Guidelines

on

Standardization ofGeneral Terms and Clauses in Health Insurance Policy Contracts

1. OBJECTIVE:

TheObjective of these guidelines is to standardize the general terms and clausesincorporated in indemnity based Health Insurance excluding Personal Accident(hereinafter called as PA) and Domestic / Overseas Travel products bysimplifying the wordings of general terms and clausesof the policy contracts and ensure uniformity across the industry.

TheseGuidelines are issued under the provisions of Section 34(1) of the InsuranceAct, 1938 read with Regulation 20 and Schedule III of IRDAI (Health Insurance)Regulations, 2016.

2. APPLICABILITY:

These Guidelines areapplicable to all General and Health Insurers offering indemnity based HealthInsurance (excluding PA and Domestic / Overseas Travel) products (bothIndividual and Group).

The provisions ofthese guidelines shall be applicable to the indemnity based Health Insuranceexcluding Personal Accident (hereinafter called as PA) and Domestic / OverseasTravel products filed as per Guidelines on Product Filing in Health InsuranceBusiness on or after 01^st October, 2020. All policy contracts of theexisting health insurance products that are not in compliance with theseguidelines shall be modified as and when they are due for renewal from 01^stApril, 2021onwards.

3. Other Provisions:

3.1Where these general terms and clauses areused, Insurers shall incorporate thesame wordings as prescribed in Annexure – 1 of these guidelines.

3.2       Insurersmay incorporate other general terms and clauses in the product as per theirproduct design in order to ensure an informed choice to the prospects/insuredpersons.

3.3       Insurers may suitably modify the general terms andclauses of the policy contract prospectively based on the Regulations orGuidelines that may be issued by the Authority time to time.

4. Definitions: The words usedherein and defined in the Insurance Act, 1938, Insurance Regulatory andDevelopment Authority Act, 1999 and Regulations notified thereunder shall havethe same meaning as assigned to them respectively.

5. This has the approval of thecompetent authority.

(D V S Ramesh)

General Manager (Health)

Annexure - 1

StandardGeneralTerms and Clauses:

1      Disclosure of Information

Thepolicy shall be void and all premium paid thereon shall be forfeited to theCompany in the event of misrepresentation, misdescription or non-disclosure ofany material fact by the policyholder.

(Explanation:“Material facts” for the purpose of this policy shall mean all relevantinformation sought by the company in the proposal form and other connecteddocuments to enable it to take informed decision in the context of underwritingthe risk)

2      Condition Precedent toAdmission of Liability

The terms andconditions of the policy must be fulfilled by the insured person for theCompany to make any payment for claim(s) arising under the policy.

3      Claim Settlement (provisionfor Penal Interest)

            i.      TheCompany shall settle or reject a claim, as the case may be, within 30 days fromthe date of receipt of last necessary document.

           ii.      Inthe case of delay in the payment of a claim, the Company shall be liable to payinterest to the policyholder from the date of receipt of last necessarydocument 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 ofthe 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 necessarydocument. In such cases, the Company shall settle or reject the claimwithin 45 days from the date of receipt of last necessary document.

          iv.      Incase of delay beyond stipulated 45 days, the Company shall be liable to payinterest to the policyholder at a rate 2% above the bank rate from the date ofreceipt 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 beginningof the financial year in which claim has fallen due)

(Note to Insurers: TheClause shall be suitably modified by the insurer based on the amendment(s), ifany to the relevant provisions of Protection of Policyholder’s InterestsRegulations, 2017)

4      Complete Discharge

Any payment tothe policyholder, insured person or his/ her nominees or his/ her legalrepresentative or assignee or to the Hospital, as the case may be, for anybenefit under the policy shall be a valid discharge towards payment of claim bythe Company to the extent of that amount for the particular claim.

5      Multiple Policies

             i.    In case of multiplepolicies taken by an insured person during a period from one or more insurerstoindemnify treatment costs, the insured person shall have the right to requirea settlement of his/herclaim in terms of any of his/her policies. In all suchcases the insurer chosen by the insured person shall be obliged to settletheclaim as long as the claim is within the limits of and according to theterms of the chosen policy.

            ii.    Insured person having multiplepolicies shall also have the right to prefer claims under this policy for theamounts disallowed under any other policy / policies even if the sum insured isnot exhausted. Then the insurershall independently settle the claim subject tothe terms and conditions of this policy.

           iii.    If the amount to be claimedexceeds the sum insured under a single policy, the insured person shall havethe right to choose insurer from whomhe/she wants to claim the balance amount.

          iv.    Where an insured person haspolicies from more than one insurer to cover the same risk onindemnity basis,the insured person shall only be indemnified the treatment costs inaccordancewith the terms and conditions of the chosen policy.

