the gimmick of health insurance schemes

8/19/2019 The Gimmick of Health Insurance Schemes

1/42

THE GIMMICK OF HEALTH INSURANCE

CHAPTER 1

INTRODUCTION

Health insurance is insurance against the risk of incurring medical

expenses among individuals. By estimating the overall risk of health

care and health system expenses, among a targeted group, an insurer can develop a

routine finance structure, such as a monthly premium or payroll tax, to ensure that

money is available to pay for the health care benefits specified in the insurance

agreement. The benefit is administered by a central organization such as a

government agency, private business, or not-for-profit entity. According to

the Health nsurance Association of America, health insurance is defined as

!coverage that provides for the payments of benefits as a result of sickness or

in"ury. ncludes insurance for losses from accident, medical expense, disability, or

accidental death and dismemberment!

Insurance in Inia refers to the market for insurance in ndia #hich covers

both the public and private sector organisations. t is listed in the $onstitution of

ndia in the %eventh %chedule as a &nion 'ist sub"ect, meaning it can only be

legislated by the $entral government.

The insurance sector has gone through a number of phases by allo#ing

private companies to solicit insurance and also allo#ing foreign direct investment.

ndia allo#ed private companies in insurance sector in ())), setting a limit

on *+ to (, #hich #as increased to / in ()0.

Ho#ever, the largest life-insurance company in ndia, 'ife nsurance

$orporation of ndia is still o#ned by the government and carries a sovereign

guarantee for all insurance policies issued by it.

0

https://en.wikipedia.org/wiki/Insurancehttps://en.wikipedia.org/wiki/Medical_expenseshttps://en.wikipedia.org/wiki/Medical_expenseshttps://en.wikipedia.org/wiki/Health_carehttps://en.wikipedia.org/wiki/Health_carehttps://en.wikipedia.org/wiki/Health_systemhttps://en.wikipedia.org/wiki/Health_Insurance_Association_of_Americahttps://en.wikipedia.org/wiki/Insurancehttps://en.wikipedia.org/wiki/Indiahttps://en.wikipedia.org/wiki/Constitution_of_Indiahttps://en.wikipedia.org/wiki/Constitution_of_Indiahttps://en.wikipedia.org/wiki/Union_Listhttps://en.wikipedia.org/wiki/Central_government_of_Indiahttps://en.wikipedia.org/wiki/Foreign_direct_investmenthttps://en.wikipedia.org/wiki/Life_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/Life_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/Medical_expenseshttps://en.wikipedia.org/wiki/Medical_expenseshttps://en.wikipedia.org/wiki/Health_carehttps://en.wikipedia.org/wiki/Health_carehttps://en.wikipedia.org/wiki/Health_systemhttps://en.wikipedia.org/wiki/Health_Insurance_Association_of_Americahttps://en.wikipedia.org/wiki/Insurancehttps://en.wikipedia.org/wiki/Indiahttps://en.wikipedia.org/wiki/Constitution_of_Indiahttps://en.wikipedia.org/wiki/Constitution_of_Indiahttps://en.wikipedia.org/wiki/Union_Listhttps://en.wikipedia.org/wiki/Central_government_of_Indiahttps://en.wikipedia.org/wiki/Foreign_direct_investmenthttps://en.wikipedia.org/wiki/Life_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/Life_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/Insurance


2/42


CHAPTER !

HISTOR"

'aunched in 0/1, the health insurance industry has gro#n significantly

mainly due to liberalization of economy and general a#areness. According to

the 2orld Bank , by ()0), more than (345 of ndia6s population had access to

some form of health insurance. There are standalone health insurers along #ith

government sponsored health insurance providers. &ntil recently, to improve the

a#areness and reduce the procrastination for buying health insurance, the 7eneral

nsurance $orporation of ndia and the nsurance 8egulatory and +evelopment

Authority had launched435 an a#areness campaign for all segments of the

population.

n ndia, insurance has a deep-rooted history. nsurance in various forms has been

mentioned in the #ritings of 9anu :9anusmrithi;, contracts.

nsurance in its current form has its history dating back until 0101,

#hen Oriental Life Insurance Company4?5 #as started by Anita Bhavsar

in =olkata to cater to the needs of @uropean community. The pre-independence era

in ndia sa# discrimination bet#een the lives of foreigners :@nglish; and ndians

#ith higher premiums being charged for the latter. n 01), Bombay Mutual Life

Assurance Society became the first ndian insurer.

At the da#n of the t#entieth century, many insurance companies #ere

founded. n the year 0/0(, the 'ife nsurance $ompanies Act and the rovident

*und Act #ere passed to regulate the insurance business. The 'ife nsurance

(

https://en.wikipedia.org/wiki/Health_insurancehttps://en.wikipedia.org/wiki/World_Bankhttps://en.wikipedia.org/wiki/Health_insurance_in_India#cite_note-4https://en.wikipedia.org/wiki/General_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/General_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/Insurance_Regulatory_and_Development_Authorityhttps://en.wikipedia.org/wiki/Insurance_Regulatory_and_Development_Authorityhttps://en.wikipedia.org/wiki/Health_insurance_in_India#cite_note-5https://en.wikipedia.org/wiki/Manu_(Hinduism)https://en.wikipedia.org/wiki/Manusm%E1%B9%9Btihttps://en.wikipedia.org/wiki/Yagnavalkyahttps://en.wikipedia.org/wiki/Kautilyahttps://en.wikipedia.org/wiki/Insurance_in_India#cite_note-3https://en.wikipedia.org/wiki/Kolkatahttps://en.wikipedia.org/wiki/Health_insurancehttps://en.wikipedia.org/wiki/World_Bankhttps://en.wikipedia.org/wiki/Health_insurance_in_India#cite_note-4https://en.wikipedia.org/wiki/General_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/General_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/Insurance_Regulatory_and_Development_Authorityhttps://en.wikipedia.org/wiki/Insurance_Regulatory_and_Development_Authorityhttps://en.wikipedia.org/wiki/Health_insurance_in_India#cite_note-5https://en.wikipedia.org/wiki/Manu_(Hinduism)https://en.wikipedia.org/wiki/Manusm%E1%B9%9Btihttps://en.wikipedia.org/wiki/Yagnavalkyahttps://en.wikipedia.org/wiki/Kautilyahttps://en.wikipedia.org/wiki/Insurance_in_India#cite_note-3https://en.wikipedia.org/wiki/Kolkata


3/42


$ompanies Act, 0/0( made it necessary that the premium-rate tables and

periodical valuations of companies should be certified by an actuary. Ho#ever, the

disparity still existed as discrimination bet#een ndian and foreign companies. The

oldest existing insurance company in ndia is the Cational nsurance $ompany ,

#hich #as founded in 0/), and is still in business.

