Health insurance holders are likely to get more wellness and preventive features, including outpatient (OP) consultations or treatments, pharmaceuticals, health check-ups and diagnostics and discount vouchers in gyms and yoga centres as part of the policy package.
“Insurers may endeavour promoting wellness amongst health insurance policy holders by offering health specific services provided by network providers or other empanelled hospitals and service providers,” the Insurance Regulatory and Development Authority (IRDAI) has said in its draft guidelines.
The services proposed include “outpatient consultations or treatments, pharmaceuticals, health check-ups/diagnostics”, including discounts on these services by redeemable vouchers.
IRDAI has also proposed redeemable vouchers to obtain protein supplements and other consumable health boosters, and membership in yoga centres or gymnasiums for participating in fitness activities. The draft norms also cover discounts on premiums and/ or increase in sums insured at the time of renewals based on the wellness regime followed by holders in the preceding policy period.
“The new proposals open up direct incentives to policy holders. But many of these will require monitoring to prevent unhealthy competition and misuse. Fraud monitoring and prevention steps will also become critical,” said K K Srinivasan, former member, IRDAI. Some insurers now offer health check-ups and diagnostics as part of their coverage.
IRDAI has said that the increase in sum insured should be independent and not linked to cumulative bonus offered, if any.
The regulator has proposed that insurers should assess the pricing impact of wellness and preventive features offered, if any, and disclose them upfront under product filing guidelines or other applicable norms.
According to the draft norms, insurers should not publish trade names or logos of third party merchandise in any of their advertisements, but may refer to the product or service offered in generic terms. However, insurers should disclose specific items of products and services offered on their website and provide a link in their advertisements and policy contracts.
“Insurers shall not accept any liability towards quality of the products or services offered by third parties and shall specify upfront that the said third party is responsible for providing the products or services stipulated under the wellness features of the product and insurer is not liable for any defects or deficiencies,” the draft norms state.
Insurers should also ensure that service providers of wellness and preventive programmes have an appropriate mechanism to discharge their obligations by offering the agreed services or products. “Other than the monetized value of the rewards points redeemed by the policy holders, no payments should be made by insurers to the third party merchants,” the norms state.
Insurers should not receive any consideration amount for offering third party products and services, they state. Third party merchant-wise and product-wise payouts should be disclosed in the annual public disclosures by insurers. “The costs towards the wellness services should be factored into the pricing of the underlying health insurance product and price factored should be disclosed in all insurance advertisements wherever wellness features are disclosed and promoted,” the norms state.
In the case of family floater plans, insurers should clearly define and disclose the manner in which accrual and redemption of wellness benefits is considered for all members covered, IRDAI has said.
Insurers should also clearly specify in the policy contract whether the accrued benefits can be carried forward or not when the policy is renewed — and the period of validity of accrued benefits. “The benefit accrued should be at periodic intervals at rates/ amounts declared upfront at the commencement of the policy and should not be linked to any dynamic factor such as interest rate, etc. The same should be specified in the policy document,” the norms state.
Insurers should notify the benefits accrued to a policy holder under the wellness feature at periodic intervals — at least once in a year, the norms state.
During FY 2017-18, insurance companies collected Rs 37,029 crore as health insurance premium, registering a growth of 21.8 per cent over FY 2016-17. Five states — Maharashtra, Tamil Nadu, Karnataka, Delhi UT and Gujarat — contributed 68 per cent of total health insurance premium, IRDAI says.
According to IRDAI’s Annual Report 2017-18, the insurance sector covered 48 crore people under the health segment, out of which 36 crore were covered under various government schemes. The industry processed 1.6 crore health insurance claims during that year.
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