6      Fraud

If anyclaim made by the insured person, is in any respect fraudulent, or if any falsestatement, or declaration is made or used in support thereof, or if anyfraudulent means or devices are used by the insured person or anyone acting onhis/her behalf to obtain any benefit under this policy, all benefits under thispolicy and the premium paid shall be forfeited.

Any amountalready paid against claims made under this policy but which are foundfraudulent later shall be repaid by all recipient(s)/policyholder(s), who hasmade that particular claim,who shall be jointly and severally liable for suchrepayment to the insurer.

Forthepurposeofthisclause,theexpression"fraud"meansanyofthefollowingactscommittedbytheinsuredpersonorbyhisagentorthe hospital/doctor/any other party acting on behalf of the insured person, withintenttodeceivetheinsurerortoinducetheinsurertoissueaninsurancepolicy:

a)    the suggestion, as a fact of that whichisnottrueandwhichtheinsuredpersondoes not believetobetrue;

b)    theactive concealmentof afactbytheinsuredpersonhavingknowledgeorbeliefofthefact;

c)    anyother act fitted to deceive; and

d)    anysuchactoromissionasthelawspeciallydeclarestobefraudulent

TheCompany shall not repudiate the claim and / or forfeit the policy benefits onthe ground of Fraud, if the insured person / beneficiary can prove that themisstatement was true to the best of his knowledge and there was no deliberateintention to suppress the fact or that such misstatement of or suppression ofmaterial fact are within the knowledge of the insurer.

7      Cancellation

i.        Thepolicyholder may cancel this policy by giving 15days’ written notice and insuch an event, the Company shall refund premium for the unexpired policyperiodas detailed below.

(Noteto Insurers: Insurer shall specify the method of refund calculation)

Notwithstandinganything contained herein or otherwise, no refunds of premium shall be made inrespect of Cancellation where, anyclaim has been admitted or has been lodged orany benefit has been availed by the insured person under the policy.

(Note toinsurers: Insurer may relax this condition as per the product design)

ii.       The Company may cancelthepolicy at any time on grounds of misrepresentation non-disclosure ofmaterial facts, fraud by the insured personby giving 15 days’ written notice. Therewould be no refund of premium on cancellation on grounds of misrepresentation,non-disclosure of material facts or fraud.

8      Migration

Theinsured person will have the option to migrate the policy to other healthinsurance products/plans offered by the company by applying for migration of thepolicyatleast30 days before the policy renewal date as per IRDAI guidelinesonMigration. If such person is presently covered and has been continuouslycovered without any lapses under any health insurance product/plan offered bythe company,the insured person will get the accrued continuity benefits inwaiting periods as per IRDAI guidelines on migration.

For DetailedGuidelines onmigration, kindly refer the link ………

(Note toInsurers: Insurer to provide link to the IRDAI guidelineson migration.Timelinesfor applying for migration may be relaxed by the insurer subject to productdesign)

9      Portability

Theinsured person will have the option to port the policy to other insurers by applying tosuchinsurer 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 renewaldate asper IRDAI guidelines related to portability. If such person is presentlycovered and has been continuously covered without any lapses under any healthinsurance policy with an Indian General/Health insurer, the proposed insuredperson will get the accrued continuity benefits in waiting periods as per IRDAIguidelines on portability.

For Detailed Guidelines onportability, kindly refer the link ………

(Note toInsurers: Insurer to provide link to the IRDAI guidelines related toportability.Timelines for applying for portability may be relaxed by theinsurer subject to product design)

10   Renewal of Policy

The policy shall ordinarilybe renewable except on grounds of fraud, misrepresentation by the insured person.

i.      The Company shall endeavorto give notice for renewal. However, the Company is not under obligation togive any notice for renewal.

ii.    Renewalshall not be denied on the ground that the insured person had made a claim orclaims in the preceding policy years.

iii.    Request for renewal alongwith requisite premium shall be received by the Company before the end of the policyperiod.

iv.   At the end of the policyperiod, the policy shall terminate and can be renewed within the Grace Period of…… days (Note to insurers: Insurer to specify grace period as per productdesign) to maintain continuity of benefits withoutbreak in policy. Coverageis not available during the grace period.

v.    No loading shall apply onrenewals based on individual claims experience.

