Report on Health insurance and consumer, it is an overview of what health insurance is all about, what are its scenario in India. It also explains about how the regulatory authority perform its function and hoe do they deal with the consumer, faulty transaction etc. We have done a survey of

1. &
SUBMITTED BY:
MS. GUNJAN GUPTA (IIT DELHI)
MR. KISHAN RAJ (HANSRAJ COLLEGE, DU)
MS. BHAVNA THAKUR (UILS,PANJAB UNIVERSITY)
MR. AKSHAY MANOCHA (HANSRAJ COLLEGE,DU)

2. OBJECTIVES
The purpose of our research is to study Health Insurance industry in India and consumer related affairs with reference to unethical
and sinful practices in general insurance which lead to an exploitation of Insuree (policy holder).
INTRODUCTION
 What is Health Insurance?
The term health insurance is a type of insurance that covers your medical expenses. A health
insurance policy is a contract between an insurer and an individual /group in which the insurer
agrees to provide specified health insurance cover at a particular “premium”.
FORMS OF HEALTH INSURANCE
Cashless Reimbursement
A Cashless facility is where the insurance company Reimbursement is when the patient pays the
directly pays the hospital for the hospitalization expenses hospital bills by himself and then submits them to the
In this case, the patient need not pay the hospital from his insurance company for reimbursement.
pocket.
TYPES OF HELATH INSURANCE COVERS
Hospitalization Cover
Hospital Cash Cover
Critical Illness Cover
Personal Accident Cover

3. Top-up Cover
.
IMPORTANCE FACTORS AFFECTING
Protects from the sudden, unexpected Age
cost of hospitalization. Previous medical history
Taking the benefit of latest medical facility Claim free years
is much more affordable.
STAKEHOLDERS:
1. IRDA:-
Stands for Insurance Regulatory and Development Authority, acts as regulatory authority of insurance companies and works in the
interest of consumers.
2. Insurance companies:-
 Private Companies-- Reliance, HDFC, Bajaj ALLIANZ, etc.
 Public companies -- LIC, SBI, etc.
3. Consumers
4. TPA
EVOLUTION
The concept of Health Insurance was proposed in the year 1694 by Hugh the elder Chamberlen.
In 19th Century “Accident Assurance” began to be available which operated much like modern disability insurance.
During the middle to late 20th century traditional disability insurance evolved in to modern health insurance programmes.
Today, most comprehensive health insurance programmes cover the cost of routine, preventive and emergency health care
procedures and also most prescription drugs.
SENARIO IN INDIA
The overall general insurance industry growth has kept pace with the GDP growth in the country and general
insurance penetration has varied in a narrow band
After liberalisation of the Indian insurance industry in the year 1999- 2000, the Indian general insurance industry has
witnessed rapid growth. The industry, in terms of gross direct premium, has grown from INR 11,446 crore in FY02 to INR
57,964 crore in FY12, which corresponds to a compounded annual growth rate (CAGR) of 17.6 percent. Insurance density,
which is defined as the ratio of premium underwritten in a given year to the total population, has increased from USD 2.4 in
2001 to USD 10 in 2011. The growth in the general insurance industry has kept pace with the nominal GDP growth rate
resulting in general insurance penetration remaining stable in the range of 0.55% to 0.75% over the last 10 years.

4. GROWTH IN INDIAN GENERAL INSURANCE INDUSTRY
60
50
40
30
20
10
0
GROSS DIRECT PREMIUM(INR Thousand Crore)
FY
2002
FY
2003
FY
2004
FY
2005
FY
2006
FY
2007
FY
2008
FY
2009
FY
2010
FY
2011
FY
2012
GROSS DIRECT
PREMIUM(INR Thousand
Crore)
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
INSURANCE PENETRATION(%)
FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012