The 7overnment of ndia issued an Drdinance on 0/ Eanuary 0/3

nationalising the 'ife nsurance sector and 'ife nsurance $orporation came into

existence in the same year. The 'ife nsurance $orporation :'$; absorbed 03

ndian, 0 non-ndian insurers as also 3 provident societiesF(3 ndian and

foreign insurers in all. n 0/( #ith the 7eneral nsurance Business

:Cationalisation; Act #as passed by the ndian arliament, and conseGuently,

7eneral nsurance business #as nationalized #ith effect from 0 Eanuary 0/?. 0)insurers #ere amalgamated and grouped into four companies, namely Cational

nsurance $ompany 'td., the Ce# ndia Assurance $ompany 'td., the Driental

nsurance $ompany 'td and the &nited ndia nsurance $ompany 'td. The

7eneral nsurance $orporation of ndia #as incorporated as a company in 0/0

and it commence business on 0 Eanuary 0/?.

The '$ had monopoly till the late /)s #hen the nsurance sector #as

reopened to the private sector. Before that, the industry consisted of only t#o state

insurers 'ife nsurers :'ife nsurance $orporation of ndia, '$; and 7eneral

nsurers :7eneral nsurance $orporation of ndia, 7$;. 7$ had four subsidiary

companies. 2ith effect from +ecember ())), these subsidiaries have been de-

linked from the parent company and #ere set up as independent insurance

companies Driental nsurance $ompany 'imited, Ce# ndia Assurance $ompany

'imited, Cational nsurance $ompany 'imited and &nited ndia nsurance

$ompany 'imited.

Inustr# structure

By ()0( ndian nsurance is a &%I( billion industry. Ho#ever, only t#o million

people :).( of the total population of 0 billion; are covered under 9ediclaim,

?

https://en.wikipedia.org/wiki/Actuaryhttps://en.wikipedia.org/wiki/National_Insurance_Companyhttps://en.wikipedia.org/wiki/1906https://en.wikipedia.org/wiki/Life_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/General_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/Oriental_Insurance_Company_Limitedhttps://en.wikipedia.org/wiki/New_India_Assurance_Company_Limitedhttps://en.wikipedia.org/wiki/New_India_Assurance_Company_Limitedhttps://en.wikipedia.org/wiki/National_Insurance_Company_Limitedhttps://en.wikipedia.org/w/index.php?title=United_India_Insurance_Company_Limited&action=edit&redlink=1https://en.wikipedia.org/w/index.php?title=United_India_Insurance_Company_Limited&action=edit&redlink=1https://en.wikipedia.org/wiki/Actuaryhttps://en.wikipedia.org/wiki/National_Insurance_Companyhttps://en.wikipedia.org/wiki/1906https://en.wikipedia.org/wiki/Life_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/General_Insurance_Corporation_of_Indiahttps://en.wikipedia.org/wiki/Oriental_Insurance_Company_Limitedhttps://en.wikipedia.org/wiki/New_India_Assurance_Company_Limitedhttps://en.wikipedia.org/wiki/New_India_Assurance_Company_Limitedhttps://en.wikipedia.org/wiki/National_Insurance_Company_Limitedhttps://en.wikipedia.org/w/index.php?title=United_India_Insurance_Company_Limited&action=edit&redlink=1https://en.wikipedia.org/w/index.php?title=United_India_Insurance_Company_Limited&action=edit&redlink=1


4/42


#hereas in developed nations like &%A about 3 of the total population are

covered under some insurance scheme. 2ith more and more private companies in

the sector, this situation is expected to change. @$7$, @%$ and A$ provide

insurance services for niche markets. %o, their scope is limited by legislation but

en"oy some special po#ers.

Insurance Re$%sit%r#

Dn 0 %eptember ()0?, 8+A launched >nsurance 8epository> services in ndia. t

is a uniGue concept and first to be introduced in ndia. This system enables policy

holders to buy and keep insurance policies in dematerialized or electronic form.

olicy holders can hold all their insurance policies in an electronic format in a

single account called electronic insurance account :eA;. nsurance 8egulatory and

+evelopment Authority of ndia has issued licenses to five entities to act as

nsurance 8epository

$+%' nsurance 8epository 'imited : $+%' 8 ; , %H$' ro"ects 'imited =arvy

nsurance repository 'imited C%+' +atabase 9anagement 'imited $A9%

8epository %ervices 'imited

Le&al structure

The insurance sector #ent through a full circle of phases from being unregulated to

completely regulated and then currently being partly deregulated. t is governed by

a number of acts.

The nsurance Act of 0/?145 #as the first legislation governing all forms of

insurance to provide strict state control over insurance business.'ife insurance in

ndia #as completely nationalized on 0/ Eanuary 0/3, through the 'ife nsurance

$orporation Act. All (3 insurance companies operating then in the country #ere

merged into one entity, the 'ife nsurance $orporation of ndia.

The 7eneral nsurance Business Act of 0/( #as enacted to nationalize about 0))

general insurance companies then and subseGuently merging them into four

companies. All the companies #ere amalgamated into Cational nsurance, Ce#

ndia Assurance, Driental nsurance and &nited ndia nsurance, #hich #ere

http://www.cirl.co.in/https://en.wikipedia.org/wiki/Insurance_in_India#cite_note-4https://en.wikipedia.org/wiki/Life_Insurance_Corporation_of_Indiahttp://www.cirl.co.in/https://en.wikipedia.org/wiki/Insurance_in_India#cite_note-4https://en.wikipedia.org/wiki/Life_Insurance_Corporation_of_India


5/42


headGuartered in each of the four metropolitan cities.&ntil 0///, there #ere no

private insurance companies in ndia. The government then introduced the

nsurance 8egulatory and +evelopment Authority Act in 0///, thereby de-

regulating the insurance sector and allo#ing private companies. *urthermore,

foreign investment #as also allo#ed and capped at ( holding in the ndian

insurance companies.

n ()), the Actuaries Act #as passed by parliament to give the profession

statutory status on par #ith $hartered Accountants, Cotaries, $ost J 2orks

Accountants, Advocates, Architects and $ompany %ecretaries.A minimum capital

of &%I1) million:8s.)) $rore; is reGuired by legislation to set up an insurance

business.

Authorities

The primary regulator for insurance in ndia is the nsurance 8egulatory and

+evelopment Authority of ndia :8+A; #hich #as established in 0/// under the

government legislation called the Insurance Regulatory and Development

Authority Act !""".43545

The industry recognises examinations conducted by A :for (1) actuaries;, :for

(.( million individual agents, 1) corporate agents, ?1) brokers and (/ third-partyadministrators; and %'A :for 1,()) surveyors and loss assessors;. There are /

licensed 2eb aggregators. TA$ is the sole data repository for the non-life industry.

