IRDAI Health Insurance Guidelines
Definition
IRDAI (Insurance Regulatory and Development Authority of India) has issued comprehensive guidelines to standardize health insurance practices across all insurers. Key regulations include mandatory portability, standardized exclusions, maximum waiting period caps, claim settlement timelines, and the creation of standard health products like Arogya Sanjeevani.
Explanation in Simple Language
IRDAI's health insurance guidelines aim to protect policyholders from unfair practices. Key regulations include: Portability — policyholders can switch insurers without losing waiting period credits. Claim settlement — insurers must settle cashless claims within 4 hours (for pre-authorized cases) and reimbursement claims within 30 days of receiving all documents. Standardized exclusion list — IRDAI has published a list of permanent exclusions (cosmetic, obesity, etc.) applicable to all insurers.
Arogya Sanjeevani is IRDAI's standard health product that every insurer must offer with identical terms — ₹1-5 Lakh SI, no room rent capping (up to SI), standardized waiting periods (30 days initial, 48 months PED, 24 months specific disease), and 5% co-pay. This allows true apple-to-apple comparison across insurers.
IRDAI also mandates free-look period of 15 days (30 days for online policies), cooling-off period for renewals, and grievance redressal timelines. The IGMS (Integrated Grievance Management System) portal enables direct complaints to IRDAI.
Real-Life Indian Example
Rajesh had a ₹5 Lakh policy with Insurer A for 3 years. He was dissatisfied with claim service and wanted to switch. Using IRDAI portability guidelines, he applied 45 days before renewal. Insurer B accepted the port with full waiting period credit — his 3-year PED waiting was carried forward, meaning only 1 more year remained instead of restarting at 4 years. He also got better service at a similar premium.
Numerical Example
Arogya Sanjeevani Standard Policy Comparison:
Feature: Same across ALL insurers (IRDAI mandate)
- Sum Insured: ₹1 Lakh to ₹5 Lakh
- Room rent: No capping up to sum insured
- Co-pay: 5% mandatory
- PED waiting: 48 months
- Specific disease waiting: 24 months
- Initial waiting: 30 days
Premium comparison (30-year-old, ₹5 Lakh SI):
- Insurer A: ₹5,800/year
- Insurer B: ₹6,200/year
- Insurer C: ₹5,500/year
- Insurer D: ₹6,000/year
Since coverage is identical, the client can compare purely on premium and claim settlement ratio (CSR). This is IRDAI's goal — standardized product, transparent pricing.
Claim Scenario
Kavita filed a reimbursement claim of ₹1.8 Lakh on 1st March. She submitted all documents by 10th March. Per IRDAI guidelines, the insurer must settle within 30 days of receiving complete documents (by 9th April). The insurer delayed settlement until June. Kavita filed a complaint on IRDAI IGMS. The insurer was directed to pay the claim amount plus interest for the delay period at the bank rate.
Learning for POSP / Advisor
- Know IRDAI timelines: cashless pre-auth in 4 hours, reimbursement in 30 days, grievance response in 15 days.
- Recommend Arogya Sanjeevani for price-conscious clients wanting standardized, no-surprises coverage.
- Always explain the 15-day free-look period — clients can cancel and get a refund if unsatisfied.
- Portability is a right, not a favour — help dissatisfied clients port without losing waiting period credits.
- Guide clients to IRDAI IGMS (igms.irda.gov.in) for unresolved grievances.
- Every POSP must know the Ombudsman jurisdiction: complaints up to ₹50 Lakh.
Summary Notes
1. IRDAI mandates portability, standard exclusions, claim timelines, and grievance redressal.
2. Arogya Sanjeevani: standard product with identical terms across all insurers (₹1-5L SI, 5% co-pay).
3. Reimbursement claims: 30 days. Cashless pre-auth: 4 hours. Grievance response: 15 days.
4. Free-look: 15 days offline, 30 days online — full refund minus proportionate premium.
5. Portability application: minimum 45 days before renewal date.
6. IGMS portal (igms.irda.gov.in) for complaints. Toll-free: 155255.
7. Ombudsman handles complaints up to ₹50 Lakh.
8. Section 45: 8-year contestability period for non-disclosure.