health insurance

Loading...
EXPOSURE DRAFT

INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY (HEALTH INSURANCE) REGULATIONS, 2012

Contents 1. Chapter 1 – Short Title and Commencement and Definitions, Definitions 2. Chapter II – Registration of Insurance companies who are exclusively doing health insurance business. 3. Chapter III - Product Design and Related Issues 4. Chapter IV – Renewability of Health Insurance Policies 5. Chapter V – Portability of Health Insurance Policies 6. Chapter VI - File and Use Procedure for health insurance products 7. Chapter V II- Protection of Policyholders’ Interest 8. Chapter VIII - Health Insurance Policy Servicing 9. Chapter IX- Third Party Administrators 10. Chapter X - Contract Between Insurer and Hospitals 11. Chapter XI - Submission of Information through Electronic Returns 12. Chapter X II- Valuation of Assets & Liabilities; Preparation of Financial Statements; Solvency Margin of Insurers and Other Issues

ANNEXURES I.

Portability form

II.

Administration of Health Plus Life Combi Products

II.

Electronic Return Non life and Life(photo image)

THE INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY (HEALTH INSURANCE) REGULATIONS, 2012. F. No. IRDA/Reg/…./2011 dated ….. - In exercise of the powers conferred under Section 114A of the Insurance Act 1938 and Section 14 read with section 24 of the IRDA Act 199 and in consultation with the Insurance Advisory Committee, the Authority hereby makes

the following regulations,

namely:CHAPTER 1 1. Short title and commencement. a.These regulations may be called Insurance Regulatory and Development Authority (Health Insurance) Regulations, 2012 b. They shall come into force from the date of their publication in the Official Gazette by the Central Government. c. Unless otherwise provided by this regulation, nothing in this regulation shall deem to invalidate the health insurance contracts entered prior to these regulations coming into force. d. These Regulations are applicable to all life, non life and health insurers, if any conducting health insurance business as defined under these regulations.

1.1 Definitions. In these Regulations, unless the context otherwise requires,-a) “Act” means the Insurance Act, 1938. b) "Agreement" means an agreement entered into between a Third Party Administrator

and an

insurance company prescribing the terms and conditions of services, which may be rendered to Insurance Company; or an agreement entered into between a Hospital /Health care provider and an Insurance Company, and may include TPA as a tri-party, prescribing the terms and conditions, which may be rendered to insured persons of the Insurance Company. c) “Authority” means Insurance Regulatory and Development Authority of India established under sub section 1 of section 3 of the IRDA Act 1999. d) “Break in policy” A break in policy occurs when the premium due on a given policy is not paid on or before the premium renewal date or within 30 days thereof. e) “Cashless facility” means a facility provided to the insured by an insurer, to make payments of treatment costs directly to the hospital in respect of treatment undergone in a network

provider, to the extent of approval given in the pre-authorization where such treatment is in accordance with the policy terms and conditions. f)

“Health insurance business” means the effecting of insurance contracts which provide for sickness benefits or medical, surgical or hospital expense benefits, travel health insurance and personal accident cover ;‟

g) "Health Services" means all the services to be rendered by a TPA under an agreement with an insurance company in connection with "health insurance business" or „health cover‟ as defined in regulation 2(f) of the IRDA (Registration of Indian Insurance Companies) Regulations, 2000, but does not include the business of an insurance company or the soliciting, directly or through an insurance intermediary including an insurance agent, of insurance business. h) “Health plus Life Combi Products” shall mean the combination of Pure Term Life Insurance cover offered by life insurance companies and Health Insurance cover offered by non life insurance companies. i) “Network Provider” means hospitals or health care providers which have an agreement with the insurer to settle claims through cashless facility. j) “Portability” Portability means the right accorded to an individual health insurance policyholder (including family cover) to transfer the credit gained by the insured for preexisting conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break. k) “Senior citizen” means any person who is sixty or more years of age as on the date of commencement of insurance policy. l) “Third Party Administrators or TPAs” means any person who is licensed by the Authority, and is engaged, for a fee or remuneration by an insurance company, for the provision of health services; m) All words or expressions not defined in these regulations but defined in the Insurance Act 1938 or Insurance Regulatory and Development Authority Act 1999 shall have the same meanings respectively assigned to them in those Acts.

CHAPTER II Registration of insurance companies who are exclusively doing health insurance business 2. Procedure for Registration

2.1. The Insurance Regulatory and Development Authority (Registration of Indian Insurance Companies) Regulations 2001 shall apply mutatis mutandis to all insurance companies who are exclusively doing health insurance business. 2.2. All insurance companies who are exclusively doing health insurance business shall satisfy the capital requirements as specified by the Authority from time to time. CHAPTER III Product Design and Related Issues 3.1 Entry and Exit Age 3.1.1. All health insurance policies shall provide for entry age at least up to 65 years, except for those referred in regulation 3.6. 3.1.2. All health insurance policies shall not have an exit age for renewal of the policies, once the proposal is accepted, provided policy is continuously renewed without break. 3.2. Term of health insurance policies 3.2.1. For all products offered to individuals, life insurers shall offer products with policy term of at least 4 years and non-life insurers shall offer products for not more than 3 years 3.2.2. For all products offered as Group Policies, all life insurance companies and nonlife insurance companies shall offer only one year Renewable Group Health Insurance Policies. 3.3. Assignment 3.3.1.

No assignment of health insurance policies shall be allowed irrespective of whether they are indemnity or benefit based.

3.4. Pan India Access: 3.4.1. All health insurance policies shall allow access for treatment in network provider or in any hospital which is not part of the network provider across pan India except in unauthorised hospitals excluded from providing health care services for health insurance policies.

3.4.2. The insurer shall explicitly state all the terms and conditions with respect to availability and availing of treatment across pan India in the policy document. 3.4.3. If different terms are offered for availing treatment across pan India, this shall be stated explicitly in all the promotion material and shall have suitable provisions built into the proposal form. 3.5. Travel Medical Insurance Policy 3.5.1. Travel medical policies may be offered either as a. a standalone product or b. an add-on cover to existing health policy as and when existing policyholder travels by charging suitable premium for the add-on cover as approved by the Authority under File And Use Procedure. 3.6. Option to migrate to suitable health insurance policy: 3.6.1. In health insurance policies, where the covers offered are specific to a particular age groups like maternity covers, children covered under a family floater policies, cover offered to students etc, insurers shall offer an option to migrate to a suitable health insurance policy, at the renewal of the policy or at the end of the specified exit age, by providing suitable credits for all the previous policy years, provided the policy has been maintained without break. 3.7. Cumulative bonus: 3.7.1.

In a health insurance policy, insurer may offer cumulative bonus which shall be stated explicitly in the prospectus and the policy document. Such cumulative bonus shall be considered along with the sum insured to arrive at the sub-limits.

3.7.2.

If a claim is made in any particular year, the cumulative bonus accrued may be treated as below:

a. May be reduced at the same rate at which it is accrued; or b. May be utilised to enhance the sum insured by accepting the pro-rate premium to the extent of cumulative bonus to be reduced in that particular year;

3.7.3.

Once the insured opts for 3.7.2 (b), it shall not be reduced in the subsequent years.

3.8. General Provisions 3.8.1. Any differences in product specifications for different age groups or for different entry ages must be clearly disclosed upfront in prospectus and policy documents. 3.8.2. Insurer shall not compel the insured to migrate to other health insurance products, if it is to the disadvantage of Insured. 3.8.3. Insurers shall ensure adequate dissemination of product information on all their health insurance products on their websites. This information shall include a description of the product, copies of the prospectus, proposal form, policy clauses and premium rates inclusive and exclusive of Service Tax as applicable. 3.8.4. Insurers shall individually and collectively take steps for evolving mechanisms for sharing of information among themselves about such persons / hospitals / institutions that are guilty of making or supporting fraudulent claims. 3.9. Underwriting 3.9.1. All insurance companies shall obtain all the required information in the proposal form and underwrite the proposals in accordance with the Board approved underwriting policy. 3.9.2. Any proposal for health insurance which is denied on any grounds shall be made in writing with reasons furnished and recorded. Such reasons shall be justifiable, transparent and fair. The insured shall be informed of any loading charged on the premium. 3.9.3. If insurance company intends to call for any further information at subsequent stages of policy with respect to change in occupation or at the time of renewal, the insurance company shall: a. prescribe standard forms to be filled up by the insured and shall make these forms part of the policy document b. Clearly state the events which will result in submission of such forms. c. Clearly state the conditions applicable in such events

3.9.4. Insurers shall devise mechanisms to reward policyholders for early entry, continued renewals, favourable claims experience etc with the same insurer and disclose upfront in prospectus and policy document, as approved under File and Use. 3.9.5. The information that the insurer has already captured at the time of underwriting/accepting the proposal, the terms & conditions offered under the policy based on underwriting and subsequent claims experience emerged during the policy shall form the basis for claim settlement. 3.10. Cost of pre-insurance health check up 3.10.1. In case of non-life insurers, where the proposal is accepted and subsequently resulted into a policy, in all such cases, insurers shall reimburse at least 50% of the cost if any, incurred by the insured in pre-insurance medical examination. Provided, for travel medical insurance policy where the premium levied is less than the costs incurred by the insured in pre-insurance medical examination, the insurer may not reimburse the cost of pre-insurance health check-up. 3.10.2. In case of life insurers, where the proposal is accepted and subsequently resulted into a policy, in all such cases, insurers shall incur the costs and may suitably allow such costs incurred by the insured in pre-insurance medical examination within the premium levied to the policyholder. 3.10.3. Insurers shall enlist or empanel government medical institutions and/or

other

relevant institutions from which such pre-insurance medical examination reports will be accepted by them. 3.11. Special Provisions for Insured Persons who are Senior Citizens 3.11.1. The premium charged for health insurance products offered to senior citizens shall be fair, justified, transparent and duly disclosed upfront. The insured shall be informed of any loading charged on the premium. 3.11.2. All health insurers and TPAs, as the case may be, shall establish a separate channel to address the health insurance related claims and grievances of senior citizens. 3.12. Pricing of Health Insurance Products

