The General Insurance Council has, pursuant to industry level deliberations and stakeholder consultations, noted the increasing adoption of modern medical technologies and treatment modalities including, inter alia, robotic surgeries, immunotherapy, precision medicine, targeted therapies and other evolving evidence-based interventions within the healthcare ecosystem.

In view of the evolving clinical landscape and the need for greater consistency, transparency and policyholder confidence in claims evaluation practices, member insurers are advised to consider adopting a harmonised and evidence-based assessment framework while evaluating admissibility of claims pertaining to such medical advancements.

The objective of this Position Statement is to facilitate a balanced and sustainable approach that:

1. Promotes patient access to medically appropriate advancements in healthcare;
2. Encourages consistency and predictability in claims adjudication practices across the insurance industry
3. Preserves principles of medical necessity, clinical efficacy and evidence-based treatment;
4. Ensures financial prudence and actuarial sustainability; and
5. Mitigates avoidable disputes arising from inconsistent interpretation of emerging treatments and allied expenses.

Accordingly, member insurers may, subject to their respective underwriting philosophy, product terms and conditions, board-approved policies, regulatory requirements and applicable law, consider aligning their internal claims adjudication mechanisms with the broad principles set out in the annexed Position Statement.

It is clarified that:

1. The Position Statement is intended solely as an industry guidance framework for reference and standardisation purposes and is not legally binding;
2. Claim admissibility shall continue to be determined on a case-to-case basis having regard to medical necessity, clinical evidence, policy coverage, exclusions, regulatory prescriptions and other relevant facts and circumstances;
3. Nothing contained herein shall be construed as mandating automatic admissibility or rejection of any specific treatment, procedure, consumable or associated expense; and
4. Each insurer shall retain independent discretion and authority in accordance with its internal governance framework, applicable IRDAI regulations and contractual obligations toward policyholders.

Member insurers are further encouraged to periodically review emerging global and domestic clinical evidence, treatment protocols, health technology assessments and jurisprudential developments to ensure that claims practices remain contemporaneous, equitable and medically justified.

The Council may, from time to time, facilitate further industry consultations and issue updated guidance notes based on evolving medical advancements, regulatory developments and market experience.

Download Modern Treatments - India & Globally

.