Insurer can't reject your claim if you meet this criteria

New guidelines for health insurance plans issued by IRDAI favour policyholders but premiums could rise.

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The change will bring more individuals in the ambit of coverage.
Health insurance companies will not be able to reject your claims if you have continuously been covered for at least eight years. This provision, along with a host of others, form part of IRDAI’s standardisation of exclusions guidelines released recently. These norms will be applicable to products filed after 1 October 2019. For existing health contracts, the new rules will come into effect from 1 October 2020. “The health policy would be incontestable except for proven fraud or any permanent exclusions. This would reduce grievances among policyholders,” says Shreeraj Deshpande, Chief Operating Officer, Future Generali India Insurance.

Insurers will also not be able to deny coverage outright to those suffering from critical illnesses or conditions like cancers, heart-related ailments, Alzheimer’s, Parkinson’s, HIV/AIDS and so on. The list covers 16 such ailment categories. Until now, those with these conditions were not considered eligible for health policies. “For instance, people who suffered from say epilepsy could not get health cover earlier even for non-related conditions. They will now be able to, with permanent exclusions for the existing diseases,” says Mahavir Chopra, Director, Life, Health and Strategic Alliances, Coverfox.com. Similar was the case with cancer survivors who contracted the illness long ago. The change will bring more individuals in the ambit of coverage. “The guidelines bring in a lot of clarity. Once the insurer decides to bring policyholders into the portfolio after excluding say chronic kidney diseases, all claims not pertaining to this condition will be covered,” explains Sanjay Datta, Chief, Underwriting, Claims and Reinsurance, ICICI Lombard.

Pre-existing diseases (PED) will be defined as the ones that were diagnosed by a physician within 48 months before the policy issuance.


In addition, the specified modern treatment procedures like deep brain stimulation, oral chemotherapy, immunotherapy etc will have to be covered by insurers. “By mandating inclusion of modern procedures, the guidelines have made polices more inclusive,” says Shanai Ghosh, CEODesignate, Edelweiss General Insurance.

However, these changes could also push up the premiums. “Most changes are welcome from a policyholder’s perspective. However, providing coverage to modern treatment procedures entails a cost. And this could get reflected in premiums once the new framework is in place,” says Amit Bhandari, Chief Technical Officer, Magma HDI General Insurance.
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