Executive Summary:
This document contains the Insurance Regulatory and Development Authority's (IRDA) first amendment regulations for health insurance in 2014. It addresses free look periods, cumulative bonuses, AYUSH coverage, and the Chairperson's power to issue clarifications. These regulations take effect from the date of publication in the Official Gazette of the Government of India, November 24, 2014.
Key Points / Main Content:
* **Short Title and Commencement:**
* These regulations are called the "Insurance Regulatory and Development Authority Health Insurance First Amendment Regulations, 2014."
* They come into force from the date of their publication in the Official Gazette of the Government of India.
* **General Provisions relating to Health Policies:**
* **Free Look Period:**
* All new individual health insurance policies (except those with a tenure of less than a year) must have a free look period of at least 15 days from the date of policy receipt.
* If no claims are made during this period, the insured is entitled to a refund of premium (less expenses for medical exams and stamp duty) or a deduction towards proportionate risk premium or the repurchase unit price.
* **Cumulative Bonus:**
* Cumulative bonus may not be allowed on benefit-based policies, with the exception of personal accident cover.
* **AYUSH Coverage:**
* Insurers may provide coverage for non-allopathic treatments in government hospitals or institutes recognized/accredited by the government and/or Quality Council of India/National Accreditation Board on Health.
* **Miscellaneous Provisions:**
* **Power of Chairperson to issue clarification etc.:**
* The Chairperson of the Authority may issue clarifications, directions, and guidelines in the form of circulars to resolve difficulties in the application or interpretation of these regulations.
Impact Analysis:
* **Insurers:**
* Impact: Must comply with new regulations regarding free look periods, cumulative bonuses, and AYUSH coverage.
* Action Required: Update policies and procedures to reflect the amended regulations.
* **Policyholders:**
* Impact: Benefit from the enhanced free look period provisions and potential coverage for AYUSH treatments.
* Action Required: Review policy terms and conditions to understand their rights and options under the new regulations.
* **Insurance Regulatory and Development Authority (IRDA):**
* Impact: Responsible for overseeing the implementation and enforcement of the amended regulations.
* Action Required: Monitor insurer compliance and provide clarifications and guidance as needed.
Key Entities Referenced
Insurance Regulatory and Development Authority: Regulatory body that oversees and regulates the insurance industry in India.
Insurance Act 1938: An act of the Indian parliament relating to the insurance business
IRDA Act 1999: Act establishing the Insurance Regulatory and Development Authority of India.
Insurance Advisory Committee: A committee consulted by the Insurance Regulatory and Development Authority.
Health Insurance First Amendment Regulations, 2014: Regulations amending existing health insurance regulations.
Government of India: The governing authority of the Republic of India.
Hyderabad, Telangana: City in Telangana, where the notification was issued from.