BA gives voice to brokers #hile 7 $ouncil and ' $ouncil are platforms for

insurers. A7@A, A@A, A@*, A'$@*, A'@A, *'$DA, 7@AA, 7@&

and C**2 cater to the employees of the insurers. n addition, there are a dozen

Dmbudsman offices to address client grievances.

3

https://en.wikipedia.org/wiki/Insurance_Regulatory_and_Development_Authority_of_Indiahttps://en.wikipedia.org/wiki/Insurance_Regulatory_and_Development_Authority_of_Indiahttps://en.wikipedia.org/wiki/Insurance_in_India#cite_note-act-5https://en.wikipedia.org/wiki/Insurance_in_India#cite_note-6https://en.wikipedia.org/wiki/Third_party_administratorhttps://en.wikipedia.org/wiki/Third_party_administratorhttps://en.wikipedia.org/wiki/Insurance_Regulatory_and_Development_Authority_of_Indiahttps://en.wikipedia.org/wiki/Insurance_Regulatory_and_Development_Authority_of_Indiahttps://en.wikipedia.org/wiki/Insurance_in_India#cite_note-act-5https://en.wikipedia.org/wiki/Insurance_in_India#cite_note-6https://en.wikipedia.org/wiki/Third_party_administratorhttps://en.wikipedia.org/wiki/Third_party_administrator


6/42


CHAPTER '

T"PES OF POLICIES

Health insurance in ndia typically pays for only inpatient hospitalizationand for treatment at hospitals in ndia. Dutpatient services #ere not payable under health policies in ndia. The first health policies in ndia #ere 9ediclaim olicies.n ())) government of ndia liberalized insurance and allo#ed private players intothe insurance sector. The advent of private insurers in ndia sa# the introduction of many innovative products like family floater plans, top-up plans, critical illness

plans, hospital cash and top up policies.

The health insurance sector hovers around 0) in density calculations. Dne

of the main reasons for the lo# penetration and coverage of health insurance is the

lack of competition in the sector. The nsurance 8egulatory Authority of ndia

:8+A; #hich is responsible for insurance policies in ndia can create health

circles, similar to telecom circles to promote competition.45

Broadly #e can divide the health insurance plans in ndia today can be

classified into three categories

• H%s$itali(ati%n

Hospitalization plans are indemnity plans that pay cost of

hospitalization and medical costs of the insured sub"ect to the sum insured.

The sum insured can be applied on a per member basis in case of individual

health policies or on a floater basis in case of family floater policies. n case

of floater policies the sum insured can be utilized by any of the members

https://en.wikipedia.org/wiki/Health_insurance_in_India#cite_note-6https://en.wikipedia.org/wiki/Health_insurance_in_India#cite_note-6


7/42


insured under the plan. These policies do not normally pay any cash benefit.

n addition to hospitalization benefits, specific policies may offer a number

of additional benefits like maternity and ne#born coverage, day care

procedures for specific procedures, pre- and post-hospitalization care,

domiciliary benefits #here patients cannot be moved to a hospital, dailycash, and convalescence.

There is another type of hospitalization policy called a top#up policy.

Top up policies have a high deductible typically set a level of existing cover.

This policy is targeted at people #ho have some amount of insurance from

their employer. f the employer provided cover is not enough people can

supplement their cover #ith the top-up policy. Ho#ever, this is sub"ect to

deduction on every claim reported for every member on the final amount

payable.

• H%s$ital ail# cash )ene*it $lans

+aily cash benefits is a defined benefit policy that pays a defined sum

of money for every day of hospitalization. The payments for a defined

number of days in the policy year and may be sub"ect to a deductible of fe#

days.

• Critical illness $lans

These are benefit based policies #hich pay a lumpsum :fixed; benefit

amount on diagnosis of covered critical lllness and medical prodcedures.These illness are generally specific and high severity and lo# feGuency in

nature that cost high #hen compared to day to day medical K treatment need.

eg heart attack, cancer, stroke etc no# some insurers have come up #ith

option of staggered payment of claims in combination to upfront lumpsum

payment.


8/42


CHAPTER +

KE" ASPECTS OF HEALTH INSURANCE

ayment options

• Direct Pa#,ent %r Cashless Facilit#

&nder this facility, the person does not need to pay the

hospital as the insurer pays directly to the hospital. &nder the

cashless scheme, the policyholder and all those #ho are

mentioned in the policy can undertake treatment from those

hospitals approved by the insurer.

• Rei,)urse,ent at the en %* the h%s$ital sta#

After staying for the duration of the treatment, the patientcan take a reimbursement from the insurer for the treatment that

is covered under the policy undertaken.

$ost and duration

1


9/42


• P%lic# $rice ran&e

nsurance companies offer health insurance from a sum

insured of 8s. 3)))K-45 for micro-insurance policies to a higher

sum insured of 8s. 3) lacs and above. The common insurance policies for health insurance are usually available from 8s. 0 lac

to 8s. 3 lacs.

• Durati%n

Health insurance policies offered by non-life insurance

companies usually last for a period of one year. 'ife insurance

companies offer policies for a period of several years.

CHAPTER -

TERMS IN HEALTH INSURANCE

THE INDI.IDUAL INSURED PERSON/S O0LIGATIONS MA" TAKE

SE.ERAL FORMS

Pre,iu, The amount the policy-holder or their sponsor :e.g. an employer; pays

to the health plan to purchase health coverage.

Deucti)le The amount that the insured must pay out-of-pocket before the health

insurer pays its share. *or example, policy-holders might have to pay a I3))

deductible per year, before any of their health care is covered by the health insurer.

t may take several doctor>s visits or prescription refills before the insured person

reaches the deductible and the insurance company starts to pay for care.

*urthermore, most policies do not apply co-pays for doctor>s visits or prescriptions

against your deductible.

C%2$a#,ent The amount that the insured person must pay out of pocket before

the health insurer pays for a particular visit or service. *or example, an insured

person might pay a I3 co-payment for a doctor>s visit, or to obtain a prescription.

A co-payment must be paid each time a particular service is obtained.

/

https://en.wikipedia.org/wiki/Health_insurance_in_India#cite_note-7https://en.wikipedia.org/wiki/Deductiblehttps://en.wikipedia.org/wiki/Out-of-pocket_expenseshttps://en.wikipedia.org/wiki/Co-paymenthttps://en.wikipedia.org/wiki/Health_insurance_in_India#cite_note-7https://en.wikipedia.org/wiki/Deductiblehttps://en.wikipedia.org/wiki/Out-of-pocket_expenseshttps://en.wikipedia.org/wiki/Co-payment


10/42


C%insurance nstead of, or in addition to, paying a fixed amount up front :a co-

payment;, the co-insurance is a percentage of the total cost that insured person may

also pay. *or example, the member might have to pay () of the cost of a surgery

over and above a co-payment, #hile the insurance company pays the other 1). f

there is an upper limit on coinsurance, the policy-holder could end up o#ing verylittle, or a great deal, depending on the actual costs of the services they obtain.

