IRDAI draft to simplify the health policy claims

IRDAI has prepared a draft to make the health policy claims easier. It aims to make the associated costs with room rent uniform to minimize confusion. This is part of Irdai’s larger focus on standardization of terms and conditions in health insurance contracts.

Currently, the total bill of hospital varies depending on the category of room picked by the policyholder. “If the sub-limit on room in a policy only allows for a twin sharing room, and the policyholder goes for a deluxe room, then insurer deducts not only the difference in the room rent but also the associated medical expenses. This has always been an area of concern and a cause for disputes because there are no clear guidelines,” said Shreeraj Deshpande, chief operating officer, Future Generali India Insurance.

In its draft, IRDAI stated that if a policy holder gets a room which exceeds the sub-limit on rooms, the proportionate deduction on “associated medical expenses” cannot include cost of medication, implants and medical devices, and diagnostics. “Hospitals cannot charge for medicines differentially for two different categories of rooms because the maximum retail price is fixed. Diagnostics, which includes scans and doctor’s fees, is where there has always been differential pricing. But Irdai is now saying that diagnostics cannot qualify as an “associated medical expense”, and therefore cannot be proced differently either,” said Mahavir Chopra, a health insurance expert.

“The regulator is trying to establish a fixed definition for ‘associated medical expenses’ to make health insurance simpler and transparent in nature,” said Deshpande.

The draft is open till 2nd April for feedback.