Modification Guidelines on Standardization in Health Insurance

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• ~I~ ~mftq .ftil, r.ifilq111ifi ~-~ ec>>ti INSURANCE REGULATORY AND ir.iai DEVELOPMENT AUTHORITY OF INDIA Ref: IRDAI/HL T/REG/CIR/ \Jf1 09/2019 2?'h September, 2019 To All Insurers and TPAs, wherever applicable, Re: Modification Guidelines on Standardization in Health Insurance: 1. Reference is invited to Clause 33 of Chapter - I of Guidelines on Standardization in Health Insurance Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29th July, 2016 where pre-existing disease is defined. The definition of Pre-existing Disease stands modified as under and the following definition is substituted at Clause 33 of the within referred Guidelines: Pre-Existing Disease (not applicable for Overseas Travel Insurance): Pre-existing Disease means any condition, ailment, injury or disease: a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or b) For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement. c) A condition for which any symptoms and or signs if presented and have resulted within three months of the issuance of the policy in a diagnostic illness or medical condition. (Life Insurers may define norms for applicability of PED at Reinstatement) 2. Reference is invited to Chapter - Ill of Guidelines on Standardization in Health Insurance Ref: IRDA/HLT/REG/CIR/146/07/2016 dated 29th July, 2016 where items for which optional cover may be offered by insurers are specified in Annexure - I. In substitution of the items specified in the within referred Guidelines, the revised items are specified in Annexure - I of these modified Guidelines. 3. The provisions of these Guidelines shall be applicable in respect of all health insurance products (both Individual and Group) filed on or after 1st October 2019. All existing health insurance products that are not in compliance with these Guidelines shall not be offered and promoted from 01 st October, 2020 onwards. 4. This has the approval of the competent authority. (DVS Ramesh) General Manager (Health) Page 1 of 7 ~ 'f. 115/1, ~ ~ . .:i1-1ifil ll-l<jsl, ~-500 032, 'IW('f Survey No. 115/1, Financial District, Nanakramguda, Hyderabad-500 032, India Q) : +91-40-2020 4000.~ : +91-40-2020 4555 Q) : +91-40-2020 4000, Fax : +91-40-2020 4555 mm : www.irdai.gov.in Website : www.irdai.gov.in Annexure - I Items for which optional cover may be offered by Insurers 1. Reference is invited to Chapter 111 of Guidelines on Standardization in Health Insurance vide Circular Ref: IRDA/HL T/REG/CIR/146/07/2016 dated 29th July, 2016 where items for which optional cover may be offered by Insurers were specified. On a review of the list of items it is decided to classify the existing 'Optional Items' into the following categories. i. LIST - I :: Items that may be retained 'as it is' as optional items - Items specified in the list are the Optional Items to which Insurers may offer coverage. ii. LIST - II :: Costs that are to be subsumed into the Room Charges - Items specified in the list shall form part of room charges iii. LIST - Ill:: Costs that are to be subsumed into the specific (say surgical) procedure charges - Items specified in the list shall be considered as part of procedure charges. Iv. LIST - IV:: Costs that are to be subsumed into the costs of treatment - Items specified in the list shall be considered as part of costs of treatment. 2. Where the costs are to be subsumed into the room charges specified in List - II or procedure charges specified in List Ill or costs of treatment (including costs of diagnostics) specified in List IV all claims shall be settled in accordance to the terms and conditions of the policy contract. Insurers shall put in place measures to ensure that items which are part of room / surgical procedure / treatment (including diagnostics) as referred in the lists herein shall not be billed to the policyholders by the hospitals and every insurer shall inform or notify the same to the hospitals and the policyholders suitably. Accordingly, all insurers