E3clusi%ns Cot all services are covered. The insured are generally expected to

pay the full cost of non-covered services out of their o#n pockets.

C%4era&e li,its %ome health insurance policies only pay for health care up to a

certain dollar amount. The insured person may be expected to pay any charges in

excess of the health plan>s maximum payment for a specific service. n addition,

some insurance company schemes have annual or lifetime coverage maxima. n

these cases, the health plan #ill stop payment #hen they reach the benefit

maximum, and the policy-holder must pay all remaining costs.

Dut-of-pocket maxima %imilar to coverage limits, except that in this case, the

insured person>s payment obligation ends #hen they reach the out-of-pocket

maximum, and health insurance pays all further covered costs. Dut-of-pocket

maxima can be limited to a specific benefit category :such as prescription drugs;

or can apply to all coverage provided during a specific benefit year.

Ca$itati%n An amount paid by an insurer to a health care provider, for #hich the provider agrees to treat all members of the insurer.

In2Net5%r6 Pr%4ier :&.%. term; A health care provider on a list of providers

preselected by the insurer. The insurer #ill offer discounted coinsurance or co-

payments, or additional benefits, to a plan member to see an in-net#ork provider.

7enerally, providers in net#ork are providers #ho have a contract #ith the insurer

to accept rates further discounted from the !usual and customary! charges the

insurer pays to out-of-net#ork providers.

Pri%r Auth%ri(ati%n A certification or authorization that an insurer provides prior

to medical service occurring. Dbtaining an authorization means that the insurer is

obligated to pay for the service, assuming it matches #hat #as authorized. 9any

smaller, routine services do not reGuire authorization.4?5

0)

https://en.wikipedia.org/wiki/Coinsurancehttps://en.wikipedia.org/wiki/Capitated_reimbursementhttps://en.wikipedia.org/wiki/Health_insurance#cite_note-Healthharbor-3https://en.wikipedia.org/wiki/Coinsurancehttps://en.wikipedia.org/wiki/Capitated_reimbursementhttps://en.wikipedia.org/wiki/Health_insurance#cite_note-Healthharbor-3


11/42


E3$lanati%n %* 0ene*its A document that may be sent by an insurer to a patient

explaining #hat #as covered for a medical service, and ho# payment amount and

patient responsibility amount #ere determined.4?5

CHAPTER 7

CASE STUDIES

CASE STUD" 1

P%lic# H%ler 8 Fertilit# Treat,ent

A private medical insurance member contacted her insurer reGuesting

authorisation to see a consultant gynaecologist stating she #as trying to conceive.

%he #as informed during by the health insurer that private health cover is

not provided for fertility consultationsKinvestigations due to it being general

scheme exclusion. The member #as unhappy #ith this response.

The health insurance member contacted the insurer a #eek later, stating that she#as confused #hen she phoned initially. %he advised that she is having a

laparoscopy for dyspareunia. The insurer reGuested a medical report from the

member6s consultant.

The medical report #as received from the consultant gynaecologist, #ith a

diagnosis of endometriosis. The consultant further reported that the laparoscopy

00

https://en.wikipedia.org/wiki/Explanation_of_Benefitshttps://en.wikipedia.org/wiki/Health_insurance#cite_note-Healthharbor-3https://en.wikipedia.org/wiki/Explanation_of_Benefitshttps://en.wikipedia.org/wiki/Health_insurance#cite_note-Healthharbor-3


12/42


#as reGuired to treat endometriosis. There #as no mention of treatment for

dyspareunia.

An investigation commenced and the member #as contacted. The member

explained that her reasons for #anting private health cover #as primarily for

fertility reasons, but had also 0#anted to treat dyspaneuria and possible

endometriosis. 9ember admitted she #as confused #hy the 7 had suggested she

had endometriosis because it had not been diagnosed before.

*urther medical records #ere reGuested from the consultant gynaecologist and

other fertility specialists that the member had consulted.

The consultant6s referral letter contained multiple references to Lfertility,

referral to fertility clinics and trying to conceive6 over the last 01 months.

A second referral letter from a fertility specialist #hich stated that the reason for

the treatment #as for fertility and that if private insurance re"ected it then the

patient #ould have to fund the treatment themselves.

nvestigative revie# found no corroborating evidence that member suffered from

dyspareunia, or endometriosis, or reGuired a laparoscopy to treat either condition.

rima facie evidence sho#ed that the primary reason for seeking cover #as for

fertility purposes, as confirmed by the member, and that the additional diagnosis

and treatment sought #as a disguise for fertility treatment.

The clai, 5as re9ecte an the ,e,)er:s $%lic# re4ie5e;

0(


13/42


CASE STUD" !

P%lic# H%ler 8 N%n iscl%sure

A privately insured member claimed for treatment to his shoulder t#o days

after obtaining a policy. The member #as on a full medical under#riting :*9&;

policy.

An nitial reGuest for the members medical history did not identify a pre

existing in"ury and the insurer commenced to fund the treatment. The members 7

confirmed in a report that the condition #as ne#.

Three months after the initial claim an anonymous caller contacted the insurer and

reported that they #ere a#are the medical insurance members in"ury #as pre

existing.

The matter #as referred to fraud investigators #ho intervie#ed the

physiotherapist. The physiotherapist informed investigators that the in"ury #as preexisting.

nvestigators intervie#ed the health insurance member #ho admitted the

fraud.

The ,e,)er re$ai the > %* *unin& that the insurer ha $ai?

their $%lic# 5as cancelle an the# 5ere re$%rte t% the HICFG;

0?


14/42


CASE STUD" '

P%lic# H%ler 8 Frauulent clai,@creatin& a *alse %cu,ent

olicyholder M submitted numerous cash-plan claims, over a short period of

time, for various treatments.

8egular reporting lead to a revie# of these claims and it #as found that 03

of these treatments did not take place N this #as confirmed by contacting the

treatment providers.

*urther investigation revealed that olicyholder M had taken out ( further

policies #ith the same company using aliases.

&nder the %(/ :?;, :anti-fraud;, provisions of the +ata rotection Act 0//1,

details of olicyholder M #ere shared #ith other H$*7 members #ho found that

the same thing had happened to them.

All $%licies 5ere cancelle an the $%lice c%ntacte; P%lic#h%ler 5asc%n4icte in a cri,inal c%urt? 5hich resulte in the, recei4in& c%,,unit#

ser4ice an )ein& %rere t% c%,$ensate *%r the ,%nies *rauulentl# &aine;

0


15/42


CASE STUD" +

Sur&e%n 8 0illin& *%r $r%ceures n%t unerta6en

9ost of the rivate 9edical nsurance companies publish their o#n L*ee

%chedules6, #hich use ndustry standard coding to list almost all commonly

performed medical procedures.

n many areas of practice there are number of possible codes #hich can be

selected based on the complexity of a procedure actually performed. By falsely

using a code for a more complex version of an operation it is possible to obtain

higher reimbursement than #as intended. This is hard to detect as the difference

may be Guite technical and the operation #ould be consistent #ith the customer6s

condition and medical history. Dne such are is gastroscopy :endoscopic

examination of the stomach; #here it is possible to perform a diagnostic procedure

:"ust a look; or a therapeutic procedure #hich is #here a treatment is given as #ell.

