Health Insurance Standardization Norms: Explained

Have you ever needed clarification on the numerous technical terms and procedures connected to your health insurance policy? The IRDAI’s standardisation norms can take care of this.

Did you know? “Health insurance plans covered around 514 million individuals in India in the fiscal year of 2021”[1]. When it comes to health insurance plans, most of us are more interested in just purchasing a policy and opt to neglect the technical aspects of the product we buy. We may consider the qualities proposed and attempt to understand the promised benefits, but do we take the time to understand the terms and conditions accompanying such benefits?

Although the technical needs for many policies that health insurance firms offer are nearly identical, there may be variations. Therefore, it can be challenging to comprehend the differences in the plans, and then compare them.

The Insurance Regulatory and Development Authority of India (IRDAI) has established particular standards and norms for health insurance firms to reduce stress. The IRDAI has set forth six different sorts of standardisation requirements insurers issuing health insurance plans can follow. Let’s define them as follows:

1.  Frequently used Phrases

You may be familiar with words like “hospitalisation”, “pre- and post-hospitalisation”, “daycare treatments”, “OPD costs”, “co-payment”, “deductible”, and others that describe the payable benefits and the limitations of your policy. The definitions of these 46 frequently-used phrases in your health insurance plans have been consistent by IRDAI.

2. Critical Illnesses Covered Definitions

Health insurance policies compete with one another regarding coverage for illnesses. Some plans can cover 7 or 8 critical conditions, while others can cover up to 20. 11 prevalent acute diseases have been established by IRDAI, along with the range and depth of coverage for each. The illnesses include kidney failure, open chest CABG, coma of a given severity, cancer of stated severity, heart attack, etc. Other plans can cover health insurance for senior citizens.*

3. Claim form and pre-authorisation form

The pre-authorisation and the necessary claim forms have been standardised to make the claim procedure easier. In addition to ensuring efficient processing, this can reduce data-entering errors using an OCR format. The policyholder must receive these forms for the claim to be registered quickly.





4. Exclusions list

A standard list of 199 exclusions published by the IRDAI covers the entirety of an exclusion list. Although insurers are free to select any exclusions from this list, the plan will not cover any other exclusions that do not appear on the list.

5. Customer Information Sheet, Database Sheet, and Application Form

The application form and other necessary paperwork have been made uniform with the related details to streamline the purchasing process. As a result, practically, all health plans will have similar applications where the product and consumer information is listed consistently.

6. An understanding between hospitals and the insurer, as well as TPAs

The best feature of your health insurance is the choice of a cashless hospitalisation through a partner with which your insurer has a relationship. And because the TPA is involved, the process is relatively simple. It contains standard clauses that can safeguard the policyholder’s rights and could be backed by the insurer’s agreement with TPAs and affiliated hospitals.

The IRDA has taken several actions to promote standardisation as far as possible to safeguard policyholder interests. It could guarantee that all interactions with the insurer, from purchasing a policy to filing claims, are clear-cut. Prepare yourself with these standardised details so that your health plan will stay on track rather than stressing over the fine print of your policy document. It’s time you start planning your family health insurance. *

* Standard T&C Apply

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

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