Last year, the Insurance Regulatory Development Authority of India’s (Irdai) master circular introduced several reforms that make health insurance significantly more customer-friendly.
You will soon be able to receive cashless treatment at any hospital you choose, thanks to a new initiative. Typically, an insurer's network covers around 10,000 to 15,000 hospitals where you can get cashless service. However, if you prefer a hospital outside this list, you can simply ask your insurer for approval.
Shorter Waiting Period For Pre-Existing Disease
The waiting period for Pre-Existing Diseases (PEDs) is now three years, down from four. Typically, when you buy a health insurance plan and have a pre-existing condition, it wouldn't be covered until after four years. That wait has now been cut to three years. This means customers will get coverage for their pre-existing conditions much faster.
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Siddharth Singhal, head of health insurance at Policybazaar, explains a significant change: "Previously, if you had continuous health insurance for eight years, your insurer couldn't dispute a claim based on non-disclosure or misrepresentation, unless it was fraud. The duration for that period has now been reduced to five years. This change should really boost customer confidence and ease worries about claims being denied."
Singhal also highlights new guidelines from the Irdai: "The Irdai has instructed all insurers to settle cashless claims within three hours. This means any cashless claim you submit should be processed within that timeframe. Insurers also need to approve or deny your cashless claim request within one hour of you submitting it. The regulator has even suggested that insurers set up help desks in hospitals to make the cashless claim process smoother for everyone."
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Also, alternative treatments under Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) will now be covered without sub-limits. “Customized insurance options are being developed for senior citizens and other specialized groups. Annual premium increases for senior citizens have been limited to a maximum of 10 per cent,” says Surinder Bhagat, head, employee benefits, large account practices, Prudent Insurance Brokers.
Benefits To The Consumer
These changes make things clearer and protect customers better in a few different ways. A shorter moratorium period (five years) and faster pre-existing diseases (PED) coverage mean fewer grey areas in claim disputes, boosting policyholder trust. With defined turnaround times (one hour for pre-authorization, three hours for settlement), customers now know what to expect, and delays can be easily flagged.
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By mandating help desks and prompt decisions, Irdai is ensuring smoother service and fewer delays or rejections.
Irdai has provided a structured list of exclusions (like cosmetic surgery, adventure sports, etc.) that must be uniformly followed, improving comparability and transparency. Additionally, Irdai has mandated that mental illness, genetic disorders, and HIV/AIDS: These are mandated to be covered under all comprehensive health policies — they can’t be excluded arbitrarily.
“These regulatory reforms are expected to reduce claim rejections and deductions while improving transparency, speed, and ease of service across the health insurance sector,” says Bhagat.
