Ref:IRDAI/HLT/REG/CIR/177/09/2019

27^thSeptember, 2019

Guidelineson Standardization of Exclusions in Health Insurance Contracts

 

Chapter	Item	Page No.
I	Objective; Applicability; Legal and other provision, Definitions	2-4
II	Exclusions not allowed in Health Insurance Policies	5
III	Standard Wordings for some of the exclusions in Health Insurance Policies	6-9
IV	Diseases allowed to be permanently excluded	10-14
V	Modern Treatment Methods and Advancement in Technologies	15
VI	Other guidelines related to exclusions	16-17

INDEX

 

 

 

 

 

 

 

 

 

GENERAL-Chapter - I

1.OBJECTIVE:

Theobjective of these Guidelines are to rationalise and standardizethe exclusions in health Insurance Contracts that every Insurer shall complywith. Health Insurance has undergone various changes and improvements over theyears. The Insurance Regulatory and Development Authority of India (HealthInsurance) Regulations as well as the TPA (Third Party Administrators)Regulations have brought in standardization of various definitions / formats inthe health insurance industry to promote uniformity keeping the customer infocus. The health insurance industry is keeping pace with the advancements intechnologies that are taking place in the healthcare industry.With the increasein number of health insurance companies as well as health insurance products inthe market, it has been desired that the health insurance industry adopts auniform approach while incorporating exclusions in the health insuranceproducts. In order to have a holistic and structured approach in devising appropriateguidelines, IRDAI, constituted a Working Group vide order Ref:IRDAI/HLT/ORD/Misc/113/07/2018 dated 24th July,2018 to review the extantpracticesandmake appropriate recommendations to meet the above objective.Report of theWorking Group was published in IRDAI website on 02/11/2018.

2.APPLICABILITY:

TheseGuidelines are applicable to all General and Health Insurers offering indemnitybased health insurance (excluding PA and Domestic / Overseas Travel) policiesoffering hospitalisation, domiciliary hospitalisation and day care treatment.

3.LEGAL AND OTHER PROVISIONS:

3.1 Theseguidelines are issued under theprovisions of Section 34 (1) of Insurance Act, 1938 and Section 14 (2) (e) ofthe IRDAI Act 1999.

 

3.2 Inorder to enhance the health insurance coverage that is granted at the time ofissuing a policy it is considered important to rationalise the exclusions that werehitherto prevalent in the health insurancepolicy contracts issued by allInsurers. Certain exclusions are prohibited to be incorporated in the healthinsurance policy contracts. Standardization of wordings of certain exclusionsthat are incorporated in the Health Insurance Contracts is also consideredimportant to ensure uniformity across the industry. In order to enable theindividuals that are suffering with any existing diseases get the healthinsurance coverage excluding the coverage to such existing disease, it isconsidered essential to let the Insurers accept such risks, subject tounderwriting policy of the respective insurers, by permanently excluding thecoverage to such existing diseases or illnesses.

3.3 Accordingly,these Guidelines are issued specifying (i) the exclusions that are not allowedin the Health Insurance Policies, (ii) Standard Wordings of some of theexclusions (iii) Existing Diseases that may be permanently excluded (iv) ModernTreatment Methods that shall be covered (v) Other Norms on Exclusions.

3.4 Exclusionsnot allowed in Health Insurance Policies are prescribed in Chapter II of theseGuidelines.No Insurer shall incorporate any exclusion specified under thischapter as part of any of the Health InsuranceProducts. No exclusion that maypotentially circumvent these exclusions is allowed in Health InsuranceProducts.

3.5 StandardWordings of some of the exclusions that are prevalent in Health InsurancePoliciesare prescribed in Chapter III of these Guidelines. While every Insurermay endeavour to minimise the number of exclusions to enhance availability ofhealth insurance coverage, where insurers prefer to incorporate theseexclusions, they shall incorporate the same wordings in-verbatim in the policycontracts as prescribed in this chapter.

