The Insurance Regulatory and Development Authority of India in its Circular dated 11th June 2020 has modified guidelines on health insurance product filing norms on proportionate deductions. The provisions of these guidelines shall be applicable to the health Insurance products filed as per Guidelines on Product Filing in Health Insurance Business on or after 01st October, 2020. All policy contracts of the existing health insurance products that are not in compliance with these guidelines shall be modified as and when they are due for renewal from 01st April, 2021 onwards.
As per the modified guidelines, cost associated with pharmacy & consumables, implants & medical devices, as well as diagnostics, shall no longer be a part of associate medical expenses. Insurers shall not recover any expenses towards proportionate deductions other than the defined ‘associate medical expenses’ while processing claims.
Further insurers are not permitted to apply proportionate deduction for ‘ICU charges’ as different categories of ICU are not there. Insurers shall ensure that proportionate deductions are not applied in respect of the hospitals which do not follow differential billing or for those expenses in respect of which differential billing is not adopted based on the room category. This shall be clearly specified in the policy terms and conditions.
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