IRDAI Insurance Rules 2025 | Waiting Period, Surrender Charges, Hospitalisation & More

In recent development, the IRDAI has revised the health insurance regulation to have a wider scope under the policyholder protection. They range from waiting periods to eliminate policies that use senior citizens as rating factors and enhancing coverage of those with severe pre-existing conditions. Below is a brief discussion about the existing 2024 IRDAI's new guidelines for insurance and their implications for the health insurance industry in India.

Latest IRDAI Rules And Health Insurance Guidelines In 2024.

The introduction of IRDAI's new guidelines for life insurance has improved access to health insurance. Here is the list of 10 rules which are newly introduced under the Health Insurance Guidelines in 2024:-

1. Specific Health Insurance Plans for Either Gender, for Any Age provisions.

• Update: Health insurance no longer has any entry age requirement.

• Impact: This situation is good for senior citizens because they were once restricted by their ages through policy-providing insurers.

2. Decreased time to diagnosis for Pre-existing Diseases (PED).

• Update: PED cover period lowered from 4 years to 3 years waiting periods.

• Impact: Treatment expenses of standard ailments such as diabetes or hypertension can be claimed after, at the most, 3 years, thus increasing the availability of treatment.

3. Shortened Wait Time for Certain Afflictions.

• Update: The proposed maximum wait time for particular diseases or procedures, including joint replacements, has been lowered to three years.

• Impact: Those who need such procedures can now file their claims three years later.

4. Policies For Providing Inclusive Care for Serious Illness.

• Update: They cannot be denied policies due to severe pre-existing conditions such as heart disease, cancer, renal failure or AIDS.

• Impact: This makes it easier to address the gaps in the enrollment of the population in health insurance programmes, thus increasing population coverage.

5. There will be no sub-limits on AYUSH treatment.

• Update: Corresponding coverage limits on treatments under AYUSH (Ayurveda, Yoga, Naturopathy, Siddha, Unani, Homoeopathy) eliminated.

• Impact: The reimbursement available for AYUSH treatment is up to the sum insured amount.

Read more: Ayushman Card

6. Specific Programmes for Particular Target Population.

• Update: The Insurance Regulatory Development Authority of India (IRDAI) compels insurers to develop products that appeal especially to senior citizens, children, maternity, and students.

• Impact: Specific groups can be able to choose those plans that are sensitive to their individual requirements.

7. Captive Service Protection to the Elderly.

• Update: Insurance companies have to open channels through which senior citizens can easily access the necessary help.

• Impact: This is achieved to enhance the quick handling of claim resolution and complaints regarding the elderly policyholders.

8. Shortened Moratorium Period.

• Update: These changes have been made, where the moratorium period has been slashed from 8 years to 5 years.

• Impact: The authors also explain that after 5 years of constant coverage, insurers can refuse to cover claims related to pre-existing diseases only in the case of fraud.

9. The Indemnity-Based Policies Ban.

• Update: Insurers are now able to issue only the benefit-based policies which pay a specific amount of money when the policyholder has been diagnosed of having the specific ailment.

• Impact: They get a predetermined amount upon diagnosis, thereby making all policies easy to claim.

10. Multiple Claims Allowed With Various Insurers.

• Update: Benefit-based policies allow policyholders to pursue claims with claim administrators of more than one insurer.

• Impact: This makes it easier and offers an opportunity to handle health care costs more effectively.

Read more: eShram Card

Health Insurance Claim Process

The health insurance claim process allows policyholders to recover medical expenses from their insurer. Claims can be settled either through a cashless process at network hospitals or by reimbursement.

Types Of Health Insurance Claims:

• Cashless Claims: A network hospital is an ideal place where insured people can benefit without incurring hefty costs upfront, as the insurer clears the bills.

• Reimbursement Claims: Beneficiaries contribute towards the cost of treatment and later present bills to the insurer for claims. It can be accessed at the network and non-network hospitals.

Claim Health Insurance:

To claim health insurance benefits, policyholders must notify their insurer, follow the required steps, and submit the necessary documents as per their claim type. Below is the step-by-step guide to claim the Health Insurance under IRDAI's new guidelines for insurance:

Step 1: Go to a network hospital and call the insurance helpdesk.

Step 2: A simple way is to ask the bearer to show their health card as a measure of identity.

Step 3: Fill in and submit a pre-authorisation form for cashless treatment.

Step 4: The insurer then assesses and concludes the claim, while any such necessary expenses are to be incurred by the insured.

Step 5: Under the terms of the policy, the insurance provider pays the hospital a direct amount.

Read more: Aadhaar Card

Steps For The Health Insurance Claim Settlement Process:

The steps for settling a health insurance claim vary for cashless and reimbursement claims, involving notifications, documentation, and approval by the insurer. To do so, follow the below mentioned steps below:-

Step 1: Inform your insurance provider about the hospitalisation.

Step 2: Find out all the hospital expenses after being discharged, and also clear them.

Step 3: In the absence of any health issues, submit your insurance company’s necessary documents to get a refund.

Step 4: In case of the approval of the claim, the insurer recompenses the sum that has been stated.

Documents Needed

Essential documents for a claim include the health card, hospital bills, medical reports, prescriptions, and a filled-in claim form. To file a claim, submit the following:

• Health Insurance Card.

• Doctor’s consultation papers.

• Completed claim form.

• Patient's history (for example, X-ray, CT scan).

• Hospital bills and receipts.

• Usually, it requires a Medico Legal Certificate (MLC) or FIR if the incident is an accident.

• Prescriptions are issued by the issuing pharmacy.

• Discharge summary.

Types Of Hospitalisation Which Can Be Claimed

Policyholders can claim for both planned hospitalisations, like scheduled treatments, and emergency hospitalisations, such as sudden accidents.

• Planned Hospitalisation: This should, however, be booked IN ADVANCE, giving the insurer a minimum of 48 hours TOPS before the scheduled treatment.

• Emergency Hospitalisation: Inform the insurer immediately, within one day of admission to the hospital for any emergent reason, such as an accident.

Read more: Jeevan Pramaan Certificate

Check The Status Of Your Health Insurance Claim

You can either call the claim support centre or visit the insurance provider’s website to track your health insurance claim status.