The Insurance Regulatory and Development Authority of India (IRDAI) has released a master circular to strengthen the rights and protections of health and life insurance policyholders. The circular, which was released on September 5, includes regulations on claim settlements, customer information sheets, and how insurers treat policyholders in general.
Key topics from the circular that you should know as a policyholder:
Customized benefit illustrations: At the point of sale, insurers must provide a bespoke benefit illustration outlining specific benefits based on the customer's profile. This ensures that policyholders fully grasp their coverage options.
Streamlined proposal processing: Insurers must process proposal forms expeditiously, intending to make a decision within seven days of receiving all relevant information. This includes quickly communicating acceptance or rejection, as well as the reasons for non-acceptance.
Electronic insurance issuance: Policies will be issued electronically upon the approval of a proposal and receipt of premium, with the option of physical documentation if required.
Customer information sheet (CIS): A statement provided by the insurer along with the policy document that summarizes critical information and basic elements of the policy issued in one place. For life insurance plans, the CIS must be in the format required in the Insurance Act's 'Schedule D'.
Key information in a CIS
Form of insurance: Indicates whether the policy is term life, whole life, or any other form.
The sum assured indicates the amount payable to the beneficiary in the event of a claim.
Benefits: Provides a full summary of the policy's coverage and advantages.
Exclusions: The policy does not cover the following conditions or scenarios.
Important factors: This section includes information on the free look time, renewal dates, policy revival and loan alternatives, and other relevant factors.
Claims Procedure: Describes the actions necessary to file a claim.
Policy Servicing provides information about customer support and help services.
Grievance redressal: Outlines the procedure for filing complaints and offers contact information for the Insurance Ombudsman.
To promote diversity, CIS and proposal forms must be provided in regional languages on request.
Free look period: Policyholders will have 30 days to review their insurance conditions. If consumers are dissatisfied, they can return the insurance for a refund, allowing them to reconsider their purchase without penalties.
Improved grievance redressal mechanisms: Insurers must implement effective grievance redressal processes, ensuring that policyholders may readily settle difficulties and receive assistance when necessary.
Mandatory nomination and updates: The proposal form will request nominee information, ensuring that claims are processed smoothly in the case of a policyholder's death. To ensure efficient servicing, policyholders are asked to keep their information up to date.
Cashless claim payment within 3 hours: In order to provide cashless claim settlement for health insurance from the date of cover beginning, the insurer must acquire the details of group members from the master policyholder as soon as possible. No claim shall be refused due to the lack of availability of group members' details.
Numerous health insurance plans: If you have numerous health insurance policies from different insurers, the claims process has become more flexible. You can now file a claim under any of your plans, specifying your preferred insurer as the primary one. If the primary insurer's coverage is insufficient to cover the entire claim amount, this insurer will work with the other insurers to settle the outstanding balance.
Search tool: Insurers must include a search engine on their websites that allows customers to verify permitted sales channels.
Premium/proposal deposit: No premium/proposal deposit is required to be paid to the life/health insurer together with the proposal form, except for policies where risk coverage begins immediately upon receipt of payment.
Insurers are expected to make accessible products/add-ons/riders to provide a wider option to policyholders/potential customers catering
A. All ages.
B. Any form of existing medical issue.
C. Pre-existing diseases or chronic disorders.
D. All medical systems and therapies, including allopathy, Ayurvedic medicine, and others.
E. Any type of treatment, including domiciliary hospitalization, outpatient treatment (0PD), day care, and homecare.
F. All areas, all occupational categories, people with disabilities, and any additional groups;
G. All types of hospitals and health-care providers that are affordable to policyholders/prospects. Policyholders will not be denied coverage in the event of an emergency.
Note: The foregoing does not imply that the insurer must have a single product to cover all of the above.
