knowledge/irdai_rules.json

{
  "metadata": {
    "source": "IRDAI Health Insurance Regulations 2024-2025",
    "description": "Standard definitions, mandated limits, and regulatory guidelines for Indian health insurance",
    "last_updated": "2025-10-01"
  },
  "standard_definitions": {
    "cashless_treatment": "Treatment where insurer settles bills directly with the network hospital, up to policy limits",
    "co_payment": "A fixed percentage of the admissible claim amount that the insured must bear. Cannot be introduced mid-policy.",
    "cumulative_bonus": "Increase in sum insured by a specified percentage (max 50%) for each claim-free year, without extra premium",
    "daycare_treatment": "Treatment requiring hospitalization of less than 24 hours due to advance medical technology. Covered if listed.",
    "deductible": "Initial specified amount of the claim that the insured must bear before the insurer pays. Can be compulsory or voluntary.",
    "domiciliary_hospitalization": "Treatment at home on doctor's advice when hospital admission is either not possible or not required, continuing for at least 3 days",
    "grace_period": "Time beyond the premium due date (usually 30 days) during which the policy remains in force",
    "network_hospital": "Hospital registered with TPA/insurer for direct settlement of claims. Non-network claims are on reimbursement basis.",
    "pre_existing_disease": "Any condition/ailment/injury/disease diagnosed within 48 months before the first health insurance policy",
    "pre_hospitalization": "Relevant medical expenses incurred during 30-60 days before hospitalization (varies by insurer)",
    "post_hospitalization": "Relevant medical expenses incurred during 60-180 days after discharge (varies by insurer)",
    "room_rent": "Charges for room accommodation during hospitalization. May be subject to sub-limits based on room category.",
    "sum_insured": "Maximum amount payable by insurer in respect of each claim or during the policy period as stated in the policy",
    "waiting_period": "Specified period from the policy start date during which certain defined benefits are not payable",
    "sub_limit": "The maximum payable for a specific item or procedure under the overall sum insured"
  },
  "mandated_limits": {
    "initial_waiting_period": {
      "maximum_days": 30,
      "description": "Initial waiting period for any new policy cannot exceed 30 days. Emergency accidents are covered from day 1.",
      "regulation": "IRDAI Health Insurance Regulations 2024 - Clause 4.1"
    },
    "specific_disease_waiting_period": {
      "maximum_months": 48,
      "typical_months": 24,
      "description": "Waiting period for specific diseases/procedures cannot exceed 48 months. Most insurers keep 24 months.",
      "common_diseases": [
        "Cataract",
        "Hernia",
        "Benign prostatic hypertrophy",
        "Hysterectomy",
        "Sinusitis",
        "Tonsillitis",
        "Kidney stones",
        "Gallbladder stones",
        "Piles/Hemorrhoids",
        "Fistula",
        "Pilonidal sinus",
        "Joint replacement",
        "Internal congenital diseases",
        "Age-related macular degeneration"
      ],
      "regulation": "IRDAI Health Insurance Regulations 2024 - Clause 4.2"
    },
    "pre_existing_disease_waiting_period": {
      "maximum_months": 48,
      "typical_months": 36,
      "description": "Pre-existing disease waiting period cannot exceed 48 months. Continuous coverage required.",
      "regulation": "IRDAI Health Insurance Regulations 2024 - Clause 4.3"
    },
    "moratorium_period": {
      "years": 8,
      "description": "After 8 continuous years of coverage, insurer cannot contest any claim citing pre-existing disease (except fraud)",
      "regulation": "IRDAI Health Insurance Regulations 2024 - Clause 4.4"
    }
  },
  "standard_exclusions": {
    "permanent": [
      {
        "name": "Cosmetic/Plastic surgery",
        "exception": "Unless necessitated by injury/illness or as part of medically necessary treatment"
      },
      {
        "name": "Dental treatment",
        "exception": "Unless requiring hospitalization"
      },
      {
        "name": "Convalescence and general debility"
      },
      {
        "name": "Rest cure and rehabilitation"
      },
      {
        "name": "Intentional self-injury"
      },
      {
        "name": "Treatment arising from alcohol/drug abuse"
      },
      {
        "name": "Treatment for obesity/weight control",
        "exception": "Unless morbid obesity with BMI > 40"
      },
      {
        "name": "Treatment related to change of gender"
      },
      {
        "name": "Infertility/sterility treatment",
        "exception": "Unless specifically covered"
      },
      {
        "name": "External aids and appliances",
        "exception": "Unless internal implants"
      },
      {
        "name": "War, nuclear contamination, terrorism injuries"
      },
      {
        "name": "Circumcision",
        "exception": "Unless medically necessary"
      },
      {
        "name": "Vaccination/Inoculation",
        "exception": "Unless post-bite treatment"
      },
      {
        "name": "Treatment for correction of eyesight",
        "exception": "Unless due to illness"
      }
    ],
    "conditional": [
      {
        "name": "Maternity expenses",
        "typical_waiting_months": 24,
        "min_waiting_months": 9
      },
      {
        "name": "Mental illness/psychiatric treatment",
        "note": "Must be covered under Mental Healthcare Act 2017"
      },
      {
        "name": "HIV/AIDS treatment",
        "note": "Cannot be excluded if contracted through medical procedure"
      }
    ]
  },
  "room_rent_guidelines": {
    "description": "IRDAI allows insurers to set room rent sub-limits but mandates transparency",
    "common_structures": [
      {
        "type": "percentage_of_si",
        "typical_value": 1.0,
        "description": "Room rent capped at 1% of sum insured per day"
      },
      {
        "type": "absolute_cap",
        "example_values": [
          3000,
          4000,
          5000,
          8000,
          10000
        ],
        "description": "Fixed daily room rent cap in INR"
      },
      {
        "type": "room_category",
        "description": "Coverage limited to specific room category (e.g., Single Private AC room)"
      },
      {
        "type": "proportional_deduction",
        "description": "If room rent exceeds cap, ALL other charges may be proportionally reduced"
      }
    ],
    "proportional_deduction_formula": "Payable = (Eligible Room Rent / Actual Room Rent) × Other Charges"
  },
  "copay_guidelines": {
    "types": [
      {
        "type": "voluntary",
        "description": "Policyholder chooses higher copay for lower premium"
      },
      {
        "type": "compulsory",
        "description": "Insurer mandates copay for certain conditions"
      },
      {
        "type": "age_based",
        "typical_ages": [
          60,
          65,
          70
        ],
        "typical_percentages": [
          10,
          20,
          30
        ]
      },
      {
        "type": "city_based",
        "description": "Higher copay in tier-1 cities (non-network hospitals)"
      },
      {
        "type": "disease_specific",
        "description": "Higher copay for specific chronic diseases"
      }
    ],
    "regulation": "Copay percentage and conditions must be clearly stated in policy document"
  },
  "compliance_guardrails": {
    "moratorium_period": "8 years (no contestability)",
    "initial_waiting_period_limit": "30 days (accidents exempt)",
    "standardized_exclusions": "List of 16 permanent exclusions as per IRDAI Master Circular 2024",
    "pre_existing_disease_cap": "Maximum 4 years waiting period"
  }
}