9ost of the insurers try to identify up coding.%everal H$*7 members observed that rovider M appeared to be invoicing

vastly more therapeutic procedures than his peers, and more than #ould

statistically be expected. His patient6s medical notes did not document the

therapeutic procedures #hich #ere claimed.

03


16/42


Des$ite se4eral 5arnin&s the inc%rrect )illin& c%ntinue an e4entuall#

se4eral HICFG ,e,)ers c%,$laine t% the General Meical C%uncil? BGMC;

A*ter a *ull in4esti&ati%n an Panel hearin&? the $r%4ier 5as sus$ene *r%,

the re&ister *%r a $eri% %* 1! ,%nths; Man# insurers als% recei4e re*uns

*r%, the $r%4ier c%ncerne;

CHAPTER

NES ARTICLES

Health insurance sche,e a &i,,ic6? sa#s Gunashe6ar

By @xpress Ce#s %ervice - BAC7A'D8@

ublished 0?th Eune ()0( )/( A9

'ast &pdated 0?th Eune ()0( )/( A9

Dpposition leader in BB9 9 = 7unashekar on Tuesday alleged that rulingBE is utilising a health insurance scheme, announced t#o and a half years ago "ust

for the sake of publicity.

%peaking to reporters, 7unashekar said the scheme, initially announced

during the administrative officer6s period, #as meant for B' card holders and

0


17/42


urban poor. The proposal of the scheme #as sent to the %tate 7overnment in

*ebruary ()0). There #ere ./ lakh estimated beneficiaries and 8s () crore #ere

earmarked for the scheme. %ubseGuently, #hen BE came to po#er, in its first

budget, it announced the same scheme in the name of andit +een +ayal %uvarna

Arogya %uraksha


18/42


@ven among those #ho have some form of coverage, are covered by publicinsurance companies, according to Cational Health rofile ()03, compiled by the$entral Bureau of Health ntelligence.

The report, #hich has a separate chapter on health financing, sho#sdespite a declining share of the $entre to#ards public health expenditure, it hasdone significantly #ell to provide insurance cover as compared to the privatesector.

ublic insurance companies have a higher share of coverage and premium for all types of policies, except the family floater policies, #here private players grabbed ) share. *amily floater policies allo# a family to claim thecomplete insurance benefit for one member of the family #hile the policy coversall its members.

Health insurance c%4era&e t% cr%ss 7'> ,n $e%$le )# !>1- 0

Health insurance coverage in ndia is expected to cross ?) million people

or 3) of the population by ()03, a2orld Bank report has said.

!Ce# generation of health financing schemes can help ndia progress

to#ards universal health coverage. 9ore than ?) million persons or half the

country>s population are likely to be covered by health insurance by ()03,! said the

study on 7overnment-%ponsored Health nsurance %chemes :7%H%;.

According to the study, over the past five years, 7%H% have contributed to

a significant increase in the population covered by health insurance in the country.

01

http://www.business-standard.com/search?type=news&q=Health+Insurancehttp://www.business-standard.com/search?type=news&q=World+Bankhttp://www.business-standard.com/search?type=news&q=Health+Insurancehttp://www.business-standard.com/search?type=news&q=World+Bank


19/42


9ost of the gro#th is likely to occur along the three lines -- 8ashtriya

%#asthya Bima


20/42


He has also proposed a top-up cover of 8s ?),))) for senior citizens over the ageof ) in this category.

!t #as being talked about for some time and has finally come through no#. t>s a positive development that #ill also help deepen insurance penetration,! saidBhargav +asgupta, 9+ and $@D, $$ 'ombard 7eneral nsurance.

8eports of such an all-encompassing scheme have been doing the rounds since thesuccess of the government-promoted radhan 9antri Eeevan Eyoti


21/42


CHAPTER =

THINGS TO KEEP IN MIND HILEPURCHASING A HEALTH INSURANCE POLIC"

A report by the nternational *ederation of Health lans sho#ed that ndianson an average spend &%I(? :8s 0(,)?; per day on hospital stay.2ith hospitalexpenses rising every year, it has become a tough "ob for the common man to

balance his savings #hile meeting the inevitable medical expenses. A basic procedure in a private hospital can cost you up to 8s ),))). A heart surgery maycosts you bet#een 8s ( to 3 lacs at a branded hospital, enough to burn a hole in

your pocket. Having a comprehensive health insurance policy in hand could rescueyou from facing financial ruin #hile trying to foot such hospital bills.

The ndian health insurance sector is booming. The number of ne# healthyinsurance policies issued surged from (,3),)),))) in ())(-())? to close to3,)),))) in ()0)-()00, according to the 8+A. The hike in the insurance cap to/ of *+ paved the #ay for multiple players in the insurance sector to offer a

(0

http://www.dnaindia.com/bangalore/1674589/report-indians-spend-rs12036-per-day-on-hospital-stay-study-showshttp://www.royalsundaram.in/health-insurance.aspxhttp://indiainbusiness.nic.in/newdesign/index.php?param=industryservices_landing/379/3http://www.dnaindia.com/bangalore/1674589/report-indians-spend-rs12036-per-day-on-hospital-stay-study-showshttp://www.royalsundaram.in/health-insurance.aspxhttp://indiainbusiness.nic.in/newdesign/index.php?param=industryservices_landing/379/3


22/42


plethora of health insurance plans designed to meet the different needs of the people of our country. n such a scenario, #ith so many brands mushrooming #iththeir P am the bestQ tags, it takes some thinking to find the best plan.

Thin&s t% Kee$ in Min )e*%re 0u#in& a Health Insurance P%lic#

Here are the most important factors to be kept in mind #hile choosing your healthinsurance policy

• P%lic# C%4era&e

=no# your policy coverage. 8ead the information brochure carefully tounderstand all its terms and conditions. There are several plans in the market thatoffer variable coverage on their health plans. $hoose the sum assured carefully.

This is the maximum amount that the insured person can claim in one policy year.*or this, one must consider rising medical costs, #hile also keeping the amountsuch that one can afford to pay the premium.

2hen selecting your coverage, think about #hat needs could arise in the*uture. f you have ageing parents or may be planning on having kids soon, youmay consider these aspects. 'ook for a policy that covers #ide age groups, such as

from children aged /0 days to dependent parents up to 3 years.