T. S. Vijayan: Chairman of the Insurance Regulatory and Development Authority.
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EXTRAORDINARY
Hkkx III—[k.M 4
PART III—Section 4
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PUBLISHED BY AUTHORITY
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No. 341] NEW DELHI, MONDAY, NOVEMBER 24, 2014/AGRAHAYANA 3, 1936
बबबबीीीीममममाााा ििििववववििििननननययययााााममममकककक औऔऔऔरररर ििििववववककककाााासससस (cid:1)(cid:1)(cid:1)(cid:1)ााााििििधधधधककककररररणणणण
अअअअििििधधधधससससचचूूचचूू ननननाााा
हदै राबाद, 19 नवंबर, 2014
बबबबीीीीममममाााा ििििववववििििननननययययााााममममकककक औऔऔऔरररर ििििववववककककाााासससस (cid:1)(cid:1)(cid:1)(cid:1)ााााििििधधधधककककररररणणणण (((((cid:8)(cid:8)(cid:8)(cid:8)ववववाााा(cid:8)(cid:8)(cid:8)(cid:8)(cid:10)(cid:10)(cid:10)(cid:10)यययय बबबबीीीीममममाााा)))) ((((पपपपहहहहललललाााा ससससशशंंशशंं ोोोोधधधधनननन)))) ििििववववििििननननययययमममम,,,, 2222000011114444
फफफफाााा.... सससस..ंं..ंं बबबबीीीी....ििििवववव....ििििवववव....(cid:1)(cid:1)(cid:1)(cid:1)ाााा....////ििििववववििििननननययययमममम////7777////99990000////2222000011114444.—बीमा अिधिनयम, 1938 क(cid:2) धारा 114ए तथा बीमा िविनयामक
और िवकास (cid:3)ािधकरण अिधिनयम, 1999 क(cid:2) धारा 26 के साथ प(cid:10)ठत धारा 14 के अधीन (cid:3)द(cid:14) शि(cid:16)य(cid:18) का (cid:3)योग करत े (cid:21)ए
तथा बीमा सलाहकार सिमित के साथ परामश (cid:24)करन े के बाद (cid:3)ािधकरण िन(cid:26)िलिखत िविनयम बनाता ह,ै अथा(cid:24)त ्:—
1111.... ससससंिंिंिंि(cid:14)(cid:14)(cid:14)(cid:14)(cid:15)(cid:15)(cid:15)(cid:15) ननननाााामममम औऔऔऔरररर (cid:1)(cid:1)(cid:1)(cid:1)ााााररररंंंंभभभभ—
a. ये िविनयम बीमा िविनयामक और िवकास (cid:3)ािधकरण ( वा "य बीमा)(पहला संशोधन) िविनयम, 2014
कहलाएँगे।
b. य े िविनयम भारत सरकार के सरकारी राजप$ म %इनके (cid:3)काशन क(cid:2) तारीख से (cid:3)वृ(cid:14) ह(cid:18)गे।
2222.... (cid:8)(cid:8)(cid:8)(cid:8)ववववाााा(cid:8)(cid:8)(cid:8)(cid:8)(cid:10)(cid:10)(cid:10)(cid:10)यययय पपपपॉॉॉॉििििललललििििससससयययय(cid:20)(cid:20)(cid:20)(cid:20) सससस ेे ेे ससससंबंबंबंबििंंििंं धधधधतततत ससससााााममममाााा(cid:22)(cid:22)(cid:22)(cid:22)यययय उउउउपपपपबबबबधधंंधधंं :::: बीमा िविनयामक और िवकास (cid:3)ािधकरण ( वा "य बीमा)
िविनयम, 2013 म,%
ििििववववििििननननययययमममम 5555((((gggg)))) ककककोोोो ििििनननन(cid:24)(cid:24)(cid:24)(cid:24)नन नन ििििललललििििखखखखतततत सससस ेे ेे(cid:1)(cid:1)(cid:1)(cid:1)िििितततत(cid:8)(cid:8)(cid:8)(cid:8)थथथथााााििििपपपपतततत (cid:28)(cid:28)(cid:28)(cid:28)ककककययययाााा जजजजाााातततताााा हहहह ैै ैै::::
(cid:29)(cid:29)(cid:29)(cid:29)(cid:30)(cid:30)(cid:30)(cid:30) ललललककुुककुु अअअअववववििििधधधध
"एक वष (cid:24) से कम अविध वाली पॉिलिसय(cid:18) को छोड़कर सभी नई वैयि(cid:16)क वा "य बीमा पॉिलिसय(cid:18) क(cid:2) एक .(cid:2) लुक
अविध होगी। यह .(cid:2) लुक अविध पॉिलसी के (cid:3)ारंभ से लाग ू होगी तथा:
4628 GI/2014 (1)2 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III—SEC. 4]
1. बीमाकृत 1ि(cid:16) के िलए पॉिलसी क(cid:2) शत2 का पुनरी5ण करन े और य6द वे वीकाय(cid:24) न ह(cid:18) तो पॉिलसी को लौटाने
के िलए पॉिलसी (cid:3)ा7 करन ेक(cid:2) तारीख से कम से कम 15 6दन क(cid:2) अविध क(cid:2) अनुमित दी जाएगी।
