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HEALTH INSURANCE GRIEVANCES_ REDRESSAL ... - IIRM

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HEALTH INSURANCE GRIEVANCES_ REDRESSAL ... - IIRM Powered By Docstoc
					HEALTH INSURANCE GRIEVANCES,
          REDRESSAL
              &
        RELATED ISSUES

                      R.SRINIVASAN
                       OSD, I.R.D.A.
     About this presentation
• Definition of Complaint/Grievance;
• Data of Health Insurance Complaints
  received by Non Life Industry;
• Classification of Health Insurance
  Complaints;
• Root Cause Analysis of Complaints;
• Redressal of complaints.
    How is a complaint defined?
• A “Grievance/Complaint” is defined as
  any communication that expresses
  dissatisfaction about an action or lack of
  action, about the standard of
  service/deficiency of service of an
  insurance      company     and/or     any
  intermediary or asks for remedial action.
HEALTH INS.COMPLAINTS VS TOTAL
         COMPLAINTS




 32%        36%
BROAD CLASSIFICATION OF HEALTH
   INSURANCE COMPLAINTS

 81%




               60%
         Main parties involved
• Insurer vs Individual Insured;

• Insurer vs Group Organizer

• TPA     vs Insured

• TPA     vs Hospital
        REFINED CLASSIFICATION OF
         COMPLAINTS RELATE TO…
•   POLICY DOCUMENT
•   CLAIM
•   PREMIUM
•   PROPOSAL
•   INSURANCE COVERAGE
•   REFUNDS
•   PRODUCT
•   OTHERS
  Complaints pertaining to Policy
• Without the consent of Insured, Insurer debited
  customer Bank A/c/Credit Card and issued policy;
• Certificate of Insurance / Policy not received by
  the Insured;
• Endorsement for modification of policy details
  not effected;
• In the renewal policy, Insurer changed the terms
  & conditions without informing the Insured;
• Insured asked for cancellation of policy BUT
  Insurer failed to respond (Frequent in tele-
  marketing business);
  Complaints pertaining to Policy…contd.

• Arbitrary Cancellation of policy - Bad Claims
  Experience;
• Forced to switch over to a new product during
  renewal OR non-TPA policy converted to TPA
  policy;
• Refusal to renew health insurance policy;
• Change of terms and conditions not intimated to
  the insured during/prior to renewal;
• Enhancement of Sum Insured not considered
  during renewal.
Policy Related complaints vis-à-vis Total Complaints –
         1.4.2011 to 31.12.2011-IGMS DATA
30000



25000              23925

20000



15000                               Policy Related
             35%                    Total Complaints

10000      8367
 5000



    0
    CLAIM RELATED COMPLAINTS
• Repudiation of claim due to delay in intimation of claim by
  Insured;
• Deduction from claim amount on account of
   – Delay in claim intimation
   – Reasonability Clause
• Insurer repudiated claim due to “pre-existing disease”
  exclusion;
• TPA insisting the insured to arrange for Sec 64 VB
  confirmation from insurer;
• Claim repudiated/closed without giving reasons;
    CLAIM RELATED COMPLAINTS..contd.
• Stocky silence of insurer/ TPA after intimation
  of claim by insured;
• Delay on the part of TPA to provide cashless
  facility;
• Cashless approved by TPA initially but revoked
  at the time of discharge;
• Insurer/TPA asking for claim documents on a
  piecemeal basis;
• Insurer/TPA has not issued claim cheque in
  spite of acceptance of offer of settlement;
      CLAIM RELATED COMPLAINTS..contd.

• Claim denied/quantum reduced based on
  internal circular or guidelines and not forming
  part of product filed with the Authority;
• Insurer repudiated claim due to dispute on
  premium paid (In spite of payment of charged
  premium by the insured);
• Change of Network Hospital/TPA not informed
  to policyholder.
Claim Related complaints vis-à-vis Total
 Complaints – 1.4.2011 to 31.12.2011




         37%
     Premium related grievances
• Premium not charged in conformity with the product
  filed with the Authority;
• Arbitrary loading of renewal premium;
• Additional premium charged after finalizing the
  insurance contract since the policy/proposal was not
  accepted by the insurer’s competent authority!
• Revision in premium during renewal not informed to
  the policyholder in time;
• High Premium – Senior Citizen complainants
  Premium Related complaints vis-à-vis
Total Complaints – 1.4.2011 to 31.12.2011




         4%
              Proposal Related
• Agent has not explained the scope of insurance
  coverage especially in regard to waiting period for
  certain diseases;
• Medical Underwriting after acceptance of the
  proposal form and premium cheque;
    Rejection of the proposal (including renewals of other
     insurers) based on ‘pre-acceptance medical check up’
     conducted after collection of premium!
• Issuance of policy without any proposal or
  confirmation in writing from Insured;
• Proposal form given by Insured was tampered by
  Agent / Insurer
  Proposal Related complaints vis-à-vis
Total Complaints – 1.4.2011 to 31.12.2011




          4%
           Insurance Coverage
• Dispute      relating     to    Interpretation   of
  perils/exclusions/conditions/warranties;
• Insurer did not attach any clause to the policy –
  coverage given under the policy not known to the
  Insured;
• OMP policy taken along with airline ticket but
  insured unaware of insurance coverage as policy
  conditions not provided by the Travel Agent!
• Existence of P.A. Coverage under a Group Policy not
  known or known belatedly after occurrence of
  contingent event.
                    Refund
• Dispute regarding quantum of premium refund;

• Refund of premium due under policy not received by
  Insured.