23/42


• E3clusi%ns aitin& Peri%

This is the most important factor to be considered. 8ead the exclusion

clauses in the policy document. 2hat are the diseases #hich are not paid duringspecific time periodR+oes the policy covers pre-existing diseases. f so from #henRR s 9ost

policies offer a #aiting period of 1 months for pre-existing diseases. t is#orth#hile to note that you should disclose your pre existing disease #hile buyingthe policy to take the advantage of such cover

• Fle3i)ilit# in the P%lic#

$over in the policy should suit yourKfamily6s reGuirement. 2hile you #ould

be reGuiring cover for expenses related to maternity, your parents #ould be keen ingetting a cover for pre existing disease as Guicker as possible. Among variousoffering in the market, one need to first chalk out #hat cover he #ants J thenchoose the correct plan. $are should be exercised to ensure that later he has rightto s#itch over to any other suitable product offered by the nsurer.

• N%2Clai, Disc%unt %r Cu,ulati4e 0%nus

Co $laim discount encourages the non claimant by giving a definedreduction in rene#al premium #hile $umulative Bonus increases the coverageamount in a defined #ay.

$heck the most suitable option to suit your financial capability*inally, make sure to read all terms and conditions carefully before finalizing ahealth insurance policy. f not, you might have to face some unpleasant surprises#hen you seek a claim

(?


24/42


CHAPTER

TOP GROUP HEALTH INSURANCE POLICIES

A$%ll% Munich Health Gr%u$ Health Insurance Plans these plans provide substantial cover for so that accidents and illnesses, #hich reGuire theinsured to be hospitalized, can be treated properly

The policyholders can also choose critical illness cover as part of their plan, #hichalso covers the follo#ing

• +iagnostic procedures

• %urgery expenses

• 'odging and boarding expenses

(


25/42


• rosthetic expenses

• $& costs

ICICI L%,)ar Gr%u$ Health Insurance the plan provides the follo#ingcoverage

• 9edical expenses at the time of hospitalization that lasts in excess of (

hours

• re hospitalization costs for ?) days

• High tech technological processes and surgeries #here less than ( hours>

hospitalization is necessary

• ost hospitalization costs for ) days

F%ll%5in& are the ,a9%r )ene*its %* this $lan

• $ustomizable plan

• $ashless service

• *amily floater options

• @xtended coverage for / important critical illnesses - this is provided in

addition to hospitalization benefits

•

HDFC Er&% Gr%u$ Meical Insurance the plan covers the follo#ing

8oom and boarding costs

• re hospitalization costs

(3


26/42


• Cursing costs

• ost hospitalization costs

• *ees of surgeons, consultants, anesthetists, specialists, and medical

practitioners

• +omiciliary hospitalization costs

• $osts of anesthesia, blood, medicines and drugs, oxygen, diagnostic

materials and x-ray, operation theatre, dialysis, surgical appliances, andchemotherapy

• +ay care treatments

• 9ax Bupa @mployee *irst Health nsurance follo#ing are the ma"or

advantages of these plans

• +irect communication #ith company - no need for third parties

• 9edical costs for day care treatment

• $hoice to change group policy to individual plan upon retirement or change

of company

• %ingle room accommodation #ithout restriction on number of days and rents

• $ashless facility at top hospitals

• Health profile of all the members

• Tax benefits

(


27/42


• Top coverage so that the best medical treatment and advice can be provided

• +iverse coverage in terms of age group of insured

CHAPTER 1>

STEPS FOR CLAIM SETTLEMENT AT S0I LIFE

At %B 'ife, #e are committed to protect the interest of our olicyholders Kstakeholders and ensure that the $laim Amount is provided to the Cominee KBeneficiary #ell #ithin the prescribed timelines laid do#n by 8+A.

Clai, Settle,ent Pr%cess is a si,$le ' ste$ $r%cess

Ste$ 1 Clai, Inti,ati%n

ntimate about the claim at any %B 'ife Branch #ith all the documents asmentioned in the policy document.

BF%r list %* %cu,ents t% )e su),itte 5ith the Clai, inti,ati%n? $lease

clic6 here

(

http://www.sbilife.co.in/sbilife/images/File/documents/List_of_Documents_for_Claim_Intimation.pdfhttp://www.sbilife.co.in/sbilife/images/File/documents/List_of_Documents_for_Claim_Intimation.pdfhttp://www.sbilife.co.in/sbilife/images/File/documents/List_of_Documents_for_Claim_Intimation.pdfhttp://www.sbilife.co.in/sbilife/images/File/documents/List_of_Documents_for_Claim_Intimation.pdf


28/42


Ste$ ! Reuire,ent su),issi%n Bi* an#

f there are any reGuirements raised by %B 'ife for checking the admissibility orother#ise of the claim, the same needs to be addressed by the $laimant.

Ste$ ' Final ecisi%n %n the Clai, Throughout the $laim %ettlement rocess,#e are al#ays there to assist in better understanding of the reGuirements and faster completion of documentation process. *or any further assistance on our claimssettlement process, please feel free to #rite to us at - clai,sJs)ili*e;c%;in

*or a seamless claim settlement process, the policy document also has a detaileddescription of the documents reGuired to be submitted along #ith the $laimintimation.

The final decision on a claim shall be based on the disclosures made by the 'ife

Assured in the proposal form, since an insurance contract is a contract of &tmost7ood *aith. All the decisions are guided by the nsurance la#s.

Health Insurance Clai,s Settle,ent Pr%cess

n most cases, the nsurance companies appoint a Third arty Administrator :TA;

for claims processing. That means once the health insurance policy is sold, the

insurer passes on the complete details to the TA. n case of a claim, the insured

has to get in touch #ith the TA for all verification and formalities.

T5% a#s 0# hich Health Insurance Clai,s Are Settle

Cashless *or planned hospitalization at authorized net#ork hospitals, the TA has to be

notified in advance for availing cashless treatment or #ithin the stipulated time

limits for emergencies. The insurance desk at hospitals #ill generally help #ith all

the paper #ork. The TA has to approve the claim amount and the hospital settles

(1

mailto:[email protected]:[email protected]


29/42


the amount #ith the TA K nsurer. There #ill be exclusions #hich #ill have to be

settled directly at the hospital by the insured.

Rei,)urse,ent 8eimbursement facility can be availed at both the net#ork and non-net#ork

hospitals. The hospital bills are directly settled at the hospital after the insured

avails the treatment. The insured can then claim reimbursement for hospitalization

by submitting relevant bills K documents for the claimed amount to the TA.

The TA mode of claims settling has its o#n problems. The TA is incentivized to

limit insurance claims and they are not the ones #ho sell the policy. There are

many cases #here the insured had a tough time to claim for his hospital expenses.

