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Autism to Hormones: 15 Things You Must Know About India’s New Health Cover Rules

The Insurance Regulatory and Development Authority of India has directed that every health cover policy purchased after April 1, 2019, will have to follow these guidelines.

Autism to Hormones: 15 Things You Must Know About India’s New Health Cover Rules

A new set of directions by the Insurance Regulatory and Development Authority of India (IRDAI) promises to make your health cover more inclusive than before. Apart from instructing health insurance companies to not discriminate based on gender or identity, the IRDAI has said that they cannot exclude mental illnesses from their packages.

However, on the other hand, the regulatory has announced that certain conditions like Alzheimer’s and epilepsy can be permanently excluded from the lists.

Here are the 15 takeaways from the notice:

  • According to the IRDAI, health insurance companies cannot exclude from their packages children who suffer from autism, cerebral palsy, Down’s syndrome, dyslexia or speech and language disorders like stammering.
  • Additionally, the plans will also have to cover puberty as well as menopause-related health issues like flushing, hormonal changes or excessive bleeding.

  • Insurance companies exploited loopholes in the rules and were selective in covering mental illnesses. The regulatory, however, has ruled that mental illnesses can no longer be excluded from the policies.
  • No more can the companies exclude people with a history of clinical depression or are prescribed to use opioids or anti-depressants. In addition to this, the failure to follow medical advice or treatment can no more be a clause to deny medical insurance.

Furthermore, the regulatory has also said that companies cannot discriminate between clients based on gender or identity.

  • Henceforth, insurers will also have to cover patients kept on artificial life maintenance. This, even in the cases where the doctors have declared that there are no chances of the patient recovering or going back to their previous health conditions.

An important thing to note here is that the above will be true only up to the date of confirmation by the doctor.

  • Oral chemotherapy and robotic surgery will also be covered by insurance packages.
  • All health insurance policies filed and cleared after 1 April 2019, will have to follow these guidelines. Those cleared before this date that do not follow the guidelines cannot be offered or promoted after April 1, 2020.

Source: Harsha K R/ Flickr.
  • Pre-existing ailment too cannot be automatically excluded by insurance companies. Only those ailments will be excluded that have been mentioned in the IRDAI given list. The guidelines towards this rule are mentioned below.
  • A total of 17 conditions have been granted permanent exclusion by the national insurance regulator. These conditions and disorders include Alzheimer’s disease, chronic liver diseases, epilepsy, Hepatitis B, HIV/AIDS, kidney diseases and Parkinson’s disease.
  • The expenses incurred by patients for illnesses within 30 days from when the policy commences will not be covered by the policies. This clause excludes accidents, which can be claimed by policyholders.

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  • Except for cases of fraud or permanent exclusions, a health insurance policy cannot be contested after the completion of eight years (this is called the moratorium period).
  • Waiting periods for a specific disease cannot exceed four years. But, the companies are allowed to impose sub-limits or annual policy limits for specific diseases. This covers the terms of amount, percentage of sum insured or the number of days of hospitalisation or treatment.
  • Similarly, the waiting period for lifestyle conditions such as hypertension or diabetes cannot be for over 30 days. The only exception to this rule is if the health issues are pre-existing and disclosed when the policy is purchased.
  • Treatment taken due to some adventure sports like rock climbing, scuba diving, mountaineering as well as diagnostic tests, infertility treatment, weight control surgeries and plastic surgeries continue to be excluded from health cover packages.
  • However, sports like dirt biking, paragliding, whitewater rafting, go-karting, F1 racing as well as ethnic sports like jallikattu and kambala will be included in the packaging.

(Edited by Saiqua Sultan)

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