Insurance Regulatory and Development Authority of India (Health Insurance) (Amendment) Regulations, 2019

Nov 25, 2019 | by Avantis RegTech Legal Research Team


Industry Specific Compliance

The Insurance Regulatory and Development Authority of India (IRDAI) on November 19, 2019, notifies the Insurance Regulatory and Development Authority of India (Health Insurance) (Amendment) Regulations, 2019 to further amend the IRDAI (Health Insurance) Regulations, 2016.

The followings are the amendments made in the IRDAI (Health Insurance) Regulations, 2016:-

Regulation 2(i)(m) and (p)related to ‘Portability’ and ‘Third Party Administrators or TPA’ has been omitted.

Regulation 8(d) related to ‘Underwriting’, a proviso has been omitted and Regulation 8(e) has been inserted, namely:-

“The insured shall be informed in writing of any underwriting loading charged over and above the premium as filed and approved under the Product Filing Guidelines and specific consent of the policyholder for such loadings shall be obtained before issuance of a policy.”

Regulation 11(e) and (f) related to ‘Designing of Health Insurance Policies’ has been newly inserted, namely:-

“(e) To enable access to the basic health insurance covers, all insurers shall offer a standard health insurance product as per the guidelines as may be specified by the Authority from time to time. 

(f) Any of the exclusions in all health insurance policies shall be subject to the guidelines as may be specified by the Authority from time to time.”

In Regulation 13(iii), a proviso has been inserted, namely:-

“Provided the renewal premium shall not be accepted more than 90 days in advance of the due date of the premium payment.”

Regulation 17(i) related to ‘Migration of health insurance policy’ has been substituted, namely:-

“General insurers and health insurers offering indemnity based health covers shall offer an option to the policyholders to migrate to a suitable alternative health insurance policy available at the time of modification or withdrawal of the policy. Further, indemnity based health covers offered to specific age groups, students, children under family floater policies, shall also offer an option to such lives to migrate to a suitable alternative health insurance policy available at the specific exit age. Every policy migrated shall be allowed suitable credits for all the previous policy years, provided the policy has been maintained without a break.”

Regulation 17(iv) has been newly inserted, namely:-

“Further to the norms on migration and portability of all policies issued by general insurers and health insurers shall be subject to the guidelines as may be specified by the Authority from time to time.”

Regulation 18(a) related to ‘AYUSH Coverage’ has been substituted, namely:-

“All insurers may endeavour to provide coverage for one or more systems covered under ‘AYUSH treatment’ provided, the treatment has been undergone in the hospitals or healthcare facilities subject to the guidelines as may be specified by the Authority from time to time.”

Regulation 19 related to ‘Wellness and Preventive aspects’ has been substituted, namely:-

“Insurers may endeavour promoting wellness amongst policyholders of health insurance as per the guidelines as may be specified by the Authority from time to time.”

Regulation 23(i) related to ‘Special Provisions for Senior Citizens’ has been substituted, namely:-

“The premium charged for health insurance products offered by Life Insurers, General Insurers and Health Insurers to senior citizens shall be fair, justified, transparent and duly disclosed upfront.”

Regulation 24(ii)(2) related to ‘Multiple Policies’ has been substituted, namely:-

“Balance claim or claims disallowed under the earlier chosen policy or policies may be made from the other policy or policies even if the sum insured is not exhausted in the earlier chosen policy or policies. The insurer(s) in such cases shall independently settle the claim subject to the terms and conditions of other policy or policies so chosen.”

Regulation 30(c) related to ‘Administration of Health Policies’ has been substituted, namely:-

“Subject to terms and conditions of the policy contract, reimbursement shall be allowed at any hospital or medical establishment. All such establishments must be licensed or registered as may be required by any Local, State or National Law as may be applicable.”

Regulation 35(c) related to ‘Data and related issues’ has been substituted, namely:-

“Authority may require insurers, third party administrators and network providers to comply with data related matters and settlement of claims through electronic means as per the guidelines as may be specified by the Authority from time to time.”

The Schedule-I related to ‘Portability of Health Insurance Policies offered by General Insurers and Health Insurers’, clause 16  has been substituted, namely:-

“Portability shall be allowed subject to the guidelines as may be specified by the Authority from time to time.”

This Notification shall come into force on the date of its publication in the Official Gazette.

[Notification No. F. No. IRDAI/Reg/14/165/2019]


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