3.12.1. The premium charged for any health insurance product offered shall be fair, justified, transparent and duly disclosed upfront. The insured shall be informed of any loading charged on the premium. 3.12.2. For calculation of premium for health insurance policies, the completed age of the prospect on the date of commencement of insurance shall only be reckoned. 3.12.3. For the purpose of providing cover under family floater, the premium levied shall take in to account the impact of the multiple incidence rates for all the family members proposed to cover and shall be filed under the File and Use. 3.12.4. The premium for the health insurance products shall be evaluated appropriately after assessing the financial sustainability and viability of the product with respect to the rates, loadings and discounts. 3.12.5. The discounts and loadings offered shall be objective and disclosed upfront in the prospectus and policy document, as approved under the File and Use. 3.12.6. The premiums shall not be allowed to increase for a period of 1 year once the product is cleared by the Authority; 3.12.7. In case of revision of premium rates after completion of such period as stated in 3.12.6, the insurer shall submit under the File and Use Procedure the justification for the revised pricing; the recent three years claims experience on the original pricing along with the expected experience and the reasoning; expected claims experience and the rationale/assumptions for the proposed pricing along with the particulars on how the proposed pricing would meet the adversities experienced, if any. 3.12.8. At the time of filing the product under the File and Use procedure, the insurer shall provide complete pricing details along with all the assumptions, loadings allowed in the premium determination. 3.13Loading on Renewals: 3.13.1 If the individual claims experience, for each of the three consecutive policy years other than the current policy year, is more than 500% of the premium under the current policy, the insurer at the time of subsequent renewal may:

a. Apply the malus as referred in the regulation 3.7.2 (a) b. Load the premium as per the pre-determined table, disclosed at the outset in prospectus and policy document, which is approved as per the File and Use procedure. c.

Accept the renewal at the prevailing premium rates without any loading or malus.

3.14 Free Look Period 3.14.1 Health insurance policies offered by the non-life insurers having duration of three years or more and health insurance policies offered by the life insurers shall have a free look period. The free look period shall be applicable at the inception of the policy and: a)

The insured has a period of 15 days from the date of receipt of the documents to review the terms and conditions of the policy and

b)

Where the policy holder disagrees to any terms and conditions, the insured has the option to return the policy stating his reasons for the objections.

c)

If the insured has not made any claim during the free look period, the insured shall be entitled toi.

refund of the premium paid subject only to a deduction of the expenses incurred by the insurer on medical examination of the insured persons 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 policyholder, refund will also be subject to a deduction for proportion risk premium for period on cover or;

iii.

Where only a part of the risk has commenced, such proportionate risk premium shall be calculated so as to commensurate with the risk covered during such period.

iv.

In respect of unit linked policy, in addition to the deductions in subclause(1) of this regulation, the insurer shall also be entitled to repurchase the unit at the price of the units on the date of cancellation.

3.14.2 Non-life insurers may voluntarily provide for free look period even for health insurance policies of duration less than three years. The terms and deductions admissible in the above sub-clause (1) (a) to (1) (c), as relevant, shall apply to such health insurance policies. 3.15 Upper Limit on the Cover Offered: 3.15.1 For any health insurance policy, if the insurer has prescribed any upper limit with respect to the cover offered, the insurer shall not accept any proposal beyond such upper limit. 3.15.2 The insurer shall ensure that the systems in place shall accept proposals only up to the prescribed upper limits. 3.15.3 If any proposal is accepted beyond such upper limit, the insurer shall not deny any claim on the ground that the policy exceeds the upper limit prescribed for that policy. 3.16 Multiple Policies 3.16.1 If two or more policies are taken by an insured during a period from one or more insurers, the contribution clause shall not be applicable for such policies where the cover/benefit offered: a. is fixed in nature; b. does not have any relation to the treatment costs; 3.16.2 In case of multiple policies which provide fixed benefits, on happening the event in accordance with the terms and conditions of the policies, the insurer shall make the claim payments independent of payments received under other similar polices. 3.16.3 If two or more policies are taken by an insured during a period from one or more insurers, where the purpose of such policies is to indemnify the treatment costs, the insurer shall not apply the contribution clause, but the policyholder shall have an

option to chose insurer with whom the claim to be settled. In all such cases, the insurer shall be obliged to settle the claim without insisting for contribution clause. 3.17 AYUSH Coverage 3.17.1 Insurers may provide coverage to non-allopathic treatments provided the treatment has been undergone in a government hospital or in any institute recognized by government and/or accredited by Quality Council of India/National Accreditation Board on Health or any other suitable institutions. 3.18

Standard Definition used in health insurance policies 3.18.1 All insurers shall adhere to the stipulated definitions, if any, as issued by the Authority from time to time.

3.19

Standard Nomenclature and Procedures for Critical Illnesses 3.19.1 All Policies offering critical illness coverage shall ensure that definitions of such terms and are in line with the definitions stipulated, if any, by the Authority from time to time.

3.20

Standard List of Excluded Expenses in Hospitalization Indemnity policies 3.20.1 For the purpose of hospitalization indemnity policies, the generally accepted list of excluded items, if any, may be stipulated by the Authority from time to time. 3.20.2 However, Insurers may include these exclusions as part of the cover, if the product design allows for it or if the cover offered includes these as part of hospitalization expenses. Insurers depending on the product design, shall clearly state the list of excluded items for each product out of the list stipulated, if any, by the Authority from time to time and such list shall be annexed to the policy document

3.21 Database for health insurance products: 3.21.1 All insurers filing health insurance products shall complete and submit Database Sheet, if any, as stipulated by the Authority from time to time, as part of file and use procedure. 3.21.2 The Database shall be certified by the Head of Product Development and countersigned by Compliance Officer.

3.22

Withdrawal of Health Insurance Product 3.22.1 To withdraw a health insurance product, the insurer shall take prior approval of the Authority by giving reasons for withdrawal and complete details of the treatment to the existing policyholders. 3.22.2 Any product that is being offered in the market by insurance companies shall not be allowed to be withdrawn in respect of the existing customers of the product, unless, the existing customers are given an option to switch to a similar product under specific written consent. 3.22.3 The withdrawn product shall not be offered to the prospective customers.

3.23

Customer Information Sheet – Insurer shall provide the customer information sheet to the prospective policyholder. The document shall be: 3.23.1 A one page document in legible font, unless the product is a composite product. 3.23.2 In simple language. 3.23.3 Covering key benefits, exclusions and grievance mechanisms. 3.23.4 A complete document in itself, without any reference made to policy document or any other document. 3.23.5 Insurers shall design Customer Information Sheet as per the format stipulated by the Authority from time to time. 3.23.6 All Insurers shall file the Customer Information Sheet along with policy document at the time of filing product under file and use procedures. Chapter- IV Renewability of Health Insurance Policies

4.1 A health insurance policy shall be ordinarily renewable except on grounds of fraud, moral hazards or misrepresentation. The renewal of the health insurance policy sought by the insured shall not be denied arbitrarily. And if denied, shall provide the policyholder with cogent reasons for non-renewal of the health insurance policy. Explanation I:- the insurer shall not reject the renewal of the health insurance policy on the ground that the insured had made a claim or claims in the previous or earlier years.

4.2

Insurer shall not compel the insured covered under one health insurance product to shift to

another health insurance product except in cases where a specific product has been upgraded or discontinued with the prior approval of the Authority. 4.3 Subject to the provisions of these regulations, prospectus of health insurance policy shall contain disclosures about the terms of its renewal. 4.4 The disclosures as aforesaid shall mandatorily contain material information regarding:a)

coverage and estimated premium for future renewals of the policy

b)

disclosure of the maximum age up to when the renewal would be available, if product is offered to specified age groups.

c)

any changes in the scope of the cover after certain duration of the policy or after a certain agesuch as including but not limited to coverage for pre-existing diseases;

d)

whether renewal premium would be guaranteed or subject to revision;

e)

the premium being charged at different age slabs;

f)

details of specific circumstances where premium could be loaded (or discount withdrawn) by the insurer and also to the extent to which it could be done.

g)

Procedure and terms for enhancing the sum insured or scope of cover , if any

4.5 The insurer shall provide for a mechanism to condone delay of renewal up to 30 days from the renewal due date, in line with break in policy. 4.6 For the purpose of this clause, the insurer shall also state, including but not limited to, the fact that coverage would not be available for break in period. 4.7 Notwithstanding anything contained in these regulations, no revision in the premium structure or terms of health insurance policies shall be affected without prior approval of the Authority 4.8 The insurers shall intimate such revision to the policyholders at least three months prior to the date of renewal of the cover. In such cases where the insurer has revised the premiums or the terms and conditions of the policy, the insurer shall send a renewal notice for health insurance policies to the policyholder.

