IRDAI, the Insurance Regulatory and Development Authority of India, regulates the national insurance sector. Its guidelines and policies protect fair practices, transparency, and policyholders. When it comes to health insurance, the guidelines given can help in making decisions, especially when one is buying, renewing or using the plans.
Introduction to IRDAI & Why Guidelines Matter
The IRDAI was formed under the IRDA Act, 1999 with the purpose of regulating insurance in India. The primary mandates of this institution is to protect policyholder interests, promote a well-structured growth of the insurance market, and to make sure that insurers are engaging in fair, transparent practices.
The guidelines help policyholders as the rules clearly state the policyholders should be shown transparent costs, and they are protected from mis-selling. So that these rules are upheld, IRDAI guides insurers so as to follow standard processes, fair disclosures, and maintain accountability.
Key Recent IRDAI Guidelines You Should Know
| Policy Aspect | Rule |
| Continuous coverage & exit age | Policies must offer lifetime renewability. Exit age limits are being phased out. |
| Group health insurance | Group policies must clearly state renewal terms. Members must be informed in advance about changes to premiums or benefits. |
| Transparency (premium & facility network) | Insurers must disclose terms, pricing, and hospital networks upfront. Policy documents should be in plain language. |
| Claims denial justification & moratorium period | Claims cannot be denied without written reasons. After 8 years of continuous renewal, claims cannot be rejected for non-disclosure unless fraud is proven. |
| Policy migration/switching | You can migrate within the same insurer or port to another, keeping waiting period credits intact. |
| Inclusion of telemedicine services | Teleconsultations must be covered if your plan includes doctor consultations. |
Claim Settlement Rules Under IRDAI
IRDAI sets guidelines on claim settlements to protect customer rights. Making sure that insurers don't exploit customer liabilities and ensuring a fair and transparent insurance claim process.
Timeline for claim settlements & interest on delay
The IRDAI introduces two primary anti-delay guidelines for insurers to follow:
- Claims must be settled or rejected within 30 days (in case of health settlements) and 45 days (in case of non-health ones) of receiving all documents, unless insurance fraud is suspected.
- Insurers must pay interest at 2% above the bank rate in case of delays.
Documentation requirements (what docs must you submit)
For health insurance claims, the commonly required documents are:
- Claim Form: A duly filled claim form provided by the insurer.
- Medical Reports: All relevant medical reports, including diagnosis, treatment details, and prescriptions.
- Hospital Bills: Original bills and receipts from the hospital or healthcare provider.
- Discharge Summary: A detailed discharge summary from the hospital.
- Policy Document: A copy of the health insurance policy document.
- Identity Proof: Valid identity proof of the policyholder.
What constitutes misrepresentation/non-disclosure
Non-disclosure: A situation can be identified as non-disclosure in the case of a hidden medical history.
Misrepresentation: Misrepresentation refers to false details about age, habits, or conditions.
In both of these conditions, if materially proven, insurers can reject claims in case of non-disclosure, with approval from a Policyholders' Management Committee (PMC) or a Claims Review Committee (CRC).
Rights and Rewards for Policyholders
IRDAI issues rights and rewards for policyholders. This incentivizes timely premium payment, guideline following, and prevents misrepresentation and non-disclosure.
What you are entitled to (rewards, benefits)
- No-claim bonuses increase coverage. When you don't need insurance claims for an entire year, you are entitled to increased coverage as a bonus.
- Wellness benefits like preventive checkups and discounted gym subscriptions.
- Insurers must inform policyholders about the terms and conditions of their health insurance policies, particularly regarding treatment at medical facilities across India.
How IRDAI protects senior citizens re: premium transparency
- Mandatory disclosure of senior citizen premium bands. Insurers need to be transparent about the different premium rates applicable to different age groups. There should be a clear definition in the policy guidelines, and it should be responsibly communicated to the customers
- Renewal must be offered regardless of age. Senior citizens cannot be denied renewal claims just because they have crossed a certain age. Renewal policies must be valid for life.
Insurer obligations: facility list, fair communication
- Insurers must share updated hospital networks. Every hospital/doctor connection must be communicated clearly to customers.
- Communication must be clear and jargon-free. Updates in policy guidelines, documents, premium rates, etc., should be clearly communicated without any hidden costs or meaning.