5. TYPES OF HEALTH INSURANCE
1. Family Floater policy:-
A family floater health insurance, as the name suggests is a plan that is tailor made for families. It is similar to individual health
plans in principle; the only difference is that it is extended to cover your entire family. This acts as an umbrella of coverage for the
entire family and therefore the name.
Advantages
 A family floater policy is easier to manage
 best health insurance for parents
 easy to add a new family member.
 maternity and new born baby cover makes it very attractive for young couples.
 Cashless feature and health id cards for all members makes it handy in case of medical emergencies.
 Income tax benefits under Section 80D.
2. Individual Health Policy
An Individual Health Policy which caters to a separate health insurance policy for each of the family members. The policyholder
can consume the entire amount alone.
3. Group Health Insurance
When a large group of people say over 20 who work, stay or are bonded by some nature of job are willing to get a Health insurance
plan, they should opt for a Group Health Policy. Under a group health policy people who may have adverse health condition can
also easily get health cover due to the greater negotiating power that a group contains versus a individual policy.
4. Travel Health Insurance
Whenever a person is travelling outside the geographical boundary of his / her health insurance plan it is always advisable that they
take a Travel Health insurance plan. This is advised so that the person in-case falls sick or has any other medical emergency abroad
need not worry about the high cost of healthcare in a foreign land. This is also mandatory to buy before travelling to a certain
countries.
5. Critical Health Insurance
A critical health insurance policy hels cover certain set of diseases as prescribed under a policy only. As the name suggest critical
health insurance, they cover all those major diseases which are either terminal or can reduce the human body to a vegetative state.
Some of these would include, Alzheimer's disease, blindness, deafness, kidney failure, major organ transplant, multiple sclerosis,
HIV/AIDS contracted by blood transfusion or during an operation, Parkinson's disease.
6. Hospitalization
Hospitalization plans only pay a pre-fixed amount as per the level of coverage for the room rent only. These plans are cheaper
when compared to full indemnity plans as they do not pay for any treatments and medicines used during the course of
hospitalization, as they only pay for room rent.
7. Senior Citizen Health Insurance
As a person enters the golden age as many state of 60yrs, they start to lead a new life a life of a retired person. The needs and

6. wants of a person at this age are completely different from those that they would have had at age 40 yrs or 50 yrs. Thus they need
health insurance plans which are suited best for them at this age, but sadly enough there aren‘t many. When a person above 60yrs
of age goes to buy a health insurance plan he needs to check:
i. The network hospital closest to his residence
ii. Co-Payment options which will ensure his hospital bills are never stopped
iii. Lowest time frame for coverage of pre-existing disease
iv. Lowest amount of waiting period
8. Maternity Insurance
Standalone maternity insurance are a rarity, thus many insurers include this as a part of their regular policies and also critical illness
policies that they specifically design for women. Under maternity insurance, the female is covered for any complication that arises
during her pregnancy and related to child birth.
INSURANCE COMPANIES
1.
2.
3.
4.
5.
LIC JEEVAN AROGYA
GROUP HEALTH INSURANCE
RELIANCE HEALTH INSURANCE/CRITICAL
ILLNESS
BAJAJ ALLIANZ HEALTH GUARD
MEDIPRIME/WELLSURANCE/CRITICARE

7. 6.
7.
8.
9.
HEALTH SURAKSHA/CRITICAL
ILLNESS
BHARTI HEALTH INSURANCE
SWASTHA KAVACH/MEDICLAIM POLICY
ICICI LOMBARD HEALTH INSURANCE
NUMBER OF NON LIFE INSURANCE OFFICES IN
INDIA (AS ON 31ST MARCH ‘13)
INSURER 2011-12 2012-13
PUBLIC SECTOR
PRIVATE SECTOR
5,354
1,696
6272
1827
TOTAL
7050
8099

8. RASTRIYA SWASTHYA BIMA YOJNA (1STAPRIL, 2008)
For people living below poverty line, an illness not only represents a permanent threat to their income
earning capacity, in many cases it could result in the family falling into a debt trap. When the need to get
the treatment arises for poor families they often ignore it because of lack of resources, fearing wage loss, or
wait till the last moment when it’s too late. Even if they do decide to get the desired health care it consumes
their savings, forces them to sell their assets and property or cut other important spending like children’s
education. Alternatively they have to take on huge debts. Ignoring the treatment may lead to unnecessary
suffering and death while selling property or taking debts may end a family’s hope of ever escaping poverty.
These tragic outcomes can be avoided through a health insurance which shares the risk of a major health
shock across many households by pooling them together. A well designed and implemented health
insurance may both increase access to healthcare and may even improve its quality over time.
In the past Government have tried to provide a health insurance cover to selected beneficiaries either at the
State level or National level. However, most of these schemes were not able to achieve their intended objectives.
Often there were issues with either the design and/ or implementation of these schemes.
Keeping this background in mind, Government of India decided to design a health insurance scheme which not
only avoids the pitfalls of the earlier schemes but goes a step beyond and provides a world class model. A
critical review of the existing and earlier health insurance schemes was done with the objective of learning
from their good practices as well as seeks lessons from the mistakes. After taking all this into account and also
reviewing other successful models of health insurance in the world in similar settings, RASTRIYA
SWASTHYA BIMA YOJNA was designed.
RSBY has been launched by Ministry of Labour and Employment, Government of India to provide health
insurance coverage for Below Poverty Line (BPL) families. The objective of RSBY is to provide protection to
BPL households from financial liabilities arising out of health shocks that involve hospitalization. Beneficiaries
under RSBY are entitled to hospitalization coverage up to Rs. 30,000/- for most of the diseases that require
hospitalization. Government has even fixed the package rates for the hospitals for a large number of
interventions. Pre-existing conditions are covered from day one and there is no age limit. Coverage extends to
five members of the family which includes the head of household, spouse and up to three dependents.
Beneficiaries need to pay only Rs. 30/- as registration fee while Central and State Government pays the
premium to the insurer selected by the State Government on the basis of a competitive bidding.
FEATURES:
The RSBY scheme is not the first attempt to provide health insurance to low income workers by the
Government in India. The RSBY scheme, however, differs from these schemes in several important ways.
Empowering the beneficiary – RSBY provides the participating BPL household with freedom of choice
between public and private hospitals and makes him a potential client worth attracting on account of the
significant revenues that hospitals stand to earn through the scheme.
Business Model for all Stakeholders – The scheme has been designed as a business model for a social
sector scheme with incentives built for each stakeholder. This business model design is conducive both in
terms of expansion of the scheme as well as for its long run sustainability.