4.9 Where such renewal notice envisages a premium higher than that paid in the previous year, the notice shall explain the reason for the increase in premium and also quantum of the increase in premium which is in accordance with the disclosures earlier made in the prospectus. 4.10

Benefit based policies where policies terminate on happening of the event as per the terms and

conditions of the policy; renewability clause shall explicitly state such conditions in the promotion material and the policy document. Ex. Critical illness benefits policies. Chapter V Portability of Health Insurance Policies 5.1 A policyholder desirous of porting his policy to another insurance company shall apply to such insurance company at least 45 days before the premium renewal date of his/her existing policy. 5.2 Insurer may not be liable to offer portability if policyholder fails to approach the new insurer at least 45 days before the premium renewal date. 5.3 Portability shall be opted by the policyholder only as stated in 5.1 and not during the currency of the policy. 5.4 In case insurer is willing to consider the proposal for portability even if the policyholder fails to approach insurer at least 45 days before the renewal date, it may be free to do so. 5.5 Where the outcome of acceptance of portability is still waiting from the new insurer on the date of renewal 5.5.1 the existing policy shall be allowed to extend, if requested by the policyholder, for the short period by accepting a pro- rate premium for such short period, which shall be of at least one month and 5.5.2 shall not cancel existing policy until such time a confirmed policy from new insurer is received or at the specific written request of the insured 5.5.3 the new insurer, in all such cases, shall reckon the date of the commencement of risk to match with date of expiry of the short period, wherever relevant. 5.5.4 if for any reason the insured intends to continue the policy further with the existing insurer, it shall be allowed to continue by charging a regular premium and without

imposing any new condition. 5.6 In case the policyholder has opted as in 55.1, and there is a claim, then existing insurer may charge the balance premium for remaining part of the policy year provided the claims is accepted by the existing insurer. In such cases, policyholder shall be liable to pay the premium for the balance period and continue with existing insurer for that policy year. 5.7 On receipt of such intimation, the insurance company shall furnish the applicant, the Portability Form as set out in Annexure „I‟ to these guidelines together with a proposal form and relevant product literature on the various health insurance products which could be offered. 5.8 The policyholder shall fill in the portability form along with proposal form and submit the same to the insurance company. 5.9 On receipt of the Portability Form, the insurance company shall address the existing insurance company seeking necessary details of medical history and claim history of the concerned policyholder. This shall be done through the web portal of the IRDA. 5.10

The insurance company receiving such a request on portability shall furnish the

requisite data in the data format for porting insurance policies prescribed in the web portal of IRDA within 7 working days of the receipt of the request. 5.11

In case the existing insurer fails to provide the requisite data in the data format to the

new insurance company within the specified time frame, it shall be viewed as violation of directions issued by the IRDA and the insurer shall be subject to penal provisions under the Insurance Act, 1938. 5.12

On receipt of the data from the existing insurance company, the new insurance

company may underwrite the proposal and convey its decision to the policyholder in accordance with the Regulation 4 (6) of the IRDA (Protection of Policyholders‟ interest) Regulations, 2002. 5.13

If on receipt of data within the above time frame, the insurance company does not

communicate its decision to the requesting policyholder within 15 days in accordance with its underwriting policy as filed by the company with the Authority in accordance with clause 6 of IRDA Form R2 of IRDA (Registration of Indian Insurance Companies) Regulations, 2000 and clause 14-15 of F&U Guidelines (circular no. 021/IRDA/F&U/Sep. 06 dated 28th

September 2006), then the insurance company shall not retain the right to reject such proposal and shall have to accept the proposal. 5.14

In order to accept a policy which is porting-in, insurer shall not levy any additional

loading or charges exclusively for the purpose of porting. 5.15

No commission shall be payable to any intermediary on the acceptance of a ported

policy. 5.16

Portability shall be allowed in the following cases:

5.16.1 All individual health insurance policies issued by non-life insurance companies including family floater policies 5.16.2 Individual members, including the family members covered under any group health insurance policy of a non-life insurance company shall have the right to migrate from such a group policy to an individual health insurance policy or a family floater policy with the same insurer. Thereafter, he/she shall be accorded the right mentioned in 5.16.1 above. 5.17

For any health insurance policy, waiting period with respect to pre-existing diseases

and time bound exclusions shall be taken into account as follows:-

S. No

No of years of continuous insurance cover with previous insurer (s)

Waiting period to be served with new insurer in number of days/years

YY Days 1 Year I. XX Days at inception (XX- (YY-XX) N/A no of days as per the policy Days document)

2 years N/A

3 years N/A

4 years N/A

Nil

1 Year

2 Years

3 Years

N/A N/A

Nil Nil

1 Year Nil

2 Years 1 Year

3Years 2 Years

N/A N/A N/A

Nil Nil Nil

1 Year Nil Nil

2 Years 1 Year Nil

3 Years 2 Years 1 Year

II. For 1 year period exclusion: 1 year N/A III. For 2 year period exclusion: 1 year 2 years IV. For 3 year period exclusion: 1 year 2 years 3 years V. For 4 year period exclusion:

1 year 2 years 3 years 4 years

N/A N/A N/A N/A

Nil Nil Nil Nil

1 Year Nil Nil Nil

2 Years 1 Year Nil Nil

3 Years 2 Years 1 Year Nil

Note 1: In case the waiting period for a certain disease or treatment in the new policy is longer than that in the earlier policy for the same disease or treatment, the additional waiting period should be clearly explained to the incoming policy holder in the portability form to be submitted by the porting policyholder. Note 2: For group health insurance policies, the individual member‟s shall be given credit as per the table above based on the number of years of continuous insurance cover, irrespective of, whether the previous policy had any pre-existing disease exclusion/time bound exclusions 6.12

The portability shall be applicable to the sum insured under the previous policy and also to an

enhanced sum insured, if requested by the insured, to the extent of cumulative bonus acquired from the previous insurer(s) under the previous policies.

For e.g. - If a person had a SI of RS 2lakhs and accrued bonus of Rs 50, 000 with insurer A; when he shifts to insurer B and the proposal is accepted, insurer B has to offer him SI of Rs 2.50lakhs by charging the premium applicable for Rs 2.50lakhs. If insurer B has no product for Rs 2.50lakhs, insurer B would offer the nearest higher slab say Rs 3lakhs to insured by charging premium applicable for Rs 3lakhs SI .However, portability would be available only up to Rs 2.50lakhs. 5.18

Insurers shall clearly draw the attention of the policyholder in the policy contract and

the promotional material like prospectus, sales literature or any other documents in any form whatsoever, that: 5.18.1 all health insurance policies are portable; 5.18.2 policyholder should initiate action to approach another insurer, to take advantage of portability, well before the renewal date to avoid any break in the policy coverage due to delays in acceptance of the proposal by the other insurer. 5.19

The insurer shall comply with the “Guidelines on Procedures to Be Adopted by

Insurance Companies on Health Insurance Portability” annexed as Annexure II and as amended by the Authority from time to time.

Chapter VI File and Use Procedure for health insurance products 6.1 All new health insurance products are required to be filed as per the File and Use guidelines and the information shall be furnished in the formats stipulated by the Authority from time to time. 6.2 For any revision or modification of the existing health insurance products, the insurer shall file as per the formats stipulated by the Authority from time to time along with the reasons for the proposed modification. Chapter VII Protection of Policyholders’ Interest 7.1

The IRDA (Policyholder Protection of Interest) Regulations, 2002 (hereinafter referred as

“2002 Regulations” shall be applicable mutatis mutandis to all health insurance policies, wherever relevant. 7.2 Unless otherwise inconsistent with this sub-clause, Regulation 8 and 9 of the 2002 Regulations shall apply to all health insurance policies. 7.3 Settlement of claim: On receipt of complete documents, an insurer shall within a period of 30 days offer a settlement of the claim to the insured. If the insurer, for any reasons to be recording in writing and communicated to the insured, decides to reject a claim under the policy, it shall do so within a period of 30 days from the receipt of complete documents. 7.4 Timeline for Submission of claims documents: 7.4.1

Insurer may stipulate a time limit latest by which the claims documents should be furnished by the policyholder/insured to make a claim.

7.4.2

In case of non submission of timely submission of claims documents, insurers shall not repudiate such claims unless and until the reasons of delay are categorically enquired about, reasons recorded and the insurers sufficiently satisfy that the delayed claims could have otherwise been rejected if reported in time.

7.4.3

All insurers shall develop a sound mechanism of their own to handle such claims with utmost care and caution. The insurers shall incorporate additional wordings in the policy documents, suitably providing insurers‟ decision to condone delay on merit for

claims which are not submitted in time, but if substantiated by the insured that the delay is beyond his/her control and due to exceptional/ unavoidable circumstances. Chapter VIII Health Insurance Policy Servicing 8.1 Administration of Network Provider a. Subject to the provision of these regulations, the Network Provider may be subject to change from time to time by the insurer. b. The insurers shall inform the policy holders at all times, the nearest network provider where cashless facility is available and conditions, if any thereof. c. Insurer shall display and update the list of Network Providers on their website as and when the list of Network providers is modified and inform the insured suitably. d. Where a policyholder has been issued a pre-authorisation for the conduct of a given procedure in a given hospital or if the policyholder is already undergoing such treatment at a hospital, and such hospital is proposed to be removed from the list of Network Provider, then insurers shall provide the benefits of cashless facility for such policy holder as if such hospital continues to be on the Network Provider list. 8.2 For the purpose of claim settlement, insurer shall make direct payments to the Network provider and to the policyholders by integrating their banking system platform with the network provider or the insured, as the case may be. 8.2.1

Explanation: - This shall be applicable to claim settlement of all health insurance business. .

