IRDAI has vide Circular dated April 28, 2022 issued Exposure Draft on Group Insurance Products under Health Insurance Business and other operational matters.
Key highlights
- This Circular proposes to supersede the following prescriptions as far as they pertain to group policies under Health insurance:
- Guidelines on Group Insurance Policies (Reference: 015/IRDA/Life/Circular/GI Guidelines/2005 dated July 14 th , 2005).
- Clarification on Guidelines on Group Insurance Policies (Reference: IRDA/Life/Cir/Misc/001/01/2011 dated January 4 th , 2011).
- Chapter V of Consolidated Guidelines on Product Filing in Health Insurance Business (Reference: IRDAI/HLT/REG/CIR/194/07/2020 dated July 22 nd , 2020).
- Definitions – The Exposure Draft specifies definitions pertaining to certificate of insurance, employer-employee group, non-employer-employee group, large group, master policyholder.
- General, Group Size and Term
- A group shall not be formed with the main purpose of availing insurance, Negotiating group rates and then forming a group is not permitted.
- No Insurer is permitted to offer any indemnity or benefit based credit linked group health products, except for coverage of accidental death and disability in respect of policies issued under Personal Accident. Existing Credit Linked Group Health Products shall be withdrawn
- Provisions pertaining to group health insurance are prescribed such as:
- Minimum size of the group to be specified in every group health product subject to the minimum number as prescribed in IRDAI (Health insurance regulation), 2016.
- Entry of members in the group
- Group coverages offered by life insurers.
- Underwriting and Pricing Aspects
- Insurers to have a Board approved group insurance underwriting policy which covers the manner in which its risk and costs are analyzed and factored into the premium cost including for “Large Group”.
- Provisions pertaining to issuance of master policy and certificate of insurance to the members of the group are prescribed.
- Insurers to review the group insurance policies offered including pricing every year.
- In case of group policies issued to promoter group companies/ subsidiary companies or other related party companies, the premium rates charged vis-à-vis the coverage granted shall be placed before the risk management committee on half-yearly basis for a review.
- Entry and Exit norms
- Master Policyholder and General / Heath Insurer concerned shall facilitate the migration/portability as per the group scheme rules.
- Entry into the group insurance policy for individual members will be from a well-defined date subject to receipt of premium in time.
- Insurance will cease as soon as a member leaves the group except where it is agreed in advance to continue the benefit even after the member leaves the group.
- Employer – Employee groups
- Employer shall issue confirmation of insurance protection to individual employees with clear reference to the group insurance policy. Reimbursement claims of individual persons insured thereunder may be paid through the employer.
- Non-Employer-Employee groups
- An individual group member would be treated as the insured beneficiary and the master policyholder will only be the holder of the policy.
- Insurer may provide the facility to the master policyholder to issue certificates of insurance and facilitating the intimation and settlement of a claim subject to the conditions as specified.
- In case of lender-borrower group insurance schemes offered by insurers, the claim payment to master policyholder is allowed subject to the provisions and procedure as specified.
- The Insurer, under an agreement with the master policyholder, may leverage on the existing infrastructure, if any, for better administration of the scheme with respect to the following services and may make payments directly to the Master Policyholder subject to conditions as specified.
- data management
- collection of premium
- issuance of Certificate of Insurance and
- claims documentation
- No payments shall be made by insurers to the agent or intermediary or master policyholder towards the administration of Group Insurance scheme except as specified.
- Servicing Norms to the Insurers and Master Policyholders
- Requirement of issuance of ID cards, maintenance of complete list of the persons insured etc.
- Unnamed policies may also be issued provided the group has non-tamperable registers or records or procedures to identify the member insured / covered.
- Disclosure
- The role of master policyholder as a facilitator shall be clearly spelt out, Further, details of grievance redressal mechanism shall be disclosed.
- The premium or benefits applicable shall be started in the policy and shall not vary with regard to the individual members.
- Additional Norms on Group Travel Insurance policies
Norms applicable to Group Policies issued towards domestic and overseas travel coverage have been specified:
- Premium shall be received not more than 90 days in advance to the date of commencement of the risk covered except in case of overseas travel which may be issued at any time.
- Norms to be adhered in case policies are offered through any travel agency or portal have been specified.
- Insurers to verify compliance with the above norms, at least once in a period of three months.
- Some of the important aspects as specified under other norms are as under:
- Requirement of conducting inspection of the books and records of the master policyholder of non-employee–employer group
- Compliance to be adhered in case an insurance intermediaries is engaged for sale of its group products
- Information pertaining to government sponsored schemes.
- The draft also prescribes
Instructions on Claim Processing for Group Policies in respect of Health Insurance Business under Lender – Borrower Group Schemes (Annexure A)
Yearly compliance certificate from the statutory auditors in respect of the entire group insurance portfolio to be submitted to the Authority within 90 days of the expiry of the financial year in the prescribed format (Annexure B).
Source category: IRDAI
Attachments
- /2022/22_EXPOSU~1.PDF
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