Health Regulation 2016, GIPSA Promotion Exam
As we all know that Marine, Fire, ENGINEERING, AVIATION, Motor, HRM Part is playing a major role in any exam weather it will be GIPSA and Para 13.2 examinations. So here we are providing the Daily one liner for every upcoming exam . Daily one liner consist top study material in one line which is important for every insurance promotion exams.
HEALTH REGULATION 2016 ONE LINER PART 1
1.“AYUSH Treatment” refers to the medical and / or hospitalization treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.
2.“Break in policy” means the period of gap that occurs at the end of the existing policy term, when the premium due for renewal on a given policy is not paid on or before the premium renewal date or within 30 days thereof
3.“Cashless facility” means a facility extended by the insurer or TPA on behalf of the insurer to the insured, where the payments for the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization is approved.
4.“Product Filing Guidelines” mean the Guidelines specified by the Authority on the procedure to be followed by insurers before marketing or offering a product falling under Health Insurance Business.
5.“Health plus Life Combi Products” mean products which offer the combination
of a Life Insurance cover offered by a life insurer and a Health Insurance cover offered by General Insurer or Health Insurer.
6.“Pilot product” means a close-ended product with a policy term of one year that may be offered for sale by General Insurers or Health Insurers for a period not exceeding five years from the date of launch of the product with a view to giving scope to innovation for covering risks that have not been offered hitherto or stand excluded in the extant products.
7.“Senior citizen” means any person who has completed sixty or more years of age as on the date of commencement or renewal of a health insurance policy.
- Life Insurers may offer long term Individual Health Insurance products i.e., for term of 5 years or more, but the premium for such products shall remain unchanged for at least a period of every block of three years, thereafter the premium may be reviewed and modified as necessary
9.A life insurer may not offer indemnity based products either Individual or Group. All existing indemnity based products offered by life insurers shall be withdrawn as specified under these Regulations.
- General Insurers and Health Insurers may offer individual health products with a
minimum tenure of one year and a maximum tenure of three years, provided that the premium remains unchanged for the tenure.
- Group Health Policies may be offered by any insurer for a term of one year except credit linked products where the term can be extended up to the loan period not exceeding five years.
12.Provided General Insurers and Health Insurers may also offer Credit Linked Group Personal Accident policies for a term extended upto the loan period not exceeding five years.
13.Group Personal Accident Policies may be offered by General Insurers and Health insurers with term less than one year also to provide coverage to specific events.
- Other Insurance Products offering Travel Cover and Individual Personal Accident
Cover may also be offered for a period less than one year.
15.Overseas or Domestic Travel Insurance policies may only be offered by General
Insurers and Health Insurers , either as a standalone product or as an add-on cover to
16.Withdrawal of a health insurance product by Life Insurers, General Insurers and
Health Insurers : the product shall be closed by giving a prospective date of closure not later than three months from the date of notification of these Regulations. For existing policyholders, the policy shall continue until the expiry of the respective policy term.
17.All particulars of any health insurance product of Life Insurers, General Insurers and Health Insurers shall, after introduction, revision or modification be reviewed by the Appointed Actuary at least once a year.
18.GROUP INSURANCE: The Group shall have a size as determined by the Insurer which shall be applicable for all its group policies, subject to a minimum of 7, to be eligible for issuance of a Group Insurance Policy.
- Any proposal for health insurance may be accepted as proposed or on modified terms or denied wholly based on the Board approved underwriting policy.
- 20. A denial of a proposal shall be communicated to the prospect in writing, by recording the reasons for denial. Provided, the denial of the coverage shall be the last resort that an insurer may consider
- The insured shall be informed in writing of any underwriting loading charged over and above the premium as filed and approved under the Product Filing Guidelines
and specific consent of the policyholder for such loadings shall be obtained before issuance of a policy
- No Insurer shall insert any clauses or conditions in the proposal forms, express or implied thereby obligating the prospect to part with the information pertaining to his/her proposal.
- Insurers shall ensure that the premium for a health insurance policy shall be based on,
- Age: for individual policies and group policies.
- Other relevant risk factors as applicable
- The premiums filed shall ordinarily be not changed for a period of three years after a product has been cleared in accordance to the product filing guidelines specified by the Authority
- The policy premium rate shall be unchanged
- for all group products for the term of the policy.
- for all individual and family floater products, other than travel insurance products offered by general insurers and health insurers, for at least:
- a period of one year in case of one year renewable policies and
- the period stipulated in 3(c) herein in case of the rest.
