Health Insurance claims can not contestable after 8 years of Premium payment : IRDAI

     Health Insurers will not be allowed to contest claims once the premium has been paid for a continuous period of eight years, regulator IRDAI said in a fresh set of guidelines.IRDAI said the objective of the guidelines is to standardise the general terms and clauses incorporated in indemnity based Health Insurance(Excluding Personal Accident and Domestic / overseas travel) produced by simplifying the wordings of general terms and claused of the policy contracts and ensure uniformity across the industry.

    All policy contracts of the existing Health Insurance products That are not in compliance with these guidelines shall be modified as when they are due for renewal from April 1 ,2021 onwards.

    After completion of eight continuous years under the policy no look back to be applied ..after expiry of MORATORIUM PERIOD no health insurance claim shall be contestable except for PROVEN FRAUD and PERMANENT EXCLUSION specified in the policy contract .The policies will ,however be subject to limits, sublimits, co-payments , deductibles as per the policy contract.

             " THIS PERIOD OF EIGHT YEARS IS KNOWN AS MORATORIUM PERIOD  "

    The Moratorium would be applicable for the sums insured of the policy and subsequent completion of eight continuous years would be applicable from the policy enhancement of sums insured only on the enhanced limits The regulator said in the guidelines on STANDARDIZATION OF GENERAL TERMS AND CLAUSES IN HEALTH INSURANCE POLICY CONTRACTS.    

    On Claim settlement,IRDAI said the insurance company should settle or reject a claim, as the case may be,within 30 days from the date of receipt of last necessary document.

     In the case of delay in the settlement of claim , the company will liable to pay interest to the policy holder from the date of receipt of last necessary document to the date of payment of claim at the rate of 2 per cent above the bank rate.

    It also said the policy will become void and all premium paid will be forfeited to the company in the event of misrepresentation, misdescription and non disclosure of any material facts by the policyholder.

    On Portability ,the guidelines said the insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy along with all the family members of the policy , if any at least 45 days before ,but not earlier than 60 days from the policy renewal date.

    If Such person is presently covered and has been continuously covered without any lapses under any health insurance policy within an indian General /Health insurer ,the proposed insured person will get the accrued continuity benefits in waiting periods.