8.3 Administration of Health Plus Life Combi Products 8.3.1

The provisions of this regulation shall also be applicable mutatis mutandis to Health component of the Health Plus Life Combi Products.

8.3.2

The administration of all health plus life combi products shall be in accordance with the Annexure II, amended from time to time by the Authority.

8.4 Standard Pre-authorization and Claim form

8.4.1

All insurers shall adhere to the stipulated claim forms prescribed by the Authority, if any from time to time.

8.5 Identity Cards issued to policyholder to avail cashless facility 8.5.1

To avail the benefit of cashless facility, insurers shall issue the Identification card either through a TPA or directly, within 15 days from the date of issue of policy.

8.5.2

The identification card shall carry details of the policyholder and logo of the insurer. The validity of card shall not exceed the term of the policy. In case the policy is renewed, provisions to be established by the insurer to ensure there shall not be any need for re-issue of fresh cards provided there is no change in the details of the policyholder. Chapter IX Third Party Administrators

9.1 Health Services: 9.1.1

The insurer shall provide the health services required to the insured to process the claims either directly or may utilize the services of the TPA under an agreement, who are licensed to provide health services in accordance with the IRDA (Third Party Administrators) Regulations, 2002.

9.1.2

The Authority may modify or bring in additional requirements with respect to the provisions of the IRDA (Third Party Administrators) Regulations, 2002 from time to time.

9.2 Bar on Non-insurance healthcare schemes 9.2.1

The TPA shall offer the health services in accordance with the IRDA (Third Party Administrators) Regulations, 2002 only to the insurers registered in India and shall not provide any services directly to non-insurance healthcare schemes or health insurance schemes promoted, sponsored or approved either by any person or by Central or State government.

9.3 Agreement with insurance company

9.3.1

A copy of the agreement entered into between the TPA and the insurance company or any modification thereof, shall be filed, within 15 days of its execution or modification, as the case may be, with the Authority.

9.3.2

More than one TPA may be engaged by an insurance company and, similarly, a TPA can serve more than one insurance company.

9.3.3

The parties to the agreement shall agree between themselves on the scope of the contract and the facilities that have to be provided. Such an agreement shall also prescribe the remuneration that may be payable to the TPA by the insurance company.

9.3.4

Insurers who enter into agreement with unlicensed organizations or companies to act as TPA is outside the scope of the provisions of the Act and the regulations and the insurers as well as the organizations who style themselves as service providers would attract penalty under the provisions of the Act or regulations.

9.3.5

The Authority from time to time may prescribe minimum standard clauses to be included in the agreement between insurer and TPA.

9.4 Change of TPAs for servicing of Health Insurance Policies 9.4.1

A change in the TPA by the insurer shall be communicated to the policyholders 30 days before giving effect to the change.

9.4.2

The contact details like helpline numbers, addresses, etc. of the new TPA shall be made immediately available to all the policyholders in case of change of TPA.

9.4.3

The insurers shall take over all the data in respect of the policies serviced by the earlier TPA and make sure that the same is transferred seamlessly to the newly assigned TPA. It shall be ensured that no inconvenience or hardship is caused to the policyholders as a result of the change. In this regard, the following aspects shall receive special attention: a. Status of cases where pre-authorization has already been issued by existing TPA.

b. Status of cases where claim documents have been submitted to the existing TPA for processing. c. Status of claims where processing has been completed by the TPA and payment is pending with the insurer/ TPA. 9.4.4

Settlement /denial of claims:

9.4.5

TPA shall, in the correspondence to the policyholder with respect to settlement/denial of the claims, state clearly the following:

“As per the instructions of the insurer , the claim is being settled/denied for Rs. on account of . For any further clarifications, you may contact directly to the insurer.” 9.4.6

The above statement shall form the mandatory part of the communication to be sent to the policyholder in case of settlement /denial of the claims.

9.4.7

The insurer shall be responsible to see that proper and prompt service is extended to the policyholders at all times. Chapter X

10 Contracts between Insurer and Hospitals 10.1

All insurers shall have an agreement directly with the hospitals to establish the list of

Network providers. The insurer shall be responsible for carrying out an empanelment process of hospitals or health care providers to provide cashless facility to policyholder. 10.2

The insurer may include the TPA as a tri-party in the agreement with the hospital;

however, the entire responsibility lies with the insurer. 10.3

The insurer shall develop a proper system of empanelment of hospitals or health care

providers which summarizes the desired infrastructure for inpatient and day care services with respect to hospitals and other health facilities to be empanelled. This process shall be carried out by the insurer directly to ensure that the hospital are equipped with all the necessary infrastructure to enable the insurer to handle the claim in a seamless manner.

10.4

The insurance company shall ensure that adequate number of both public and private

providers shall be empanelled. They shall also make efforts that the empanelled providers are spread across different cities of the country and not confined only to metro cities. 10.5

The service agreements between the insurer and empanelled network Providers shall

make provisions for the tariff applicable with respect to various kinds of health care services, non-compliance/default clause while signing the same. 10.6

The insured shall have access to all the network providers of an insurer to avail

cashless facility as long as the insurer has a service agreement with the network provider and such network providers shall remain unchanged irrespective of change in TPAs. 10.7

Once a hospital or nursing home is empanelled, the insurer shall enter into arrangement

with other insurance companies for allowing sharing of network hospitals, transfer of claim & transaction data arising in areas beyond the service area. To ensure this, the insurer shall sign an agreement with other insurers so that beneficiaries can get seamless access of health care services across India. 10.8

The Authority from time to time may prescribe minimum standard clauses to be

included in the service agreement between insurer and Network provider. Chapter IX Submission of Information through Electronics Returns. 11.1Each insurer shall submit the information regarding health insurance business as specified in the forms in Annexure III for the period ending September and March of every financial year, within a period of one month from the last day of the respective month, commencing with the period ending September 30th (non-life insurer) and life insurers commencing from period beginning 1st April 11.2 The information shall be sent to Insurance Regulatory and Development Authority, 3rd Floor,

Parisrama

Bhavan,

Basheer

Bagh

HYDERABAD

500

004

Andhra Pradesh (INDIA ) in a compact disc, meeting the technical requirements as specified in the Data Manual annexed hereto. 11.3The forms in regulation 11.1 may be amended by the Authority from time to time, if required.

CHAPTER X 12 Valuation of Assets & Liabilities; Preparation of Financial Statements; Solvency Margin of Insurers and Other Issues 12.1All insurance companies carrying on health insurance business are required to comply, mutatis mutandis, all relevant regulations, directions, guidelines circulars issued by the Authority from time to time.

Annexure-I Portability Form Part-I 1)

Name of the Policyholder / insured (s)

2)

Date of Birth/Age

3)

Address of the policyholder/insured

4)

Details of existing insurer

5)

i.

Name of the product

ii.

Sum Insured

iii.

Cumulative Bonus

iv.

Add-ons/riders taken

v.

Policy number

Details of the proposed insurance i.

Name of the product proposed/intend to

ii.

take Sum Insured Proposed

iii.

Whether Cumulative Bonus to be converted to an enhanced sum insured 6) Reason(s) for portability 7) No. of family member to be included I the policy to be ported. Enclosure: Photocopy of the existing policy documents Date:

Signature of the policyholder

PART –II

1. Whether the PED exclusions / time bound exclusion have longer exclusion period than the existing policy: (Please indicate Yes / NO): 2. If yes, please give written consent to the declaration below: “I am aware that the waiting period for the following disease(s)/treatment(s) is ….. days/years more than the previous policy terms. I hereby agree to observe the additional waiting period for the following disease(s)/treatment(s) Signature of the policyholder

ANNEXURE -II Administration of Health Plus Life Combi Products 1) The product of this class shall be named as „Health plus Life Combi Products‟ referred as „Combi Products‟ hereinafter in these guidelines. 2) These guidelines do not apply to Micro Insurance Products which are governed by IRDA (Micro Insurance) Regulations, 2005. Guidelines:All insurance companies that promote „Health plus Life Combi products‟ shall adhere to the following guidelines 1) Scope of Combi Product Class: 1) The „Combi Products‟ may be promoted by all Life Insurance and Non-Life Insurance Companies. 2) The „Combi Product‟ shall be the combination of Pure Term Life Insurance cover offered by life insurance companies and Health Insurance cover offered by non life insurance companies. Health Insurance for the purpose of this product class means effecting of contracts which exclusively provide sickness benefits or medical, surgical or hospital expense benefits, whether in-patient or out-patient, on an indemnity or reimbursement basis. 3) The Policy Term and Sum Assured limits are as proposed and cleared under File and Use norms.