- In case of individual health products offered by life insurers, every block of three years as stipulated in Regulation
HEALTH REGULATION 2016 ONE LINER PART 2
- Health insurance product may be designed to offer various covers;
- For specific age or gender groups
- For different age groups
- For treatment in all hospitals throughout the country, provided the hospitals comply with the definition specified
- For treatment in specific hospitals only, provided the morbidity rates used are representative
- For treatment in specific geographies only, provided the morbidity rates used are representative
- Every Pilot product may be offered upto a period not exceeding 5 years.
- After 5 years of launch of the pilot product, the product needs to get converted into a regular product or based on valid reasons may be withdrawn subject to the insured being given an option to migrate to another product subject to portability conditions.
- In case of migration from a withdrawn product, the insurer shall offer the policyholder an alternative available product subject to portability conditions.
- all health insurance policies shall ordinarily provide for an entry age of at least up to 65 years
- once a proposal is accepted and a policy is issued which is thereafter renewed periodically without any break, further renewal shall not be denied on grounds of the age of the insured.
- A health insurance policy shall ordinarily be renewable except on grounds of fraud, moral hazard or misrepresentation or non-cooperation by the insured, provided the policy is not withdrawn.
- An insurer shall not deny the renewal of a health insurance policy on the ground that the insured had made a claim or claims in the preceding policy years, except for benefit based policies where the policy terminates following payment of the benefit covered under the policy like critical illness policy.
- The insurer shall provide for a mechanism to condone a delay in renewal up to 30 days from the due date of renewal without deeming such condonation as a break in policy. However coverage need not be available for such period.
10.The renewal premium shall not be accepted more than 90 days in advance of the due date of the premium payment
- All new individual health insurance policies issued by Life Insurers, General Insurers and Health Insurers, except those with tenure of less than a year shall have a free look period
- The insured will be allowed a period of at least 15 days from the date of receipt of the policy to review the terms and conditions of the policy and to return the same if not acceptable.
- If the insured has not made any claim during the free look period, the insured shall be entitled to—
- A refund of the premium paid less any expenses incurred by the insurer on medical examination of the insured persons and the stamp duty charges or;
- where the risk has already commenced and the option of return of the policy is exercised by the policyholder, a deduction towards the proportionate risk premium for period on cover or;
- Where only a part of the insurance coverage has commenced, such proportionate premium commensurate with the insurance coverage during such period;
- In respect of unit linked policy, in addition to the above deductions, the insurer shall also be entitled to repurchase the unit at the price of the units as on the date of the return of the policy
- The cost of any pre-insurance medical examination shall generally form part of the expenses allowed in arriving at the premium. However in case of products with term of one year and less, if such cost is to be incurred by the insured, not less than 50% of such cost shall be borne by the insurer once the proposal is accepted, except in travel insurance policies.
- Cumulative bonus
- Cumulative bonuses offered under policies, shall be stated explicitly in the prospectus and the policy document.
- If a claim is made in any particular year, the cumulative bonus accrued may be reduced at the same rate at which it has accrued;
- In case of multiple policies which provide fixed benefits, on the occurrence of the insured event in accordance with the terms and conditions of the policies, each insurer shall make the claim payments independent of payments received under other similar polices.
- If two or more policies are taken by an insured during a period from one or more insurers to indemnify treatment costs, the policyholder shall have the right to require a settlement of his/her claim in terms of any of his/her policies.
- In all such cases the insurer who has issued the chosen policy shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.
- Balance claim or claims disallowed under the earlier chosen policy/policies may be made from the other policy/policies even if the sum insured is not exhausted in the earlier chosen policy/policies. The insurer(s) in such cases shall independently settle the claim subject to the terms and conditions of other policy / policies so chosen.
- If the amount to be claimed exceeds the sum insured under a single policy after considering the deductibles or co-pay, the policyholder shall have the right to choose insurers from whom he/she wants to claim the balance amount.
- Where an insured has policies from more than one insurer to cover the same risk on indemnity basis, the insured shall only be indemnified the hospitalization costs in accordance with the terms and conditions of the chosen policy.
- For Individual products, the loadings on renewal shall be in terms of increase or decrease in premiums offered for the entire portfolio and shall not be based on any individual policy claim experience.
- The discounts and loadings offered shall:
- not be at the discretion of the insurer;
- be based on an objective criterion;
- be disclosed upfront in the prospectus and policy document along with the objective criteria, and shall be as approved under the Product Filing Guidelines.
- No Insurer shall resort to fresh underwriting by calling for medical examination, fresh proposal form etc. at renewal stage where there is no change in Sum Insured offered.
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