9. • Insurers – The insurer is paid premium for each household enrolled for RSBY. Therefore, the
insurer has the motivation to enroll as many households as possible from the BPL list. This will
result in better coverage of targeted beneficiaries.
• Hospitals – A hospital has the incentive to provide treatment to large number of beneficiaries as it
is paid per beneficiary treated. Even public hospitals have the incentive to treat beneficiaries
under RSBY as the money from the insurer will flow directly to the concerned public hospital
which they can use for their own purposes. Insurers, in contrast, will monitor participating
hospitals in order to prevent unnecessary procedures or fraud resulting in excessive claims.
• Intermediaries – The inclusion of intermediaries such as NGOs and MFIs which have a greater
stake in assisting BPL households. The intermediaries will be paid for the services they render in
reaching out to the beneficiaries.
• Government – By paying only a maximum sum up to Rs. 750/- per family per year, the
Government is able to provide access to quality health care to the below poverty line population. It
will also lead to a healthy competition between public and private providers which in turn will
improve the functioning of the public health care providers.
Information Technology (IT) Intensive – For the first time IT applications are being used for social
sector scheme on such a large scale. Every beneficiary family is issued a biometric enabled smart card
containing their fingerprints and photographs. All the hospitals empanelled under RSBY are IT enabled
and connected to the server at the district level. This will ensure a smooth data flow regarding service
utilization periodically.
Safe and foolproof – The use of biometric enabled smart card and a key management system makes this
scheme safe and foolproof. The key management system of RSBY ensures that the card reaches the
correct beneficiary and there remains accountability in terms of issuance of the smart card and its usage.
The biometric enabled smart card ensures that only the real beneficiary can use the smart card.
Portability – The key feature of RSBY is that a beneficiary who has been enrolled in a particular district
will be able to use his/ her smart card in any RSBY empanelled hospital across India. This makes the
scheme truly unique and beneficial to the poor families that migrate from one place to the other. Cards
can also be split for migrant workers to carry a share of the coverage with them separately.
Cash less and Paperless transactions – A beneficiary of RSBY gets cashless benefit in any of the
empanelled hospitals. He/ she only needs to carry his/ her smart card and provide verification through
his/ her finger print. For participating providers it is a paperless scheme as they do not need to send all
the papers related to treatment to the insurer. They send online claims to the insurer and get paid
electronically.
Success of RSBY
The scheme has won plaudits from the World Bank, the UN and the ILO as one of the world's best
health insurance schemes. Germany has shown interest in adopting the smart card based model for
revamping its own social security system, the oldest in the world, by replacing its current, expensive,
system of voucher based benefits for 2.5 million children. The Indo-German Social Security Programme,
created as part of a co-operation pact between the two countries is guiding this collaboration

10. One of the big changes that this scheme is bringing investments to unsaved areas. Most of private
investments in healthcare in India have been focused on tertiary or specialized care in urban areas.
However, with RSBY coming in, the scenario is changing. New age companies like Global Healthcare
Systems, a company based out of Kolkata and funded by Tier I Capital Funds like Sequoia Capital and
Elevar Equity are setting up State of Art Hospitals in Semi Urban - rural settings. This trend can create
the infrastructure that India's healthcare system desperately needs.

