Out-of-pocket expenses set to fall for policyholders after new Irdai rules

Out-of-pocket expenses of policyholders will reduce as the insurance regulator has asked companies selling indemnity-based health products to not include cost of pharmacy, implants, medical devices, and diagnostics as part of the associated medical expenses. 

Now insures have to define the associate medical expenses which will be deducted proportionately if a person opts for a higher room category than the category that is eligible, according to the terms and conditions of the policy.

Insurers shall not recover any expenses towards proportionate deductions other than the defined ‘associate medical expenses’ while processing claims, the regulator said. 

Moreover, the regulator has asked insurers to ensure proportionate deductions are not applied in respect of hospitals which do not follow differential billing or for those expenses in respect of which differential billing is not adopted based on the room category. This shall be clearly specified in the policy terms and conditions.

Insurers have also been advised to refrain from applying proportionate deduction for ‘ICU charges’ as different categories of ICU are not there. 

“Insurers will negotiate with their hospital networks to see that the increase in rates of associate medical expenses with change in room category is in control so as to benefit the customer,” said Bhaskar Nerurkar, head–health claims, Bajaj Allianz General Insurance. 

These rules will come into effect for new policies from October 1, and existing health products have to adhere to these regulations by April 1.

Telemedicine to be part of claim settlement

Irdai has asked insurers to allow telemedicine wherever consultation with a medical practitioner is allowed in the terms and conditions of policy contract. Provision of allowing telemedicine has to be a part of claim settlement. The Medical Council of India has allowed registered medical practitioners to provide health care using telemedicine.  Subrata Panda