4) Riders / Add-on covers may be offered subject to File and Use clearance. 5) The premium components of both risks are to be separately identifiable and disclosed to the policyholders at both pre-sale stage and post-sale stage and in all documents like policy document, sales literature. 6) The product may be offered both as individual insurance policy and on group insurance basis. However in respect of health insurance floater policies, the pure term life insurance coverage is allowed on the life of one of the earning members of the family who is also the proposer on health insurance policy subject to insurable interest and other applicable underwriting norms of respective insurers. 7) The integrated premium amount of the „Combi Product‟ shall be basis for reckoning the threshold limit / applicability of extant Regulations, guidelines and circulars etc. issued by the Authority or any other statutory body. 8) Commission and Claim payouts in respect of „Combi Products‟ shall be by respective insurers only. 9) „Combi product‟ shall have a free look option as outlined in IRDA (Health Insurance Regulations) 2010. Free Look option is to be applied to the „Combi Product‟ as a whole. 10) The Health portion of the „Combi Product‟ shall entitle its renewability at the option of policy holder to have an independent / standalone health insurance policy from Non-Life Insurance Company

of

the

respective

„Combi

Product‟. 2) Tie up between insurers: 1) It is mandatory that insurance companies offering the „Combi Product‟ shall have in place a Memorandum of Understanding covering the modus operandi of marketing, policy service and sharing of common expenses. 2) Insurers forming the tie-up shall obtain prior approval of IRDA by duly filing the copy of the agreement entered in this regard. Approval may be obtained by any one of insurers. 3) A tie up is permitted between one life insurer and one non-life insurer only. Thus a life insurer is permitted to tie up with only one non-life insurer and vice-versa. 4) Between these two Insurers any number of „Combi Products‟ may be promoted. 5) It is expected that insurance companies would carry out an appropriate due diligence before establishing the business relationship for the purpose of promoting „Combi Products‟. Insurers are also expected to have a long-term understanding for effective policy service of the proposed „Combi Products‟.

6) Withdrawal from the tie-up is generally not desirable. However, in exceptional cases where insurers desire to withdraw from MOU they shall obtain prior permission of the Authority. 7) There shall be specific time frames / Turn around Times (TAT) to be agreed between the insurance companies as part of MOU for effective policy service, transmission of premiums received etc. at various stages of policy i.e., at pre-sale stage and post-sale stage. 3) Lead Insurer: 1) As two insurance companies are involved in offering the „Combi Product‟ one of the insurance companies may be mutually agreed to act as a lead insurer in respect of each „Combi Product‟ marketed with agreed terms, conditions and considerations. 2) The Lead Insurer for the purpose of these guidelines is the insurance company mutually agreed by both the insurers to play a critical role in facilitating the policy service as a contact point for rendering various services as required in these guidelines. It is envisaged that the lead insurer would play a major role in facilitating underwriting and policy service. 3) The role of lead insurer shall not deter in relying upon the existing operational infrastructure of the partner-insurance company for effective policy servicing of „Combi Products‟. 4) Either of the insurers are not absolved of their responsibility of proactive settlement of claims. 4) Underwriting: Under the „Combi Product‟, underwriting of respective portion of risk shall be underwritten by respective insurance companies, that is; Life Insurance risk shall be underwritten by Life Insurance Company and the Health Insurance portion of risk to be underwritten by Non-Life Insurance Company. 5) File and Use: 1) Both the independent products shall be integrated as a single product and filed with a common brand name. 2) Insurers may also utilize the existing insurance products „as it is without modifications‟ that are already cleared under the extant File and Use norms by the Authority. 3) „Combi Product‟ is to be filed at the stage of integrating for getting File and Use approval irrespective of the earlier approval to either of products. 4) „Combi Product‟ filing shall follow the File and Use guidelines in vogue and all such guidelines that would be issued from time to time. 5) „Combi Product‟ is to be filed with Actuarial Department of Authority in File and Use formats that are in vogue. 6) The Combi Product shall be approved by the Authority at File and Use.

7) The File and Use application of the „Combi Product‟ shall also specify the following:a. Lead Insurer for the „Combi Product‟ and demarcation of functions between insurers for carrying out activities:b.

Procedures proposed for issuance of the premium notices, where applicable and final lapse notices in terms of Section 50 of the Insurance Act, 1938.

c. Where the servicing is to be necessarily attended by the original insurer, the lead insurer shall facilitate the policy servicing. As far as the policyholder is concerned lead insurer shall be made as the single nodal point for receiving the servicing requests, fulfilling the services and issuing acknowledgements. d. Results of feasibility study, if any, in giving a limited access to the policydata base of policies for effecting over-the-counter policy service requests to the lead insurer. e. Lead insurer in settlement of claims shall ensure:i) Based on the type of claim, the other insurer shall also take proactive measures for settlement of claims. ii) As far as health portion of „Combi Policies‟ are concerned, they may be serviced by Third Party Administrators. iii) Where the policies are serviceable directly, the lead insurer shall play a facilitative role. iv) Lead insurer may not to guarantee the settlement of claim on behalf of the other insurer. The risks accepted by one insurer under „Combi Product‟ shall not affect the business of other insurance company. v) The operational procedures proposed to be put in place for timely dispatch of the policy bond of „Combi Products‟. f. Filing the advertisements in accordance with IRDA (Insurance Advertisements and Disclosures) Regulations, 2000 within 30 days from the date of issuing the advertisement with Authority. g. Proposed procedures for obtaining the prior approval of IRDA for issuing Joint Sale Advertisements along with the common corporate agents. h. The results of the cost benefit analysis carried out by both the insurers. i. The modus operandi of proposed policy service at various stages of the policy viz., proposal stage, policy servicing, premium collection arrangements and claims service etc.

j. The Information Technology systems put in place for supporting the sale and policy service of the „Combi Products‟. k. Agreement on reimbursement of expenses in consideration of common services rendered by each other of insurance companies. Distribution Channel wise maximum commission allowed under the „Combi Products‟.

l.

m. The manner in which premium is proposed to be collected subject to provisions of Section 64 VB of Insurance Act, 1938. n. The procedures put in place for expeditious transfer of the portion of premium that pertains to the other insurer of the product. o. Operational procedures put in place for updating premium on policy data base on a real time basis. p. Proposal forms to be used for „Combi Products‟ q. The Terms and Conditions under which the Health portion of the „Combi Product‟ entitles its renewability at the option of policy holder to have an independent / standalone health insurance policy from Non-Life Insurance Company of the respective „Combi Product‟. r. Options available to policyholders of „Combi Products‟ to discontinue either portion of risk coverage while continuing with the other portion. s. Copy of proposed common Sales Literature / Sales Illustrations to be issued by both the insurers in respect of „Combi Products‟. Common Advertisements of „Combi Products‟ shall be restricted to the features, terms

t.

and conditions of the „Combi Product‟. 6) Distribution Channel: 1) The sale of „Combi Product‟ shall be through:a. Direct Marketing channels b. Brokers and c. Composite Individual and Corporate Agents, common to both insurers 2) „Combi Products‟ are not allowed to be marketed through „Bank Referral‟ arrangements. 3) Insurers shall ensure that the „Combi Product‟ is not marketed by those insurance intermediaries who are not authorized to market either of the products of either of the insurers. 7) Mandatory Minimum Disclosures: 1) The mandatory minimum disclosures for a Combi Product shall be;

a) The product is jointly offered by abc insurance company (specify non-life insurer name) and xyz insurance company (specify life insurer name) b) The risks of this „Combi Product‟ are distinct and are assumed / accepted by respective insurance companies. c) The liability to settle the claim benefits vests with respective insurers that is for health insurance benefits abc insurance company (specify non-life insurer name) and for life insurance benefits xyz insurance company (Specify life insurer name) d) The legal/quasi legal disputes, if any, shall be dealt with the respective insurers for respective benefits e) The policy holders of the „Combi Product‟ under reference shall be eligible to continue with either part of the policy discontinuing the other during the policy term. f) Where guaranteed renewability of health insurance plan is allowed, the health insurance portion of this „Combi Product‟ is entitled to that facility g) Specific Disclosures on the available premium payment options on these „Combi Products‟. h) Specific Disclosures about the available Policy Servicing facilities for these „Combi Products‟. i) Specific Disclosures about the proposed claims service of these policies under both the risks. j) Specific Disclosures on the availability of services of „Third Party Administrators (TPAs)‟ for health insurance portion of risk, if available. k) Specific Disclosures on the available Grievances Redressal Options including particulars of Ombudsman under these „Combi products‟. l) Policyholders are to be advised to familiarize themselves with the policy benefits and policy service structure of the „Combi Product‟ before deciding to purchase the policy. 2) Policy documents of „Combi Products‟ shall contain the above referred points c, d, e, f, g, h, i and k as minimum disclosures. 3) Declaration from the prospect shall be obtained and attached to proposal form that he / she has understood the disclosures mentioned at a), b), h) and i) above. 8) In respect of „Combi Products‟ both the insurers shall comply with the provisions Insurance Act, 1938 and Regulations notified there under and other guidelines, circulars that are applicable to health insurance business and life insurance business respectively. 9) For the purpose of these guidelines non-life insurance company includes standalone health insurance Company also.

10) In order to monitor the progress of the penetration of the product class before enlarging the scope of the same all insurance companies that are marketing „Combi Products‟ shall submit the information that is required by the Authority from time to time. 11) The Authority may stipulate such other terms and conditions from time to time for monitoring activities of insurance companies offering „Combi Products‟.