%o before taking a health insurance policy, check #ho the TA is and ho# good

they are #hen it comes to claims processing. nternet search and a friendly chat

#ith the hospital staff can give you good insight on the insurer K TA. There are

also some health insurance providers #ho do not employ TAs and manage claims

settlement directly #hich is called n-House TA

CHAPTER 11

INSURANCE CO:S IN INDIA

• Aviva 'ife nsurance

• Ba"a" Allianz 'ife nsurance

• Birla %un 'ife nsurance

• H+*$ %tandard 'ife nsurance

• C7 Oysya 'ife nsurance

• 'ife nsurance $orporation of ndia

• 9ax 'ife nsurance $ompany

(/

http://business.mapsofindia.com/india-company/a/aviva-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/b/bajaj-allianz-insurance-india.htmlhttp://business.mapsofindia.com/india-company/b/birla-sun-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/s/standard-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/i/ing-vysya-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/l/life-insurance-corporation-ltd.htmlhttp://business.mapsofindia.com/india-company/m/max-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/a/aviva-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/b/bajaj-allianz-insurance-india.htmlhttp://business.mapsofindia.com/india-company/b/birla-sun-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/s/standard-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/i/ing-vysya-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/l/life-insurance-corporation-ltd.htmlhttp://business.mapsofindia.com/india-company/m/max-life-insurance-india.html


30/42


• 9et'ife ndia nsurance

• 8eliance 'ife nsurance

•%ahara ndia 'ife nsurance

• %B 'ife nsurance

• Tata A7 nsurance $ompany 'td

• Dm =otak 9ahindra nsurance $ompany

• Agriculture nsurance $ompany of ndia 'td

• Amsure nsurance

• ACS nsurance

• $hola mandalam 7eneral nsurance

• @mployee>s %tate nsurance $orporation

• $$ 'ombard 7eneral nsurance• **$D-Tokio 7eneral nsurance

• Cational nsurance $ompany 'td

• Driental nsurance $ompany 'td

• eerless %mart *inancial %olutions

• 8oyal %undaram Alliance nsurance ndia

• Tata A7 nsurance $ompany 'td

• @xport $redit 7uarantee $orporation of ndia 'td

-

?)

http://business.mapsofindia.com/india-company/m/metlife-insurance.htmlhttp://business.mapsofindia.com/india-company/r/reliance-life-insurance.htmlhttp://business.mapsofindia.com/india-company/s/sahara-india-life-insurance.htmlhttp://business.mapsofindia.com/banks-in-india/sbi-life-insurance.htmlhttp://business.mapsofindia.com/india-company/t/tata-aig-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/o/om-kotak-mahindra-insurance-india.htmlhttp://business.mapsofindia.com/india-company/a/agriculture-insurance-company-of-india-ltd.htmlhttp://business.mapsofindia.com/india-company/a/amsure-insurance.htmlhttp://business.mapsofindia.com/india-company/a/anz-insurance.htmlhttp://business.mapsofindia.com/india-company/c/cholamandalam-ms-general-insurance.htmlhttp://business.mapsofindia.com/india-company/e/employee-state-insurance-corporation.htmlhttp://business.mapsofindia.com/india-company/i/icici-lombard.htmlhttp://business.mapsofindia.com/india-company/i/iffco-tokio.htmlhttp://business.mapsofindia.com/india-company/n/national-insurance-company-ltd.htmlhttp://business.mapsofindia.com/india-company/o/oriental-insurance-company-ltd.htmlhttp://business.mapsofindia.com/india-company/p/peerless-smart-financial-solutions.htmlhttp://business.mapsofindia.com/india-company/r/royal-sundram-alliance-insurance-india.htmlhttp://business.mapsofindia.com/india-company/t/tata-aig-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/e/export-credit-guarantee-corporation-of-india-ltd.htmlhttp://business.mapsofindia.com/india-company/m/metlife-insurance.htmlhttp://business.mapsofindia.com/india-company/r/reliance-life-insurance.htmlhttp://business.mapsofindia.com/india-company/s/sahara-india-life-insurance.htmlhttp://business.mapsofindia.com/banks-in-india/sbi-life-insurance.htmlhttp://business.mapsofindia.com/india-company/t/tata-aig-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/o/om-kotak-mahindra-insurance-india.htmlhttp://business.mapsofindia.com/india-company/a/agriculture-insurance-company-of-india-ltd.htmlhttp://business.mapsofindia.com/india-company/a/amsure-insurance.htmlhttp://business.mapsofindia.com/india-company/a/anz-insurance.htmlhttp://business.mapsofindia.com/india-company/c/cholamandalam-ms-general-insurance.htmlhttp://business.mapsofindia.com/india-company/e/employee-state-insurance-corporation.htmlhttp://business.mapsofindia.com/india-company/i/icici-lombard.htmlhttp://business.mapsofindia.com/india-company/i/iffco-tokio.htmlhttp://business.mapsofindia.com/india-company/n/national-insurance-company-ltd.htmlhttp://business.mapsofindia.com/india-company/o/oriental-insurance-company-ltd.htmlhttp://business.mapsofindia.com/india-company/p/peerless-smart-financial-solutions.htmlhttp://business.mapsofindia.com/india-company/r/royal-sundram-alliance-insurance-india.htmlhttp://business.mapsofindia.com/india-company/t/tata-aig-life-insurance-india.htmlhttp://business.mapsofindia.com/india-company/e/export-credit-guarantee-corporation-of-india-ltd.html


31/42


CHAPTER 1!

DIFFERENT COMPANIES IN HEALTH INSURANCE

CHOLA INSURANCE

Features %* health clai,s•

roprietary %upport team !$hola 9% Help! to handle all Health $laimsreGuirements

• @xtensive net#ork of over ())) hospitals for cashless settlement

• 00 minor surgeries that reGuire less than ( hours hospitalization covered

under the &C&@ day care procedure

?0


32/42


• $ustomer can track the status of the claim through our (x $ustomer

%upport team

•

*air and Guick settlement of claims #ith minimal documentation

• 9ember login for Health nsurance

• $orporate login for Health nsurance

• 'ist of net#ork hospitals

HDFC ERGO HEALTH INSURANCE

Ste$ 1

7et admission in net#ork hospital.

Ste$ !

ntimate the call center about the hospitalization as soon as possible.

Ste$ '

?(

http://www.cholainsurance.com/mlogin/http://www.cholainsurance.com/clogin/http://www.cholainsurance.com/nwhosp/http://www.cholainsurance.com/mlogin/http://www.cholainsurance.com/clogin/http://www.cholainsurance.com/nwhosp/


33/42


rovide the health card of the patient along #ith the photo d proof to the hospital.

Dbtain the pre-authorization form from hospital and get the same filled in and

signed by the attending doctor.

Ste$ +

The hospital #ill faxKmail the pre-authorization form to the H$%KTA along #ith

necessary medical details like investigation report etc at the number mentioned in

your Health $ardKolicy %chedule.

Ste$ -

0.


