The Insurance Regulatory and Development Authority of India (IRDAI) has issued a master circular aimed at enhancing the rights and protections for health and life insurance policyholders. Released on September 5the circular has regulations on claim settlements, customer information sheets, and the overall treatment of policyholders by insurers.
Key points from the circular that you must know as a policyholder
Customised benefit illustrations: Insurers must provide a tailored benefit illustration at the point of sale, detailing specific benefits based on the customer’s profile (age, premium amount, etc.). This will ensure that policyholders understand their coverage options clearly.
Streamlined proposal processing: Insurers are required to process proposal forms efficiently, aiming for a decision within seven days of receiving all necessary information. This includes communicating acceptance or rejection promptly, along with reasons for any non-acceptance.
Electronic policy issuance: Upon acceptance of a proposal and receipt of premium, policies will be issued electronically, with the option for physical documents if requested.
Customer information sheet (CIS): It is a statement provided by the insurer along with the policy document that provides in simple words, important information and basic features of the policy issued at one place. The CIS must be provided in the format specified in ‘Schedule D’ of the Insurance Act for life insurance policies.
Key information in a CIS
Type of insurance: Specifies whether the policy is term life, whole life, or other insurance type.
Sum assured: Indicates the amount payable to the beneficiary in the event of a claim.
Benefits: Provides a comprehensive description of the coverage and advantages offered by the policy.
Exclusions: Lists the conditions or scenarios that are not covered by the policy.
Important Details: Includes information on the free look period, renewal dates, options for policy revival and loans, and other pertinent details.
Claims Procedure: Outlines the steps required to file a claim.
Policy Servicing: Offers details on customer support and assistance services.
Grievance redressal: Describes the process for filing complaints and provides contact information for the Insurance Ombudsman.
CIS and proposal forms must be made available in regional languages upon request to support inclusivity.
Free look period: Policyholders will have a 30-day free look period to review their policy terms. If unsatisfied, they can return the policy for a refund, ensuring they have the opportunity to reconsider their purchase without penalties
Improved grievance redressal mechanisms: Insurers are mandated to establish effective grievance redressal systems, ensuring that policyholders can easily resolve issues and receive support when needed.
Mandatory nomination and updates: The proposal form will require details of nominees, ensuring that claims can be processed smoothly in the event of a policyholder’s death. Policyholders are also encouraged to keep their information updated to facilitate efficient service .
Cashless claim settlement within 3 hours: In order to provide cashless claim settlement for health insurance from the date of commencement of cover, the Insurer shall obtain the details of members of the group from the master policyholder, at the earliest. No claim shall be denied for non-availability of details of members of the group.
Multiple health insurance policies: If you hold multiple health insurance policies from various insurers, the process for settling claims has become more flexible. You can now choose to file a claim under any of your policies, designating the chosen insurer as the primary one. If the coverage from the primary insurer is insufficient to cover the full claim amount, this insurer will coordinate with the other insurers to settle the remaining balance.
Search tool: Insurers are required to offer a search tool on their websites that allows users to verify authorised sales channels.
Premium /proposal deposit: No premium / proposal deposit is required to be paid to the life /health insurer along with the proposal form except in case of policies where risk cover commences immediately on receipt of premium.
Insurers are required to make available products/add-ons/riders to provide wider choice to the policyholders/ prospects catering to
a. All ages;
b. All types of existing medical conditions.
c. Pre-existing diseases and chronic conditions.
d. All systems of medicine and treatments including Allopathy, AYUSH and other systems of medicine.
e. Every situation of treatment including domiciliary hospitalisation, outpatient treatment (0PD), day care and homecare treatment.
f. All regions, all occupational categories, persons with disabilities and any other categories;
g. All types of Hospitals and Health Care Providers to suit the affordability of the policyholders/ prospects. Policyholders shall not be denied coverage in case of emergency situations.
Note: The above does not imply that the insurer shall have one product to cater to all of the above.
First Published: Sep 06 2024 | 4:04 PM IST
