'Group should have a minimum 20 members for health insurance'

Insurance sector regulator IRDAI today proposed a 'Group' should have a minimum size of 20 members to be eligible for issuance of a Group Health Insurance Policy.
Releasing an exposure draft on IRDAI (Health Insurance) Regulations, 2016, the authority also proposed that the "premiums filed shall ordinarily not be changed" for a period of three years after a product has been cleared in accordance to the product filing guidelines specified by it.
Thereafter, the insurer may vary the premium rates depending on the experience.
On Group Health Insurance, the draft said no policy would be issued by any insurer where a Group is "formed with the main purpose of availing itself" of insurance.

"There shall be a clearly evident relationship between the members of the group and the group policy holder for services other than insurance.
"The Group shall have a minimum size of 20 members to be eligible for issuance of a Group Insurance Policy," it added.

To examine the extant regulatory framework vis-a-vis the Business practices, the Insurance Regulatory and Development Authority of India had constituted an Expert Committee on in December 2014, which has submitted its report in April, 2015.
On examining the recommendations, experience gained in reviewing the regulatory framework, IRDAI has said it has proposed to revisit the existing Health Insurance Regulations, 2013 by suitably aligning the TPA Regulations as well as revisit some of the provisions.

On renewal of policies, the draft said the insurer would provide for a mechanism to condone a delay in renewal up to 30 days from the due date of renewal without deeming such condonation as a break in policy. However coverage need not be available for such period.
Further, the cost of any pre-insurance medical examination should generally form part of the expenses allowed in arriving at the premium.
"However in case of products with term of one year and less, if such cost is to be incurred by the insured, not less than 50 per cent of such cost shall be borne by the insurer once the proposal is accepted, except in travel insurance policies...," the draft said.

Insurers could also provide coverage to AYUSH treatment
provided it done at government hospital or in any institute recognised by government and/or accredited by Quality Council of India or National Accreditation Board on Health.
It has also proposed that all health insurers and Third Party Administrators (TPAs), should establish a separate channel to address the health insurance related claims and grievances of senior citizens.
The draft also said that an insurer should settle claims, including its rejection, within thirty days of the receipt of the last 'necessary' document.
Further, insurers should extend to all policy holders a cashless facility for treatment at specified establishments or the reimbursement of the costs of medical and health treatments or services availed at any medical establishment.

For the purpose of claim settlement, insurer could make direct payments to the Network provider and to the policyholders by integrating their banking system platform with the network provider or the insured.
The draft also said that if there is a change in the TPA, insurers should communicate to the policyholders 30 days before giving effect to the change.
IRDAI has invited comments on the draft till February 1.