Genetic diseases, mental illness cannot be excluded from health insurance coverage: IRDAI

The insurance regulator has said genetic disorders, menopause, mental illnesses among several such health issues cannot be excluded from health insurance coverage. As part of an exposure draft on the standardisation of exclusions, Insurance Regulatory and Development Authority of India (IRDAI) said any disease contracted after taking the policy also have to be mandatorily covered.

All existing health insurance products that are not in compliance with these rules have to be withdrawn by April 1, 2020.

Puberty and menopause-related disorders including menopausal bleeding or flushing will be covered by health insurance plans.

Legally, insurance companies were required to provide covers to individuals battling mental illnesses. However, insurers were still very selective in offering such covers. Now, IRDAI has said the treatment of mental illness, stress or psychological disorders and neurodegenerative disorders will have to be covered.

Among other things, the use of drugs/anti-depressants prescribed by a medical practitioner would also be part of health insurance coverage. Similarly, failure to seek or follow medical advice or failure to follow treatment cannot be used as a clause to deny medical insurance.

In case of artificial life maintenance, including the use of life support machines, IRDAI said that expenses up to the date of confirmation by the treating doctor that the patient is in a vegetative state will be covered. Also, oral chemotherapy and robotic surgeries will be covered by insurance.

However, among the things that will continue to be excluded are pre-existing diseases (with a maximum waiting period of two years before a claim is filed), diagnostic tests, infertility treatment, weight control surgeries or plastic surgery.

The waiting period for lifestyle conditions like hypertension, diabetes and cardiac conditions is not allowed for more than 30 days except if these diseases are pre-existing and disclosed while buying a policy.

Similarly, expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, like rock climbing, mountaineering, scuba diving among others, will not be covered.

IRDAI has also identified a set of illnesses that can be permanently excluded from coverage. Some of these include Epilepsy, Hepatitis B, Alzheimer's disease and Parkinson's disease, chronic liver and kidney diseases and HIV/AIDS among others.

After completion of eight continuous years under the policy, no insurance policy claim can be contested except if there is a proven case of fraud.