IRDAI Master Circular for *Health Insurance* Companies | NEW Rules 2024 | Gurleen Kaur Tikku

Health Insurance Business Whether it is a stand-alone health insurance company or a general insurance company They have to adhere to the guidelines of the IRDA And MasterCircular came out for the health insurance business on May 29, 2024 In which they took some guidelines and told some of their rules Which insurance companies will have to follow I have received some requests from you To simplify MasterCircular and tell what is there for policyholders So today I have come to decode MasterCircular for this only It will be made till the end of the video There are a lot of things that are in your favor and in your interest So to know that, you have to stay till the end Before starting the video, I would like to introduce myself My name is Gurleen Kautikku I am a Certified Financial Planner I bring videos for you every week So that your insurance bank journey can be easy and happy Because this is the tagline of our company Creating a wealth of happiness So MasterCircular was launched on May 29, 2024 You must remember that I made a video in April IRDA regulations which came in 2024 So with that, MasterCircular was launched on the health insurance business So MasterCircular is reviewed every year Until and unless some major change has to be brought in between But it is reviewed every year Second, it has to be made applicable by immediate effect Insurance companies have to be considered by immediate effect Like it came out on May 29 So these changes, insurance companies will immediately bring in their plans In their products, in their way of working Until and unless a date has been specified That this date has been given to IRDA insurance companies Third, any existing product of the insurance company And that IRDA regulations 2024 and MasterCircular Which was launched on May 29, 2024 It is not in sync with that So the time is given that by September 30, 2024 They have to change that product or implement those things By September 30, 2024, the last date has been given Before that or until then, they have to complete this work PMC is Product Management Committee Which will take care that policyholders get credit for everything Like waiting periods, their moratorium benefits Existing conditions carry forward All that work is of PMC, Product Management Committee We will see what are the other roles of PMC Now let's talk about what is there in MasterCircular 2024 What changes will come in the health insurance business Did they say what new things will you bring for policyholders Will you implement changes in yourself Because of which the pain points, like claims Sometimes you don't get policy due to pre-existing conditions To cover all these pain points IRDA has come up with a lot of things Which will be helpful for policyholders We will talk about it one by one First, IRDA said that every insurance company Has to bring a product for everyone Means for every age For every pre-existing condition If you have a pre-existing condition, you face a lot of challenges That you don't get the policy There are some conditions in which there is a permanent upfront rejection list Or permanent exclusion and you don't get the policy IRDA also said that you will have to bring a provision That they also have to give a policy Whether you bring a new product or change it to an existing product Whether you bring an add-on or rider Policyholders should have flexibility and they should get this cover All types of medical conditions, pre-existing diseases And policies will be brought for chronic conditions All treatments have to be covered Like allopathy, Ayush And all kinds of treatments can be done Because everyone's preference is different Someone wants to do allopathy treatment Someone wants to do Ayush Policyholders should get all those options And all those should be covered in policies Every situation related to your health Related to your medical treatment should be covered Like OPD, your home care Your domiciliary hospitalization Day care procedure, inpatient hospitalization Everything should be covered So the policy should come holistically With add-ons or inbuilt features So that policyholders get cover from everywhere Policy should be given in every region If someone has a disability Policies will be brought for them If someone has an occupational hazard Where there is a high risk occupation Insurance policy should be given to them So all these changes insurance companies Will have to make in their policies And it was also said that Customization option in your product Means flexibility to choose riders Which rider do you want? What do you want to add? What do you not want? That flexibility should be with the policyholder Rather than the insurance company For example, if somebody is buying Policy at the age of 45 or 50 Family size is 2 plus 2 Father, mother, two children Now the policy they want to take The policy they like Suppose it has maternity coverage So maybe they don't want it So this option should be like an add-on Rather than inbuilt So every insurance company will launch such products Second, they said Products will cover technological advancements And treatments Means they will cover modern treatments There are still some policies where There is no coverage of modern treatments So it was said that such products will come Because in the future it is the future You will see that every hospital Will focus on modern treatments So those advanced treatments Should be covered in your policies IAD has shared 12 lists That this advanced treatment should be done And if there is someone else other than this Then you will also include that So these 12 lists are in front of you Which will be covered in every insurance policy Third, the health insurance products Should be in compliance With various laws So there are some laws Which should be in compliance with Mental health care act Right of person with disabilities act Surrogacy act Transgender persons act HIV and AIDS prevention and control act So with these laws Products should be in sync Fourth, this is very important Customer information sheet Many times it happens that you take health insurance policy You have the policy wording That is 30, 40, 50 pages Didn't understand And many terminologies are such that You don't understand No matter how much you try Even after reading the policy wording There are some things that are left Which are realized later So for that, your customer information sheet Which will be in a very simple language So the customer information sheet Will be of every policy And the format is given That format is annexure 1 According to that, the customer information sheet will be taken out So there will be basic features of policy Whatever are your basic features of policy It will be explained in a very simple way So some things will be written in this Like what type of insurance you have What is the time shot, what is the coverage What are the