health insurance grievances, redressal & related issues r.srinivasan osd, i.r.d.a
TRANSCRIPT
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HEALTH INSURANCE GRIEVANCES,REDRESSAL
&RELATED ISSUES
R.SRINIVASANOSD, I.R.D.A.
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About this presentation• Definition of Complaint/Grievance;• Data of Health Insurance Complaints
received by Non Life Industry;• Classification of Health Insurance
Complaints;• Root Cause Analysis of Complaints;• Redressal of complaints.
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How is a complaint defined?
• A “Grievance/Complaint” is defined as any communication that expresses dissatisfaction about an action or lack of action, about the standard of service/deficiency of service of an insurance company and/or any intermediary or asks for remedial action.
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HEALTH INS.COMPLAINTS VS TOTAL COMPLAINTS
32% 36%
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BROAD CLASSIFICATION OF HEALTH INSURANCE COMPLAINTS
81%
60%
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Main parties involved
• Insurer vs Individual Insured;
• Insurer vs Group Organizer
• TPA vs Insured
• TPA vs Hospital
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REFINED CLASSIFICATION OF COMPLAINTS RELATE TO…
• POLICY DOCUMENT• CLAIM • PREMIUM• PROPOSAL• INSURANCE COVERAGE• REFUNDS• PRODUCT• OTHERS
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Complaints pertaining to Policy
• Without the consent of Insured, Insurer debited customer Bank A/c/Credit Card and issued policy;
• Certificate of Insurance / Policy not received by the Insured;
• Endorsement for modification of policy details not effected;
• In the renewal policy, Insurer changed the terms & conditions without informing the Insured;
• Insured asked for cancellation of policy BUT Insurer failed to respond (Frequent in tele-marketing business);
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Complaints pertaining to Policy…contd.
• Arbitrary Cancellation of policy - Bad Claims Experience;
• Forced to switch over to a new product during renewal OR non-TPA policy converted to TPA policy;
• Refusal to renew health insurance policy;• Change of terms and conditions not intimated
to the insured during/prior to renewal;• Enhancement of Sum Insured not considered
during renewal.
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Policy Related complaints vis-à-vis Total Complaints – 1.4.2011 to 31.12.2011-IGMS DATA
8367
23925
0
5000
10000
15000
20000
25000
30000
Policy Related
Total Complaints35%
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CLAIM RELATED COMPLAINTS• Repudiation of claim due to delay in intimation of claim by
Insured;• Deduction from claim amount on account of
– Delay in claim intimation– Reasonability Clause
• Insurer repudiated claim due to “pre-existing disease” exclusion;
• TPA insisting the insured to arrange for Sec 64 VB confirmation from insurer;
• Claim repudiated/closed without giving reasons;
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CLAIM RELATED COMPLAINTS..contd.
• Stocky silence of insurer/ TPA after intimation of claim by insured;
• Delay on the part of TPA to provide cashless facility;
• Cashless approved by TPA initially but revoked at the time of discharge;
• Insurer/TPA asking for claim documents on a piecemeal basis;
• Insurer/TPA has not issued claim cheque in spite of acceptance of offer of settlement;
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CLAIM RELATED COMPLAINTS..contd.
• Claim denied/quantum reduced based on internal circular or guidelines and not forming part of product filed with the Authority;
• Insurer repudiated claim due to dispute on premium paid (In spite of payment of charged premium by the insured);
• Change of Network Hospital/TPA not informed to policyholder.
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Claim Related complaints vis-à-vis Total Complaints – 1.4.2011 to 31.12.2011
37%
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Premium related grievances
• Premium not charged in conformity with the product filed with the Authority;
• Arbitrary loading of renewal premium; • Additional premium charged after finalizing the
insurance contract since the policy/proposal was not accepted by the insurer’s competent authority!
• Revision in premium during renewal not informed to the policyholder in time;
• High Premium – Senior Citizen complainants
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Premium Related complaints vis-à-vis Total Complaints – 1.4.2011 to 31.12.2011
4%
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Proposal Related• Agent has not explained the scope of insurance
coverage especially in regard to waiting period for certain diseases;
• Medical Underwriting after acceptance of the proposal form and premium cheque; Rejection of the proposal (including renewals of other
insurers) based on ‘pre-acceptance medical check up’ conducted after collection of premium!
