Tag Archives: insurance contracts

issuance of digital insurance policies

IRDAI circular dated 9th February, 2021 on the subject, which is self explanatory

All Insurers excluding GIC Re, FRBs and Lloyd’s (India)

Re: Issuance of digital insurance policies by insurance companies via Digilocker

Digilocker is an initiative under the Digital India program by the Government of India where citizens can get authentic documents/ certificate in digital format from original issuers of these certificates. It aims at eliminating or minimising the use of physical documents and will enhance effectiveness of service delivery, making these hassle free and friendly for the citizens.

2. In the insurance sector, Digilocker will drivereduction in costs, elimination of customer complaints relating to non-delivery of policy copy, improved turnaround time of insurance services, faster claims processing and settlement, reduction in disputes, reduction in fraud and improvement in customer contactability. On the whole it is expected that it will lead to better customer experience. 

3. In order to promote the adoption of Digilocker in the insurance sector, the Authority advises all insurers to enable their IT systems to interact with Digilocker facility to enable policyholders to use digilocker for preserving all their policy documents.

4. The insurers should inform their retail policyholders about Digilocker and how to use it. Insurers are also advised to enable the process by which the policyholders can place their policies in the digilocker.

5. Digilocker team in NeGD (National e-Governance Division) under Ministry of Electronics and Information Technology shall provide necessary technical guidance and logistic support to facilitate adoption of Digilocker. A brief for on-boarding documents and contact details of resource persons in NeGD is annexed.

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Telemedicine in health policies

IRDA has vide its circular dated 11th June, 2020 advised insurance companies to allow telemedicine wherever consultation with a medical practitioner is allowed within the terms of the insurance contract. Allowing telemedicine shall be part of the claims settlement of the insurers and they need not refer to the IRDA for modification. It has been ipso facto allowed without the need for health insurance companies to file a modification of their products.

Telemedicine allowed should of course be within the guidelines dated 25th March, 2020 issued by the Medical Council of India.

IRDA circular can be found https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo4155

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Health Insurance Policy contracts – standard terms & clauses

IRDA has issued a circular dated 11th June, 2020 wherein it has stipulated standardized terms & clauses in indemnity based health insurance policy contracts (except personal accident insurance and domestic / overseas travel policy). This comes into effect from 1st October 2020 and in case of renewals from 1st April, 2021 onwards.

https://www.irdai.gov.in/ADMINCMS/cms/Circulars_Layout.aspx?page=PageNo4157

Objective of this is to standardise the clauses in these contracts.

Gist of the standardized terms & clauses are given below

StandardGeneralTerms and Clauses:

1      Disclosure of Information

The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, misdescription or non-disclosure of any material fact by the policyholder.

(Explanation: “Material facts” for the purpose of this policy shall mean all relevant information sought by the company in the proposal form and other connected documents to enable it to take informed decision in the context of underwriting the risk)

2      Condition Precedent to Admission of Liability

The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payment for claim(s) arising under the policy.

3      Claim Settlement (provision for Penal Interest)

             i.       The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary document.

            ii.       In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.

           iii.       However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, the Company shall settle or reject the claim within 45 days from the date of receipt of last necessary document.

           iv.       In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.

(Explanation: “Bank rate” shall mean the rate fixed by the Reserve Bank of India (RBI) at the beginning of the financial year in which claim has fallen due)

(Note to Insurers: The Clause shall be suitably modified by the insurer based on the amendment(s), if any to the relevant provisions of Protection of Policyholder’s Interests Regulations, 2017)

4      Complete Discharge

Any payment to the policyholder, insured person or his/ her nominees or his/ her legal representative or assignee or to the Hospital, as the case may be, for any benefit under the policy shall be a valid discharge towards payment of claim by the Company to the extent of that amount for the particular claim.

5      Multiple Policies

              i.    In case of multiple policies taken by an insured person during a period from one or more insurers toindemnify treatment costs, the insured person shall have the right to require a settlement of his/herclaim in terms of any of his/her policies. In all such cases the insurer chosen by the insured person shall be obliged to settle theclaim as long as the claim is within the limits of and according to the terms of the chosen policy.

             ii.    Insured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other policy / policies even if the sum insured is not exhausted. Then the insurershall independently settle the claim subject to the terms and conditions of this policy.

            iii.    If the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to choose insurer from whomhe/she wants to claim the balance amount.

           iv.    Where an insured person has policies from more than one insurer to cover the same risk onindemnity basis, the insured person shall only be indemnified the treatment costs in accordancewith the terms and conditions of the chosen policy.

6      Fraud

If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited.

Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that particular claim,who shall be jointly and severally liable for such repayment to the insurer.

Forthepurposeofthisclause,theexpression”fraud”meansanyofthefollowingactscommittedbytheinsured personorbyhisagentor the hospital/doctor/any other party acting on behalf of the insured person, withintenttodeceivetheinsurerortoinducetheinsurertoissueaninsurancepolicy:

a)    the suggestion, as a fact of that whichisnottrueandwhichtheinsured persondoes not believetobetrue;

b)    theactive concealmentof afactbytheinsured personhavingknowledgeorbeliefofthefact;

c)    anyother act fitted to deceive; and

d)    anysuchactoromissionasthelawspeciallydeclarestobefraudulent

The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the insured person / beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such misstatement of or suppression of material fact are within the knowledge of the insurer.

7      Cancellation

i.         The policyholder may cancel this policy by giving 15days’ written notice and in such an event, the Company shall refund premium for the unexpired policyperiod as detailed below.

