The Covid-19 pandemic was a wake-up call for both health insurance companies and policyholders. While it exposed the vulnerabilities in the healthcare system, it also offered the regulator an opportunity to eliminate many lacunas and add new features that can offer enhanced and adequate protection to health insurance policy buyers. Here is how the health insurance coverage has improved after the pandemic.

Coverage for OPD and other expenses
One of the major disadvantages of health insurance plans have been the lack of coverage for outpatient treatment — which does not require 24-hour hospitalisation. But that is also changing slowly. “OPD has become an important part of healthcare expenditure. An individual with a health insurance policy with OPD as a rider, which approximately costs (15%-20% extra premium), can claim expenses such as doctor's consultation fees, diagnostic tests, pharmacy bills, etc. The coverage also guards agains expenses like lab tests, X-rays, routine check-ups, vaccinations, dental, hearing and optical treatments. The range of sum insured for OPD coverage can range between Rs 5,000 and Rs 50,000. Some plans also give an option to upgrade the coverage as per policy and provide worldwide coverage,” says Siddharth Singhal, Business Head-Health Insurance, Policybazaar.com.

Chatterjee says RenewBuy recently launched its Health Wellness Plan, which offers a host of benefits in pre-hospitalisation and OPD treatments. “The products are simple, easy to understand, 30% cheaper than the usual plans and a permanent solution to non-hospital costs. The plans offer OPD benefits, unlimited doctor on phone consultations, free lab tests, heavy concession for offline OPD consultations, modern treatment under very low sum insured, no room rent capping, maternity cover with cover with significantly low waiting period; along with an array of other benefits (under certain T&C),” he says. More launches of affordable productsStandard basic health insurance coverage still remains low in non-metro locations. Many people in these locations were looking for affordable plans which had also begun with standard basic coverage products. “Consumers who do not have deep pockets; young adults/ millennials; consumers in Tier 2/3 cities and beyond; people with limited incomes have shown significant inclination towards these products,” says Chatterjee. The IRDA introduced standard health insurance products like Arogya Sanjeevani, Corona Kavach, Corona Rakshak and Saral Suraksha Bima that offer consistent coverage and benefits to policyholders, from various insurers.

Wellness and preventive measuresPrevention is always better than cure. Health insurers have of late been putting greater emphasis on encouraging policyholders to develop healthier habits and also rewarding them for their efforts. “As per the directions of Insurance Regulatory and Development Authority of India (IRDAI), health insurers give reward points to policyholders who adopt healthy behaviours and engage in physical activity, such as jogging, cycling, or exercising. Customers can can use these reward points to pay their premiums at the time of renewal. These points can also be exchanged for savings on prescription costs, diagnostic fees, outpatient visits, and so on,” says Singhal. Digitally integrated buying to claim settlement processAn integrated platform to manage all insurance needs will help policyholders immensely. “The ongoing wave of digitisation in the insurance sector, especially with the inception of Bima Sugam by IRDAI, will serve as a one -stop technology platform for all insurance needs, right from policy buying to claim settlement and much more in real-time, across life, health and general insurance,” says Bhabatosh Mishra, Director of Underwritings, Products, and Claims, at Niva Bupa Health Insurance. Focus more on efficient claim handlingAdvancements in IT and artificial intelligence have made their way into health insurance processes as well. “Robotic process automation (RPA) and artificial intelligence
(AI) are increasingly enhancing the operational efficiency of health insurance companies. AI/ML is also extensively being used to help insurance companies reach out to more consumers with data-backed underwriting. Most importantly, insurance and insurtech companies are working relentlessly to reduce the turnaround time for claim settlements and make it smooth, which will bring a transformational change in the insurance industry,” says Chatterjee.

Other prominent IRDA’s move to broaden health coverageThe IRDAI made it mandatory for health insurers to offer coverage for treating mental health issues, with the same care as physical ailments.

Mental illness coverage: “Insurers are making sure that mental conditions must be treated the same as physical illnesses. Most mental health issues such as anxiety disorders, post-traumatic stress disorder, dementia, acute depression, and bipolar disorder are covered under the comprehensive health policy. Moreover, it is recommended that policyholders already using antidepressants must declare it as a pre-existing disease (PED) in advance so that the underwriter can evaluate the possible risk,” says Singhal.

Coverage for HIV and disabilities: "The IRDAI in February 2023 directed general insurers to offer a specific cover for persons with disabilities (PWD), persons afflicted with HIV/AIDS and those with mental illness and put in place a board-approved underwriting policy in place," says Chaturvedi.

Clear and consistent expense guidelines: The IRDAI has given clear definitions of pre-existing diseases, pre- and post-hospitalisation expenses, day care treatments, etc.

Efficient and transparent claim settlement process: IRDAI has made it compulsory for insurers to not reject a claim after 8 years of uninterrupted renewal of the policy, to settle a claim within 30 days of getting all the documents, to offer cashless facility at network hospitals, etc.

Allowing health insurance portability: The insurance regulator also issued guidelines to make it easier for policyholders to switch or upgrade their health insurance policies across insurers and plans. For example, the regulator has made it mandatory for insurers to allow switching without any extra underwriting or waiting period, to allow upgrading to a higher sum insured or a better plan without any loss of benefits, etc.

Introducing preventive features in health insurance: IRDA issued guidelines to motivate insurers to offer wellness and preventive features in health insurance policies. For example, the regulator has made it compulsory for insurers to reveal the wellness benefits and rewards given to policyholders, insurers have to offer discounts or vouchers for health check-ups, fitness activities, healthy food, etc.