IRDAI Health Insurance Guidelines
The rules IRDAI currently applies to health insurance — where they are found, what they require at purchase, at renewal and at claim time, what they leave to each product, and the standard Arogya Sanjeevani policy.
Where the rules sit
The Insurance Regulatory and Development Authority of India (IRDAI) regulates health insurance. The current framework is the IRDAI (Insurance Products) Regulations, 2024, in force from 1 April 2024, and the Master Circular on Health Insurance Business of 29 May 2024. The Master Circular replaced earlier circulars, including the 2020 circular on standard terms, and the 2024 regulations replaced the IRDAI (Health Insurance) Regulations, 2016. Material that cites those older instruments is out of date.
At purchase
Every policy must come with a Customer Information Sheet setting out its main features, sub-limits, deductibles and waiting periods. A policy with a term of one year or more carries a 30-day free-look period in which it can be returned. Insurers must offer products for all ages.
Waiting periods for pre-existing and specified diseases are capped at 36 months. AYUSH treatment, meaning Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy, must be treated on a par with other systems of medicine in the insurer's underwriting policy. Separately, section 21(4) of the Mental Healthcare Act, 2017 requires every insurer to provide cover for mental illness on the same basis as for physical illness.
At renewal and at claim time
A health policy must be renewed when the premium is paid. The insurer cannot refuse because of claims made in earlier years, and cannot underwrite afresh unless the sum insured is increased. The exceptions are established fraud, non-disclosure and misrepresentation. If a product is withdrawn, the insurer offers migration to another product.
After 60 continuous months of cover, the moratorium, a claim cannot be contested for non-disclosure unless fraud is established. A cashless request must be decided within one hour and final discharge authorisation given within three hours.
What the rules leave open
The rules do not guarantee that every claim is approved: each claim is assessed against the policy terms. Nor do they fix product features such as room-rent limits, co-pay or bonus rates, which each policy sets. Parity for AYUSH likewise does not settle what a particular policy pays for, or at which hospitals.
Arogya Sanjeevani
Arogya Sanjeevani is a standard indemnity health product introduced in 2020, with common terms. Under its standard terms it carries a 5% co-pay on claims, and the sum insured rises by 5% for each claim-free year up to a maximum of 50%. Room rent is 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 terms currently on offer can be checked in the insurer's product document.
Rules at a glance
A renewal after a costly year
Illustration: Lakshmi, 58, made two large claims on her policy last year and wonders whether the insurer will take her back. Unless fraud, non-disclosure or misrepresentation is established, it must: the policy is renewed on payment of the premium, past claims are not a ground for refusal, and she is not underwritten afresh because she is keeping the same sum insured.
Arogya Sanjeevani's standard terms in numbers
- Assumption: a sum insured of ₹5,00,000 under the standard terms described above.
- Room rent: 2% × ₹5,00,000 = ₹10,000, but the cap is ₹5,000, so the limit is ₹5,000 a day.
- ICU: 5% × ₹5,00,000 = ₹25,000, but the cap is ₹10,000, so the limit is ₹10,000 a day.
- Co-pay on an admissible claim of ₹1,00,000: 5% × ₹1,00,000 = ₹5,000 borne by the policyholder; the insurer pays ₹95,000.
- Cumulative bonus after three claim-free years, taking 5% of the sum insured a year: 3 × ₹25,000 = ₹75,000, giving ₹5,75,000. The maximum bonus is 50% × ₹5,00,000 = ₹2,50,000.
Result. Daily limits of ₹5,000 (room) and ₹10,000 (ICU), a ₹5,000 co-pay on a ₹1,00,000 claim, and a sum insured that can grow to at most ₹7,50,000.
Key points
- The framework is the IRDAI (Insurance Products) Regulations, 2024 and the Master Circular on Health Insurance Business of 29 May 2024.
- Buyers get a Customer Information Sheet and, for policies of a year or more, a 30-day free-look period.
- Renewal cannot be refused because of past claims.
- IRDAI's rules do not promise approval of every claim or fix product features.
Common misunderstandings
- IRDAI's rules do not mean every claim is paid: a claim is still assessed against the policy terms.
- The free-look period is not available on every policy: it applies where the term is one year or more.
- Renewal protection is not unconditional: established fraud, non-disclosure and misrepresentation are exceptions.
Questions people ask
Can an insurer underwrite again at renewal?
Not unless the sum insured is being increased.
Does parity for AYUSH mean every AYUSH treatment is paid?
No. Insurers must treat AYUSH on a par with other systems in their underwriting policy, but what a particular policy pays for depends on its terms.
What happens if the insurer withdraws a product?
The insurer offers migration to another product, with credits such as waiting periods served carried over to the extent of the earlier cover.
What this lesson relies on
- IRDAI (Insurance Products) Regulations, 2024
- IRDAI Master Circular on Health Insurance Business (29 May 2024)
- Mental Healthcare Act, 2017 — section 21(4)
- 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.