers offering indemnity based Health
Insurance (excluding PA and Domestic / Overseas Travel) products (both
Individual and Group).
The provisions of
these guidelines shall be applicable to the indemnity based Health Insurance
[excluding Personal Accident (hereinafter called as PA) and Domestic / Overseas
Travel] products filed as per Guidelines on Product Filing in Health Insurance
Business on or after 01st October, 2020. All policy contracts of the
existing health insurance products that are not in compliance with these
guidelines shall be modified as and when they are due for renewal from 01st
April, 2021onwards.
3. Other Provisions:
3.1
Where these general terms and clauses areused, Insurers shall incorporate the
same wordings as prescribed in Annexure – 1 of these guidelines.
3.2
Insurers
may incorporate other general terms and clauses in the product as per their
product design in order to ensure an informed choice to the prospects/insured
persons.
3.3 Insurers may suitably modify the general terms and
clauses of the policy contract prospectively based on the Regulations or
Guidelines that may be issued by the Authority time to time.
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. This has the approval of the
competent authority.
(D V S Ramesh)
General Manager (Health)
Annexure - 1
StandardGeneralTerms and Clauses:
1 Disclosure of Information
The
policy shall be void and all premium paid thereon shall be forfeited to the
Company in the event of misrepresentation, misdescription or non-disclosure of
any material fact by the policyholder.
(Explanation:
“Material facts” for the purpose of this policy shall mean all relevant
information sought by the company in the proposal form and other connected
documents to enable it to take informed decision in the context of underwriting
the risk)
2 Condition Precedent to
Admission of Liability
The terms and
conditions of the policy must be fulfilled by the insured person for the
Company to make any payment for claim(s) arising under the policy.
3 Claim Settlement (provision
for Penal Interest)
i.
The
Company shall settle or reject a claim, as the case may be, within 30 days from
the date of receipt of last necessary document.
ii.
In
the case of delay in the payment of a claim, the Company shall be liable to pay
interest to the policyholder from the date of receipt of last necessary
document to the date of payment of claim at a rate 2% above the bank rate.
iii.
However,
where the circumstances of a claim warrant an investigation in the opinion of
the Company, it shall initiate and complete such investigation at the earliest,
in any case not later than 30 days from the date of receipt of last necessary
document. In such cases, the Company shall settle or reject the claim
within 45 days from the date of receipt of last necessary document.
iv.
In
case of delay beyond stipulated 45 days, the Company shall be liable to pay
interest to the policyholder at a rate 2% above the bank rate from the date of
receipt of last necessary document to the date of payment of claim.
(Explanation: “Bank rate”
shall mean the rate fixed by the Reserve Bank of India (RBI) at the beginning
of the financial year in which claim has fallen due)
(Note to Insurers: The
Clause shall be suitably modified by the insurer based on the amendment(s), if
any to the relevant provisions of Protection of Policyholder’s Interests
Regulations, 2017)
4 Complete Discharge
Any payment to
the policyholder, insured person or his/ her nominees or his/ her legal
representative or assignee or to the Hospital, as the case may be, for any
benefit under the policy shall be a valid discharge towards payment of claim by
the Company to the extent of that amount for the particular claim.
5 Multiple Policies
i. In case of multiple
policies taken by an insured person during a period from one or more insurers
toindemnify treatment costs, the insured person shall have the right to require
a settlement of his/herclaim in terms of any of his/her policies. In all such
cases the insurer chosen by the insured person shall be obliged to settle
theclaim as long as the claim is within the limits of and according to the
terms of the chosen policy.
ii. Insured person having multiple
policies shall also have the right to prefer claims under this policy for the
amounts disallowed under any other policy / policies even if the sum insured is
not exhausted. Then the insurershall independently settle the claim subject to
the terms and conditions of this policy.
iii. If the amount to be claimed
exceeds the sum insured under a single policy, the insured person shall have
the right to choose insurer from whomhe/she wants to claim the balance amount.
iv. Where an insured person has
policies from more than one insurer to cover the same risk onindemnity basis,
the insured person shall only be indemnified the treatment costs in
accordancewith the terms and conditions of the chosen policy.
