6 New Health Insurance Claim Rules Every Policyholder Should Know

Recently, the Insurance Regulatory and Development Authority of India (IRDAI) changed a number of regulations to improve policyholders’ experiences, smoother claims processes, and ensure broader coverage. These changes are set to benefit a big chunk of policyholders, with specific improvements affecting health insurance claims, waiting periods for pre-existing conditions, and coverage for alternative treatments. In this article, we will explore the six significant updates that every policyholder should be aware of.

1. Cashless Everywhere

One of the most impactful changes is the extension of the cashless claim facility to all hospitals, including non-network ones. Previously, policyholders admitted to non-network hospitals (hospitals that are not listed under the contract with the health insurance company) had to pay out-of-pocket initially and seek reimbursement after discharge. This process was often cumbersome and financially straining. With the new rule, you can now make cashless claims regardless of the hospital’s network status. This change simplifies the claims process, ensuring you get medical attention on time without worrying about paying for it right away.

2. Pre-existing Diseases/Specific Ailments Waiting Period Reduced

Pre-existing conditions, as well as certain illnesses, now have a three-year waiting period instead of a four-year one. This implies that the insurer will now cover specific medical issues after three years rather than four if you have them at the time you purchase a health insurance policy. This reduction in waiting time is a significant relief for many policyholders, allowing earlier access to necessary treatments and reducing the financial burden associated with prolonged waiting periods.

3. No Limitations on Ayush Treatments

Ayurveda, Yoga, Unani, Siddha, and Homeopathy (collectively known as Ayush treatments) have gained increased recognition. IRDAI has mandated that insurers must have a Board-approved policy for Ayush coverage without any limitations. This brings Ayush treatments on par with allopathic treatments, ensuring that your claims for these traditional forms of medicine are honoured, provided you meet the specified conditions. This change promotes holistic healthcare options and caters to a broader spectrum of medical preferences.

4. 3-Hour Cashless Claim Clearance

The new rule mandates insurers to clear claims within three hours of receiving them from the hospital during discharge. Additionally, there is now a one-hour window for clearing cashless claim requests at the time of admission. This swift processing of claims reduces the waiting time for patients and their families during critical moments. The prompt clearance helps in minimising stress and ensures that policyholders can focus on recovery rather than administrative hurdles.

5. The Moratorium Period Reduced to 5 Years

The moratorium period, which is the duration during which an insurer cannot contest any claim on the grounds of non-disclosure or misrepresentation (except in cases of fraud), has been reduced from 8 years to 5 years. If you have maintained continuous coverage for 5 years, including through portability and migration, your insurer cannot dispute your claims based on these grounds. This reduction enhances the policyholder’s security and trust in their health insurance plan, ensuring long-term reliability.

6. Claims with Multiple Insurers

Another beneficial change is the ability to make claims for a single hospitalisation with multiple health insurance policies. If you hold multiple policies, you can now utilise all of them to cover your medical expenses. For instance, if you have two health policies with coverage amounts of ₹8 lakh and ₹10 lakh, respectively, and you incur a hospital bill of
₹14 lakh, you can use both policies to settle the claim. This provision provides greater financial flexibility and ensures comprehensive coverage, particularly useful in high-cost medical scenarios.

Conclusion

These recent health insurance claim rule changes reflect IRDAI’s commitment to enhancing the policyholder experience, ensuring faster and more inclusive coverage. Policyholders are now better equipped to manage their healthcare needs without unnecessary delays or financial stress. Staying informed about these updates is essential for making the most of your health insurance policy and ensuring peace of mind in times of medical need.