exclusions, what are the sub-limits What are the deductibles What are the waiting periods And important things like Free look period, policy renewal clauses Migration, portability And moratorium period And the tax mention of claim procedure Policy servicing should also be there What service does the insurance company give in the turnaround time So this one Customer information sheet will be very helpful For customers, for policy holders And it is mandatory that every insurance Company has to give with its policies Fifth, free look period So free look period of 30 days When you bought the policy Free look period of 30 days should be given Where the policy holder has the option That he can cancel his policy Without incurring any charges Means today you took the policy You are not satisfied with terms and conditions You read the policy document After taking the policy, you realized that this was the thing And I don't want it So you can cancel your policy in the free look period And the free look period will be of 30 days Next, the policy holder will be given the option That his indemnity policy Means the health insurance policy He will also have the option to cancel it So there are two things here Now you are seeing that multi-tenure policies also come Means there are policies above 1 year People take policy of 2 years, 3 years How will it be there First, if you have a policy of 1 year And you cancel it in between Then on a proportionate basis The amount will be refunded by the insurance company You can cancel Now assume that you have a policy of 2 years, 3 years After 1 year, you feel that I don't want to continue in this policy So what you didn't use the cover Assume that after 1 year You wanted to discontinue So the next 2 years premium The period of uncovered tenure will be refunded Next point is nomination So the policy holder is still given the option To add that nomination in his policy The purpose of nomination in health insurance is Assume that you as a policy holder If there is any mishappening with you During hospitalization So there will be some claim amount left That nominee can claim So the nomination right is with the policy holder Initially, when they are applying the policy They will elect the nomination Who wants to make a nominee If you want to change the nominee in between Then that option is also available Grace period, so when you take your health insurance policy When you have to renew next year Or if you have to renew on the next policy anniversary Then the company gives you a grace period Such a period where if you renew the policy during that Then your features remain intact Your coverage in the future So if it is a monthly policy Then the grace period is given for 15 days If it is a quarterly, half yearly or yearly policy Then the grace period is given for 30 days Means if you renew your policy within 30 days Then all the benefits you have The grace period that has been accumulated No claim bonus, benefits of waiting period All get carried forward Next is availability of insurance coverage during grace period Coverage should be there during the grace period If you have taken this policy in installments According to Master Circular Tenth point is renewal of your existing health insurance policy Many people ask me this question Today we have taken the policy So how long will the insurance company allow us to renew So you have the option of lifelong renewability So this is the clause in every insurance policy Lifelong renewability There are three things here First, the insurance company cannot refuse you for renewal Until and unless the product has been withdrawn Suppose that product does not exist The company has withdrawn it by giving you a notice Then it will not be renewed You will be shifted to another product Otherwise, your renewal cannot be refused There is lifelong renewability Second, renewal cannot be refused on the grounds of claims Now your claim has come Now we will not renew the policy Third point, the insurance company will not do fresh underwriting Until you do not increase the time shot Suppose you took a policy of 10 lakhs today After 5 years, the insurance company cannot say That I will underwrite 10 lakhs again What are your health conditions You tell me, then we will allow you to renew It is not like that If you are continuing at the same time shot Then your guarantee of renewal is given by the insurance company It is a guarantee of lifelong renewability Eleventh is migration So migration happens within the same insurance company If you are shifting your policy So migration in case of indemnity policy Is possible Indemnity is your health insurance policy So here you are from one product to another Means today you took an insurance product You think that in the future some other good insurance product came Within the same insurance company So you have migration available You can move from one product to another And all your benefits Your sum and short continuity Your no claim bonus Your waiting period of pre-existing diseases Waiting period of slow-growing illnesses And moratorium benefits All the benefits will be carried forward with migration Next is portability in case of indemnity policy As you know You can port your policy from one insurance company to another So portability is allowed And portability is your choice So here New insurance company And existing insurance company So what used to happen now The information you used to share New insurance company or acquiring insurance company Based on that your policy used to be issued There was no role of existing insurance company So now IRDA has said that old company And new company Means new company can take information from old company About your health, about your policy, about your claim history And the old company will have to give that information to the new company So here 72 hours time was given If new company asks for information from old company Then within 72 hours they have to give information Related to your policy And request can go to Insurance Information Bureau of India A website has been mentioned From the new company to the old company And it will be managed through this portal And Portability decision You have to give decision within 5 days Whether your policy can be ported or not Sometimes It takes more time Sometimes it takes 7-10 days New company reviews And will not take more than 5 days It has also been said When you will port Then all your benefits Your sum insured, continuity, no claim bonus Pre-existing diseases waiting period, specific exclusions waiting period Moratorium benefits All benefits will be carried forward with portability 13th point This is a very important point Policy claim can't be contested If you took health insurance policy And continued for 60 months Whether with one company or two If you continued for 5 years Then no insurance company will reject your claim Yes No insurance company will reject your claim On ground of non-disclosure And misrepresentation