11. ROLE OF IRDA
INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY
Insurance Regulatory and Development Authority (IRDA) is an autonomous apex statutory body which regulates
and develops the insurance industry in India. It was constituted by a Parliament of India act called Insurance
Regulatory and Development Authority Act, 1999 and duly passed by the Government of India.
As Health Insurance is in its very early phase, the role of IRDA will be very crucial. It has to ensure that this
sector develops rapidly and benefit of insurance goes to the consumers. It has to guard against the ill effects of
privatization. Unless privatization and development of health insurance is managed well it may have negative
impact of health care, especially to a large segment of rural population in the country. If it is well managed
then it can improve access to care and health status in the country rapidly. Experience from other countries
suggest that the entry of private firms into the health insurance sectors, if not properly regulated , does have
adverse consequences for the cost of care, equity, consumer satisfaction, fraud and ethical standards. Some of
the areas of concern which the regulator has to look into are:
 Many times the insurance claims are rejected due to small technical reasons. This leads to disputes
 Various conditions included in the insurance policy contract is not negotiable and these are binding on
consumer
 There no analysis on what is fair practice and what is unfair practice
 The most important area of dispute and unfair treatment is the knowledge and implications of pre-existing
conditions.
 The main danger in the health insurance business is that the private companies will cover the risk of
middle class who can afford to pay high premiums. Unregulated reimbursement of medical costs by the
insurance companies will push up the prices of private care. So large section of India’s population who are not
insured will be at a relatively disadvantage as they will, in future, have to pay more for the private care.
IRDA has stipulated regulations for both life and non-life insurance companies in many aspects of business but
the same is lacking in respect of health insurance business. Given the health insurance is assuming greater
significance, it is time for the regulator to etch a frame work for operating the health schemes.
IRDA will have to evolve mechanism so that the private insurance companies do not skim the market by
focusing on rich and upper class clients and in the process neglect a major section of India’s population.
In a view to ensure that the rural and less-developed areas do not fall prey to a step-motherly treatment in
penetration of health business, the Regulator may ensure, in line with its rules jotted down for private life and
non-life insurers, that minimum annual targets are given to the benefit providers so that at any given point in
time, a decent portfolio of health coverage’s represent the rural sector

12. IRDA should ensure and encourage different organizations and private insurers to develop products for the
poorer segment of the community and if possible build an element of cross subsidy for them.
The IRDA will have a significant role in regulating the health insurance sector and safe guarding the
interests of the policy holders by minimizing the unintended consequences.
MISSION STATEMENT OF THE AUHTORITY

To protect the interest of and secure fair treatment to policyholders;
 To bring about speedy and orderly growth of the insurance industry
(including annuity and superannuation payments), for the benefit of
the common man, and to provide long term funds for accelerating
growth of the economy;

To set, promote, monitor and enforce high standards of integrity,
financial soundness, fair dealing and competence of those it
regulates;

To ensure speedy settlement of genuine claims, to prevent insurance
frauds and other malpractices and put in place effective grievance
redressal machinery;

To promote fairness, transparency and orderly conduct in financial
markets dealing with insurance and build a reliable management
information system to enforce high standards of financial soundness
amongst market players;

To take action where such standards are inadequate or ineffectively
enforced;

To bring about optimum amount of self-regulation in day-to-day
working of the industry consistent with the requirements of
prudential regulation.

13. FEES FOR SERVICES
PREMIUM REIMBURSEMENT
HEALTH SERVICES
REGULATORY
(IRDA)
INSURER
Government or private
(for profit or non profit)
INSURED
Individual &/or employer
Making regular payment to a Fund
HEALTH CARE PROVIDER
Government and/or Private
(For profit or non profit)
T
P
A

