How the new health insurance customer insurance sheet (CIS) will help policyholders

Insurers must start issuing newly updated Customer Information Sheets (CIS) from January 2024. This document includes the time it takes to resolve a claim, a complaint resolution guide, and health insurance contract portability.

From January 1, 2024, insurers will be required to provide health insurance policyholders with up-to-date documentation that provides at-a-glance information on key policy terms and conditions, claim payment deadlines, grievance redress processes, and more.

The Insurance Regulatory and Development Authority of India (IRDAI) has mandated a new format for issuing such documents called Customer Information Sheets (CIS) along with policy documents at the time of purchase and renewal. The aim is to provide a quick overview of important policy terms and conditions, as policyholders may not be able to read and understand large policy documents.

Insurers are still required to share this CIS (a standardized format was introduced in 2020) with policyholders, but newer updated versions will come with explanations in simpler language. I am.

Also read: IRDAI’s proposal: Consolidate key health insurance features and provisions in one easy-to-decipher document.

Here are the key features of CIS (existing and new) that will help you easily decipher the wording of your health insurance contract.

Insurance amount and type of insurance

The currently used CIS format does not include information on sum insured, even though this is central to insurance. The new CIS specifies the sum insured or indemnity for individual and family floater insurance.

The insurance company should also specify whether the policy operates on a reimbursement basis, with hospitalization costs reimbursed up to the insured amount, or whether it is a defined benefit policy that pays out a pre-agreed amount at the time of diagnosis. There is a need to.

Benefits based on policy

The CIS contains information about the benefits you are entitled to under your insurance contract and the conditions under which they apply. For example, hospitalization benefits will be paid if you stay in the hospital for more than a certain amount of time (usually his 24 hours, except for day care procedures listed), details of pre- and post-hospitalization costs, Lists, etc. – Covered care procedures, OPD, maternity coverage, etc.

free look period

Unlike other financial products, insurance contracts come with unique features. In other words, it is an option to “return” your insurance if you notice a gap between what was promised and what was actually delivered. You can do this for the first 15 to 30 days after you receive your insurance policy. In the new CIS, this period will be clearly stated in advance.

How long does it take to resolve a claim?

In its current form, the CIS does not require health insurance companies to spell out claim payment deadlines. However, from January 1, it will be necessary to mention the time required for insurance claim payments and pre-authorization for cashless payments.

This allows policyholders to know how long they have to escalate complaints regarding delays in claims processing.

The CIS will also communicate information such as list of network hospitals where cashless facilities are available, information on blacklisted hospitals and helpline numbers.

Waiting Periods, Exclusions, and Deductions

These are important provisions that directly affect the resolution of claims and therefore form part of the current and new CIS. Certain surgeries, such as hernias and cataracts, initially have a waiting period of 1 to 2 years, while pre-existing conditions can lead to a wait of up to 4 years.

This means that during the waiting period, no benefits related to such illness will be paid. The insurance company should also mention exclusions, i.e. expenses that will not be paid, and deductibles, i.e. the amount you must pay before the insurance company will settle your claim.

The new CIS requires all exclusions to be listed, so customers don’t suffer from heartburn due to unpaid fees during claims processing.

Similarly, a quick glance at the CIS shows that the policyholder has rent limits, copayments (if the policyholder has to pay a portion of the claim), deductibles (such as a cap on upfront costs), etc. It is useful to understand the lower bound of . insurance does not pay claims), etc.

Complaint redress

The insurance company will share the contact details of its Complaints Handling Officer and the Office of the IRDAI-appointed Ombudsman in the CIS so that customers can get convenient guidance to address their complaints through appropriate channels There is a need to.

Portability and migration

Insurers should spell out the process for transferring to another product or porting to another insurance company. Currently, insurance companies only need to mention the email ID and address of the company officer who the policyholder needs to contact if he wishes to switch to another insurance company.

moratorium period

Suspension rules changed in 2019, but many health insurance policyholders may not be aware of the resulting benefits. A moratorium is a period during which an insurance company is prohibited from raising questions regarding disclosures regarding pre-existing conditions that a policyholder may have had at the time of taking out the policy.

Simply put, the health disclosures you made when signing up for insurance will not be questioned after this period. As per IRDAI rules, the moratorium will be triggered after the policy continues for eight years. “After the expiration of the grace period, no health insurance policy may be challenged, except for fraud and permanent exclusions specified in the policy,” says the new CIS.