6 Fraud
If any
claim made by the insured person, is in any respect fraudulent, or if any false
statement, or declaration is made or used in support thereof, or if any
fraudulent means or devices are used by the insured person or anyone acting on
his/her behalf to obtain any benefit under this policy, all benefits under this
policy and the premium paid shall be forfeited.
Any amount
already paid against claims made under this policy but which are found
fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has
made that particular claim,who shall be jointly and severally liable for such
repayment to the insurer.
Forthepurposeofthisclause,theexpression"fraud"meansanyofthefollowingactscommittedbytheinsured
personorbyhisagentor
the hospital/doctor/any other party acting on behalf of the insured person, withintenttodeceivetheinsurerortoinducetheinsurertoissueaninsurancepolicy:
a) the suggestion, as a fact of that whichisnottrueandwhichtheinsured
persondoes not believetobetrue;
b) theactive concealmentof afactbytheinsured
personhavingknowledgeorbeliefofthefact;
c) anyother act fitted to deceive; and
d) anysuchactoromissionasthelawspeciallydeclarestobefraudulent
The
Company shall not repudiate the claim and / or forfeit the policy benefits on
the ground of Fraud, if the insured person / beneficiary can prove that the
misstatement was true to the best of his knowledge and there was no deliberate
intention to suppress the fact or that such misstatement of or suppression of
material fact are within the knowledge of the insurer.
7 Cancellation
i.
The
policyholder may cancel this policy by giving 15days’ written notice and in
such an event, the Company shall refund premium for the unexpired policyperiod
as detailed below.
(Note
to Insurers: Insurer shall specify the method of refund calculation)
Notwithstanding
anything contained herein or otherwise, no refunds of premium shall be made in
respect of Cancellation where, anyclaim has been admitted or has been lodged or
any benefit has been availed by the insured person under the policy.
(Note to
insurers: Insurer may relax this condition as per the product design)
ii. The Company may cancel
thepolicy at any time on grounds of misrepresentation non-disclosure of
material facts, fraud by the insured personby giving 15 days’ written notice. There
would be no refund of premium on cancellation on grounds of misrepresentation,
non-disclosure of material facts or fraud.
8 Migration
The
insured person will have the option to migrate the policy to other health
insurance products/plans offered by the company by applying for migration of the
policyatleast30 days before the policy renewal date as per IRDAI guidelineson
Migration. If such person is presently covered and has been continuously
covered without any lapses under any health insurance product/plan offered by
the company,the insured person will get the accrued continuity benefits in
waiting periods as per IRDAI guidelines on migration.
For DetailedGuidelines on
migration, kindly refer the link ………
(Note to
Insurers: Insurer to provide link to the IRDAI guidelineson migration.Timelines
for applying for migration may be relaxed by the insurer subject to product
design)
9 Portability
The
insured person will have the option to port the policy to other insurers by applying to
suchinsurer to port the entire policy along with all the members of the family,
if any, at least 45 days before, but not earlier than 60 days from the policy renewal
date as
per IRDAI guidelines related to portability. If such person is presently
covered and has been continuously covered without any lapses under any health
insurance policy with an Indian General/Health insurer, the proposed insured
person will get the accrued continuity benefits in waiting periods as per IRDAI
guidelines on portability.
For Detailed Guidelines on
portability, kindly refer the link ………
(Note to
Insurers: Insurer to provide link to the IRDAI guidelines related to
portability.Timelines for applying for portability may be relaxed by the
insurer subject to product design)
10 Renewal of Policy
The policy shall ordinarily
be renewable except on grounds of fraud, misrepresentation by the insured person.
i. The Company shall endeavor
to give notice for renewal. However, the Company is not under obligation to
give any notice for renewal.
ii. Renewal
shall not be denied on the ground that the insured person had made a claim or
claims in the preceding policy years.
iii. Request for renewal along
with requisite premium shall be received by the Company before the end of the policy
period.
iv. At the end of the policy
period, the policy shall terminate and can be renewed within the Grace Period of
…… days (Note to insurers: Insurer to specify grace period as per product
design) to maintain continuity of benefits withoutbreak in policy. Coverage
is not available during the grace period.
v. No loading shall apply on
renewals based on individual claims experience.
