HYDERABAD: In a double bonanza for health insurance policy holders, the Insurance Regulatory and Development Authority of India (
) announced on Thursday guidelines that will help people save on out-of-pocket healthcare expenditure.
While the insurance regulator said health insurers can no longer bracket costs associated with pharmacy and consumables, implants and medical devices as well as diagnostics under "associate medical expenses" as part of their health policies, it has also directed insurers to start including
as part of medical consultation cover in health policies after
the Medical Council of India
(MCI) issued "Tele Medicine Practice Guidelines" in March this year to enable registered medical practitioners to provide healthcare via telemedicine.
As per the modified guidelines on product filing in the health insurance business, IRDAI said insurers shall not recover any expenses towards proportionate deductions other than the defined "associate medical expenses" while processing claims. It also said that insurers are not permitted to apply proportionate deduction for "ICU charges" as different categories of ICU are not there.
IRDAI has said the provisions of these modified guidelines are applicable to new health insurance products filed on or after October 1, 2020, and all policy contracts of existing health insurance products not in compliance with these guidelines shall be modified as and when they are due for renewal from April 1, 2021 onwards.
Bhaskar Nerurkar, head, health claims,
Allianz General Insurance, said the move will reduce out-of-pocket expenses of customers and insurers will have to negotiate with their hospital networks.
Terming both moves as beneficial to customers, Shanai Ghosh, ED & CEO,
Edelweiss General Insurance
, said, "Earlier, if the customer opted for a room that was higher than entitled, there was a proportionate deduction on associated medical charges. Now, IRDAI has advised insurers to be specific about what these medical costs would entail, and that pharmacy, diagnostic, consumables and other implants would not be included under any circumstances. IRDAI has also said that there will be no deduction for ICU admission as it is a single category. For insurers, this will translate into higher claim size."
Talking about telemedicine, Ghosh said the new guidelines require and allow all insurers to cover telemedicine costs if their policy covers medical consultation which usually is covered under OPD or pre/post hospitalization.
"For instance, if the policy doesn’t have cover for OPD, then telemedicine consultation as part of pre- or post-hospitalisation may not be covered. If the policy has OPD and pre- or post-hospitalisation covered, the following situations can be covered — telemedicine consultation with a medical practitioner under OPD post-hospitalisation, follow-up consultation with the doctor offered through telemedicine, if needed by the customer," she explained.
S Prakash, managing director, Star Health and Allied Insurance, said telemedicine has emerged as a credible additional health services delivery mechanism during the Covid-19 pandemic.