14. Health insurance fraud is described as an intentional act of deceiving, concealing, or misrepresenting information that
results in health care benefits being paid to an individual or group.
Fraud can be committed by both a member and a provider. Member fraud consists of ineligible members and/or
dependents, alterations on enrolment forms, concealing pre-existing conditions, failure to report other
coverage, prescription drug fraud, and failure to disclose claims that were a result of a work related injury. Provider fraud
consists of claims submitted by bogus physicians, billing for services not rendered, billing for higher level of
services, diagnosis or treatments that are outside the scope of practice, alterations on claims submissions, and providing
services while under suspension or when license have been revoked. Independent medical examinations are used to
debunk false insurance claims and allow the insurance company or claimant to seek a non-partial medical view for injury
related cases.
According to The Coalition Against Insurance Fraud, health fraud depletes taxpayer-funded programs like Medicare, and
may victimize patients in the hands of certain doctors. Some scams involve double-billing by doctors who charge insurers
for treatments that never occurred, and surgeons who perform unnecessary surgery.
One of the main reasons that medical fraud is such a prevalent practice is that nearly all of the parties involved find it
favourable in some way. Many physicians see it as necessary to provide quality care for their patients. Many patients,
although disapproving of the idea of fraud, are sometimes more willing to accept it when it affects their own medical care.
Program administrators are often lenient on the issue of insurance fraud, as they want to maximize the services of their
providers.
The most common perpetrators of healthcare insurance fraud are health care providers. One reason for this is that the
historically prevailing attitude in the medical profession is one of “fidelity to patients”. This incentive can lead to
fraudulent practices such as billing insurers for treatments that are not covered by the patient’s insurance policy. To do
this, physicians often bill for a different service, which is
covered by the policy, than that which was rendered.
Mis-selling ,is one the type of fraud which means selling a
product by giving a wrong picture of a product, it may
include, giving wrong information, giving unrealistic
information, not giving full information about the product.
You must have heard an insured, saying – but this was not I
asked for. And, your agent accusing, but then I did
mentioned all the details upfront, didn’t I? Insurance is a
business of selling commitments and here is a case where
this was broken. Unfortunately the product was mis-sold.
Mis-selling is not unique to insurance and happens in various
lines of businesses (loans, credit cards, investment products,
pharmacy, hospitality etc.), but Insurance being an intangible
service – the principle of Caveat emptor prevails in
insurance.
Another motivation for insurance fraud in the healthcare
industry, just as in all other types of insurance fraud, is a
desire for financial gain. Public healthcare programs such
as Medicare and Medicaid are especially conducive to
COMPLAINTS AND FRAUDS
Differen types of Fraud
affecting insurance
companies
Commission Rebating Fake Documentation
Collusion Between Parties Misselling
16%
24%
29%
31%

15. fraudulent activities, as they are often run on a fee-for service structure. Physicians use several fraudulent techniques to
achieve this end. These can include “up-coding” or “upgrading,” which involve billing for more expensive treatments
than those actually provided; providing and subsequently billing for treatments that are not medically necessary;
scheduling extra visits for patients; referring patients to another physician when no further treatment is actually necessary;
"phantom billing," or billing for services not rendered; and “ganging,” or billing for services to family members or other
individuals who are accompanying the patient but who did not personally receive any services.
Perhaps the greatest total dollar amount of fraud is committed by the health insurance companies themselves. There are
numerous studies and articles detailing examples of insurance companies intentionally not paying claims and deleting
them from their systems, denying and cancelling coverage, and the blatant underpayment to hospitals and physicians
beneath what are normal fees for care they provide. Although difficult to obtain the information, this fraud by insurance
companies can be estimated by comparing revenues from premium payments and expenditures on health claims.
FRAUD COMMITTED BY INSURER/ COMPLAINTS BY INSUREE (POLICY HOLDER)
45
40
35
30
25
20
15
10
5
CLASSIFICATION OF NON-LIFE COMPLAINTS( IN %) DURING 2011-13
The non-life insurance companies resolved 98.47% of the complaints received during the year. The private non-life
insurance companies resolved 99.79% of the complaints registered and public non-life companies resolved 94.51% of the
complaints filed against them with the Authority. As on 31st March, 2013, 1235 complaints were still pending with the
50
45
40
35
30
25
20
15
10
5
0
CLASS-WISE NON-LIFE
COMPLAINTS(IN %) DURING 2010-
13
2010-11 2011-12 2012-13
MOTOR
HEALTH
OTHERS
insurance companies for resolution, out of which 128 pertained
to private sector and 1107 to public sector non-life insurance
companies
The pattern of complaints in IGMS (Integrated grievances
management system) data as regards non-life insurance
industry indicates that claims related and policy related
complaints far out-numbered other types of complaints. Out of
the total 78,927 complaints during the year 2012-13, 35,793
related to motor insurance business and 30,279 related to
health insurance business. Motor insurance and Health
insurance constitutes around 70% of the total non-life business.
However, it is worth noting that the total numbers of
complaints has been showing a declining trend in the past few
years, because of the various initiatives taken by the authority.
0
CLAIMS COVER NOTE
RELATED
COVERAGE OTHERS POLICY
RELATED
PREMIUM PRODUCT PROPOSAL
RELATED
REFUND
2011-12
2012-13

