Soon, pay less and get better health cover: IRDAI hints at new changes

Health insurers cannot include the cost of pharmacy, implants, medical devices and diagnostics as part of the associated medical expenses, said the Insurance Regulatory and Development Authority.

In cases where a policyholder opts for a room that has a higher rent than what is covered in their policy, the hospital bill is not fully reimbursed, said the regulator and asked for a uniform approach while applying for proportionate deductions in claims.

In such cases, the insurer can subject the claim of the policyholder to proportionate deductions of associated medical expenses, the regulator said. This would mean insurers would partially reimburse the policyholder’s claim.

The move is aimed at helping policyholders as the insured would pay less while getting better coverage.

But, some of the charges which were earlier a part of the associated medical expense have now been removed.

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

“Insurers are also not permitted to apply proportionate deduction for ‘ICU charges’ as different categories of ICU are not there.” 

Also, insurers have to ensure that proportionate deductions are not applied in respect of the hospitals which do not follow differential billing based on the room category.

Towards this, the policy conditions shall be specified that the proportionate deduction would be applied only in the case of a hospital that follows differential billing practice based on the room category occupied by a patient.