IRDA Circular No: IRDA/HLT/REG/CIR/125/07/2013 (03-Jul-13) Amendment to Guidelines on Standardization in Health Insurance
This is issued in terms of Section 14(2) of IRDA Act 1999 and has reference to Circular ref: IRDA/HLT/CIR/036/02/2013 dated 20/02/2013 regarding Guidelines on Standardization in Health Insurance. The following amendments may kindly be noted:-
A. Standard Definitions of terminology used in Health Insurance Policies
In terms of Regulation 5 (n) of the IRDA Health Insurance Regulations, 2013 and with reference to Para 1 of the above-mentioned circular dealing with standard defintions, the Authority hereby stipulates the following amended definitions while defining the respective terms in all health insurance policies:-
Sl No. 1. Accident
An accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.
Sl No 2. Co-payment
A co-payment is a cost-sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible claim amount. A co-payment does not reduce the Sum Insured.
Sl No 4. Deductible
Deductible is a cost-sharing requirement under a health insurance policy that provides that the insurer will not be liable for a specified rupee amount in case of
indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the insurer. A deductible does not reduce the Sum Insured.
( Insurers to define whether the deductible is applicable per year, per life or per event and the specific deductible to be applied)
Sl No.5. Dependant child
This definition stands deleted.
Sl No. 8. Hospital
A hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
--has qualified nursing staff under its employment round the clock;
--has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;
--has qualified medical practitioner(s) in charge round the clock;
--has a fully equipped operation theatre of its own where surgical procedures are carried out;
--maintains daily records of patients and makes these accessible to the insurance company''s authorized...
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