The IRDA has taken a number of initiatives on development of the Health insurance market in the country in the year 2011-12. Further progress was also made on other initiatives taken up in 2010-11. A summary of some of these initiatives is given below:
Health Insurance Forum
The Health Insurance segment of the insurance industry has been growing significantly in recent years. The IRDA has underpinned the growth of this market by registering â€˜Stand-alone Health Insurance companiesâ€™ and by nurturing the development of Third Party Administrators (TPAs) to enable cash-less system of claims settlement.
In the background of these developments, the IRDA felt the necessity to create a Forum for an effective dialogue amongst the service providers (hospitals), the insurance companies, TPAs and the consumers in general.
The IRDA has constituted the Health Insurance Forum vide its Order dated 2nd February, 2012. The Forum has been constituted by taking on board the representatives from Life Insurance Companies, Non-life Insurance Companies, Stand-alone health insurance companies, Ministry of Family and Welfare, Ministry of Labour and Employment, National Accreditation Board for Hospitals & Health Care Providers (NABH), Government Hospitals, Private Hospitals, TPAs, FICCI, CII, apart from the IRDA itself.
The Forum is meant to act as a consultative body in order to facilitate the evolution of a regulatory structure, which would better meet the needs of this growing sector taking into account the aspirations/needs of all the stakeholders involved.
The functions of the Forum have been broadly identified as below:
- To aid, advise and assist the IRDA in evolving regulations relating to health insurance business in India;
- To facilitate the creation and adoption of standard processes and definitions in the insurance industry, health insurance administration and health services where applicable;
- To aid, advise and assist the IRDA in collecting, maintaining and disseminating data required for the efficient conduct of health insurance business in India;
- To act as a consultative forum between insurance companies and other stakeholders; and
- To aid, advise and assist the IRDA in developing regulations for rendering health insurance Forum more effectively.
Delay in Claim Intimation / Documents Submission
The IRDA has advised all (Life & Non-Life) insurance companies not to reject the genuine claims intimated or submitted, at a later date than the time specified in the policy, where such delay is caused due to unavoidable circumstances.
The insurance companies have also been advised that the insurerâ€™s decision to reject a claim due to delay in submission of intimation or documents, shall have to be based on sound logic and valid grounds as the time limitation clause is neither absolute nor does it work in isolation.
As such, it has been advised that insurers shall not repudiate any claim unless and until the reasons for delay have been specifically ascertained, recorded and the insurers satisfy themselves that those claims would have even otherwise been rejected even if reported on time.
Health Insurance Portability
The IRDA had issued a Circular in 2010-11 (dated 10th February, 2011) on the portability of health insurance. The salient features of the Circular include the following:
Insurance companies to permit the policyholders to carry forward the credit gained for pre-existing conditions in terms of waiting period when he or she switches from one insurer to another; or from one plan to another, provided the previous policy has been maintained without break.
The entire database of the companies, including the claim details, in respect of policies where the policyholders have opted for port ability will have to be shared with their counterparts, if requested by the counterpart within seven working days of such request. A time period of three days has been granted by the regulator to acknowledge portability applications.
The IRDA issued another Circular in 2011-12 (dated 9th September, 2011) on this subject. The salient features of the Circular are:
- ï€ It was felt necessary to put in place a system to enable collection of data on the history of health insurance and monitoring the transfer of records of the porting policyholder.
- The implementation of portability of health insurance policies mandated to commence no later than 1st October, 2011.
- Detailed procedures on health insurance portability have been set out.
Definition of Portability and break in policy:
Portability: Portability means the right accorded to an individual health insurance policyholder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break.
Break in policy: A break in policy occurs when the premium due on a given policy is not paid on or before the premium renewal date or within 30 days thereof.
- Grace period henceforth increased to 30 days.
- Portal on Portability of health insurance.
The IRDA has implemented the â€˜Portabilityâ€™ in health insurance products/plans, which is a landmark achievement. This has benefited the customers and industry at large. In order to facilitate quick and time bound portability, an exclusive web portal has also been created to exchange data between insurers for porting policies.
Courtesy IRDA Annual Report 2011-12