11   Withdrawal of Policy

         i.      Inthe likelihood of this product being withdrawn in future, the Company willintimate the insured person about the same 90 days prior to expiry of the policy.

        ii.      InsuredPerson will have the option to migrate to similar health insurance productavailable with the Company at the time of renewal with all the accruedcontinuity benefits such as cumulative bonus, waiver of waiting period. as perIRDAI guidelines, provided the policy has been maintained without a break.

12   Moratorium Period

After completion of eightcontinuous years under the policy no look back to be applied. This period ofeight years is called as moratorium period. The moratorium would be applicablefor the sums insured of the first policy and subsequently completion of 8continuous years would be applicable from date of enhancement of sums insuredonly on the enhanced limits. After the expiry of Moratorium Period no healthinsurance claim shall be contestable except for proven fraud and permanentexclusions specified in the policy contract. The policies would however besubject to all limits, sub limits, co-payments, deductibles as per the policycontract.

13   Premium Payment inInstalments (Wherever applicable)

If theinsured person has opted for Payment of Premium on an instalment basis i.e.Half Yearly, Quarterly or Monthly, as mentioned in the policySchedule/Certificate of Insurance, the following Conditions shall apply(notwithstanding any terms contrary elsewhere in the policy)

i.        GracePeriod of ___ (Note to Insurers: Insurer to specify grace period as perproduct design) days would be given to pay the instalment premium due forthe policy.

ii.       During such grace period, coveragewill not be available from the due date of instalment premium till the date ofreceipt of premium by Company.

iii.      The insured person will getthe accrued continuity benefit in respect of the “Waiting Periods”, “SpecificWaiting Periods” in the event of payment of premium within the stipulated gracePeriod.

iv.     No interest will be chargedIf the instalment premium is not paid on due date.

v.       In case of instalmentpremium 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 rightto recover and deduct all the pending installments from the claim amount dueunder the policy.

14   Possibility of Revision ofTerms of the Policy Including the Premium Rates

The Company, with prior approval of IRDAI, may reviseor modify the terms of the policy including the premium rates. The insuredperson shall be notified three months before the changes are effected.

15   Free look period

The FreeLook Period shall be applicable on new individual health insurance policies andnot on renewals or at the time of porting/migrating the policy.

Theinsured person shall be allowed free look period of fifteen days from date ofreceipt of the policy document to review the terms and conditions of the policy,and to return the same if not acceptable.

Ifthe insured has not made any claim during the Free Look Period, the insuredshall be entitled to

i.     arefund of the premium paid less any expenses incurred by the Company on medicalexamination of the insured person and the stamp duty charges or

ii.   wherethe risk has already commenced and the option of return of the policy isexercised by the insured person, a deduction towards the proportionate riskpremium for period of coveror

iii.  Whereonly a part of the insurance coverage has commenced, such proportionate premiumcommensurate with the insurance coverage during such period;

(Note toinsurers: Insurer may increase the free look period as per the product design)

16  Redressalof Grievance

In case ofany grievance the insured person may contact the company through

Website:

Toll free:

E-mail:

Fax :

Courier:

Insuredperson may also approach the grievance cell at any of the company’s brancheswith the details of grievance

If Insuredperson is not satisfied with the redressalof grievance through one of the abovemethods, insured person may contact the grievance officerat ………….

For updated details ofgrievance officer, kindly refer the link……….

(Note toinsurers: Address of the Grievance Officer and link having updated details ofgrievance officer on website to be specified by the insurer. Insurer to alsospecify separate contact details for senior citizens)

If Insuredperson is not satisfied with the redressalof grievance through above methods,theinsured person may also approach the office of Insurance Ombudsman ofthe respective area/region for redressal of grievanceas per Insurance OmbudsmanRules 2017. (Note to insurers: Insurer to specify the latest contact detailsof offices of Insurance Ombudsman)

Grievancemay also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/

17  Nomination:

The policyholder isrequired at the inception of the policy to make a nomination for the purpose ofpayment 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 andsuch 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 {asnamed in the Policy Schedule/Policy Certificate/Endorsement (if any)} and incase there is no subsisting nominee, to the legal heirs or legalrepresentatives of the policyholder whose discharge shall be treated as fulland finaldischarge of its liability under the policy.