Document Detail

Title: परिपत्र
Reference No.: आईआरडीएआई/एचएलटी/आरईजी/सीआईआर/176/09/2019
Date: 27/09/2019
स्वास्थ्य बीमा में मानकीकरण पर संशोधन दिशानिर्देश स्वास्थ्य बीमा में मानकीकरण पर संशोधन दिशानिर्देश

 

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

27thSeptember, 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 29th 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 29th 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 1stOctober2019. All existing health insurance products that are not in compliance with theseGuidelines shall not be offered and promoted from 01stOctober, 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 29thJuly, 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

 

Sl

No

Item

1

BABY FOOD

2

BABY UTILITIES CHARGES

3

BEAUTY SERVICES

4

BELTS/ BRACES

5

BUDS

6

COLD PACK/HOT PACK

7

CARRY BAGS

8

EMAIL / INTERNET CHARGES

9

FOOD CHARGES (OTHER THAN PATIENT~s DIET PROVIDED BY HOSPITAL)

10

LEGGINGS

11

LAUNDRY CHARGES

12

MINERAL WATER

13

SANITARY PAD

14

TELEPHONE CHARGES

15

GUEST SERVICES

16

CREPE BANDAGE

17

DIAPER OF ANY TYPE

18

EYELET COLLAR

19

SLINGS

20

BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES

21

SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED

22

Television Charges

23

SURCHARGES

24

ATTENDANT CHARGES

25

EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED CHARGE)

26

BIRTH CERTIFICATE

27

CERTIFICATE CHARGES

28

COURIER CHARGES

29

CONVEYANCE CHARGES

30

MEDICAL CERTIFICATE

31

MEDICAL RECORDS

32

PHOTOCOPIES CHARGES

33

MORTUARY CHARGES

34

WALKING AIDS CHARGES

35

OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)

36

SPACER

37

SPIROMETRE

38

NEBULIZER KIT

39

STEAM INHALER

40

ARMSLING

41

THERMOMETER

42

CERVICAL COLLAR

43

SPLINT

44

DIABETIC FOOT WEAR

45

KNEE BRACES (LONG/ SHORT/ HINGED)

46

KNEE IMMOBILIZER/SHOULDER IMMOBILIZER

47

LUMBO SACRAL BELT

48

NIMBUS BED OR WATER OR AIR BED CHARGES

49

AMBULANCE COLLAR

50

AMBULANCE EQUIPMENT

51

ABDOMINAL BINDER

52

PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES

53

SUGAR FREE Tablets

54

CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals payable)

55

ECG ELECTRODES

56

GLOVES

57

NEBULISATION KIT

58

ANY KIT WITH NO DETAILS MENTIONED DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC

59

KIDNEY TRAY

60

MASK

61

OUNCE GLASS

62

OXYGEN MASK

63

PELVIC TRACTION BELT

64

PAN CAN

65

TROLLY COVER

66

UROMETER, URINE JUG

67

AMBULANCE

68

VASOFIX SAFETY

 

List II – Items that are to be subsumed intoRoom Charges

 

Sl

No

Item

1

BABY CHARGES (UNLESS SPECIFIED/INDICATED)

2

HAND WASH

3

SHOE COVER

4

CAPS

5

CRADLE CHARGES

6

COMB

7

EAU-DE-COLOGNE / ROOM FRESHNERS

8

FOOT COVER

9

GOWN

10

SLIPPERS

11

TISSUE PAPER

12

TOOTH PASTE

13

TOOTH BRUSH

14

BED PAN

15

FACE MASK

16

FLEXI MASK

17

HAND HOLDER

18

SPUTUM CUP

19

DISINFECTANT LOTIONS

20

LUXURY TAX

21

HVAC

22

HOUSE KEEPING CHARGES

23

AIR CONDITIONER CHARGES

24

IM IV INJECTION CHARGES

25

CLEAN SHEET

26

BLANKET/WARMER BLANKET

27

ADMISSION KIT

28

DIABETIC CHART CHARGES

29

DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES

30

DISCHARGE PROCEDURE CHARGES

31

DAILY CHART CHARGES

32

ENTRANCE PASS / VISITORS PASS CHARGES

33

EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE

34

FILE OPENING CHARGES

35

INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)

36

PATIENT IDENTIFICATION BAND / NAME TAG

37

PULSEOXYMETER CHARGES

 

List III – Items that are to be subsumed intoProcedure Charges

 

Sl

No.

Item

1

HAIR REMOVAL CREAM

2

DISPOSABLES RAZORS CHARGES (for site preparations)

3

EYE PAD

4

EYE SHEILD

5

CAMERA COVER

6

DVD, CD CHARGES

7

GAUSE SOFT

8

GAUZE

9

WARD AND THEATRE BOOKING CHARGES

10

ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS

11

MICROSCOPE COVER

12

SURGICAL BLADES, HARMONICSCALPEL,SHAVER

13

SURGICAL DRILL

14

EYE KIT

15

EYE DRAPE

16

X-RAY FILM

17

BOYLES APPARATUS CHARGES

18

COTTON

19

COTTON BANDAGE

20

SURGICAL TAPE

21

APRON

22

TORNIQUET

23

ORTHOBUNDLE, GYNAEC BUNDLE

 

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

 

Sl

No.

Item

1

ADMISSION/REGISTRATION CHARGES

2

HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE

3

URINE CONTAINER

4

BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES

5

BIPAP MACHINE

6

CPAP/ CAPD EQUIPMENTS

7

INFUSION PUMP– COST

8

HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC

9

NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET CHARGES

10

HIV KIT

11

ANTISEPTIC MOUTHWASH

12

LOZENGES

13

MOUTH PAINT

14

VACCINATION CHARGES

15

ALCOHOL SWABES

16

SCRUB SOLUTION/STERILLIUM

17

Glucometer& Strips

18

URINE BAG

 

 

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