Health insurance firms must now offer cover for mental illness, adventure sports mishaps

The insurance regulator has introduced new rules in an attempt to standardise exclusions in health insurance products in a fast proliferating market. For instance, insurers now can't deny coverage to genetic diseases, psychological and neurodevelopmental disorders, menopause-related disorders and adventure sports

By BusinessToday.In  
Monday, May 20, 2019

The Insurance Regulatory and Development Authority of India (IRDAI) has introduced new rules in an attempt to standardise exclusions in health insurance products in a fast proliferating market. The regulator had previously constituted a working group to look into this and had been mulling proposals to bar insurers from excluding several critical illnesses such as mental problems, genetic diseases, psychological and neurodevelopmental disorders from health policies.

As per the new rules issued on Friday, insurers can neither decline coverage to those who have used opioids or anti-depressants any longer, nor exclude those with a history of clinical depression, personality or neurodegenerative disorders, sociopathy and psychopathy, The Times of India reported. Puberty and menopause-related disorders and age-related macular problems, too, cannot be denied cover.

Moreover, insurers can no longer exclude coverage or payment for treatment costs for children suffering from development disorders, ranging from speech disorders to Down's syndrome, cerebral palsy, autism and dyslexia. This is a significant development given that nearly 1 in 8 children in India suffers from a neurodevelopmental condition, according to a 2018 study by INCLEN Trust International.

Another decision which will have wide ramifications on the industry is that insurers can no longer reject claims of a person discovered to be a smoker or suffering from a disease/pre-existing condition if he/she has been availing of insurance for eight years in continuity. IRDAI added that insurers cannot exclude coverage or reject claims if the policyholder has "failed to seek or follow medical advice or follow treatment". Insurers hitherto have been known to penalise patients for failure to follow through on a prescribed regime.

Bringing cheer to adventure sports companies as well as sports enthusiasts, IRDAI's new rules make it clear that insurers now have to cover high-adrenaline, risky pursuits such as dirt biking, paragliding, whitewater rafting, go-karting and F1 racing, as well as ethnic sports like jallikattu and kambala. Last but not the least, insurers can no longer discriminate on the basis of gender and identity, which is great news for the LGBT community.

While insurers cannot refuse to provide coverage or reject claims if a person is on life support, they are allowed to reject claims if the patient is in a vegetative state. However, insurers will be required to provide coverage and pay expenses till the patient is so certified by competent authorities.

The regulator has also proposed that insurers can incorporate waiting periods for any specific diseases but only up to four years.

With PTI inputs

Also read: Non-life insurers witness 13 pc rise in premium in FY19

Also read: Insurers asked to make provisions for IL&FS, Reliance Capital defaults

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