From July 1, no company will be able to deny health cover to a senior citizen without furnishing a documented reasoning. “Any proposal for health insurance of senior citizens, which are denied on any grounds, should be made in writing with reasons furnished and recorded. Such reasons should stand the scrutiny of reasonableness and fairness,” the circular said.

Besides, companies will not be able to charge exorbitant premium rates for senior citizens as well. The IRDA has said that the premium rates should be fair, justified, transparent and duly disclosed upfront. The details of any loading charged must also be made available to the insured.

The regulator has made it mandatory for all companies to clearly spell out the differences in product specifications for different age groups or for different entry ages upfront in the prospectus and policy documents.

The regulator has gone a step further and asked all insurance companies to give choice to the consumers in terms of TPAs (third-party administrators) as well. In case of any grievance with regards to the TPA, the insured has the right to switch to some other TPA empanelled by the insurer. “Policy-holders shall be given an option to seek a change of TPA which could be exercised 30 days before the renewal date of the policy. Such changed TPA would be allocated by the insurer from amongst TPAs empanelled by the insurer for this purpose,” the circular said. The insurers also runs the risk of penalty in case of delay in issue of identity cards to policy-holders beyond 30 days from issue of policy. “All health insurance policies must enclose an annexure briefly describing in simple language the coverage and the key terms and conditions of the policy,” the circular said.

Besides, from July 1, companies will have to reimburse at least 50 per cent of the cost incurred by the insured in pre-insurance medical examination, in cases where the risk is accepted.

“Insurers will also enlist (or empanel, as the case may be) government medical institutions from which such pre-insurance reports will be accepted by them. Where the risk is accepted, copies of such medical examination reports should also be made available to the insured if requested for,” the circular said.

Further, it has asked all insurers to ensure adequate information dissemination of product information on all their health insurance products on their websites. The circular also said that insurers would have to work towards evolving mechanisms for action against medical establishments, TPAs and policy-holders guilty of making or supporting fraudulent claims and for sharing of such information among themselves.

This is the second such directive by the regulator. In April, IRDA had mandated that no company would be able to deny claim to insured on the basis of the past claim history.

All these steps are being taken to bring insurance industry to the next level, when medical portability will be allowed.