34/42


A;


35/42


D%cu,ents reuire *%r clai, $r%cess

• +uly filled J signed claim form

•

All hospital bills in original including final hospital bill :#ith bill number signed J stamped by the hospital; #ith itemized bill J original receipts

• +ischarge card or discharge summary :original; or death certificate in case

of death :in hospital;

• All original investigation reports J medicine bills #ith doctor6s prescription.

• *ollo#-up advice or letter for line of treatment after discharge from hospital

from doctor.

• n case the hospital is not registered, please get letters on the hospital

letterhead mentioning the number of beds and availability of doctors and nurses

round the clock.• n case of non-net#ork hospital, you may have to get the hospital and

doctor6s registration number in hospital letterhead and get the same signed andstamped by the hospital, if reGuired.

I,$%rtant in*%r,ati%n

As soon as there is a need for hospitalization, please intimate the H$%KTA on

(x customer helpline number 01)) ( )) )) K 01)) ()) 0 /// as mentioned inyour Health $ardKolicy %chedule.

'ist of net#ork hospital is available on our #ebsite.


36/42


Clai,s $r%cess

n case of hospitalization, intimation should be provided to the $ompany KTA immediately and not later than days. n all other cases, the $ompany K TAmust be informed of any event or occurrence that may give rise to a claim under

this olicy at least days. rior to any conseGuent treatment, consultation or procedure being taken and the $ompany K TA should pre-authorise suchtreatment, consultation or procedure.

Any documentation and information reGuested to establish the circumstancesof the claim, its Guantum or the $ompany6s liability for the claim, should besubmitted #ithin 0) days of our reGuest or discharge from Hospital or completionof treatment, #hichever is earlier.

?


37/42


CHAPTER 1'

DUTIES? POERS FUNCTIONS OF IRDA

Secti%n 1+ %* IRDAI Act? 1 la#s %5n the uties? $%5ers an *uncti%ns %*

IRDAI;;

%ub"ect to the provisions of this Act and any other la# for the time being inforce, the Authority shall have the duty to regulate, promote and ensure orderlygro#th of the insurance business and re-insurance business.

0. 2ithout pre"udice to the generality of the provisions contained in sub-section

:0;, the po#ers and functions of the Authority shall include, -

• issue to the applicant a certificate of registration, rene#, modify, #ithdra#,

suspend or cancel such registrationU

• protection of the interests of the policy holders in matters concerning

assigning of policy, nomination by policy holders, insurable interest,settlement of insurance claim, surrender value of policy and other terms andconditions of contracts of insuranceU

• specifying reGuisite Gualifications, code of conduct and practical training for

intermediary or insurance intermediaries and agents

• specifying the code of conduct for surveyors and loss assessorsU

• promoting efficiency in the conduct of insurance businessU

• promoting and regulating professional organisations connected #ith the

insurance and re-insurance businessU

• levying fees and other charges for carrying out the purposes of this ActU

?


38/42


• calling for information from, undertaking inspection of, conducting

enGuiries and investigations including audit of the insurers, intermediaries,insurance intermediaries and other organisations connected #ith theinsurance businessU

•

control and regulation of the rates, advantages, terms and conditions thatmay be offered by insurers in respect of general insurance business not socontrolled and regulated by the Tariff Advisory $ommittee under section& of the nsurance Act, 0/?1 : of 0/?1;U

• specifying the form and manner in #hich books of account shall be

maintained and statement of accounts shall be rendered by insurers and other insurance intermediariesU

• regulating investment of funds by insurance companiesU

• regulating maintenance of margin of solvencyU

•

ad"udication of disputes bet#een insurers and intermediaries or insuranceintermediariesU

• supervising the functioning of the Tariff Advisory $ommitteeU

• specifying the percentage of premium income of the insurer to finance

schemes for promoting and regulating professional organisations referredto in clause :f;U

• specifying the percentage of life insurance business and general insurance

business to be undertaken by the insurer in the rural or social sectorU and

• exercising such other po#ers as may be prescribed

?1


39/42


CHAPTER 1+

CURRENT AARENESS OF IRDA

PERSONAL SAFET"

Holi is coming. lay it safely. $ontinuing the tradition of smearing color onthe faces of friends and thro#ing colored #ater in a playful manner on guests is ahallmark of the ndian *estival Holi.

Historically, Holi, the festival of bright and cheerful colours, used to be

played #ith natural dyes made from henna leaves, margosa leaves, marigoldflo#ers, turmeric, kumkum and 7ulal made from red sandal#ood po#der etc.2ith changing times, chemical dyes and synthetic colours entered into the market.These may contain dangerous toxins that have harmful effect on the human body.Therefore, one has to be careful #hile using the colours for

playing holiU most of the modern colours are in fact chemical dyes and can causeskin allergies. %ome of the skin problems that could occur are itching, rashes,dryness and irritation. @yes are extremely vulnerable and need to be

protected since sometimesU these harmful colours come in contact #ith eyesresulting in eyeinfection etc.

2hy don6t #e all start using herbal colours made up of natural substancesR2e should spread the message of not using chemical colours having harmfulsubstances such as lead and mercury etc. This is the first step of risk avoidance tohave a vibrant and safe holi.

Dne more aspect of danger is that the floor becomes slippery due to playing#ith #ater colours. %o #hile playing holi, avoid running or "umping on #et floorsas one may get in"ured due to slippery floors spoiling the mood of the day.

?/


40/42


The second step is minimizing risk by applying oil on the skin and hair before playing holi. This #ay, the dyes #ill not catch hold on to the body easily.&sing oil may help to minimize the side effects, even if some of the colours used

by friends happen to be chemical colours. And finally, one should never force anyone to play holi against their #ill.

8emember, it is all about taking a little care and exercising due caution even#hile en"oying the Holi #ith your near and dear on

CHAPTER 1-

CONCLUSION

n ndia, health insurance policies are on a huge rise. The 9ain healthKlife insurer '$ is providing various benefits after purchasing of policies. @ven the privateinsurance companies like chola, hdfc life.sbi life, etc are the toughest competititors.Hence, #e can expect a more rise in health insurance in the future.

)


41/42


CHAPTER 17

REFERENCES

E0LIOGRAPH"

• ###.#ikipedia.com

• ###.irdai.gov.in

• ###.hdfcergo.com

• ###.cholainsurance.com

• ###.slideshare.net

0I0ILIOGRAPH"

• rinciples J ractices of Banking J nsurance-Oipul ublications

• 'a#s 7overning Banking J nsurance-Oipul ublications

• nnovations in Banking J nsurance-Oipul ublications

0

http://www.wikipedia.com/http://www.irdai.gov.in/http://www.hdfcergo.com/http://www.cholainsurance.com/http://www.wikipedia.com/http://www.irdai.gov.in/http://www.hdfcergo.com/http://www.cholainsurance.com/


42/42