Annexure-III

Data Format – Life Insurer All data submitted must be in ASCII format. DATA FIELD HEADING FIELD

HEALTH DATA DICTIONERY FIEL FIELD D DATA DICTIONAR TYPE SIZE Y REFERENCE

1

Txt_TPA_Code

Text

5

150001

2

Txt_Insurer_Code

Text

3

150002

3

Txt_U_W_Office_Code

Text

20

150003

4

Txt_Policy_Number

Text

50

150004

5

Txt_Member_Reference_ Key

Text

50

150005

6

Date_Of_Birth

Date

10

150006

7

Num_Age_Of_Insured

Numeric

3

150007

8

Date_Policy_Start

Date

10

150008

9

Date_Policy_End

Date

10

150009

10

Boo_Pre-Existing_Diseases _Covered

Boolean

1

150012

Remarks

Please enter TPA Registration number. Please refer "TPA Master" attached Please enter Insurer Registration number. Please refer "Insurer Master" attached Branch/ Divisional Office Code or Name as available. If Branch/ Division not applicable, enter '0' Self explanatory TPAs & Insurers should ensure that the Member Reference Key (MRK) is a unique number denoting each individual member. Date of birth of the insured member dd/mm/yyyy Completed years at commencement of policy Date of commencement of policy dd/mm/yyyy Date of expiry of policy dd/mm/yyyy If Pre-Existing Diseases are covered, enter '1', other wise enter '0'

DATA FIELD HEADING

FIELD

FIELD

TYPE

11

FIEL D

DATA DICTIONAR SIZE Y REFERENCE

Remarks

Boo_Waiver_Of_1St_Year_ Exclusion Boo_Maternity_Cover

Boolean

1

150013

Boolean

1

150014

Boo_Baby_Cover_As_Part_ Of_ Maternity Boo_Floater_Applicable

Boolean

1

150015

Boolean

1

150016

15

Num_Corporate_Floater_Su m_ Insured

Numeric

16

150017

16

Num_Group_Size

Numeric

8

150018

17

Txt_Gender

Text

1

150019

18

Num_Sum_Insured

Numeric

16

150020

19

Txt_Relationship_Of_Insured

Text

2

150021

Individual Hospitalisation Sum Insured. Specific Sum Insured for the Member excluding any Floater or Bonus Sum Insured. Refer Relationship Master

20

Txt_Occupation

Text

3

150022

Refer Occupation Master

21

Num_Policy_Premium

Numeric

16

150023

22

Num_Individual_Premium

Numeric

16

150024

23

Txt_Claim_Number

Text

20

150025

24

Txt_Diagnosis_Code_Primary

Text

20

150027

25

Txt_Procedure_Description_ Primary Txt_Name_Of_The_Hospital

Text

50

150028

Text

50

150029

Premium on which Service Tax is calculated. For 'Universal Health Type policies, premium will be 'Net Final Premium' inclusive of all subsidies. Individual Premium on which Service Tax is calculated. (If available) Unique number generated by TPA ICD-10 Code applicable for disease - Primary diagnosis. Description of procedure Primary procedure Full Name of Hospital

Text

20

150030

28

Txt_Registration_Number_Of _ Hospital Txt_Pan_Of_Hospital

Text

20

150031

29

Txt_Pin_Code_Of_Hospital

Text

10

150032

30

Date_Of_Admission

Date

10

150033

12 13 14

26 27

If this exclusion is waived, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If floater is applicable enter '1', otherwise enter '0' Buffer amount - (Amount that floats over entire policy) Applicable only for Corporate Floater Policies Number of members in the group 1-Male, 2- Female, 3- Others

Registration Number allotted by appropriate authority, if available Income Tax Perrmanent Account Number of hospital 6 digit Postal Pin Code. Refer Pincode Master Self explanatory dd/mm/yyyy

DATA FIELD HEADING

FIELD

FIELD

TYPE

FIEL D

DATA DICTIONAR SIZE Y REFERENCE

Remarks

31

Date_Of_Discharge

Date

10

150034

Self explanatory dd/mm/yyyy

32

Num_Total_Amount_Claimed

Numeric

16

150035

33

Num_Room_&_Nursing_ Charges_ Claimed

Numeric

16

150036

34

Num_Surgery_Charges_ Claimed

Numeric

16

150037

35

Num_Consultation_Charges _Claimed

Numeric

16

150038

36

Num_Investigation_Charges _Claimed

Numeric

16

150039

37

Num_Medicine_Charges_Cl aimed

Numeric

16

150040

38

Num_Miscellaneous_Charges _Claimed

Numeric

16

150041

39

Num_Pre_Hospitalisation_ Expenses_Included_Under_ 150035_Claimed

Numeric

16

150042

Total amount claimed for the particular incident without any bifurcation (Include amounts under various subdivisions from 150036 to 150043 and 150085, 150120,150121) Amount Claimed classified as Room & Nursing Charges incurred between date of admission and discharge. Inclusive of ICU charges, patient diet, HVAC and other room chanrges Amount Claimed classified as Surgery Charges incurred between date of admission and discharge. including Surgeon/ Asstt. Surgeon/ Anesthestist fees but Excluding OT charges Amount Claimed classified as Consultation Charges incurred between date of admission and discharge, exclusing Surgery Charges. Amount Claimed classified as Investigation Charges incurred between date of admission and discharge. Amount Claimed classified as Medicine Charges incurred between date of admission and discharge. All unspecified expenses incurred between date of admission and discharge, other than those claimed above. Total amount claimed for prehospitalisation treatment without any bifurcation.

40

Num_Post_Hospitalisation_ Expenses_Included_Under_ 150035_Claimed

Numeric

16

150043

Total amount claimed for posthospitalisation treatment without any bifurcation

41

Num_Total_Claim_Paid

Numeric

16

150046

Total amount of claim paid for the particular incident without any bifurcation (on amounts claimed under various subdivisions from 150036 to 150043, 150085, 150120,150121)

DATA FIELD HEADING

FIELD

FIELD

TYPE

FIEL D

DATA DICTIONAR SIZE Y REFERENCE

Remarks

42

Txt_Reason_For_Rejection_ Of_ Claim

Text

3

150047

Refer Rejection/ Reduction Master

43

Num_Floater_Amount

Numeric

16

150048

44

Txt_Remarks_Of_TPA

Text

50

150049

If 150016 is "1", amount to be filled up in case of "Proposer" or "Employee" only. In all other cases, leave blank. Remarks of TPA

Boolean

1

150050

Boolean

1

150051

Boolean

1

150052

48

Boo_Baby_Cover_From_ Date_Of_ Birth Boo_Ambulance_Cover

Boolean

1

150053

49

Boo_Health_Check_Up

Boolean

1

150054

50

Boolean

1

150055

Text

20

150056

Text

20

150057

Text

50

150059

54

Boo_Any_Pre_Existing_ Diseases_ Declared Txt_Pre_Existing_Diseases_ Code_ Primary Txt_Diagnosis_Code_ Additional Txt_Procedure_Code_ Additional Txt_Medical_History

Text

255

150061

55

Txt_Hospital_Code

Text

20

150062

56

Boo_Policy_Or_Endorsement

Boolean

1

150063

57

Txt_Endorsement_Number

Text

50

150064

58

Txt_Procedure_Code_Primary

Text

50

150065

Text

50

150066

Text

20

150068

Text

3

150072

3

150073

45 46 47

51 52 53

59 60 61 62

Boo_Post_Hospitalization_ Beyond_60_Days_Is_Covered Boo_Out_Patient_Cover

Txt_Procedure_Description_ Additional Txt_Pre_Existing_Diseases_ Code_ Additional Txt_Reason_For_Reduction _Of_ Claim Txt_Type_Of_Claim_PaymentText

If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If declared, enter '1', otherwise enter '0' Refer 'Top 20 PED Master' for disease - Primary level ICD-10 Code applicable for disease - additional diagnosis ICD 10 PCS Codes - additional procedure Medical History - as given in claims documents Refer Unique Id for hospital in Hospital Master If Policy, enter '1', if Endorsement enter '0'. Self explanatory ICD 10 PCS Codes - Primary prodcedure Description of procedure - any additional procedure Refer 'Top 20 PED Master' for disease - Additional, if any Refer Rejection/ Reduction Master Refer Claim Payment Type Master

DATA FIELD HEADING

FIELD

FIELD

TYPE

FIEL D

DATA DICTIONAR SIZE Y REFERENCE

Remarks

63

Num_Family_Floater_Sum_ Insured

Numeric

16

150074

64

Num_Declaration_Floater_ Sum_ Insured

Numeric

17

150075

65

Boo_Maternity_Cover_Given _With_A_ Waiting_Period Txt_Endorsement_Type

Boolean

1

150080

Text

3

150081

67

Boo_Claim_Made_Under_ Alternate_ Medicine

Boolean

1

150082

68

Txt_System_Of_Medicine_ Used Boo_Hospital_Is_Networked

Text

3

150083

Boolean

1

150084

70

Num_Other_Non_Hospital_ Expenses

Numeric

16

150085

71

Num_Amount_Of_Co_Payme nt_Or_Access_If_Applicable

Numeric

16

150086

72

Num_Opening_Claims_Outs tanding_As_ On_31_3_2008

Numeric

12

150089

73

Num_Claims_Paid_During_T he_Period_1- 4-2008_To_ 31_3_2009 Num_Closing_Claims_Outst anding_As_ On_31_3_2009

Numeric

12

150090

Amount of total of all claims paid during the Financial Year

Numeric

12

150091

Amount of Claims outstanding at the end of Financial Year

75

Txt_Metro_Nonmetro_Urban _Rural

Text

1

150092

76

Date_Of_Payment

Date

10

150093

Whether policy holder location is 1=Metro, 2=Urban other than metro and 3=Rural. Metros are 4 metros including Banglore and Hyderabad. Date of cheque issued/cash paid to the insured in dd/mm/yyyy

77

Txt_Payment_Reference_ Number Boo_Policy_Having_CoInsurance Num_Your_Co_Insurance_ Share

Text

25

150094

Boolean

1

150095

Numeric

6

150096

66

69

74

78 79

Buffer amount - (Amount that floats over entire policy) Applicable only for Family Floater Policies Buffer amount - (Amount that floats over entire policy) Applicable only for Declaration Floater Policies If covered with waiting period, enter '1', otherwise enter '0' Refer Endorsement Type Master If claim is under alternate medicine, enter '1', if not enter '0' Refer System of Medicine Code Master If hospital is networked, enter '1', if not enter '0' All non-hosptital expenses claimed as part of the claim e.g. telephone charges, attendent food etc. If applicable on a lumpsum basis, state amount of copayment or excess applicable. Amount of Claims outstanding at the beginning of Financial Year

Payment Reference Number allotted by TPA/Insurer If Policy is with Co-Insurance, enter '1' otherwise enter '0' If Co-Insurance is there, mention your share in percentage (nnn.nn). If no Co-Insurance, mention 100.

