IRDA (HEALTH INSURANCE) REGULATIONS, 2013
NOTIFICATION F. NO. IRDA/REG./14/72/2013,
In exercise of the powers conferred under Section 114A of the Insurance Act, 1938 and Section 14 read with section 26 of the IRDA Act, 1999 and in consultation with the Insurance Advisory Committee, the Authority hereby makes the following regulations, namely:-
1. Short title and commencement.
2. In these Regulations, unless the context otherwise requires,—
3. Registration and Scope of Health Business
4. File and Use Procedure for health insurance products
5. General Provisions relating to Health Policies
7. Principles of Pricing of Health Insurance Products
8. Protection of Policyholders' Interest
9. Administration of Health Policies
10. Agreement between Insurers, Network Providers and TPAs
11. Payments to Network Providers and Settlement of Claims of Policyholders:
12. Services offered by TPA in relation to Health Insurance Policies
13. Agreement between a TPA and an Insurance company
14. Change of TPAs for servicing of Health Insurance Policies
15. Data and related issues:
16. Submission of Returns to the Authority
17. Transitory Provisions
18. Repeal and Savings:
SCHEDULE : I
Portability of Health Insurance Policies offered by Life and General Insurers:
1. A policyholder desirous of porting his policy to another insurance company shall apply to such insurance company, to port the entire policy along with all the members of the family, if any, at least 45 days before the premium renewal date of his/her existing policy.
2. Insurer may not be liable to offer portability if policyholder fails to approach the new insurer at least 45 days before the premium renewal date.
3. Portability shall be opted by the policyholder only as stated in (1) above and not during the currency of the policy.
4. In case insurer is willing to consider the proposal for portability even if the policyholder fails to approach insurer at least 45 days before the renewal date, it may be free to do so.
5. Where the outcome of acceptance of portability is still waiting from the new insurer on the date of renewal
6. In case the policyholder has opted as in 5 (a), and there is a claim, then existing insurer may charge the balance premium for remaining part of the policy year provided the claims is accepted by the existing insurer. In such cases, policyholder shall be liable to pay the premium for the balance period and continue with existing insurer for that policy year.
7. On receipt of such intimation, the insurance company shall furnish the applicant, the Portability Form as set out in Annexure 'I' to these guidelines together with a proposal form and relevant product literature on the various health insurance products which could be offered.
8. The policyholder shall fill in the portability form along with proposal form and submit the same to the insurance company.
9. On receipt of the Portability Form, the insurance company shall address the existing insurance company seeking necessary details of medical history and claim history of the concerned policyholder. This shall be done through the web portal of the IRDA.
10. The insurance company receiving such a request on portability shall furnish the requisite data in the data format for porting insurance policies prescribed in the web portal of IRDA within 7 working days of the receipt of the request.
11. In case the existing insurer fails to provide the requisite data in the data format to the new insurance company within the specified time frame, it shall be viewed as violation of directions issued by the IRDA and the insurer shall be subject to penal provisions under the Insurance Act, 1938.
12. On receipt of the data from the existing insurance company, the new insurance company may underwrite the proposal and convey its decision to the policyholder in accordance with the Regulation 4 (6) of the IRDA (Protection of Policyholders' interest) Regulations, 2002.
13. If on receipt of data within the above time frame, the insurance company does not communicate its decision to the requesting policyholder within 15 days in accordance with its underwriting policy as filed by the company with the Authority, then the insurance company shall not retain the right to reject such proposal and shall have to accept the proposal.
14. In order to accept a policy which is porting-in, insurer shall not levy any additional loading or charges exclusively for the purpose of porting.
15. No commission shall be payable to any intermediary on the acceptance of a ported policy.
16. Portability shall be allowed in the following cases:
17. For any health insurance policy, waiting period with respect to pre-existing diseases and time bound exclusions shall be taken into account as follows:-
Note 1: In case the waiting period for a certain disease or treatment in the new policy is longer than that in the earlier policy for the same disease or treatment, the additional waiting period should be clearly explained to the incoming policy holder in the portability form to be submitted by the porting policyholder.
Note 2: For group health insurance policies, the individual member's shall be given credit as per the table above based on the number of years of continuous insurance cover, irrespective of, whether the previous policy had any pre-existing disease exclusion/time bound exclusions.
18. The portability shall be applicable to the sum insured under the previous policy and also to an enhanced sum insured, if requested by the insured, to the extent of cumulative bonus acquired from the previous insurer(s) under the previous policies.
For e.g. - If a person had a SI of Rs. 2 lakhs and accrued bonus of Rs. 50, 000 with insurer A; when he shifts to insurer B and the proposal is accepted, insurer B has to offer him SI of Rs. 2.50 lakhs by charging the premium applicable for Rs. 2.50 lakhs. If insurer B has no product for Rs. 2.50 lakhs, insurer B would offer the nearest higher slab say Rs. 3 lakhs to insured by charging premium applicable for Rs. 3 lakhs SI .However, portability would be available only up to Rs 2.50 lakhs.
19. Insurers shall clearly draw the attention of the policyholder in the policy contract and the promotional material like prospectus, sales literature or any other documents in any form whatsoever, that:
1. Whether the PED exclusions/time bound exclusion have longer exclusion period than the existing policy:
(Please indicate Yes/NO):
2. If yes, please give written consent to the declaration below:
Administration of Health Plus Life Combi Products
1. The product of this class shall be named as 'Health plus Life Combi Products' referred as 'Combi Products' hereinafter in this schedule.
2. This schedule does not apply to Micro Insurance Products which are governed by IRDA (Micro Insurance) Regulations, 2005.
3. All insurance companies that promote 'Health plus Life Combi products' shall adhere to the following:
4. Underwriting: Under the 'Combi Product', underwriting of respective portion of risk shall be carried out by respective insurance companies, that is; Life Insurance risk shall be underwritten by Life Insurance Company and the Health Insurance portion of risk shall be underwritten by Non-Life/stand-alone health Insurance Company.
5. File and Use:
6. Lead insurer in settlement of claims shall ensure:-
7. Distribution Channel :
8. Mandatory Minimum Disclosures:
9. In respect of 'Combi Products' both the insurers shall comply with the provisions Insurance Act, 1938 and Regulations notified thereunder and other guidelines, circulars that are applicable to health insurance business and life insurance business respectively.
10. For the purpose of these guidelines non-life insurance company includes stand alone health insurance Company also.
11. In order to monitor the progress of the penetration of the product class before enlarging the scope of the same all insurance companies that are marketing 'Combi Products' shall submit the information that is required by the Authority from time to time.
12. The Authority may stipulate such other terms and conditions from time to time for monitoring activities of insurance companies offering 'Combi Products'.
Health Insurance Returns to be submitted by Insurance Companies