16. INTEGRATED GRIEVANCES MANAGEMENT SYSTEM (IGMS)
The Integrated Grievance Management System (IGMS) facilitates online registration of policyholder’s complaints
and helps track their status.
A policyholder can make optimum use of this system by giving accurate information about the complaint like the
policy number, name of the insurer, complainant’s contact details etc. It would be useful to keep the policy document
ready while registering the complaint online.
The Complaint Registration Process involves the following TWO SIMPLE steps:
Step 1 : Register yourself by entering your credentials
Step 2 : Use Registered credentials to register complaints / view their status.
With the successful implementation of
the IGMS, the status of complaints across
the industry is available to the Authority
on a real time basis. The IGMS is now
the repository of the industry’s
complaints including the status as well as
the various analytical reports on the
public grievances. The insurer is first port
of call for a complainant and in case
he/she is not satisfied with the insurer’s
decision, he/she may escalate the
complaint online on the IGMS or through
the Integrated Grievance Call Centre. All
these complaints are now part of a single
repository, viz. IGMS.
IRDA also regularly accesses the portal
of the Department of Administration and
Public Grievances (DARPG),
Government of India and ensures that
complaints relating to the insurance
sector are downloaded and necessary
action to get them examined by the
insurers is taken.
PUBLIC GRIEVANCES

17. PROCESS OF FILING A COMPLAINT
If your insurance company does not resolve your complaint to your satisfaction you can escalate your complaint to
IRDA.
 If your complaint is suitable for taking to the Insurance Ombudsman IRDA will help you resolve it by taking it
up with the insurance company
 For disputes where enquiry or adjudication are required you should approach the Consumer Forum or Courts.
JUDGEMENTS
National Consumer Dispute Redress Commission
“Merely stating that the complainant suffered from a pre-existing ailment is not enough to repudiate
the claim. Onus lies on the insurer to prove firstly that the insured knowingly concealed this
material fact from the insurer and secondly that the pre-existing condition has nexus with the
medical condition eventually suffered by the insured for which the claim has been raised.”

18. As stated by State Commission, UT, Chandigarh and upheld by National Consumer Dispute Redress Commission in its
judgments in a case of Revision Petition No. 3541 of 2006 (against the order dated. 11/09/2006 in Appeal No. 640/2006
of the State Commission, UT, Chandigarh) of Ms. Pooja Gupta vs. Tata-AIG General Insurance Company.
State Commission which ruled against the District Commission that had rejected the claim petition made by the
complainant on grounds of ‘pre-existing medical condition’ prior to date of policy and ‘incorrect particulars’ given by
the complainant while seeking new policy after lapse of the first policy and that the policy opted for by the complainant
without plan ‘A’ relating to Accident and Sickness Medical expenses did not give sickness benefit cover to the
complainant as mentioned as grounds for repudiation of claim by the Insurance company.
In an appeal against the above order, the State Commission came to the conclusion that, in this case, emergency
evacuation and sickness relating to it, are both covered under the policy plan taken by the complainant. This conclusion
was reached by comparing the terms of the two policy documents taken up by the complainant , first one for period of
27.07.2004 to 24.10.2004 (90 days of her one year stay in France) and subsequent one for 270 days from 06.11.2004 to
02.08.2005.
On second ground of repudiation, question of pre-existing condition, the State commission noted that in the policy, the
term ‘pre-existing’ is defined as a disease which was contracted within two years preceding the commencement of
coverage under the policy, for which advice was recommended from a physician or a condition which required
hospitalization or surgery within a period of five years preceding the date of commencement of coverage under the
policy. The State Commission has also observed that mere statement that Complainant had suffered from a pre-existing
ailment is not enough to repudiate the claim. The onus lies on the insurer to prove firstly that the insured knowingly
concealed this material fact from the insurer and secondly that the pre-existing condition has nexus with the medical
condition referred by the insured for which the claim has been raised. In the present case, the Insurance company has
produced no supporting medical evidence to substantiate the claim of Dr. George Oommen who said that the
complication in the complainant’s health arose due to ongoing treatment of a pre-existing disease. He has gone on to
recommend the rejection of claim on the same.
In the revision petition, the question of pre-existing medical condition has been agitated again through a reference to the
hospitalization of the Complainant in August 2003, before the policy was taken. According to the records of the case,
the documents relating to treatment of complainant subsequent to 1981 had been made available to the Insurance
Company. Therefore, The State Commission has rightly come to the conclusion that there was no concealment of any
material fact relating to medical condition of the complainant. The NCDRC also agreed on the ground rejecting the
opinion of Dr. George Oommen and held that his role is limited to giving his opinion with reference of pre-existing
medical condition.
To the point that emergency evacuation had not been triggered in the case raised by the Revision Petitioner, it has been
held that neither in the Revision Petition, nor during the course of the arguments by counsel for the revision Petitioner,
any attempt has been made to clarify as to what else was required to be done on behalf of the complainant when she was
suddenly taken ill and needed emergency evacuation. Therefore, The NCDRC agreed with the order of State
Commission in Appeal No. 640 of 2006 that the attendant hospitalization expenses of Rs. 680863.53 should be
reimbursed to the Complainant.

