IRDAI vide an Exposure Draft dated August 30, 2023 has notified about the revision of Customer Information Sheet as sated in “Consolidated Guidelines on Product filing in Health Insurance Business dated July 22, 2020”. Further reference can be drawn towards Regulation 26 of IRDAI (Health Insurance) Regulations, 2016* which mandates every policyholder to be provided with a Customer Information Sheet (CIS). This revision is brought in order to ensure that the health insurance policy information is provided in a simple and understandable language.
The Customer Information Sheet is required to be is as follows:
CUSTOMER INFORMATION SHEET/KNOW YOUR POLICY
This document provides key information about your policy. You are also advised to go through your policy document.
Sr No.
Title
Description
1.
Name of Insurance Product/Policy
—-
2.
Type of Insurance Product/ Policy
- Indemnity- Where insured losses are covered up to the Sum Insured under the policy.
- Benefit- Where Insurance Policy pays a fixed amount under the policy on the occurrence of a covered event.
- Both Indemnity and Benefit (where policy has elements of both the above)
3.
Sum Insured (Basis)
(Along with amount)
- Individual Sum Insured- Where each member has a separate sum insured under the policy).
- Floater Sum Insured- Where all members under the policy have a single sum insured limit which may be utilized by any or all members.
4.
Policy Coverage (Policy Clause Number/s)
Insurer must ensure that all the benefits of the policy are listed above)
5.
Exclusions (what the policy does not cover)
Insurer has to ensure that all the applicable exclusions are listed here
6.
Waiting period
(Time period during which specified diseases/treatments are not covered. It is counted from the beginning of the policy coverage.)
- Initial waiting Period
- Specific Waiting periods (Not applicable for claims arising due to an accident)
- Pre-existing diseases
7.
Financial limits of coverage
- Sub-limit (It is a pre-defined limit and the insurance company will not pay any amount in excess of this limit)
- Co-payment (It is a specified amount /percentage of the admissible claim amount to be paid by policyholder/insured).
- Deductible (It is a specified amount:
– up to which an insurance company will not pay any claim.
– which will be deducted from total claim amount (if claim amount is more than the specified amount)
- Any other limit (as applicable)
The policy will pay only up to the limits specified hereunder for the following diseases/procedures:
XX XX
In case of a claim, this policy requires you to share the following costs: Expenses exceeding the following Sub-limits
- Room / ICU charges beyond ————
- For the following specified diseases:
- ______________
- ______________
Deductible of Rs. XXX per claim / per year / both
8.
Claims/Claims Procedure
Details of procedure to be followed for cashless service as well as for reimbursement of claim including pre and post hospitalization.
Turn Around Time (TAT) for claims settlement: XX
Provide the details /web link for following:
- Network Hospital details
- Helpline number
- Downloading/getting claim form
9.
Policy Servicing
Call center number of the insurer
Details of Company officials
10.
Grievances/Complaints
Details of:
- Grievance Redressal Officer of the insurer
- Insurance company grievance portal/ Department
- Ombudsman
(Please provide contact details, Toll free number/email)
11.
Things you need to know
- Free Look cancellation: You may cancel the insurance policy if you do not want it, within xx days from the beginning of the policy.
Insurer to specify the process for free look cancellation
- Policy renewal: Except on grounds of fraud, moral hazard or misrepresentation or non-cooperation, renewal of your policy shall not be denied, provided the policy is not withdrawn.
- Migration and Portability: When your policy is due for renewal, you may migrate to another policy with us or port your policy to another insurer.
Insurer to specify the process for migration and portability.
12.
Your Obligations
Please disclose all pre-existing disease/s or condition/s before buying a policy. Non-disclosure may affect the claim settlement.
Disclosure of other material information during the policy period.)
Insurer to specify the material information
Declaration by the Policy Holder;
I have read the above and confirm having noted the details.
Place:
Date: (Signature of the Policy)
Note:
- Insurer shall provide web-link where the product related documents including the Customer Information sheet are available on the website of the insurer.
- In case of any conflict, the terms and conditions mentioned in the policy document shall prevail.
- Insurer to take confirmation of the policyholder regarding receiving of the Customer Information Sheet.
Note: All Stakeholders need to review the exposure draft and provide their views and comments in the prescribed format on or before September 13, 2023.
Reference:
*IRDAI (Health Insurance) Regulations, 2016
“26. Protection of Policyholders’ Interest:
a. Unless otherwise provided, the IRDA (Policyholder Protection of Interest) Regulation, 2002 is applicable to all health insurance policies.
b. Every insured shall be provided with a Customer Information Sheet as specified by the Authority in the Guidelines. The insurer shall establish necessary systems, procedures, offices and infrastructure to enable efficient issuance of pre-authorizations on a 24-hour basis and the prompt settlement of claims and grievances.”
Source category: IRDAI
Attachments
- /2023/252_Exposure_Draft_Customer_Information_Sheet_Know_Your_Policy.pdf
Comments are closed