Ref:IRDAI/HLT/REG/CIR/176/ 09/2019

27^thSeptember, 2019

To

AllInsurers and TPAs, wherever applicable,

Re: ModificationGuidelines on Standardization in Health Insurance:

1.   Referenceis invited to Clause 33 of Chapter –I of Guidelines on Standardization inHealth Insurance Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29^th July,2016 where pre-existing disease is defined.The definition of Pre-existingDisease stands modified as underand the following definition is substituted atClause 33 of the within referred Guidelines:

Pre-ExistingDisease (not applicable for Overseas Travel Insurance):

Pre-existing Disease meansany condition, ailment, injury or disease:

a)  That is/are diagnosedby a physician within 48 months prior to the effective date of the policyissued by the insureror

b)  For which medicaladvice or treatment was recommended by, or received from, a physician within 48months prior to the effective date of the policy or its reinstatement.

c)  A condition for whichany symptoms and or signs if presented and have resulted within three months ofthe issuance of the policy in a diagnostic illness or medical condition.

(LifeInsurers may define norms for applicability of PED at Reinstatement)

2.   Referenceis invited to Chapter – III of Guidelines on Standardization in HealthInsurance Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29^th July, 2016where items for which optional cover may be offered by insurers are specifiedin Annexure – I. In substitution of the items specified in the within referredGuidelines, the revised items are specified in Annexure – I of these modifiedGuidelines.

3.   Theprovisions of these Guidelines shall be applicable in respect of all healthinsurance products (both Individual and Group) filed on or after 1^stOctober2019. All existing health insurance products that are not in compliance with theseGuidelines shall not be offered and promoted from 01^stOctober, 2020onwards.

4.   Thishas the approval of the competent authority.

(DVSRamesh)

GeneralManager (Health)

Annexure – I

Items for which optional cover may beoffered by Insurers

1.       Reference is invitedto Chapter III of Guidelines on Standardization in Health Insurance videCircular Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29^thJuly, 2016where items for which optional cover may be offered by Insurers were specified.On a review of the list of items it is decided to classify the existing‘Optional Items’ into the following categories.

                     i.       LIST– I:: Items that may be retained ‘as it is’ as optional items – Items specifiedin the list are the Optional Items to which Insurers may offer coverage.

                   ii.       LIST– II:: Costs that are to be subsumed into the Room Charges – Items specified inthe list shall form part of room charges

                  iii.       LIST– III:: Costs that are to be subsumed into the specific (say surgical)procedure charges – Items specified in the list shall be considered as part ofprocedure charges.

                  iv.       LIST– IV::Costs that are to be subsumed into the costs of treatment – Itemsspecified in the list shall be considered as part of costs of treatment.

2.       Where the costs areto be subsumed into the room charges specified in List – II or procedurecharges specified in List III or costs of treatment (including costs ofdiagnostics) specified in List IV all claims shall be settled in accordance tothe terms and conditions of the policy contract. Insurers shall put in placemeasures to ensure that items which are part of room / surgical procedure /treatment (including diagnostics) as referred in the lists herein shall not bebilled to the policyholders by the hospitals and every insurer shall inform ornotify the same to the hospitals and the policyholders suitably. Accordingly,all insurers are advised to make it part of their service level agreement withthe network providers (hospitals) in case of cashless cases. In case ofreimbursements (with other than network providers) Insurers shall settle theclaims as per the terms and conditions of the policy contract.

List I – Optional Items

List II – Items that are to be subsumed intoRoom Charges

List III – Items that are to be subsumed intoProcedure Charges

List IV – Items that are to be subsumed intocosts of treatment