19. CHANGING TRENDS IN LAWS BY AUTHORITY
Changes in the regulatory environment substantially impacted the industry dynamics
Apart from macro-economic, social, and demographic growth drivers, the evolving regulatory landscape had a
significant impact on the growth and profitability trends in the industry. The most notable of them was the price
detariffication in 2007 which significantly impacted the premium rates and growth for commercial lines and health
insurance.
KEY REGULATORY CHANGES IMPACT OF THE CHANGES
IRDA Bill Cleared
Liberalisation of the sector & formation
1999 of an independent regulator
IRDA issues TPA regulation &
foreign players allowed
entering with FDI limit of 26%
Entry of TPAs specifically focused on
servicing health insurance business &
entry of a number of foreign players
bringing capital, strong technical expertise
2001
IRDA issue insurance
brokers & corporate agent
regulation.
Thrust on insurance distribution through
2002 corporate intermediaries.
Entry of Stand-alone Health
insurance Players allowed.
Entry of stand- alone health
insurance players.
2006
Creation of Indian Motor Third Party
Insurance pool & Price Detariffication. 2007
Mechanism to equitably share CVTP losses
& significant changes in the premium rates
for the commercial lines.
Merger Acquisition Guidelines 2011
Enabled consolidation, inorganic
transactions in the industry.
Introduction of Declined Risk pool & TP
premium increased.
2012 Improvement in overall profitability of
the CV segment .

20. CONCLUSION
In the last few years, growth was the primary agenda across competition segments including public sector,
old private sector and new private sector general insurance players. Changes in the external environment
would continue to present growth opportunities and insurance companies would be better equipped to
exploit them based on market insights and internal capabilities developed over the period of time. In order
to deliver on the shareholders’ expectations, the companies will be driven to strike a balance between
growth, profitability and risk as they go forward. This would entail marked changes in the business
strategy and the same would be cascaded to operational decisions related to product design, pricing,
channel monitoring, and operational effectiveness. Companies with a one-dimensional focus on growth or
on profitability would lose competitive power either due to strain on capital or due to insignificance of the
scale. Either way, this would support the emerging trend of overall profitable growth for the industry.
Such a scenario would also aid niche players to develop sustainable business models and co-exist with the
large players adding to the depth and maturity of the industry.
TIPS FOR CONSUMERS (POLICY HOLDER)
 Choose your insurance company wisely.
 You need to think of the needs that might arise in the future.
 Make an informed decision about the type of health insurance.
 Choose the right amount as ‘sum assured’ depending upon your premium paying capacity.
 Check the empanelled hospitals.
 Understand the premium calculation process.
 Read the fine print.
 Check flexibility of the policy.
 Check if the company offers a no-claim bonus or discount.
 Read reviews and compare policies.
 Offer yourself for a medical examination before company appointed medical empanelled doctors
 Do not hide any material facts.
 Never believe in agents.

21. METHODOLOGY
As a group of 4 members we started with brainstorming. In this we come up with various points. We think
from the consumer’s perspective and discussed on valid issues. Then we framed a grouping of valid questions
which can be part of the study. Out of those questions we concluded to form a final set of 18 questions:
1. What is your sex?
2. What is your age?
male
70%
SEX
female
30%
4% AGE
3. Do you have insurance policy?
All the consumers which we interviewed:
Female were 30%
Male were 70%
74%
22%
<40
40-60
>60
All the consumers which we interviewed:
Below age of 40 years were 74%
40 years - 60 years were 22%
Elder than 60 years were 4%
QUESTIONAIRES
Insurance Policy
no
4%
yes
96%
All the consumer which we interviewed:
96% people have insurance policy.
4% people do not have insurance policy.

22. 4. Does it cover health insurance?
Health Insurance Out of people holding insurance policy:-
yes
85%
5. How many members are covered?
Members Covered 52% people out of Health insurance holders said all
6. Insurance Policy which you subscribed is of which company?
Insurance Subscribed From Top
0 5 10 15 20 25 30
Others
SBI General
Bajaj Allianz
IFFCO-TOKYO
Reliance general Insurance
Bharti AXA
LIC
ICICi Lombared
HDFC ERGO
TATA AIG
Companies
no
15%
85% were also having Helath insurance policy
15% were not having Health insurance policy.
All
52%
Adults
only
48%
members of their family are covered under policy.
While 48% said only adults are covered.
26.1%, i.e., maximum insurance
holders said they are covered under
policy of LIC
While 2nd position was taken by ICICI
took with 21.7%
3rd position is shared by Reliance and
Bajaj with around 9%.
Rest are as shown in graph.