3.6 ExistingDiseases allowed to be permanently excluded are prescribed in Chapter IV of theseGuidelines.Every insurer may endeavour to extend health insurance coverage to allthe persons to be insured who disclosed pre-existing disease at the point ofunderwriting in accordance to Regulation (8) of IRDAI (Health Insurance)Regulations, 2016. Insurers while granting health insurance coverage to thepersons with the existingdiseases referred in Chapter IV may levy suitablehealth loading based on objective criteria as laid down in the board approvedunderwriting policy. Where underwriting policy of the Insurer does not enablethe Insurer to offer the Health Insurance Coverage for the given existing diseasedisclosed even after levying the loading, Insurers are allowed to permanentlyexclude the Health Insurance coverage to the existing disease specified in the withinreferred Chapter. Other than the diseases listed in Table –1 of Chapter – IV, any other pre-existing disease disclosed by the person to beinsured shall be covered subject to the norms applicable for preexisting diseases.

3.7 Inorder to ensure that the policyholders of health insurance policies are notdenied getting access to the technologically and medically advanced treatmentprocedures, Insurers shall not exclude the treatment procedures specified inChapter V.

3.8 Othernorms related to exclusions are prescribed in Chapter VI of these Guidelines.

4.Definitions: The words used herein and defined in the Insurance Act, 1938, InsuranceRegulatory and Development Authority Act, 1999 and Regulations notifiedthereunder shall have the same meaning as assigned to them respectively.

 

5. EFFECTIVEDATE:

Theprovisions of these Guidelines shall be applicable in respect of all healthinsurance products (Other than Personal Accident, Domestic and Overseas TravelPolicies) (both Individual and Group)referred in Clause (2) above filed on orafter 01^stOctober,2019. All existing health insurance products thatare not in compliance with these Guidelines shall not be offered and promotedfrom 01^stOctober, 2020 onwards.

 

 

Thishas the approval of the competent authority.

 

 

(DVSRamesh)

GeneralManager (Health)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTERII

Exclusionsnot allowed in Health InsurancePolicies:

1.   Onexamining the extant wordings in the health insurance policy contracts and theprevailing exclusions, it is directed that the following exclusions shall notbe allowed in health insurance (Other than PA & Travel) policies. NoHealth Insurance Policy shall incorporate the following exclusions in the termsand conditions of the policy contract.

a.   Diseasescontracted after taking the health insurance policy, except for the conditions excludedfor which standard wordings are prescribed in Chapter III.

b.    Injury or illnessassociated with hazardous activities. (Explanation: However, only treatmentnecessitated due to participation in adventure or hazardous sports is permittedas exclusion.)

c.    Impairment ofPersons’ intellectual faculties by usage of drugs, stimulants or depressantsas prescribedby a medical practitioner.

d.    Artificial lifemaintenance, including life support machine use, where such treatment will notresult in recovery or restoration of the previous state of health under anycircumstances unless in a vegetative state as certified by the treating medicalpractitioner. (Explanation: Expenses up to the date of confirmation by thetreating doctor that the patient is in vegetative state shall be covered as perthe terms and conditions of the policy contract).

e.    Treatment of mentalillness, stress or psychological disorders and neurodegenerative disorders.

f.     Puberty and Menopauserelated Disorders:Treatment for any symptoms, Illness, complications arisingdue to physiological conditions associated with Puberty, Menopause such asmenopausal bleeding or flushing.

g.    Age Related MacularDegeneration (ARMD)

h.    Behavioural andNeurodevelopmentalDisorders:

                       i.    Disorders of adultpersonality ;

                      ii.    Disorders of speechand language including stammering, dyslexia;

i.      Expenses related toany admission primarily for enteral feedings.

j.      Internal congenital diseases,genetic diseases or disorders.

k.    If specified aetiology for themedicalcondition is not known.

l.     Failureto seek or follow medical adviceor failure to follow treatment.

 

 

 

 

 

 

 

 

CHAPTERIII

StandardWordings for some of the exclusions in Health Insurance Policies:

1.    To make the wordingsof exclusions uniform and specific across the Industry, the wordings of the followingexclusions are standardized. Where these exclusions or exclusions similar tothe ones specified hereunder are used, Insurers shall incorporate the samewordings in verbatim in the health insurance policy contracts.

2.    Against eachexclusion a code number is specified. Insurers are directed to put in placeoperational and system procedures to capture exclusion code specific claimrepudiations for the purpose of deriving data/information relating to exclusionwise repudiation of health insurance claims.