(Note to Insurers: Insurer shall specify the method of refund calculation)

Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where, anyclaim has been admitted or has been lodged or any benefit has been availed by the insured person under the policy.

(Note to insurers: Insurer may relax this condition as per the product design)

ii.       The Company may cancel thepolicy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by the insured personby giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud.

8      Migration

The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company by applying for migration of the policyatleast30 days before the policy renewal date as per IRDAI guidelineson Migration. If such person is presently covered and has been continuously covered without any lapses under any health insurance product/plan offered by the company,the insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on migration.

For DetailedGuidelines on migration, kindly refer the link ………

(Note to Insurers: Insurer to provide link to the IRDAI guidelineson migration.Timelines for applying for migration may be relaxed by the insurer subject to product design)

9      Portability

The insured person will have the option to port the policy to other insurers by applying to suchinsurer to port the entire policy along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines related to portability. If such person is presently covered and has been continuously covered without any lapses under any health insurance policy with an Indian General/Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability.

For Detailed Guidelines on portability, kindly refer the link ………

(Note to Insurers: Insurer to provide link to the IRDAI guidelines related to portability.Timelines for applying for portability may be relaxed by the insurer subject to product design)

10   Renewal of Policy

The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured person.

i.      The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to give any notice for renewal.

ii.    Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.

iii.    Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.

iv.   At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of …… days (Note to insurers: Insurer to specify grace period as per product design) to maintain continuity of benefits withoutbreak in policy. Coverage is not available during the grace period.

v.    No loading shall apply on renewals based on individual claims experience.

11   Withdrawal of Policy

          i.       In the likelihood of this product being withdrawn in future, the Company will intimate the insured person about the same 90 days prior to expiry of the policy.

         ii.       Insured Person will have the option to migrate to similar health insurance product available with the Company at the time of renewal with all the accrued continuity benefits such as cumulative bonus, waiver of waiting period. as per IRDAI guidelines, provided the policy has been maintained without a break.

12   Moratorium Period

After completion of eight continuous years under the policy no look back to be applied. This period of eight years is called as moratorium period. The moratorium would be applicable for the sums insured of the first policy and subsequently completion of 8 continuous years would be applicable from date of enhancement of sums insured only on the enhanced limits. After the expiry of Moratorium Period no health insurance claim shall be contestable except for proven fraud and permanent exclusions specified in the policy contract. The policies would however be subject to all limits, sub limits, co-payments, deductibles as per the policy contract.

13   Premium Payment in Instalments (Wherever applicable)

If the insured person has opted for Payment of Premium on an instalment basis i.e. Half Yearly, Quarterly or Monthly, as mentioned in the policy Schedule/Certificate of Insurance, the following Conditions shall apply (notwithstanding any terms contrary elsewhere in the policy)

i.         Grace Period of ___ (Note to Insurers: Insurer to specify grace period as per product design) days would be given to pay the instalment premium due for the policy.

ii.       During such grace period, coverage will not be available from the due date of instalment premium till the date of receipt of premium by Company.

iii.      The insured person will get the accrued continuity benefit in respect of the “Waiting Periods”, “Specific Waiting Periods” in the event of payment of premium within the stipulated grace Period.

iv.     No interest will be charged If the instalment premium is not paid on due date.

v.       In case of instalment premium due not received within the grace period, the policy will get cancelled.

vi.     In the event of a claim, all subsequent premium instalments shall immediately become due and payable.

vii.    The company has the right to recover and deduct all the pending installments from the claim amount due under the policy.

14   Possibility of Revision of Terms of the Policy Including the Premium Rates

The Company, with prior approval of IRDAI, may revise or modify the terms of the policy including the premium rates. The insured person shall be notified three months before the changes are effected.

15   Free look period

The Free Look Period shall be applicable on new individual health insurance policies and not on renewals or at the time of porting/migrating the policy.

The insured person shall be allowed free look period of fifteen days from date of receipt of the policy document to review the terms and conditions of the policy, and to return the same if not acceptable.

If the insured has not made any claim during the Free Look Period, the insured shall be entitled to

i.      a refund of the premium paid less any expenses incurred by the Company on medical examination of the insured person and the stamp duty charges or

ii.    where the risk has already commenced and the option of return of the policy is exercised by the insured person, a deduction towards the proportionate risk premium for period of coveror

iii.   Where only a part of the insurance coverage has commenced, such proportionate premium commensurate with the insurance coverage during such period;

(Note to insurers: Insurer may increase the free look period as per the product design)

16   Redressal of Grievance

In case of any grievance the insured person may contact the company through

Website:

Toll free:

E-mail:

Fax :

Courier:

Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance

If Insured person is not satisfied with the redressalof grievance through one of the above methods, insured person may contact the grievance officerat ………….

For updated details of grievance officer, kindly refer the link……….

(Note to insurers: Address of the Grievance Officer and link having updated details of grievance officer on website to be specified by the insurer. Insurer to also specify separate contact details for senior citizens)

If Insured person is not satisfied with the redressalof grievance through above methodstheinsured person may also approach the office of Insurance Ombudsman of the respective area/region for redressal of grievanceas per Insurance Ombudsman Rules 2017. (Note to insurers: Insurer to specify the latest contact details of offices of Insurance Ombudsman)

Grievance may also be lodged at IRDAI Integrated Grievance Management System – https://igms.irda.gov.in/

17   Nomination:

The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the policy in the event of death of the policyholder. Any change of nomination shall be communicated to the company in writing and such change shall be effective only when an endorsement on the policy is made. In the event of death of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there is no subsisting nominee, to the legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and finaldischarge of its liability under the policy.

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