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Health insurance: stop arbitrary premium increases

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The regulator had specified that the increase in the premium due to the change in standards would not exceed 5% of the premium rates initially approved.

General and independent health insurance companies will not be allowed to increase the premium of a policy by modifying existing benefits and adding new benefits to existing products. However, insurers can offer the addition of new guarantees or the upgrade of existing guarantees in the form of additional coverages or optional coverages with an autonomous premium rate to guarantee an informed choice to the insured.

Product pricing
In a circular, the Insurance Regulatory and Development Authority of India (Irdai) asked insurers to ensure that the appointed actuary reviews the financial viability of each health insurance product at the end of each fiscal year. The report of this review must be submitted to their board of directors with the analysis of the favorable or unfavorable experience of each product as well as the recommended corrective measures, in order to ensure the durability of the product and to protect the interests of the insured. of the underlying product.

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The regulator’s circular comes at a time when several insurers have increased the premium for health insurance policies, citing regulations for broader coverage and standardization of exclusions. Last year, the regulator standardized the nomenclature and procedure for 22 serious illnesses that are part of a health insurance policy. All health insurers should use the definitions without exception wherever products are offered for coverage. Insurers have also increased the premium due to the increase in Covid-related claims and rising medical inflation. The regulator had specified that the increase in the premium due to the change in standards would not exceed 5% of the premium rates initially approved.

In addition, in order to allow all sections of the insured to easily understand the content of the policy contracts, the policy contracts of all health insurance products should have a clear heading such as standard definitions, specific definitions , benefits covered by the policy, exclusions, etc. , to attract the attention of policyholders. The wording of all standard exclusions, standard clauses and clauses and standard definitions used in the policy contract shall conform to the wording specified by the regulator. This new format will have to be done for all health insurance policies issued from October 1, 2021.

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Settlement of complaints
In another circular, the regulator stressed that policyholders must obtain clear and transparent communication at different stages of processing claims. Insurers should have systems in place to enable policyholders to track the status of cashless claims / claims filed with the insurer / third party administrators (TPA) through the website / portal / app or other authorized electronic means. The status will cover from the time of receipt of the request to the time of disposition of the complaint with the decision taken.

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In cases where claims are handled through TPAs, insurers can let their TPAs ​​operationalize the claims tracking mechanism and policyholders will be informed in all communications. Insurers will need to ensure that the repudiation of the claim is not based on “guesswork and guesswork”. If the request is refused or rejected, communication regarding the refusal or repudiation must be made only by the insurer, specifically indicating the reasons for the refusal or repudiation. The insurer will also provide the complaints redress procedures available from the insurance company and the insurance ombudsman as well as the detailed addresses of the respective offices.

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