 

A.  Exclusion Name:Pre-Existing Diseases - Code- Excl01

a)    Expenses related tothe treatment of a pre-existing Disease (PED) and its direct complicationsshall be excluded until the expiry of #### months of continuous coverage afterthe date of inception of the first policy with insurer.

b)    In case ofenhancement of sum insured the exclusion shall apply afresh to the extent of suminsured increase.

c)    If the Insured Personis continuously covered without any break as defined under the portabilitynorms of the extant IRDAI (Health Insurance) Regulations, then waiting periodfor the same would be reduced to the extent of prior coverage.

d)    Coverage under thepolicy after the expiry of ##### months for any pre-existing disease is subjectto the same being declared at the time of application and accepted byInsurer.

(Explanation:Subject to product design the number of months, not exceeding 48 months, shallbe specified or a reference may be given to the policy schedule)

 

B.  Exclusion Name:Specified disease/procedure waiting period- Code- Excl02

 

a)  Expenses related tothe treatment of the listed Conditions, surgeries/treatments shall be excludeduntil the expiry of <####> months of continuous coverage after the dateof inception of the first policy with us. This exclusion shall not beapplicable for claims arising due to an accident.(Explanation: Subject to productdesign the number of months, not exceeding 48 months, shall be specified)

b)  In case ofenhancement of sum insured the exclusion shall apply afresh to the extent ofsum insured increase.

c)  If any of thespecified disease/procedure falls under the waiting period specified forpre-Existing diseases, then the longer of the two waiting periods shall apply.

d)  The waiting periodfor listed conditions shall apply even if contracted after the policy or declaredand accepted without a specific exclusion.

e)  If the Insured Personis continuously covered without any break as defined under the applicable normson portability stipulated by IRDAI, then waiting period for the same would bereduced to the extent of prior coverage.

f)   List of specificdiseases/procedures(Explanation: “List of specific diseases / Procedures inrespect of which waiting period is imposed shall be specified here or referenceto be furnished”.)

 

C. 30-day waiting period- Code- Excl03

 

a)  Expenses related tothe treatment of any illness within 30 days from the first policy commencementdate shall be excluded except claims arising due to an accident, provided thesame are covered.

b)  This exclusion shallnot, however, apply if the Insured Person has Continuous Coverage for more thantwelve months.

c)  The within referredwaiting period is made applicable to the enhanced sum insured in the event ofgranting higher sum insured subsequently.

 

D. Investigation &Evaluation- Code- Excl04

a)  Expenses related toany admission primarily for diagnostics and evaluation purposes only areexcluded.

b)  Any diagnosticexpenses which are not related or not incidental to the current diagnosis andtreatment are excluded.

 

E.  Exclusion Name: RestCure, rehabilitation and respite care- Code- Excl05

a)     Expenses related toany admission primarily for enforced bed rest and not for receiving treatment.Thisalso includes:

            i.    Custodial care eitherat home or in a nursing facility for personal care such as help with activitiesof daily living such as bathing, dressing, moving around either by skillednurses or assistant or non-skilled persons.

           ii.    Any services forpeople who are terminally ill to address physical, social, emotional andspiritual needs.

 

(Note: However,Insurers may endeavour to develop add-on riders to offer respite care and homecare, especially, the coverage that kicks in at age 65 onwards, provided thecoverage under base policy is continued without break.)

 

F.  Obesity/ WeightControl:Code-Excl06

 

Expenses related to the surgical treatment ofobesity that does not fulfil all the below conditions:

1)    Surgery to beconducted is upon the advice of the Doctor

2)    The surgery/Procedureconducted should be supported by clinical protocols

3)    The member has to be18 years of age or older and

4)    Body Mass Index (BMI);

a)    greater than or equalto 40 or

b)    greater than or equalto 35 in conjunction with any of the following severe co-morbidities followingfailure of less invasive methods of weight loss:

                                 i.           Obesity-relatedcardiomyopathy

                               ii.           Coronaryheart disease

                              iii.           SevereSleep Apnea

                              iv.           UncontrolledType2 Diabetes

 

G. Change-of-Gendertreatments:Code- Excl07

 

Expensesrelated to any treatment, including surgical management, to changecharacteristics of the body to those of the opposite sex.

 

H. Cosmetic or plasticSurgery:Code- Excl08

 

Expensesfor cosmetic or plastic surgery or any treatment to change appearance unlessfor reconstruction following an Accident, Burn(s) or Cancer or as part ofmedically necessary treatment to remove a direct and immediate health risk tothe insured. For this to be considered a medical necessity, it must becertified by the attending Medical Practitioner.