Compliance, Enforcement & What Happens If Insurers Don't Follow Rules
Any issued regulation is as good as its enforcement. IRDAI has been given the responsibility to issue a set of rules which can protect policyholders and help in maintaining fairness. They monitor insurers constantly and if any insurer fails to follow the rules, strict actions are taken against them.
Audits & reporting by insurers
- Regular audits: Whether an insurer is adhering to IRDAI's guidelines or not is audited and verified by internal and external audits. They look at everything from claim settlement timelines to how the policy is worded as well as how the insurance has been sold (to counter mis-selling).
- Mandatory reporting: Companies are required to submit periodic compliance reports to IRDAI. This report will show the financials in detail, what the claim ratio is, the operational practices and also, if there are customer grievances. This level of transparency helps regulators identify any red flag or deviation by the insurer and they can issue warnings so that insurers can take steps to correct themselves.
- On-site inspections: IRDAI can conduct surprise inspections or investigations. This happens especially when there is a pattern of complaints. These checks make sure that insurers do not bypass the rules.
Penalties & dispute resolution mechanisms
Penalty systems are designed so that insurers who do not follow rules are punished with penalties and so that they can resolve their issues. IRDAI issues several guidelines where they have defined what are financial and operational penalties for insurers:
- Financial penalties: Financial penalties are penalties that take place when insurers delay claims, misrepresent policies or do not disclose certain hospital networks. In such a situation, they face monetary fines
- Operational restrictions: Sometimes, IRDAI may not only put a financial penalty but can operationally restrict an insurer. This can be done by launching of new products, limiting advertising, or even suspending a license of an insurer to operate, in case of serious violations. This incentivizes insurers to follow said rules and maintain operational standards.
- Dispute resolution: Policyholders with unresolved complaints can approach the Insurance Ombudsman. It is an independent body that has also been set up by IRDAI. The Ombudsman is placed to provide a cost-free and impartial resolution mechanism. Decisions made by the Ombudsman are binding on insurers and this body helps consumers get a fair chance to have their concerns addressed.
What policyholders can do (grievances, IRDAI contact)
| Action | Details |
| File a grievance with your insurer | Contact the dedicated grievance redressal officer and keep written proof. |
| Escalate to IRDAI | If unresolved within 15 days, use IRDAI's IGMS, helpline (155255 / 1800-425-4732), or email. |
| Approach the Insurance Ombudsman | For persistent issues, the Ombudsman offers a free, speedy resolution without the need for a lawyer. |
What Changes for You — How to Use These Guidelines When Buying or Renewing Insurance
The IRDAI guidelines are there to protect you if a non-compliant insurer is looking to exploit you. But you also need to keep certain responsibilities in mind and be aware of insurance details:
Check your policy for the continuity & exit age clause
You should check your policy and see whether they have lifetime renewability or is there an absence of hidden exit age restrictions. Insurance policies are usually lifelong, however, you should check for continuity and exit age clauses.
Ensure the plan covers telemedicine, and read the terms carefully
The COVID-19 pandemic has highlighted the importance of remote consultations. The IRDAI now requires health insurance policies to cover telemedicine services, allowing policyholders to provide medical opinions remotely.
Document checklist before filing claims
Keep the document checklist mentioned in the blog handy to avoid any delays.
When switching plans or insurers: what credit/migration rights
Let's say you want to switch policies. During the switch, always confirm if waiting period credits transfer when you migrate. Move forward with the switch only if this condition is fulfilled.
Stay Informed and Protected with ManipalCigna Health Insurance
Understanding the IRDAI guidelines is crucial for ensuring your health insurance policy meets the highest standards of transparency and fairness. At ManipalCigna Health Insurance, we are committed to adhering to these regulations and providing you with top-notch coverage and support.
Explore our health insurance plans today and benefit from our dedication to compliance and customer satisfaction. Visit ManipalCigna's website to find the right plan for you and ensure your health insurance is aligned with the latest IRDAI standards.
FAQs
Can an insurer deny coverage due to pre-existing conditions after 8 years of continuous renewal?
No, insurers cannot reject claims after 8 years of continuous coverage, except in cases of insurance fraud.
If I don't renew on time, do I lose all benefits?
Yes. A lapse may cause loss of waiting period credits, no-claim bonuses, and continuity. And moreover, this can cause you to lose out on insurance coverage during the lapse time.
Is telemedicine covered by all health insurance plans now?
Yes, since COVID-19, IRDAI requires telemedicine coverage if your policy already includes doctor consultations.
