What's IRDAI Health Insurance and Why It Matters to You?

IRDAI is the regulatory body which has been given the work of controlling and overseeing India's insurance ecosystem. The mandate of IRDAI includes promoting and protecting the interests of policy-holders, making sure insurer is financially strong, and continuously developing India's insurance market.

In case of health insurance, which is not the same as life insurance, IRDAI's role includes:

• Monitoring and guiding health-insurance products (what features they should include, waiting periods, etc).
• Keeping track of insurers’ claim-settlement behaviour, mainly judging its speed and fairness.
• Creating IRDA new guidelines for the industry that raise the bar for coverage, transparency and service.
• Making sure policy-holders are protected via policyholder rights, disclosure information etc.
• Making sure all insurers maintain sufficient solvency, capital, and operational standards to honour claims.
• Governing distribution channels, grievance mechanisms, and insurer conduct (mis-selling etc).

IRDAI’s supervision builds trust among customers. When a customer buys a health insurance policy, they need the insurer to honour the claim when it's needed. IRDAI's role is to ensure the insurer is held accountable.

Note: IRDAI health insurance is broadly referred to health insurance products regulated under IRDAI’s domain. And IRDAI health insurance claim settlement ratio signals one of the most important metrics you must check.

Let's try to understand IRDAI’s major functions in the health-insurance industry and its relevance for Indian health insurance policy-holders.

Claim settlement ratio (CSR) is one of the most important metrics while evaluating any insurer. This essentially tells how often and timely the insurer settles claims.

While IRDAI plays a crucial role in protecting health insurance policyholders, its principles extend across the insurance industry. This includes life insurance companies such as Axis Max Life as well.

In FY 2024–25, Axis Max Life achieved an impressive 99.70% Individual death claims settlement ratio in its individual death claim segment. This clearly shows our strong governance and customer-first philosophy.

Choosing the right health insurer is extremely important because in times of stress and uncertainty, you want to be quite sure about at least your health insurance claim.

• Find the health-insurance CSR: While the figures above are for life insurance, you should check the health-product specific CSR for other insurers before making the decision.
• Check time-to-settlement: A high CSR is good, but also check how quickly claims are settled.
• Network hospital support: Evaluate how many hospitals are on the insurer’s network. This ensures easy accessibility in any city or town you live.
• Transparency: How clearly are the terms, waiting-periods, co-payments, and exclusions disclosed.

This formula helps you determine the taxable amount on which short-term capital gains tax will be applied. Just make sure to keep your purchase and sale records handy for accurate calculation.

IRDAI has rolled out some updates recently under IRDA new guidelines (for health insurance). These changes aim to boost inclusivity, transparency, speed and fairness. Below are key items relevant for policy-holders:

• No age-cap: Effective from 1 April 2024 onward, IRDAI removed the maximum entry‐age limit for health insurance policies. This means senior citizens or even older adults can access health insurance.
• Reduced waiting period: The maximum waiting period for pre-existing diseases has been reduced from 4 years to 3 years in many policies.
• Reduced moratorium period: The moratorium period (after which insurer cannot reject a claim due to non-disclosure unless fraud) was reduced from 8 years to 5 years.
• Inclusive covers: Insurers are instructed not to refuse policies purely on the basis of serious illnesses like heart disease, cancer, or AIDS (subject to underwriting).
• Removal of sub-limits on AYUSH treatments: New IRDAI guidelines have asked insurers to remove limits on AYUSH treatments. These treatments include Ayurveda, Yoga, Unani, Siddha, and Homeopathy, as long as it fits within the total sum insured.
• Transparency and digital issuance: The Master Circular on Health Insurance Business and the Protection of Policyholders’ Interests circular (2024) emphasise: e-policy issuance, digital disclosures, free look, standardised Customer Information Sheet, regional language options, etc.

Here is how Axis Max Life stands out under the IRDAI-governed environment with its simple compliance process. At Axis Max Life Insurance, we understand that life is full of uncertainties. Our aim is to make sure you and your loved ones always feel safe and taken care of.

Our dedicated team of expert make the life insurance claims experience as simple and stress-free as possible through a transparent, three-step process:

• Claim registration & document submission
• Claim evaluation
• Claim decision & settlement

For FY 2024–25, Axis Max Life Insurance achieved an exceptional Individual Death claims settlement ratio of 99.70%, showing our commitment to fulfilling every genuine claim.

To make the experience even smoother, we assign a dedicated Claims Relationship Officer (CRO) to guide beneficiaries and claimants through each step of the process.

We also have our “3-Hours claims promise” for eligible life insurance claims via “InstaClaim™” initiative. All claims that qualify will be paid within 3 hrs from the date of submission of all mandatory documents.

The 3-hour claim settlement for lives insured is available for the following:

• Eligible, active, premium-paying policies that have completed three continuous years
• The claim does not warrant field verification
• All mandatory documents are submitted before 3 pm at any Axis Max Life Insurance office from Monday to Friday
• Nominee title must be clear
• Claim amount on all eligible policies is up to Rs. 50 lakh

Furthermore, if you don't receive the payment within the time frame, you'll be entitled to additional payments in the form of ‘interest’ on the total amount of your death benefit. T&C apply.

The table below shows the claim settlement ratio of Axis Max Life Insurance over the last 5 years as reported by IRDAI.

In order to raise a claim you must have all the mandatory documents in place. You need to have:

• Original life insurance policy document
• Original/attested copy of death certificate issued by the local municipal authority
• Death claim application form (Form A)
• NEFT mandate form attested by bank authorities along with a canceled cheque of bank account passbook
• Nominee's photo identity proof such as copy of Passport, PAN card, Voter identity card, Aadhar (UID) card, etc.
• Current address proof of the claimant. (Any one of the following: Aadhar Card, Valid Passport or Driver's License, Voters ID are considered as proofs)
• Signed copy of PAN card / Form 60 of the claimant
• Employer certificate with complete leave records - Form E
• ITR for last 3 years/GST certificate in case of Self-employed
• Other life/health insurance details with claim history details
• Bank statement of last 2 years of the Life Assured
• Body transfer certificate / Embassy documents/Post Mortem report whichever applicable in case of death in foreign country
• Complete passport copy in case of death in foreign country
• Medical booklet/CGHS card details in case of Defence and Central Govt personnel
• Attending physician's statement (Form 'C')
• Medical records (admission notes, discharge/death summary, test reports, etc.) of current and /or any previous admissions
• Additional documents required based on the cause of death are: