IRDA want insurers to provide health cover up to 65 years

Sectoral regulator IRDA has proposed to make it mandatory for health insurers to provide policy cover to people up to 65 years and settle all claims within a month.

In its draft guidelines for health insurance companies, the IRDA said that insurers would have to provide cashless facility to policyholders undergoing treatment in a particular hospital even after it is removed from the list of preferred service providers.

These provisions form part of IRDA's exposure draft on Insurance Regulatory and Development Authority (Health Insurance) Regulations 2012. The draft also talks about portability, under which a policy holder can migrate to another health insurance providing company, without losing any benefit.

Besides, it has also proposed special provisions for senior citizens whose need for health care is pressing. Under the proposed norms, insurer will have to provide customers all relevant information to customers in a simple language in single page.

The insurer will be required to provide reasons for denial of claims to insured persons, said the draft. "... if the policyholder is already undergoing such treatment at a hospital, and such hospital is proposed to be removed from the list of Network Provider, then insurers shall provide the benefits of cashless facility for such policy holder as if such hospital continues to be on the Network Provider list," IRDA has said.

The guidelines seek to address the problems of the health insurance sector which came into light in 2010 after four public sector insurers removed private hospitals from their preferred list citing over charging by them under the cashless scheme.

As per the draft norms, insurers should ensure that empanelled hospitals - where cashless facilities are offered for policyholders - are spread across different cities of the country and not confined only to metro cities.

"The insurance company shall ensure that adequate number of both public and private providers shall be empanelled," it added. IRDA has also suggested that insurers should at all times keep policyholders informed on nearest hospital where cashless facility is available. The insurers should also display the updated list of network providers on their websites.

"For the purpose of claim settlement, insurer shall make direct payments to the network provider and to the policyholders by integrating their banking system platform with the network provider or the insured, as the case may be," the draft said.

It has also provided for issuance of travel insurance policies by companies on standalone basis. The insurers, it said, will also be allowed to come out with 'Health-plus Life Combi' products which would be a combination of life and health insurance cover.

There are currently over seven crore health insurance customers and their premiums add up to more than Rs 11,000 crore.