 

I.   Hazardousor Adventure sports:Code- Excl09

 

Expensesrelated to any treatment necessitated due to participation as a professional inhazardous or adventure sports, including but not limited to, para-jumping, rockclimbing, mountaineering, rafting, motor racing, horse racing or scuba diving,hand gliding, sky diving, deep-sea diving.

 

J.  Breachof law:Code- Excl10

 

Expensesfor treatment directly arising from or consequent upon any Insured Person committingor attempting to commit a breach of law with criminal intent.

 

K. ExcludedProviders:Code- Excl11

 

Expensesincurred towards treatment in any hospital or by any Medical Practitioner orany other provider specifically excluded by the Insurer and disclosed in itswebsite / notified to the policyholders are not admissible. However, in caseof life threatening situations following an accident, expenses up to the stageof stabilization are payable but not the complete claim.

(Explanation:Details of excluded providers shall be provided with the policy document. Insurersto use various means of communication to notify the policyholders, such ase-mail, SMS about the updated list being uploaded in the website.)

 

L. Treatmentfor, Alcoholism, drug or substance abuse or any addictive condition andconsequences thereof.Code- Excl12

 

M. Treatments receivedin heath hydros, nature cure clinics, spas or similar establishments or privatebeds registered as a nursing home attached to such establishments or whereadmission is arranged wholly or partly for domestic reasons.Code- Excl13

 

N. Dietary supplementsand substances that can be purchased without prescription, including but notlimited to Vitamins, minerals and organic substances unless prescribed by amedical practitioner as part of hospitalization claim or day care procedure.Code-Excl14

 

O. Refractive Error:Code- Excl15

 

Expenses related to the treatment for correction of eye sightdue to refractive error less than 7.5 dioptres.

 

P.  Unproven Treatments: Code- Excl16

 

Expensesrelated to any unproven treatment, services and supplies for or in connectionwith any treatment. Unproven treatments are treatments, procedures or suppliesthat lack significant medical documentation to support their effectiveness.

 

Q. Birth control,Sterility and Infertility:Code- Excl17

 

Expenses related to Birth Control, sterility and infertility.This includes:

(i)    Anytype of contraception, sterilization

(ii)  AssistedReproduction services including artificial insemination and advancedreproductive technologies such as IVF, ZIFT, GIFT, ICSI

(iii) GestationalSurrogacy

(iv) Reversalof sterilization

 

R. Maternity: Code Excl18

 

     i.       Medicaltreatment expenses traceable to childbirth (including complicated deliveriesand caesarean sections incurred during hospitalization) except ectopicpregnancy;

   ii.       Expensestowards miscarriage (unless due to an accident) and lawful medical terminationof pregnancy during the policy period.

 

 

 

 

CHAPTERIV

ExistingDiseases allowed to be permanently excluded:

1.   Notwithstandingthe provisions of Clause (1) of Chapter- II, Insurers are allowed to incorporatethe following existing diseases disclosed by the person to be insured at thetime of underwriting as permanent exclusions with due consent of the proposeror person to be insured, where underwriting policy of the Insurer does notenable the Insurer to offer the Health Insurance Coverage for the givenexisting disease disclosed even after levying the loading.The permanentexclusion would be specific for the following listed conditions. However, it isemphasized that these permanent exclusions shall be allowed only in cases wherethe policyholder may be denied coverage as per the underwriting policy of theInsurer for the existing diseases disclosed at the time of underwriting.

 

