The second set of guidelines is on telemedicine. Since the Medical Council of India has issued guidelines in March 2020 enabling Registered Medical Practitioners to provide healthcare using telemedicine, insurers have been advised to allow claim settlement for telemedicine consultation wherever normal consultation with a medical practitioner is allowed in the terms and conditions of the policy contract.
The third set of guidelines is regarding norms on proportionate deductions in claims. This is useful for policy buyers who choose a higher category of hospital room than what is allowed by the capping on their insurance policy.
Let us say you have a Rs 5 lakh health insurance policy with a 1 per cent daily room rent capping. The maximum hospital room tariff that you are thus eligible for is Rs 5,000 per day. However, if you choose to occupy a room costing Rs 7,000 for your treatment (which is 40 per cent higher than your room rent capping), your insurer would typically deduct 40 per cent from your total claim, including room charges and other charges, which are often called associate medical expenses. This is because hospitals typically increase the billing on all your other chargeable items. For instance, increase in doctors’ consultation fees in proportion to the increase in your room tariff.
However, the new guidelines call for ‘associate medical expenses’ to be clearly defined in the policy contract, and disallows the costs of pharmacy and consumables, implants and medical devices, and diagnostics, to be considered in this category. Insurers are not to recover expenses towards proportionate deductions other than the defined ‘associate medical expenses’ while processing claims. Hence, the total deductions made on your claim will reduce, which is in your favour.
There are two further benefits for policyholders. Insurers are to ensure that proportionate deductions are not applied in respect of hospitals which do not follow differential billing, or for expenses where differential billing based on the room category are not followed. Finally, insurers are not permitted to apply proportionate deduction for ICU charges, as there usually aren’t different categories of ICUs.
Here too, the provisions of these guidelines shall apply to new health insurance products filed on or after October 1, 2020, while for existing health insurance products the modifications can be made with their renewal from April 1, 2021.
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