2. य6द बीमाकृत 1ि(cid:16) न े उपयु(cid:24)(cid:16) .(cid:2) लुक अविध के दौरान कोई दावा नह9 6कया ह,ै तो बीमाकृत 1ि(cid:16)
िन: निलिखत के िलए हकदार होगा—
(a) बीमाकृत 1ि(cid:16)य(cid:18) क(cid:2) डॉ=टरी जाँच के संबंध म % बीमाकता(cid:24) @ारा 6कय े गय े 6कसी भी 1य और मुAांक
शुBक (cid:3)भार को घटाकर (cid:3)द(cid:14) (cid:3)ीिमयम क(cid:2) वापसी अथवा;
(b) जहाँ जोिखम (cid:3)ारंभ हो चुका ह ै और पॉिलसीधारक @ारा पॉिलसी को वापस करन े के िवकBप का (cid:3)योग
6कया गया ह,ै वहाँ र5ा संबंधी अविध के िलए आनुपाितक जोिखम (cid:3)ीिमयम हते ु कटौती अथवा;
(c) जहाँ केवल जोिखम का एक भाग (cid:3)ारंभ (cid:21)आ है, वहाँ ऐसा आनुपाितक जोिखम (cid:3)ीिमयम जो ऐसी अविध
के दौरान र5ा (cid:3)ा7 जोिखम के अनुDप हो।
(d) यूिनट-सहबE पॉिलसी के संबंध म % उपयु(cid:24)(cid:16) कटौितय(cid:18) के अित(cid:10)र(cid:16), ब9माकता(cid:24) पॉिलसी क(cid:2) वापसी क(cid:2)
तारीख को िवGमान ि थित के अनुसार यूिनट(cid:18) के मूBय पर यूिनट क(cid:2) 6फर से खरीद करने के िलए भी
हकदार होगा।
ििििववववििििननननययययमममम 5555((((iiii))))((((iiiiiiiiiiii)))) ककककोोोो ििििनननन(cid:24)(cid:24)(cid:24)(cid:24)नन नन ििििललललििििखखखखतततत सससस ेे ेे(cid:1)(cid:1)(cid:1)(cid:1)िििितततत(cid:8)(cid:8)(cid:8)(cid:8)थथथथााााििििपपपपतततत (cid:28)(cid:28)(cid:28)(cid:28)ककककययययाााा जजजजाााातततताााा हहहह ैै ैै
ससससचचंंचचंं ययययीीीी बबबबोोोोननननसससस
"वैयि(cid:16)क दघु (cid:24)टना र5ा के अपवाद को छोड़कर लाभ आधा(cid:10)रत पॉिलिसय(cid:18) पर संचयी
बोनस क(cid:2) अनुमंित नह9 दी जाए"
ििििववववििििननननययययमममम 5555((((llll))))((((iiii)))) ककककोोोो ििििनननन(cid:24)(cid:24)(cid:24)(cid:24)नन नन ििििललललििििखखखखतततत सससस ेे ेे(cid:1)(cid:1)(cid:1)(cid:1)िििितततत(cid:8)(cid:8)(cid:8)(cid:8)थथथथााााििििपपपपतततत (cid:28)(cid:28)(cid:28)(cid:28)ककककययययाााा जजजजाााातततताााा हहहह ैै ैै
आआआआययययषषुुषषुु ससससररुुररुु (cid:14)(cid:14)(cid:14)(cid:14)ाााा ::::
"बीमाकता (cid:24) गैर-एलोपथै ी िच6कLसाM के िलए सुर5ा (cid:3)दान कर सकते ह N बशत O 6क िच6कLसा 6कसी सरकारी अ पताल म %
अथवा सरकार @ारा माPयता(cid:3)ा7 और/या भारतीय गुणव(cid:14)ा प(cid:10)रषद/ वा "य संबंधी राQीय (cid:3)ािधकरण बोड (cid:24) @ारा
(cid:3)ािधकृत 6कसी सं थान म %(cid:3)ा7 क(cid:2) गई हो।"
3333.... ििििववववििििववववधधधध उउउउपपपपबबबबधधंंधधंं ::::
एक नया िविनयम 19 िन: नानुसार सि:मिलत 6कया जाता ह ै
""""ििििववववििििननननययययमममम 11119999 :::: (cid:8)(cid:8)(cid:8)(cid:8)पपपप ीीीीककककररररणणणण आआआआ(cid:28)(cid:28)(cid:28)(cid:28)दददद जजजजााााररररीीीी ककककररररनननन ेे ेे ककककेेेे ििििललललएएएए अअअअ%%%%यययय(cid:14)(cid:14)(cid:14)(cid:14) ककककाााा अअअअििििधधधधककककााााररररःःःः इन िविनयम(cid:18) को लाग ू करन े अथवा इनका
अथ (cid:24) लगान े म % 6कसी भी क(cid:10)ठनाई को दरू करने के िलए (cid:3)ािधकरण का अSय5 प(cid:10)रप$(cid:18) के Dप म % पTीकरण, िनदेश और
6दशािनदOश जारी कर सकता ह।ै """"
टी. एस. िवजयन, अSय5
[िवUापन III/4/161/14/असा.]¹Hkkx IIIµ[k.M 4º Hkkjr dk jkti=k % vlk/kj.k 3
INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY
NOTIFICATION
Hyderabad, the 19th November, 2014
INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY (HEALTH INSURANCE)
(FIRST AMENDMENT) REGULATIONS, 2014