TABLE- 1

Sr. No.	Disease	ICD Code
1	Sarcoidosis	D86.0-D86.9
2	Malignant Neoplasms	C00-C14 Malignant neoplasms of lip, oral cavity and pharynx, • C15-C26 Malignant neoplasms of digestive organs, • C30-C39 Malignant neoplasms of respiratory and intrathoracic organs• C40-C41 Malignant neoplasms of bone and articular cartilage• C43-C44 Melanoma and other malignant neoplasms of skin • C45-C49 Malignant neoplasms of mesothelial and soft tissue • C50-C50 Malignant neoplasms of breast • C51-C58 Malignant neoplasms of female genital organs • C60-C63 Malignant neoplasms of male genital organs • C64-C68 Malignant neoplasms of urinary tract • C69-C72 Malignant neoplasms of eye, brain and other parts of central nervous system • C73-C75 Malignant neoplasms of thyroid and other endocrine glands • C76-C80 Malignant neoplasms of ill-defined, other secondary and unspecified sites • C7A-C7A Malignant neuroendocrine tumours • C7B-C7B Secondary neuroendocrine tumours • C81-C96 Malignant neoplasms of lymphoid, hematopoietic and related tissue• D00-D09 In situ neoplasms • D10-D36 Benign neoplasms, except benign neuroendocrine tumours • D37-D48 Neoplasms of uncertain behaviour, polycythaemia vera and myelodysplastic syndromes • D3A-D3A Benign neuroendocrine tumours • D49-D49 Neoplasms of unspecified behaviour
3	Epilepsy	G40 Epilepsy
4	Heart Ailment Congenital heart disease and valvular heart disease	I49 Other cardiac arrhythmias, (I20-I25) Ischemic heart diseases, I50 Heart failure, I42 Cardiomyopathy; I05-I09 - Chronic rheumatic heart diseases. • Q20 Congenital malformations of cardiac chambers and connections • Q21 Congenital malformations of cardiac septa • Q22 Congenital malformations of pulmonary and tricuspid valves • Q23 Congenital malformations of aortic and mitral valves • Q24 Other congenital malformations of heart • Q25 Congenital malformations of great arteries • Q26 Congenital malformations of great veins • Q27 Other congenital malformations of peripheral vascular system• Q28 Other congenital malformations of circulatory system • I00-I02 Acute rheumatic fever • I05-I09 • Chronic rheumatic heart diseases Nonrheumatic mitral valve disorders mitral (valve): • disease (I05.9) • failure (I05.8) • stenosis (I05.0). When of unspecified cause but with mention of: • diseases of aortic valve (I08.0), • mitral stenosis or obstruction (I05.0) when specified as congenital (Q23.2, Q23.3) when specified as rheumatic (I05), I34.0Mitral (valve) insufficiency • Mitral (valve): incompetence / regurgitation - • NOS or of specified cause, except rheumatic, I 34.1to I34.9 - Valvular heart disease.
5	Cerebrovascular disease (Stroke)	I67 Other cerebrovascular diseases, (I60-I69) Cerebrovascular diseases
6	Inflammatory Bowel Diseases	K 50.0 to K 50.9 (including Crohn~s and Ulcerative colitis) K50.0 - Crohn~s disease of small intestine; K50.1 -Crohn~s disease of large intestine; K50.8 - Other Crohn~s disease; K50.9 - Crohn~sdisease, unspecified. K51.0 - Ulcerative (chronic) enterocolitis; K51.8 -Other ulcerative colitis; K51.9 - Ulcerative colitis,unspecified.
7	Chronic Liver diseases	K70.0 To K74.6 Fibrosis and cirrhosis of liver; K71.7 - Toxic liver disease with fibrosis and cirrhosis of liver; K70.3 - Alcoholic cirrhosis of liver; I98.2 - K70.-Alcoholic liver disease; Oesophageal varices in diseases classifiedelsewhere. K 70 to K 74.6 (Fibrosis, cirrhosis, alcoholic liver disease, CLD)
8	Pancreatic diseases	K85-Acute pancreatitis; (Q 45.0 to Q 45.1) Congenital conditions of pancreas, K 86.1 to K 86.8 - Chronic pancreatitis
9	Chronic Kidney disease	N17-N19) Renal failure; I12.0 - Hypertensive renal disease with renal failure; I12.9 Hypertensive renal disease without renal failure; I13.1 - Hypertensive heart and renal disease with renal failure; I13.2 - Hypertensive heart and renal disease with both (congestive) heart failure and renal failure; N99.0 - Post procedural renal failure; O08.4 - Renal failure following abortion and ectopic and molar pregnancy; O90.4 - Postpartum acute renal failure; P96.0 - Congenital renal failure. Congenital malformations of the urinary system (Q 60 to Q64), diabetic nephropathy E14.2, N.083
10	Hepatitis B	B16.0 - Acute hepatitis B with delta-agent (coinfection) with hepatic coma; B16.1 – Acute hepatitis B with delta-agent (coinfection) without hepatic coma; B16.2 - Acute hepatitis B without delta-agent with hepatic coma; B16.9 –Acute hepatitis B without delta-agent and without hepatic coma; B17.0 –Acute delta- (super)infection of hepatitis B carrier; B18.0 -Chronic viral hepatitis B with delta-agent; B18.1 -Chronic viral hepatitis B without delta-agent;
11	Alzheimer~s Disease, Parkinson~s Disease -	G30.9 - Alzheimer~s disease, unspecified; F00.9 - G30.9Dementia in Alzheimer~s disease, unspecified, G20 - Parkinson~s disease.
12	Demyelinating disease	G.35 to G 37
13	HIV & AIDS	B20.0 - HIV disease resulting in mycobacterial infection; B20.1 - HIV disease resulting in other bacterial infections; B20.2 - HIV disease resulting in cytomegaloviral disease; B20.3 - HIV disease resulting in other viral infections; B20.4 - HIV disease resulting in candidiasis; B20.5 - HIV disease resulting in other mycoses; B20.6 - HIV disease resulting in Pneumocystis carinii pneumonia; B20.7 - HIV disease resulting in multiple infections; B20.8 - HIV disease resulting in other infectious and parasitic diseases; B20.9 - HIV disease resulting in unspecified infectious or parasitic disease; B23.0 - Acute HIV infection syndrome; B24 - Unspecified human immunodeficiency virus HIV disease
14	Loss of Hearing	H90.0 - Conductive hearing loss, bilateral; H90.1 - Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side; H90.2 - Conductive hearing loss, unspecified; H90.3 - Sensorineural hearing loss, bilateral; H90.4 - Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side; H90.6 - Mixed conductive and sensorineural hearing loss, bilateral; H90.7 - Mixed conductive and sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side; H90.8 - Mixed conductive and sensorineural hearing loss, unspecified; H91.0 - Ototoxic hearing loss; H91.9 - Hearing loss, unspecified
15.	Papulosquamous disorder of the skin	L40 - L45 Papulosquamous disorder of the skin including psoriasis lichen planus
16.	Avascular necrosis (osteonecrosis)	M 87 to M 87.9

