Arbitrary premium hikes and claim processing delays could soon be a 
thing of past, with the Insurance Regulatory and Development Authority 
(Irda) finalising norms on health Insurance to address these issues. 
These directives, which will come into effect from October 1, are 
expected to change many practices in the health insurance space. 
Some of the guidelines, like mandatory lifetime renewal and minimum 
entry age limit of 65 years, are already in place. However, a few new 
ones like prohibiting insurers from hiking renewal premiums simply 
because of a claim made in the previous year will definitely help many 
policyholders. Claim-based loading — an industry practice where renewal 
premiums are hiked when you make claims — is often a cause of heartburn 
for policyholders. 
After October 1, insurers will not be allowed
 to load premiums arbitrarily — they will have to base it on preceding 
three years’ claims experience as also expected claims experience. The 
reasoning behind proposed pricing will have to be justified. "Loading 
will apply only when individual claims experience for three consecutive 
years is 500% of current year premium. So, the insurance company can 
apply loading only, if say, the current year premium is . 15,000 and 
claims for three consecutive years amount to over . 75,000," explains 
Mahavir Chopra, head of personal lines and e-business with health 
insurance consultancy firm medimanage. 
Also, you will be 
informed about any change in premium or renewal terms three months in 
advance. "The ’Delayed claim settlement to attract interest’ clause will
 have to be added to policy document. Also, insurers cannot reject 
claims without a proper medical reason," says activist Gaurang Damani, 
who had filed a petition in the Bombay High Court that led to Irda to 
formulating health insurance guidelines. Policyholders exasperated with 
third party administrators’ functioning can also expect some relief. 
The
 insurance company, and not the TPA, will now have to take on the 
responsibility of settling or rejecting the claim. "TPA cannot settle 
claims, but only process claim. This will have a great impact, as only 
insurance companies can settle claims now. In cases where third-party 
administrators (TPA) issued cheques for claims, often, payments used to 
get delayed. Also, it was difficult to ascertain whether the TPA had 
handed over the entire claim amount approved by the insurer to the 
policyholder," says Damani. 
This apart, the regulator has also 
sought to standardise definitions of certain terms, critical illnesses 
and exclusion among other things. "Policyholders will surely benefit due
 to the reduction in ambiguity of the various terms used by the 
different insurers leading to fewer disputes between them and the 
insurers. It also educates customers and reduces chances of their being 
taken for a ride by unscrupulous health care providers ," says Amarnath 
Ananthanarayan , CEO & MD, Bharti-AXA General Insurance.
 Standardisation of norms 
Given
 the voluminous policy documents and complicated language that 
policyholders have to deal with, it is hardly surprising that very few 
go through them. Besides, due to the ambiguity , clauses are open to 
interpretation , resulting in disputes. Therefore , Irda has come up 
with standard definitions for certain terms. "The standard definition 
has been prescribed for the 45 most common terms used in health 
insurance — such as day care treatment, hospital, inpatient care, 
pre-existing disease etc — that will help in reducing different 
interpretation by various stakeholders ," says Antony Jacob, CEO, Apollo
 Munich. 
Henceforth, all insurers will have to stick to these 
definitions in their policy documents. Irda has also defined 11 critical
 illnesses that are covered under various policies. "Defining critical 
illnesses will reduce disappointment at the claims stage on the coverage
 norms and exclusions under each critical illness. This should certainly
 avoid confusion among consumers and industry," says Ramesh Ramani, 
senior vice-president , consumer lines, Tata-AIG General. 
Common list of exclusions 
As
 one of the chief causes for disputes is exclusions, the insurance 
regulator has finalised a list of expenses the insurance companies need 
not pay for. "The standardisation will reduce the disputes between the 
customers and the industry companies with respect to what is covered 
under an insurance policy, and therefore, payable as a claim," says 
Ananthanarayan. Irda has put out a list of 199 items and has indicated 
whether they are admissible or not. "The interpretation of the excluded 
items has been different at every stage by every stakeholder . 
Standardising the interpretation will ensure clarity. Policy coverage 
hasn’t been defined and has been left to the insurers. If the insurers 
wish to include these as part of the hospitalisation expenses in their 
product design , they are free to do so," adds Ramani. 
Uniform claim forms 
Yet
 another step towards eliminating confusion, this measure could come to 
the aid of policyholders at the most critical stage — at the time of 
making claims. "Standard pre-authorisation (for cashless claims) and 
claim form will significantly streamline processes at every stage. By 
implementing it in an optical character recognition (OCR) format, the 
ability to transfer data from a handwritten paper-based form to IT 
systems has been enhanced , thus reducing data entry issues for TPAs and
 insurers. This will help in reducing the turnaround time and hence 
result in swifter claim settlements," says Jacob. 
source: ET