11 Withdrawal of Policy
i.
In
the likelihood of this product being withdrawn in future, the Company will
intimate the insured person about the same 90 days prior to expiry of the policy.
ii.
Insured
Person will have the option to migrate to similar health insurance product
available with the Company at the time of renewal with all the accrued
continuity benefits such as cumulative bonus, waiver of waiting period. as per
IRDAI guidelines, provided the policy has been maintained without a break.
12 Moratorium Period
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 claim 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
contract.
13 Premium Payment in
Instalments (Wherever applicable)
If the
insured person has opted for Payment of Premium on an instalment basis i.e.
Half Yearly, Quarterly or Monthly, as mentioned in the policy
Schedule/Certificate of Insurance, the following Conditions shall apply
(notwithstanding any terms contrary elsewhere in the policy)
i.
Grace
Period of ___ (Note to Insurers: Insurer to specify grace period as per
product design) days would be given to pay the instalment premium due for
the policy.
ii. During such grace period, coverage
will not be available from the due date of instalment premium till the date of
receipt of premium by Company.
iii. The insured person will get
the accrued continuity benefit in respect of the “Waiting Periods”, “Specific
Waiting Periods” in the event of payment of premium within the stipulated grace
Period.
iv. No interest will be charged
If the instalment premium is not paid on due date.
v. In case of instalment
premium due not received within the grace period, the policy will get cancelled.
vi. In the event of a claim,
all subsequent premium instalments shall immediately become due and payable.
vii. The company has the right
to recover and deduct all the pending installments from the claim amount due
under the policy.
14 Possibility of Revision of
Terms of the Policy Including the Premium Rates
The Company, with prior approval of IRDAI, may revise
or modify the terms of the policy including the premium rates. The insured
person shall be notified three months before the changes are effected.
15 Free look period
The Free
Look Period shall be applicable on new individual health insurance policies and
not on renewals or at the time of porting/migrating the policy.
The
insured person shall be allowed free look period of fifteen days from date of
receipt of the policy document to review the terms and conditions of the policy,
and to return the same if not acceptable.
If
the insured has not made any claim during the Free Look Period, the insured
shall be entitled to
i.
a
refund of the premium paid less any expenses incurred by the Company on medical
examination of the insured person and the stamp duty charges or
ii.
where
the risk has already commenced and the option of return of the policy is
exercised by the insured person, a deduction towards the proportionate risk
premium for period of coveror
iii.
Where
only a part of the insurance coverage has commenced, such proportionate premium
commensurate with the insurance coverage during such period;
(Note to
insurers: Insurer may increase the free look period as per the product design)
16
Redressal
of Grievance
In case of
any grievance the insured person may contact the company through
Website:
Toll free:
E-mail:
Fax :
Courier:
Insured
person may also approach the grievance cell at any of the company’s branches
with the details of grievance
If Insured
person is not satisfied with the redressalof grievance through one of the above
methods, insured person may contact the grievance officerat ………….
For updated details of
grievance officer, kindly refer the link……….
(Note to
insurers: Address of the Grievance Officer and link having updated details of
grievance officer on website to be specified by the insurer. Insurer to also
specify separate contact details for senior citizens)
If Insured
person is not satisfied with the redressalof grievance through above methods,
theinsured person may also approach the office of Insurance Ombudsman of
the respective area/region for redressal of grievanceas per Insurance Ombudsman
Rules 2017. (Note to insurers: Insurer to specify the latest contact details
of offices of Insurance Ombudsman)
Grievance
may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/
17
Nomination:
The policyholder is
required at the inception of the policy to make a nomination for the purpose of
payment of claims under the policy in the event of death of the policyholder.
Any change of nomination shall be communicated to the company in writing and
such change shall be effective only when an endorsement on the policy is made.
In the event of death of the policyholder, the Company will pay the nominee {as
named in the Policy Schedule/Policy Certificate/Endorsement (if any)} and in
case there is no subsisting nominee, to the legal heirs or legal
representatives of the policyholder whose discharge shall be treated as full
and finaldischarge of its liability under the policy.