IRDAI NEW REGULATIONS IN FORCE FROM 1ST.APRIL 2024

 

IRDAI made some changes in health insurance, through their recently released regulations. These come in force from 1st April 2024.

Change in definition of Pre-existing disease.

Earlier pre-existing disease was any disease, condition that was diagnosed, treated or medical advice seeked in the last 48 months. It has been changed to 36 months.This means diseases that were diagnosed and completely cured 36 months before commencement of the policy, would not have a waiting period.

IMPORTANT:

Note, this DOES NOT MEAN you do not have to declare diseases treated & cured before 36 mths. Insurers can ask for diseases cured before 36 mths too.

No specific treatment or disease will be excluded for more than 36 months. Earlier, some insurers did apply 48 months waiting period for treatments like knee replacements. These are now restricted to 36 months.

While the definition of pre-existing has been restricted to 36 months, even the maximum waiting period for pre-existing diseases has also been reduced to 36 months now.

No insurer can have a waiting period of more than 36 months for pre-existing diseases, as per standard definitions of IRDAI (explained earlier).

So, for new policies, the waiting period will now be 36 mths max. For existing policies, the waiting period will reduce to 36 mths on renewal.

Fraud vs non-disclosure is a thin line but will usually mean that insurer will have to prove that the motive of hiding the disease was ulterior and to gain from the insurer. If it is an innocent miss, insurer cannot contest after 60 months. What this means is that insurers cannot apply a waiting period for a disease cured before 36 months.

This is grey, of course, and may be cause for legal disputes, especially for large claims.

Also, we were expecting some clarity on moratorium in case of portability cases, but that is again missing. In absence of regulation, moratorium is generally understood to restart when you port from one insurer to another.

Here's the summary of changes. 

1. Pre-existing disease definition reduced from 48 to 36 mths 2. Maximum Pre-existing waiting period, reduced from 48 to 36 mths 3. Maximum waiting period on specified diseases from 48 to 36 mths. 4. Moratorium reduced from 96 mths to 60 mths.