F. No. IRDA/Reg/7/90/2014.—In exercise of the powers conferred under Section 114A of the
Insurance Act 1938 and Section 14 read with section 26 of the IRDA Act 1999 and in consultation with the
Insurance Advisory Committee, the Authority hereby makes the following regulations, namely:-
1. Short title and commencement.
a. These Regulations may be called Insurance Regulatory and Development Authority (Health
Insurance) (First Amendment) Regulations, 2014
b. They shall come into force from the date of their publication in the Official Gazette of the
Government of India.
2. General Provisions relating to Health Policies: In the Insurance Regulatory and Development
Authority (Health Insurance) Regulations, 2013,
Reg 5 (g) is substituted by the following:
Free Look Period
“All new individual health insurance policies except those with tenure of less than a year shall
have a free look period. The free look period shall be applicable at the inception of the policy
and:
1. The insured will be allowed a period of at least 15 days from the date of receipt of the
policy to review the terms and conditions of the policy and to return the same if not
acceptable
2. If the insured has not made any claim during the free look period, the insured shall be
entitled to-
a. A refund of the premium paid less any expenses incurred by the insurer on medical
examination of the insured persons and the stamp duty charges or;
b. where the risk has already commenced and the option of return of the policy is
exercised by the policyholder, a deduction towards the proportionate risk premium
for period on cover or;
c. Where only a part of the risk has commenced, such proportionate risk premium
commensurate with the risk covered during such period.
d. In respect of unit linked policy, in addition to the above deductions, the insurer shall
also be entitled to repurchase the unit at the price of the units as on the date of the
return of the policy.
Reg 5 (i)(iii) is substituted by the following
Cumulative bonus
“Cumulative bonus may not be allowed on benefit based policies with the exception of
Personal Accident cover”4 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III—SEC. 4]
Reg 5 (l)(i) is substituted by the following
AYUSH Coverage:
“Insurers may provide coverage to non-allopathic treatments provided the treatment has been
undergone in a government hospital or in any institute recognized by government and/or
accredited by Quality Council of India/National Accreditation Board on Health”.
3. Miscellaneous Provisions:
A new regulation 19 is inserted as under
“Reg. 19: Power of Chairperson to issue clarification etc.: In order to remove any difficulties
in the application or interpretation of these regulations, the Chairperson of the Authority may
issue clarifications, directions and guidelines in the form of circulars.”
T. S. VIJAYAN, Chairman
[ADVT. III/4/161/14/Exty.]
Printed by the Manager, Government of India Press, Ring Road, Mayapuri, New Delhi-110064
and Published by the Controller of Publications, Delhi-110054.