are advised to make it part of their service level agreement with the network providers (hospitals) in case of cashless cases. In case of reimbursements (with other than network providers) Insurers shall settle the claims as per the terms and conditions of the policy contract. List I - Optional Items SI Item No 1 BABY FOOD 2 BABY UTILITIES CHARGES 3 BEAUTY SERVICES 4 BELTS/ BRACES 5 BUDS 6 COLD PACK/HOT PACK 7 CARRY BAGS 8 EMAIL/ INTERNET CHARGES 9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL) Page 2 of 7 10 LEGGINGS 11 LAUNDRY CHARGES 12 MINERAL WATER 13 SANITARY PAD 14 TELEPHONE CHARGES 15 GUEST SERVICES 16 CREPE BANDAGE 17 DIAPER OF ANY TYPE 18 EYELET COLLAR 19 SLINGS 20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES 21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED 22 Television Charges 23 SURCHARGES 24 ATTENDANT CHARGES 25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED CHARGE) 26 BIRTH CERTIFICATE 27 CERTIFICATE CHARGES 28 COURIER CHARGES 29 CONVEYANCE CHARGES 30 MEDICAL CERTIFICATE 31 MEDICAL RECORDS 32 PHOTOCOPIES CHARGES 33 MORTUARY CHARGES 34 WALKING AIDS CHARGES 35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL) 36 SPACER 37 SPIROMETRE 38 NEBULIZER KIT 39 STEAM INHALER 40 ARMSLING 41 THERMOMETER 42 CERVICAL COLLAR 43 SPLINT 44 DIABETIC FOOT WEAR 45 KNEE BRACES (LONG/ SHORT/ HINGED) 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER 47 LUM BO SACRAL BELT Page 3 of 7 48 NIMBUS BED OR WATER OR AIR BED CHARGES 49 AMBULANCE COLLAR 50 AMBULANCE EQUIPMENT 51 ABDOMINAL BINDER 52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES 53 SUGAR FREE Tablets 54 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals payable) 55 ECG ELECTRODES 56 GLOVES 57 NEBULISATION KIT 58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC] 59 KIDNEY TRAY 60 MASK 61 OUNCE GLASS 62 OXYGEN MASK 63 PEL VIC TRACTION BELT 64 PAN CAN 65 TROLL Y COVER 66 UROMETER, URINE JUG 67 AMBULANCE 68 VASOFIX SAFETY List II - Items that are to be subsumed into Room Charges SI Item No 1 BABY CHARGES (UNLESS SPECIFIED/INDICATED) 2 HAND WASH 3 SHOE COVER 4 CAPS 5 CRADLE CHARGES 6 COMB 7 EAU-DE-COLOGNE/ ROOM FRESHNERS 8 FOOT COVER 9 GOWN 10 SLIPPERS Page 4 of 7 11 TISSUE PAPER 12 TOOTH PASTE 13 TOOTH BRUSH 14 BED PAN 15 FACE MASK 16 FLEX! MASK 17 HAND HOLDER 18 SPUTUM CUP 19 DISINFECTANT LOTIONS 20 LUXURY TAX 21 HVAC 22 HOUSE KEEPING CHARGES 23 AIR CONDITIONER CHARGES 24 IM IV INJECTION CHARGES 25 CLEAN SHEET 26 BLANKET/WARMER BLANKET 27 ADMISSION KIT 28 DIABETIC CHART CHARGES 29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES 30 DISCHARGE PROCEDURE CHARGES 31 DAILY CHART CHARGES 32 ENTRANCE PASS / VISITORS PASS CHARGES 33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE 34 FILE OPENING CHARGES 35 INCIDENTAL EXPENSES/ MISC. CHARGES (NOT EXPLAINED) 36 PATIENT IDENTIFICATION BAND / NAME TAG 37 PULSEOXYMETER CHARGES List Ill - Items that are to be subsumed into Procedure Charges SI Item No. 1 HAIR REMOVAL CREAM 2 DISPOSABLES RAZORS CHARGES (for site preparations) 3 EYE PAD 4 EYE SHEILD 5 CAMERA COVER 6 DVD, CD CHARGES Page 5 of 7 7 GAUSE SOFT 8 GAUZE 9 WARD AND THEATRE BOOKING CHARGES 10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 11 MICROSCOPE COVER 12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER 13 SURGICAL DRILL 14 EYE KIT 15 EYE DRAPE 16 X-RAY FILM 17 BOYLES APPARATUS CHARGES 18 COTTON 19 COTTON BANDAGE 20 SURGICAL TAPE 21 APRON 22 TORNIQUET 23 ORTHOBUNDLE, GYNAEC BUNDLE List IV - Items that are to be subsumed into costs of treatment SI Item No. 1 ADMISSION/REGISTRATION CHARGES 2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE 3 URINE CONTAINER 4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES 5 BIPAP MACHINE 6 CPAP/ CAPO EQUIPMENTS 7 INFUSION PUMP- COST 8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC 9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET CHARGES- 10 HIV KIT 11 ANTISEPTIC MOUTHWASH 12 LOZENGES Page 6 of 7 13 MOUTH PAINT 14 VACCINATION CHARGES 15 ALCOHOL SWABES 16 SCRUB SOLUTIONISTERILLIUM 17 Glucometer & Strips 18 URINE BAG Page 7 of 7