The Insurance Regulatory and Development Agency of India (IRDA) has a set of regulations to protect your rights as an Insured.
All Insurance Companies in India have to abide by these regulations. In case of violation of these rights , you can seek relief at the Grievance cell of the Insurance Company, the Insurance Ombudsman, the Grievance cell of the IRDA Consumer Affairs Department and the Consumer Courts , preferably in that order.
You need to go to the Civil Courts or the Criminal Courts only in exceptional cases. The host of IRDA regulations are available in their website. However, it is intimidating to trudge through all of the regulations to find the correct ones for you.
Here are the regulations which are relevant for Health Insurance (MEDICLAIM) .
- IRDA Policy Holders Protection of Interest Regulation 2002
This is the basic regulation which spells out rights and obligations of the Insured and Insurance Company. For example your obligation as an Insured is to fill the proposal form, give out the correct information i.e age, previous disease conditions, other insurance policies etc, pay the premium and follow the claims procedure.
The Insurance companies obligation is to Issue the policy, clearly mention the sum insured, clearly mention the medical conditions which are covered and those which are excluded, clearly specify the claims process and so on.
There are a host of similar other issues, sometimes in fine print which come up only when there is a claim. It is important to be aware.
Here is the complete IRDA PHPI 2002 regulation as a download
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IRDA Health Insurance Regulations 2016
This is the basic regulation guiding all aspects of a Health Insurance ( Mediclaim ) in India. This has a lot of operational details for the Insurance Company on how to handle a health policy. For the Insured it spells out the rights and obligations.
For example one of your obligations as an Insured is to inform the Insurance Company or its Third Party Agents (TPA) anytime between 48 – 72 hours before admission to a hospital ( not in case of emergency admission ).
However, this regulation spells out a relief too – in case you cannot intimate the Insurance Company in time , you can intimate the Insurance Company later but you have to give a valid reason.
For example a patient of cataract can plead that before surgery he could not see well and therefore had to wait till after his cataract surgery to inform the Insurance Company.
Here is the complete IRDA Health Insurance Regulation 2016 as a a download
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IRDA TPA Regulations 2016
Insurance Companies are allowed by the IRDA to employ agents to do their job of collecting claim documents from you and having a tie up with your hospital to give you a “ cashless” facility if your policy allows it.
These agents are called Third party Agents (TPA). This regulation again has a lot of operational details about the TPAs but spells out clearly , how they should be going about dealing with MEDICLAIM.
For example , the TPA should have a 24 hours set up to handle Insurance Claims. Even in weekends their call center is supposed to be working to help in in case you have an emergency.
Here is the complete IRDA TPA Regulation 2016 as a download
INSURE YOURSELF ADEQUETELY AND HAVE A BASIC IDEA
ABOUT YOUR RIGHTS AND OBLIGATIONS