 

2.    With reference to SlNo. 13 of the above table, it is clarified that Insurers shall comply with theprovisions of Section 3 (j) of the Human Immunodeficiency Virus and AcquiredImmune Deficiency Syndrome (Prevention and Control) Act 2017 which specifiesthat no person shall discriminate against the protected person on any groundincluding the denial of, or unfair treatment in the provision of insuranceunless supported by actuarial studies. While complying with the provisionsof the HIV and AIDS (Prevention and Control) Act 2017, Insurers shall be boundby these provisions, where the Actuarial studies support the denial of the healthinsurance coverage, the above approach of allowing to incorporate HIV / AIDS(refer Sl No. 13) as the permanent exclusion at the time of underwriting, maybeconsidered by the Insurers in order to enable these sections of policyholdersto get the health insurance coverage for conditions other than the conditionsreferred in Sl No. 13 above.

3.    Exclusion of coveragein respect of the existing diseases referred in Table – 1 of this chapter shallbe limited to the ICD Codes of the respective diseases. No claim which does notrelate to the ICD codes referred herein shall be denied by attributing to thediseases referred herein. The policyholders shall be entitled to costs oftreatment in respect of any other treatments, other than, the treatmentdirectly attributable to ICD Codes referred in Table – I above subject to termsand conditions of the policy contract.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER V

ModernTreatment Methods and Advancement in Technologies:

1.   Toensure that the policyholders are not denied availability of health insurancecoverage to Modern Treatment Methods Insurers shall ensure that the followingtreatment procedures shall not be excluded in the health insurance policycontracts. These Procedures shall be covered (wherever medically indicated)eitheras in-patient or as part of domiciliary hospitalization oras day care treatmentin a hospital.

 

A.  Uterine Artery Embolizationand HIFU

 

B. Balloon Sinuplasty

 

C. Deep Brainstimulation

 

D. Oral chemotherapy

 

E.  Immunotherapy-Monoclonal Antibody to be given as injection

 

F.  Intra vitrealinjections

 

G. Robotic surgeries

 

H. Stereotactic radiosurgeries

 

I.    BronchicalThermoplasty

 

J.  Vaporisation of theprostrate (Green laser treatment or holmium laser treatment)

 

K. IONM - (IntraOperative Neuro Monitoring)

 

L.  Stem cell therapy: Hematopoietic stemcells for bone marrow transplant for haematological conditions to be covered.

 

2.    Subject to productdesign sub-limits may be imposed for any of the above treatments.

 