If you have done some non-disclosure On that basis, insurance company can't deny your claim Until and unless It is an established fraud If it is proved fraudulent Then insurance company will not give They are not liable to pay Otherwise, claim will not be denied It doesn't mean that people start misusing Start buying policy on non-disclosure It is not like that But you have to make sure When you are taking policy You have to give all the information properly By chance, something went wrong And you came to know after 5 years And claim came Then insurance company will not contest And will not deny your claim 14th point, no claim bonus Yesterday, someone asked me I haven't taken any claim from my policy for 5 years What benefit did I get I told them, you got no claim bonus Which is a cumulative bonus Your sum insured is increasing every year They said, there is no discount on premium I thought there should be on premium If someone is not taking claim, he should get benefit IRD did the same They said, if you don't take claim You will get no claim bonus in 2 forms Either you enhance your sum insured Or you take discount on premium This option will be given This is a good move Those who already have high sum insured Suppose, it is a policy of 1 crore They don't want more sum insured They want discount on the premium If we didn't take any claim, we should get benefit This option is also available Next is approval for cashless facility If you are taking cashless treatment Many times, it takes time in claims Suppose, you go to hospital Insurance company or TPA Takes time for approval IRD said, it will be 100% cashless It will be time bound Time is defined Cashless claim settlement should be done within 1 hour Initial approval When we are getting admitted Initial approval Should be given to insurance company Not later than that All the necessary system To install insurance company 31st July, 2024 Time is given So that, this facility can be passed on to policy holders It is also said You should have a dedicated desk For insurance company Which is easier for policy holder to communicate Every insurance company should have a dedicated desk Next is Final authorization during discharge Now, we are admitted Initial approval is done within 1 hour But, there is a challenge during discharge When you have to go home You are ready to go home You just want to go home Lie on your bed and rest If your insurance claim is getting late You get angry You get frustrated You want hassle-free claim experience For that, insurance company said Within 3 hours You have to settle the claim During discharge As soon as documents are sent to hospital You have to settle the claim within 3 hours This is a good point This is a good point of insurance companies Which will be passed on to policy holders That there will not be a delay for 3 hours If there is a delay for more than 3 hours And hospital charges additional Sometimes, if it takes more than 3 hours Then hospital charges additional For 1 day So, insurance company will bear that expense If unfortunately, there is a death Insurance company has to immediately Settle the claim And to release the dead body Insurance company has to help Next is During claim settlement Claim gets rejected No claim will be rejected Without PMC approval PMC is Product Management Committee 3 member committee will be formed Which is called Claims Review Committee After reviewing the claim It can be rejected If you have multiple policies How will your claim get settled? If it is an indemnity policy Means health insurance policy If you have taken more than one health insurance policy Then you can choose Which insurance policy you want to claim If your first policy is of 2 lakhs Then there is a policy of 10 lakhs So, you have claimed with first policy Then you are claiming with second policy Here, insurance company has to give hassle-free experience It is not like that Insurance company takes time in claim settlement So, here both have to give hassle-free experience To policy holder Because if policy holder has taken 2 policies Then The hassle of claims Should not be on policy holder Now, let's assume It is a fixed benefit policy If this happens in the insurance company Then we will give fixed benefit Like your personal accidental policy, critical illness insurance policy There, you will get different amount from each policy If you have taken one fixed benefit policy And another one Then claim will be given from both In indemnity, we will give as much loss as possible We will give as much hospital bill as possible But in fixed benefit You will get coverage of each policy Individually Redressal of grievance of policy holder Sometimes it happens that your claims are not settled You go for grievance redressal Every insurance company has grievance redressal Now, what will happen It will be told in a very simple way You have to make a robust system Which works for policy holder Sometimes you see that grievance does not reply Or it takes time to reply So, the system will be such Where all contact numbers will be mentioned Who you can contact Next step of ombudsman will be given Which contact person you have With the contact number and email id So that it is easy for you If you want to escalate to the next level Next is implementation of ombudsman award It means that if you went to the ombudsman Your insurance company was not settling your claim So the ombudsman passed your claim And awarded It is called award That insurance company has to be honored If the insurance company does not honor your award in 30 days Means the amount Ombudsman told the insurance company To give you your claim If it does not give, then a fine of Rs. 5000 will be imposed If it is not honored in 30 days So many times people complain Ombudsman approved Gave our claim award But the insurance company did not give money Now the insurance company will give you money on time So all the points you are seeing In master circular You will see that all of them are in favor of policy holders All of them are towards better processes Keeping your pain points in mind What are your pain points What is the problem you have in taking insurance So that the common man Who wants to take insurance And the peace of mind Who wants to take insurance Will definitely get it from these guidelines And as I told you These guidelines will be applicable to your policies So this was decodent master circular On health insurance 2024 Give your feedback How did you like it How did they introduce you How did you like the points Give your feedback Let's discuss in the comment section And if you want to reach out to our team If you want to take our policy through us You can connect Our contact number and email id is given Before leaving, a quick reminder If you have not subscribed to our channel yet Do it so that you get the useful and the right information at the right time Like I gave you now See you in the next video with a new topic Till then stay safe, take care, bye bye