IRDAI Health Insurance Guidelines
The rules IRDAI currently applies to health insurance: where they are found, what they fix (waiting-period ceilings, the moratorium, free-look, portability, cashless and claim timelines), what they leave to each product, and the standard Arogya Sanjeevani policy.
Where the rules are
IRDAI, the Insurance Regulatory and Development Authority of India, sets the rules that standardise health insurance practice across insurers, covering portability, standard exclusions, maximum waiting periods, cashless and claim timelines, and standard products. The current framework is principally the IRDAI (Insurance Products) Regulations, 2024, in force from 1 April 2024, and the Master Circular on Health Insurance Business of 29 May 2024.
These replaced the IRDAI (Health Insurance) Regulations, 2016 and a number of earlier circulars, so material that cites the older instruments is out of date.
Rules that protect the buyer
Every policy must come with a Customer Information Sheet. A policy with a term of one year or more carries a free-look period of 30 days from receipt of the policy document, whatever the sales channel, during which it can be returned.
The pre-existing disease waiting period and the specific-disease waiting period cannot exceed 36 months; older material quotes 48 months for pre-existing disease. After 60 continuous months of cover, the moratorium, a policy or claim cannot be contested for non-disclosure or misrepresentation unless fraud is established.
Portability lets a policyholder move to another insurer at renewal without losing waiting-period credit already earned, to the extent of the sum insured ported. The existing insurer supplies the data within 72 hours and the new insurer decides within 5 days. Renewal cannot be refused because of past claims.
Rules about claims
An insurer must decide a cashless authorisation request immediately, and in no case later than one hour after receiving it. Final authorisation at discharge must be given within three hours of the hospital's request; if it takes longer, the insurer bears the extra hospital charges. Older material quotes two hours or more.
A reimbursement claim must be settled within 15 days of submission; the earlier limit was 30 days. Interest at 2% above the bank rate is payable for delay.
Complaints against insurers and intermediaries can be registered and tracked on Bima Bharosa, IRDAI's portal, the successor to the Integrated Grievance Management System (IGMS). The portal routes a complaint to the insurer; IRDAI does not itself decide individual claims.
Arogya Sanjeevani and what the rules leave open
Arogya Sanjeevani is the standard health product that IRDAI requires general and health insurers to offer. Its features are standardised, which makes comparison straightforward: a 5% co-pay on every claim, room rent limited to 2% of the sum insured (at most ₹5,000 a day) and ICU charges to 5% (at most ₹10,000 a day). The premium, hospital network and service still differ from insurer to insurer.
For other products the rules set outer limits and timelines but do not fix product features. Room-rent limits, co-pay, deductibles and bonus rates are set by each policy, and every claim is still assessed against the policy terms.
Rules at a glance
A discharge-day clock
Illustration: Thomas is admitted to a network hospital in Kottayam on a Monday evening. The hospital sends the cashless request at 7.00 p.m., so the insurer's decision is due by 8.00 p.m. On Friday the hospital sends the final bill for authorisation at 10.30 a.m.; the insurer's final authorisation is due by 1.30 p.m. If it arrives later and the hospital charges for the extra hours, that additional charge is the insurer's to bear.
Arogya Sanjeevani limits in numbers
- Assumptions, for arithmetic only: a sum insured of ₹2,00,000 under the standard terms described above, and an admissible claim of ₹90,000.
- Room-rent limit: 2% × ₹2,00,000 = ₹4,000 a day. This is below the ₹5,000 ceiling, so the limit is ₹4,000 a day.
- ICU limit: 5% × ₹2,00,000 = ₹10,000 a day, which equals the ₹10,000 ceiling.
- Co-pay: 5% × ₹90,000 = ₹4,500, borne by the policyholder.
- Insurer pays ₹90,000 − ₹4,500 = ₹85,500.
Result. Daily limits of ₹4,000 for the room and ₹10,000 for ICU; on a ₹90,000 admissible claim the insurer pays ₹85,500 and the policyholder ₹4,500.
Key points
- The framework is the IRDAI (Insurance Products) Regulations, 2024 and the Master Circular on Health Insurance Business of 29 May 2024.
- Free-look is 30 days from receipt of the policy document, for any sales channel, on policies of one year or more.
- PED and specific-disease waiting periods are capped at 36 months; the moratorium is 60 months.
- A cashless request is decided within one hour and discharge authorisation given within three hours.
- A reimbursement claim is settled within 15 days of submission.
- Arogya Sanjeevani is a standard product with a 5% co-pay that insurers must offer.
Common misunderstandings
- IRDAI's rules do not fix room-rent limits or co-pay levels for products in general: those are set by each policy, and only the standard product has uniform terms.
- The free-look period does not depend on how the policy was bought: it is 30 days for every sales channel, on policies with a term of one year or more.
- Bima Bharosa does not decide claims: it registers, tracks and routes complaints to the insurer.
Questions people ask
Is Arogya Sanjeevani priced the same by every insurer?
No. Its features are standardised, but the premium, hospital network and service differ from insurer to insurer.
What is IGMS?
The Integrated Grievance Management System, IRDAI's earlier complaint portal. Its successor is Bima Bharosa.
Can an insurer refuse renewal after a year of heavy claims?
No. Renewal cannot be refused because of claims made in earlier years.
What this lesson relies on
- IRDAI (Insurance Products) Regulations, 2024 (in force 1 April 2024)
- IRDAI Master Circular on Health Insurance Business (29 May 2024)
- IRDAI Master Circular on Protection of Policyholders' Interests (5 September 2024)
- Arogya Sanjeevani — standard product terms as published in insurers' product documents
This lesson was reviewed independently against these sources on 8 October 2026. Rules change: check the current regulation, scheme document or policy wording before relying on any figure. This is education, not advice.