IRDAI issues Draft Guidelines on Wellness and Preventive Features and Benefits of health insurance products

Nov 08, 2019 | by Avantis RegTech Legal Research Team


The Insurance Regulatory and Development Authority of India (IRDAI) on November 07, 2019, has proposed a comprehensive draft guidelines on wellness and preventive features or benefits in order to enhance the scope of services offered in health insurance products under the provisions of the Insurance Act 1938.

The followings are the norms prescribed by IRDAI:-

a) Any wellness and preventive feature shall be designed only with the objective of maintaining good health and improving it.

b) No Wellness feature or benefit shall be offered without it being filed or incorporated as part of the product in terms of the Product Filing Guidelines.

c) There shall be no discrimination in providing any of the wellness features or benefits offered to the same or similarly placed categories of policyholders of the underlying health insurance product. 

d) Every Insurer shall assess the pricing impact of wellness and preventive features offered, if any, and the same shall be disclosed upfront in the File and Use or Use and File application, as may be the case, prescribed in the Product Filing Guidelines or applicable File and Use norms.

e) Based on fitness and wellness criteria stipulated and disclosed, insurers may endeavour promoting wellness amongst health insurance policyholders by offering various health specific services.

f) Insurers shall not publish the trade names or trade logos of third party merchandize in any of the insurance advertisements, but may refer the product or service offered in generic term.

g) Insurers shall not accept any liability towards quality of the products or services offered by third parties.

h) Insurers shall also ensure that the service providers under wellness or preventive programs have put in place appropriate mechanism to discharge their obligations by offering the agreed services or products under wellness program of every health insurance product.

i) No payments shall be made by insurers to the third party merchants other than the monetized value of the rewards points redeemed by the policyholders.

j) Insurers shall not receive any consideration amount for offering the third party products.

k) Third party merchant wise, product wise pay-outs made shall be disclosed in the annual public disclosures by insurers.

l) The costs towards the wellness services shall be factored into the pricing of the underlying health insurance product.

m) Insurer shall clearly specify in the policy contract as to whether the accrued benefits can be carried forward or not when the policy is renewed.

n) The benefit accrued shall be at periodic intervals at rates or amounts declared upfront at the commencement of the policy.

o) Insurer shall notify the benefits accrued to the credit of a Policyholder and entitlements of the policyholders under the said feature at periodic intervals, at least once in a year. 

p) Insurers shall specify the manner of redeeming the benefits allowed.

q) Insurer shall be responsible for any errors or omission in calculation of accrued benefits and shall address the same through their in-house Grievance Redressal Mechanism.

The Authority reserves the right to instruct the insurers to withdraw any Wellness feature which is not in compliance with any regulations or guidelines. These Guidelines shall come into force from immediate effect and are applicable to all health insurance products offered by all Insurers.

[IRDAI/HLT/REG/CIR/XXX/10/2019]


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