DATA

FIELD HEADING

FIELD

FIELD TYPE

FIEL D

DATA DICTIONAR SIZE Y REFERENCE

Remarks

80

Date_Member_Entry

Date

10

150097

81

Date_Member_Exit

Date

10

150098

82

Date_Claim_Intimation

Date

10

150099

Member's entry date into policy dd/mm/yyyy Member's exit date from policy dd/mm/yyyy Date on which claim is intimated

83

Num_Bonus_Sum_Insured

Numeric

16

150100

Sum Insured added as Bonus.

84

Txt_Unq_Product_Code

Text

20

150101

85

Txt_Coverage_Scope

Text

30

150102

Give File & Use Product Code issued by IRDA Refer Coverage Scope Master

86

Txt_Payout_Basis

Text

3

150103

Refer Payout Basis Master

87

Txt_Insured_Type

Text

3

150104

Refer Insured Type Master

88

Txt_Policy_Term

Text

3

150105

Enter Policy period in years

89

Txt_Contract_Acceptance_ Special_ Term

Text

255

150106

90

Boo_Type_Of_Premium

Boolean

1

150107

Mention contract acceptance terms of the product and policy type If 1st time premium, enter '1' else enter '0' for Renewal premium.

91

Txt_Other_Co-Insurance_ Share Num_Premium_Discount

Text

50

150108

Numeric

16

150109

93

Boo_Whether_Sub_Standard _Cases

Boolean

1

150110

94

Txt_Sub_Standard_Cases

Text

50

150111

95

Txt_If _Ped_Code_Is_99_ Description

Text

50

150112

96

Txt_Reason_For_ Hospitalisation

Text

3

150113

97

Txt_Reason_For_Injury

Text

3

150114

98

Txt_Master_Claim_Id

Text

20

150115

92

Provide name of Co-Insurer and their share in free text Mention discount amount on premium Not Coverable as a normal case/rates, but covered as a special case. If Sub_Standard Case, enter '1', otherwise enter '0'. If 150110 is '1' then Mention substandard cases details If PED code is 99 i.e. others, provide description of the preexisting disease Enter 1 for Illness, 2 for Injury and 3 for Maternity If field 150113 is Injury, Enter '1' for Alcohal Consumption or 2 ro Sabstance Abyse. Provide master claim id/no. In case of multiple payments made under of single incident of claim, a master id should be given and subsequent payments should contain child number.

DATA FIELD HEADING

FIELD

FIELD

TYPE

FIEL D

DATA DICTIONAR SIZE Y REFERENCE

99

Txt_Child_Claim_Id

Text

20

150116

100

Txt_Treating_Doctor_ Registration_ Number

Text

50

150117

101

Txt_Type_Of_Admission

Text

3

150118

102

Txt_Details_Of_Lumpsum_ Or_Cash_ Benefit_Claimed

Text

3

150119

103

Txt_Room_Category_ Occupied

Text

3

150120

104

Num_Professional_Charges _Claimed

Numeric

16

150121

105

Num_ot_Charges_Claimed

Numeric

16

150122

106

Num_Surgical_Implant Charges_Claimed

Numeric

16

150123

107

Num_Room_&_Nursing_ Charges_ Paid

Numeric

16

150124

108

Num_Surgery_Charges_ Paid

Numeric

16

150125

109

Num_Professional_Charges _Paid

Numeric

16

150126

110

Num_Consultation_Charges _Paid

Numeric

16

150127

111

Num_Investigation_Charges _Paid

Numeric

16

150128

Remarks

Provide child claim id/no. under master claim id/no. above Provide Registration number of the Medical Practitioner caring for the patient during hospitalisation Enter 1 for emergency, 2 for Planned, 3 for Day Care Enter 1 - Hospital Daily Cash, 2 for Surgical Cash, 3 for Critical Illness benefit, 4 for Covalescence, 5 for Pre/Post Hospitalisation Lumpsum Benefit and 99 for Others. Enter 1 for Single bed, 2 for Twin Sharing, 3 for three or more beds and 4 Day care This field will contain Surgeon/ Asstt. Surgeon/ Anaesthesist Charges Claimed Amount Claimed classified as Operation Theatre Charges incurred between date of admission and discharge. Amount Claimed classified as Surgical Implant Charges incurred between date of admission and discharge. Claim amount paid classified as Room & Nursing Charges between date of admission and discharge.Inclusive of ICU charges, patient diet, HVAC and other room chanrges Claim amount paid classified as Surgery Charges incurred between date of admission and discharge. including Surgeon/ Asstt. Surgeon/ Anesthestist fees but Excluding OT charges This field will contain Surgeon/ Asstt. Surgeon/ Anaesthesist Charges Paid Claim amount paid classified as Consultation Charges between date of admission and discharge., exclusing Surgery Charges. Claim amount paid classified as Investigation Charges between date of admission and discharge.

DATA FIELD HEADING

FIELD

FIELD

TYPE

112

FIEL D

DATA DICTIONAR SIZE Y REFERENCE

Remarks

Num_ot_Charges_Paid

Numeric

16

150129

113 Num_Medicine_Charges_Paid

Numeric

16

150130

114

Num_Surgical_Implant_ Charges_Paid

Numeric

16

150131

115

Num_Miscellaneous_Charges _Paid

Numeric

16

150132

116

Num_Pre_Hospitalisation_E xpenses_Included_Under_1 50046_Paid Num_Post_Hospitalisation_ Expenses_Included_Under_ 150046_Paid Num_Co_Payment_ Dedcuctible

Numeric

16

150133

Numeric

16

150134

Numeric

16

150135

119

Date_of_Receipt_Of _Complete_Claim_Document

Date

10

150136

Enter Date on which full claim documents are received.

120

Boo_Whether_Claim_Paid_ for_ PED

Boolean

1

150137

121

Txt_If_Yes_PED_Code

Text

3

150138

If claim paid is for Pre_Existing_Diseases, Enter '1', if not enter'0'. If field 150134 is '1', enter PED code from PED Master.

117

118

Claim amount paid classified as Operation Theatre Charges between date of admission and discharge. Claim amount paid classified as Medicine Charges between date of admission and discharge. Claim amount paid classified as Surgical Implant Charges between date of admission and discharge. All unspecified expenses paid between date of admission and discharge, other than those paid above. Total amount paid for prehospitalisation treatment without any bifurcation. Total amount paid for posthospitalisation treatment without any bifurcation Provide Co-Payment Dedcuctible Amount.

HEALTH L1 - POLICY FORMAT DATA FIELD HEADING FIEL D

FIELD TYPE

FIEL D

DATA

SIZE DICTIONARY REFERENCE

1

Txt_TPA_Code

Text

5

150001

2

Txt_Insurer_Code

Text

3

150002

3

Txt_U_W_Office_Code

Text

20

150003

4 5

Txt_Policy_Number Txt_Unq_Product_Code

Text Text

50 20

150004 150101

6

Date_Policy_Start

Date

10

150008

41

REMARKS

Please enter TPA Registration number. Please refer "TPA Master" attached Please enter Insurer Registration number. Please refer "Insurer Master" attached Branch/ Divisional Office Code or Name as available. If Branch/ Division not applicable, enter '0' Self explanatory Give File & Use Product Code issued by IRDA Date of commencement of policy dd/mm/yyyy

7

Date_Policy_End

Date

10

150009

Date of expiry of policy dd/mm/yyyy

8 9 10 11 12

Text Text Text Text Text Boolean

30 3 3 3 25 5 1

150102 150103 150104 150105 150106

13

Txt_Coverage_Scope Txt_Payout_Basis Txt_Insured_Type Txt_Policy_Term Txt_Contract_Acceptance_ Special_Term Boo_Type_of_Premium

Refer Coverage Scope Master Refer Payout Basis Master Refer Insured Type Master Enter Policy period in years Mention contract acceptance terms of the product and policy type If 1st time premium, enter '1' else enter '0' for Renewal premium.

