Insurance regulator IRDAI on Friday came out with new rules which will have widespread ramifications for health insurers and the general public. Insurers henceforth cannot decline coverage to people who have used opioids or anti-depressants. Nor can they exclude those with a history of clinical depression, personality disorders, sociopathy, psychopathy, or neurodegenerative disorders.
They cannot exclude children affected by development disorders like Down’s syndrome, brain disease, and autism, or those suffering from a learning disorder, stuttering and different disorders of speech and language. Batting for the LGBTQ community, IRDAI has same that insurers cannot discriminate on the premise of gender and identity. Insurers cannot refuse to provide coverage or reject claims if an individual is on life support. Insurers can reject claims on condition that the patient is certified as being in a very vegetative state, however, even then insurers are required to provide coverage/pay expenses until that date.
For young women and older women that suffer from excessive bleeding, hormonal changes because of the onset of puberty or menopause, insurers can not exclude coverage or payment for treatment prices. Insurers cannot deny coverage to geriatric patients, affected by age-related macular degeneration (ARMD) and people suffering from rare or orphan diseases.
Insurers will have to cover adventure sports like dirt biking, paragliding, whitewater rafting, go-karting, F1 racing, and ethnic sports like jallikattu and kambala. this would be a relief to sports enthusiasts, clubs and adventure trip organisers.
Another vital decision is that at the point of claims if the person is discovered to be a smoker or affected by a disease/pre-existing condition, the insurance firm cannot reject the claim if he/she has been availing of insurance for eight years in continuity.
IRDAI has said that insurers cannot exclude coverage or reject claims if the policyholder has “failed to seek or follow the medical recommendation or follow treatment”. often patients undergoing treatment for a condition stop the treatment towards the final stages or stop taking drugs midway. Insurers are known to penalize patients for failure to follow through on a prescribed regime.