3.    Insurers mayendeavour to cover any other modern treatment methods

 

 

 

 

CHAPTERVI

Otherguidelines related to exclusions:

1.      Notwithstandingthe provisions of Clause (1) of Chapter – II, Insurers are allowed toincorporate waiting periods for any specific disease condition(s) however to amaximum of 4 years. Subject to product design Insurers are also allowed toimpose sub limits or annual policy limits for specific diseases / conditions; beit in terms of amount, percentage of sums insured or number of days ofhospitalisation/ treatment in the policy.However, Insurers shall adopt anobjective criterion while incorporating any of these limitations and shall bebased on sound actuarial principles.

 

2.     Insurersare advised to consider the following options to handle the cases ofNon-declaration/Misrepresentation of material facts that are surfaced duringthe course of the policy contract. The options specified hereunder for thepurpose of continuing the health insurance coverage to the policyholders andthe underlying claim, if any, shall be subject to terms and conditions of theapplicable policy contract.

 

a)    If the non-disclosedcondition or disease is from the list of the Permanent exclusions specified in ChapterIV above the insurer can take consent from the policyholder or insured personand permanently exclude the existing disease and continue with the policy.

 

b)    If the non-disclosedcondition is other than from the list of permanent exclusions, then the insurercan incorporate additional waiting period of not exceeding 4 years for thesaidundisclosed disease or condition from the date the non-disclosed condition wasdetected and continue with the policy subject to obtaining the prior consent ofthe policyholder or the insured person. The within referred additional waitingperiod that may be imposed for the undisclosed conditions is allowed notwithstandingthe moratorium period referred in Clause no. 3 hereunder. However, theadditional waiting period referred herein, shall be imposed, only in thosecases where had the medical condition / disease been disclosed by thepolicyholder or the Insured person at the point of underwriting, the insurerwould have imposed the waiting period not exceeding forty-eight months at thetime of underwriting.

 

c)    Where thenon-disclosed condition allows the Insurer to continue the coverage by levyingextra premium or loading based on the objective criteria laid down in the Boardapproved underwriting policy, the Insurer may levy the same prospectively fromthe date of noticing the non-disclosed condition. However, in respect of policycontracts for a duration exceeding one year, if the undisclosed condition issurfaced before expiry of the policy term, the Insurer may charge the extrapremium or loading referred herein retrospectively from the first year ofissuance of policy or renewal, whichever is later.

 

d)    The above threeoptionswill not prejudice the rights of the insurer to invoke the cancellation clause of‘Disclosure to Information norm’ under the policy for non-disclosure/misrepresentation subject to its underwriting policy.

 

3.      After completion of eightcontinuous years under the policy no look back to be applied. This period of eightyears is called as moratorium period.The moratorium would be applicable for thesums insured of the first policy and subsequently completion of 8 continuousyears would be applicable from date of enhancement of sums insured only on theenhanced limits. After the expiry of Moratorium Period no health insurancepolicy shall be contestable except for proven fraud and permanent exclusionsspecified in the policy contract. The policies would however be subject to alllimits, sub limits, co-payments, deductibles as per the policy.The moratorium periodis applicable for health insurance policies issued by General and HealthInsurers.

4.      The wordings of theexclusions or waiting periods shall be specific and unambiguous. No open-endedexclusions like“Indirectly related to”, “such as”, “etc.” are allowed while incorporatingthe exclusions and in the waiting periods.

5.     Waitingperiod for life style conditions namely, Hypertension, Diabetes, Cardiacconditions is not allowed for more than90 days except if these diseases arepre-existing and disclosed at the time of underwriting.

6.     Insurersshould not deny coverage for claims of Oral Chemo therapy, where Chemo therapyis allowed and Peritoneal Dialysis, where dialysis is allowed subject toproduct design.

7.     Pre/Posthospitalization cover under Domiciliary Treatment benefit shall not be excludedwhere pre/post hospitalization cover is offered in case of in-patienthospitalization under the product and the underlying product covers domiciliaryhospitalization. (Explanation: On a review of the definition given todomiciliary treatment, it is evident that this treatment is taken only undercertain unavoidable circumstances that may be beyond the control of thepolicyholder. Hence, in fitness of things it is important that the policyholdercan have pre / post hospitalization expenses as are otherwise made available incase of in-patient hospitalization.)