14

Num_Policy_Premium

Numeric

16

150023

15

Boo_Post_Hospitalization_ beyond_ 60_days_is_Covered

Boolean

1

150050

16

Boo_Out_patient_cover

Boolean

1

150051

17

Boo_Baby_Cover_from_Date_of _Birth

Boolean

1

150052

18

Boo_Ambulance_Cover

Boolean

1

150053

19

Boo_Health_Check_Up

Boolean

1

150054

20

Boo_Policy_or_Endorsement

Boolean

1

150063

Text Text Boolean

50 3 1

150064 150081 150095

Numeric

6

150096

Text

50

150108

21 22 23

Txt_Endorsement_Number Txt_Endorsement_Type Boo_Policy_having_CoInsurance 24 Num_Your_Co_Insurance_Share

25

Txt_Other_Co-Insurance_Share

150107

Premium on which Service Tax is calculated. For 'Universal Health Type policies, premium will be 'Net Final Premium' inclusive of all subsidies. If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If Policy, enter '1', if Endorsement enter '0'. Self explanatory Refer Endorsement Type Master If Policy is with Co-Insurance, enter '1' otherwise enter '0' If Co-Insurance is there, mention your share in percentage (nnn.nn). If no Co-Insurance, mention 100. Provide name of Co-Insurer and their share in free text

HEALTH L2 - MEMBER FORMAT DAT A FIEL D

FIELD HEADING

FIELD TYPE

FIEL D

DATA

SIZE DICTIONARY REFERENCE

1

Txt_TPA_Code

Text

5

150001

2

Txt_Insurer_Code

Text

3

150002

3

Txt_U_W_Office_Code

Text

20

150003

4

Txt_Policy_Number

Text

50

150004

5

Txt_Unq_Product_Code

Text

20

150101

6

Date_Policy_Start

Date

10

150008

42

Remarks

Please enter TPA Registration number. Please refer "TPA Master" attached Please enter Insurer Registration number. Please refer "Insurer Master" attached Branch/ Divisional Office Code or Name as available. If Branch/ Division not applicable, enter'0' Self explanatory Give File & Use Product Code issued by IRDA Date of commencement of policy

dd/mm/yyyy 7

Date_Policy_End

Date

10

150009

Date of expiry of policy dd/mm/yyyy

8 9

Txt_Endorsement_Number Txt_Member_Reference_Key

Text Text

50 50

150064 150005

10

Date_of_Birth

Date

10

150006

11

Num_Age_of_Insured

Numeric

3

150007

12

Boo_Pre-existing_Diseases_ Covered Boo_Waiver_of_1st_Year_ Exclusion Boo_Maternity_Cover

Boolean

1

150012

Boolean

1

150013

Boolean

1

150014

Boo_Baby_Cover_as_Part_of_ Maternity Boo_Floater_Applicable

Boolean

1

150015

Boolean

1

150016

17

Num_Corporate_Floater_Sum_ Insured

Numeric

16

150017

Self explanatory TPAs & Insurers should ensure that the Member Reference Key (MRK) is a unique number denoting each individual member. Date of birth of the insured member dd/mm/yyyy Completed years at commencement of policy If Pre-Existing Diseases are covered, enter '1', otherwise enter '0' If this exclusion is waived, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If floater is applicable enter '1', otherwise enter '0' Buffer amount - (Amount that floats over entire policy) Applicable only for Corporate Floater Policies

18 19 20

Num_Group_Size Txt_Gender Num_Sum_Insured

Numeric Text Numeric

8 1 16

150018 150019 150020

21

Txt_Relationship_of_Insured

Text

2

150021

Number of members in the group 1-Male, 2- Female, 3- Others Individual Hospitalisation Sum Insured. Specific Sum Insured for the Member excluding any Floater or Bonus Sum Insured. Refer Relationship Master

22

Txt_Occupation

Text

3

150022

Refer Occupation Master

13 14 15 16

Data Format-Non life Insurer All data submitted must be in ASCII format. HEALTH DATA DICTIONERY DATA FIELD

FIELD HEADING

FIELD TYPE

1

Txt_TPA_Code

Text

5

150001

2

Txt_Insurer_Code

Text

3

150002

3

Txt_U_W_Office_Code

Text

20

150003

4 5

Txt_Policy_Number Txt_Member_Reference_ Key

Text Text

50 50

150004 150005

43

FIELD SIZE

DATA DICTIONARY REFERENCE

REMARKS

Please enter TPA Registration number. Please refer "TPA Master" attached Please enter Insurer Registration number. Please refer "Insurer Master" attached Branch/ Divisional Office Code or Name as available. If Branch/ Division not applicable, enter '0' Self explanatory TPAs & Insurers should ensure that the Member Reference Key (MRK) is a unique number denoting each individual member.

6

Date_of_Birth

Date

10

150006

7

Num_Age_of_Insured

Numeric

3

150007

8

Date_Policy_Start

Date

10

150008

9

Date_Policy_End

Date

10

150009

Date of birth of the insured member as dd/mm/yyyy Completed years at commencement of policy Date of commencement of policy as dd/mm/yyyy Date of expiry of policy as dd/mm/yyyy

10 11

Txt_Product_Type Txt_Type_of_Policy

Text Text

3 3

150010 150011

Refer Product Type Master Refer Policy Type Master

FIELD HEADING

FIELD TYPE

Boo_Pre-existing_Diseases _Covered Boo_Waiver_of_1st_Year_ Exclusion Boo_Maternity_Cover

Boolean

1

150012

Boolean

1

150013

Boolean

1

150014

Boo_Baby_cover_as_part_of _ Maternity Boo_Floater_applicable

Boolean

1

150015

Boolean

1

150016

17

Num_Corporate_Floater_ Sum_ Insured

Numeric

16

150017

18 19 20

Num_Group_Size Txt_Gender Num_Sum_Insured

Numeric Text Numeric

8 1 16

150018 150019 150020

21 22 23

Txt_Relationship_of_Insured Txt_Occupation Num_Policy_Premium

Text Text Numeric

20 20 16

150021 150022 150023

24

Num_Individual_Premium

Numeric

16

150024

25

Txt_Claim_Number

Text

20

150025

27

Text

20

150027

Text

50

150065

Text Text

50 20

150029 150030

31

Txt_Diagnosis_Code_ Level _I Txt_Procedure_Code_ Level_I Txt_Name_of_the_Hospital Txt_Registration_Number_of _ Hospital Txt_PAN_of_Hospital

Text

20

150031

32

Txt_Pin_Code_of_Hospital

Text

10

150032

33 34

Date_of_Admission Date_of_Discharge

Date Date

10 10

150033 150034

DATA FIELD

12 13 14 15 16

28 29 30

44

FIELD SIZE

DATA DICTIONARY REFERENCE

REMARKS

If Pre-Existing Diseases are covered, enter '1', other wise enter '0' If this exclusion is waived, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If this cover is given, enter '1', otherwise enter '0' If floater is applicable enter '1', otherwise enter '0' Buffer amount - (Amount that floats over entire policy) Applicable only for Corporate Floater Policies Number of members in the group 1-Male, 2- Female, 3- Others Individual Hospitalisation Sum Insured. Specific Sum Insured for the Member excluding any Floater or Bonus Sum Insured. Refer Relationship Master Refer Occupation Master Premium on which Service Tax is calculated. For 'Universal Health Type policies, premium will be 'Net Final Premium' inclusive of all subsidies. Individual Premium on which Service Tax is calculated. (If available) Unique number generated by TPA ICD-10 Code applicable for disease Primary level. ICD 10 PCS Codes - Primary level Full Name of Hospital Registration Number allotted by appropriate authority, if available Income Tax Permanent Account Number of hospital, if available 6 digit Postal Pin Code. Refer Pin code Master Self explanatory as dd/mm/yyyy Self explanatory as dd/mm/yyyy

Loading...

health insurance

EXPOSURE DRAFT INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY (HEALTH INSURANCE) REGULATIONS, 2012 Contents 1. Chapter 1 – Short Title and Commence...

965KB Sizes 7 Downloads 25 Views

Recommend Documents

Health Insurance Underwriting Guidelines | Health Insurance News
Health Insurance Underwriting Guidelines from Blue Cross Blue Shield, Cigna, Aetna, and Humana. ... I am not sure as it

Health Insurance
prices, backed up by a network of over 5000+ hospitals, and come with features like. Enhanced No Claim Bonus, flexible p

New jubilee health insurance panel hospital etiqa - Health Insurance
Jul 19, 2017 - In addition, the new jubilee health insurance panel compare health insurance grand rapids mn hotels hospi

New jubilee health insurance panel hospital aia - Health Insurance
Mar 7, 2017 - By the time you've practiced a new jubilee health insurance panel hospital aia few times, you'll see a big

Best Health Insurance | Health Insurance Quotes | AIA NZ - AIA FSN
Protect You And Your Family Against Some Of The Major Health Issues In New Zealand With AIA Insurance. Call 0800 800 242

Health Insurance Jobs in Mumbai - Health Insurance Openings in
Apply to 1377 Health Insurance Jobs in Mumbai on Naukri.com, India's No.1 Job Portal. Explore Health Insurance job openi

Billing & Insurance - Cone Health
Contact Us. Get answers to your questions about billing and financial assistance. ... Cone Health recently partnered wit

Mandatory Private Health Insurance
compensate insurers for any financial disadvantage they incur in insuring high-risk individuals. Dutch law also provides

Common Health Insurance Terms
MassHealth - A program providing comprehensive health insurance coverage and other assistance to certain low-income and

HEALTH INSURANCE CLAIM FORM
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the