• Issuance of policy without any proposal or confirmation in writing from Insured;
• Proposal form given by Insured was tampered by Agent / Insurer
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Proposal Related complaints vis-à-vis Total Complaints – 1.4.2011 to 31.12.2011
4%
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Insurance Coverage• Dispute relating to Interpretation of
perils/exclusions/conditions/warranties;• Insurer did not attach any clause to the policy –
coverage given under the policy not known to the Insured;
• OMP policy taken along with airline ticket but insured unaware of insurance coverage as policy conditions not provided by the Travel Agent!
• Existence of P.A. Coverage under a Group Policy not known or known belatedly after occurrence of contingent event.
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Refund
• Dispute regarding quantum of premium refund;
• Refund of premium due under policy not received by Insured.
Above complaints usually arise in proposals sourced through telemarketing
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Product related• Misleading Advertisement issued by Insurer.
Product was different from what it was advertised;
• Product (policy) received by insured is not what it was negotiated at the time of sale;
• Infirmities in the product detected during claim/complaint;
• Group Policy beneficiaries not informed/aware of policy/claims servicing office.
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Others• Toll Free Number of TPA/Insurer not working;• Failure of online transaction though premium was
deducted through credit card;• Insurer gave premium quote but later went back on
acceptance of risk;• Insurer imposed additional conditions not forming
part of pre-sale discussion;• Insurer not considered the cumulative bonus in claim
settlement;• Group Policy beneficiary unaware that Group
Organizer has not renewed the policy and hence left uncovered after policy expiry.
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R.C.A of Complaints - Insurer• Suspense on the ultimate claim amount payable;• Insurer not monitoring the TAT of claim disposal by
TPAs;• Misselling by Intermediaries (sab payment ho
jayega);• Hazards of multiple choice - Health products of the
same insurer differ in minute changes but have a bearing on the claim;
• Medical & Legal jargons used;• Websites not updated regularly.
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R.C.A of Complaints - Policyholders• Mutual mistrust;• General reluctance to read the policy brochure terms
and conditions;• Not aware of availing seamless Cashless Procedure in
non-emergency hospitalization;• Economical with truth on disclosure of material fact;• Importance of timely renewal not appreciated;• Implication of availing higher room rent than eligible
amount (Table of Benefits)under the policy is not foreseen.
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T.A.T for service issues- Health Insurance• Decision on a health insurance proposal should be
communicated within 15 days of its receipt;• Claim should be disposed within 30 days of receipt of
claim documentation;• Policyholders’ Servicing requests to be responded
within 10 days;• Changes in premium/terms & conditions during
renewal, should be informed atleast 3 months prior to date of renewal;
• Time-frames for Portability.
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Grievance Redressal Mechanisms
• First Port of Call is the Grievance Redressal Officer of the insurer (Contact details from the policy document);
• Insurer is required to acknowledge a complaint within 3 days and resolve within 15 days;
• If insured is not satisfied with the resolution he may approach the IRDA or Insurance Ombudsman
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Grievance Redressal Mechanism in IRDA
• Facilitating role;• Integrated Grievance Call Centre;• Integrated Grievance Management System;• Flagging of complaints as part of Business
Conduct study of regulated entities;• On-site & Off-Site inspection of policyholder
complaints;• Feedback to regulatory departments.
s cy
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Regulatory Framework for Grievances
Protection of Policyholders Interests Regulations 2002;
Grievance Redressal Guidelines;Board Approval of Grievance Redressal
Policy of Insurers;Mandating Policyholders Protection Sub-
Committee of the Board;Public Disclosure of Grievance Information.Board
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Complaints disposal by Insurance Ombudsman – RPG Rules 1998
• Complainant ought to have exhausted insurer’s grievance redressal mechanism;
• Claim amount should not exceed Rs.20 lacs;• Redressal of disputes like short settlement of
claim, repudiation of claim; • Recommendation or Award;• Time frame of 3 months prescribed for
disposal of the complaintAn insurer cannot go on appeal against the order
of Insurance Ombudsman
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Example of MEDICAL JARGON• The diagnosis by a Physician of primary pulmonary hypertension with substantial right ventricular enlargement established
by investigations including cardiac catheterization, resulting in permanent irreversible physical impairment to the degree of atleast class 3 of the New York Heart Association Classification of cardiac impairment and resulting in the insured being unable to perform his usual occupation.
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Example of MEDICAL JARGON• The diagnosis by a Physician of primary
pulmonary hypertension with substantial right ventricular enlargement established by investigations including cardiac catheterization, resulting in permanent irreversible physical impairment to the degree of atleast class 3 of the New York Heart Association Classification of cardiac impairment and resulting in the insured being unable to perform his usual occupation.
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THANK YOU!