23. 7. Did you study the Insurance Policy documents?
Study Policy
yes
64%
no
36%
8. What is amount of sum assured?
Sum Assured
11%
30%
22%
37%
<200000
200000-500000
500000<
don’t know
9. What is amount of Premium?
Amount of premium
40%
16%
28%
16%
64% policy holders said they read policy documents carefully
before taking that policy.
While 36% said no.
less than 20000
20000-50000
more than 50000
don’t know
When asked about amount of sum assured :-
11% were in bracket of less than Rs.2lac. 30%
were covered by amount between Rs.2-5lac.
37% were having sum assured more than
Rs.5lac.
22% were unknown of it because their
insurance was done by their employers (MNCs).
40% were paying premium less than Rs.20000, 16%
were paying more than Rs.20000 but less than
Rs.50000 and 16% were paying more than Rs.50000
While 16% were unknown of premium paid for the
same reason as above of sum assured

24. 10. What is type of your policy?
Type of policy Floater and individual policies are equally
Floater
50%
individu
al
50%
11. Is it Cashless or Reimbursement?
preferred by people.
Policy Model 65% people were having Cashless policy and 18%
Cashles
s
65%
Reimbu
rsemen
t
18%
Both
17%
were having Reimbursement Policy.
While 17% were having blend of both.

25. 12. If cashless, then
 Whether you have any hospital covered under cashless hospital in your locality?
Availabilty Of
Local Hospital
Yes
81%
No
19%
 Have you ever faced any problem in getting admitted in the hospital?
Addmission
Problem
yes
12%
No
67%
N/A
21%
13. Have you faced any problem in claim?
Claim Problem
Yes
12%
No
71%
N/A
17%
81% people said that there is availability of local hospital
which is covered in the policy.
While 19% said no.
67% people never had problem while admitting to
hospital
12% face some type of problem
While 21% didn’t admitted.
71% people never had problem while settlement of
claim.
12% face some type of problem
While 17% didn’t applied for claim.

26. 14. How much time taken by company to settle claim?
Time Taken For
Settlement
45%
25%
25%
5%
<1Month
1month-3months
3MONTHS<
N/A
15. Do you get any No Claim Bonus?
No Claim Bonus
Yes
33%
N/A
29%
No
38%
16. Have you get any chances to report against insurance company?
Complaint
Yes
8%
No
71%
N/A
21%
45% said their claim were settled within 1 month
25% said their settlement was done within time
period of 3 months but more than 1month.
5% got settled their claim in more than 3 months
While 25% didn’t attempted this.
33% said they got their No Claim Bonus
38% said they didn’t get
While 29% didn’t attempted.
71% said they didn’t ever have complaint against any
insurance company for their incovinience.
8% said they filed complaint.
While 21% didn’t attempted.

27. 17. Are you aware of complaint redress system in Insurance sector?
knowledge about
Redressal system 46% people are unaware of Redressal system in
Yes
37%
N/A
17%
No
46%
insurance sector.
37% have idea about it
While 17% didn’t attempted.
REDRESSAL PROCESS OF POLICYHOLDERS COMPLAINTS
INSURANCE CONSUMER (POLICYHOLDER)
NODAL OFFICE OF THE COMPANY
HEAD OFFICE OF THE COMPANY
INSURANCE OMBUDSMAN
IRDA (INSURANCE REGULATORY & DEVELOPMENT AUTHORITY)
CONSUMER FORUM
STATE & NATIONAL COMMISSION
SUPREME COURT (SC)

28. BIBLOGRAPHY
SOURCES:
1. ASI HIB Workshop on Health Insurance/ care Regulatory issues
2. WHO statistics
3. IRDA journals
4. Directorate General Of Health services
5. Health Policy Challenges for India: Private Health Insurance and Lessons from the
international Experience by Ajay Mahal
6. Health Insurance in India by Sujatha Rao
7. Different Countries, Different Needs: The Role of Private Health Insurance in Developing
Countries by Denis Drechsler, Johannes Jütting
8. Health Insurance in India by Kasturbhai Lalbhai
9. Health Insurance For The Poor In India by Rajeev Ahuja
10. Health Insurance - Wikipedia
“THE HEALTHIER YOU ARE, THE BETTER YOU WILL
PERFORM. VALUE YOUR HEALTH AND FITNESS.
THERE IS ALWAYS TIME TO MAKE TIME”.
-@ BROOKE GRIFFIN
THANK YOU