  Above complaints usually arise in proposals
   sourced through telemarketing
             Product related
• Misleading Advertisement issued by Insurer.
  Product was different from what it was
  advertised;
• Product (policy) received by insured is not
  what it was negotiated at the time of sale;
• Infirmities in the product detected during
  claim/complaint;
• Group        Policy     beneficiaries       not
  informed/aware of policy/claims servicing
  office.
                      Others
• Toll Free Number of TPA/Insurer not working;
• Failure of online transaction though premium was
  deducted through credit card;
• Insurer gave premium quote but later went back on
  acceptance of risk;
• Insurer imposed additional conditions not forming
  part of pre-sale discussion;
• Insurer not considered the cumulative bonus in claim
  settlement;
• Group Policy beneficiary unaware that Group
  Organizer has not renewed the policy and hence left
  uncovered after policy expiry.
    R.C.A of Complaints - Insurer
• Suspense on the ultimate claim amount payable;
• Insurer not monitoring the TAT of claim disposal by
  TPAs;
• Misselling by Intermediaries (sab payment ho
  jayega);
• Hazards of multiple choice - Health products of the
  same insurer differ in minute changes but have a
  bearing on the claim;
• Medical & Legal jargons used;
• Websites not updated regularly.
   R.C.A of Complaints - Policyholders
• Mutual mistrust;
• General reluctance to read the policy brochure terms
  and conditions;
• Not aware of availing seamless Cashless Procedure in
  non-emergency hospitalization;
• Economical with truth on disclosure of material fact;
• Importance of timely renewal not appreciated;
• Implication of availing higher room rent than eligible
  amount (Table of Benefits)under the policy is not
  foreseen.
    T.A.T for service issues- Health Insurance
• Decision on a health insurance proposal should be
  communicated within 15 days of its receipt;
• Claim should be disposed within 30 days of receipt of
  claim documentation;
• Policyholders’ Servicing requests to be responded
  within 10 days;
• Changes in premium/terms & conditions during
  renewal, should be informed atleast 3 months prior to
  date of renewal;
• Time-frames for Portability.
 Grievance Redressal Mechanisms
• First Port of Call is the Grievance Redressal
  Officer of the insurer (Contact details from the
  policy document);
• Insurer is required to acknowledge a
  complaint within 3 days and resolve within 15
  days;
• If insured is not satisfied with the resolution
  he may approach the IRDA or Insurance
  Ombudsman
     Grievance Redressal Mechanism
                 in IRDA
• Facilitating role;
• Integrated Grievance Call Centre;
• Integrated Grievance Management System;
• Flagging of complaints as part of Business
  Conduct study of regulated entities;
• On-site & Off-Site inspection of policyholder
  complaints;
• Feedback to regulatory departments.
    s cy
   Regulatory Framework for
          Grievances
Protection of Policyholders Interests
 Regulations 2002;
Grievance Redressal Guidelines;
Board Approval of Grievance Redressal
 Policy of Insurers;
Mandating Policyholders Protection Sub-
 Committee of the Board;
Public Disclosure of Grievance Information.
Board
      Complaints disposal by Insurance
       Ombudsman – RPG Rules 1998
• Complainant ought to have exhausted
  insurer’s grievance redressal mechanism;
• Claim amount should not exceed Rs.20 lacs;
• Redressal of disputes like short settlement of
  claim, repudiation of claim;
• Recommendation or Award;
• Time frame of 3 months prescribed for
  disposal of the complaint
  An insurer cannot go on appeal against the order
   of Insurance Ombudsman
       Example of MEDICAL JARGON
•   The diagnosis by a Physician of primary pulmonary hypertension with substantial right ventricular enlargement established
    by investigations including cardiac catheterization, resulting in permanent irreversible physical impairment to the degree of
    atleast class 3 of the New York Heart Association Classification of cardiac impairment and resulting in the insured being
    unable to perform his usual occupation.
   Example of MEDICAL JARGON
• The diagnosis by a Physician of primary
  pulmonary hypertension with substantial right
  ventricular enlargement established by
  investigations          including       cardiac
  catheterization, resulting in permanent
  irreversible physical impairment to the degree
  of atleast class 3 of the New York Heart
  Association     Classification    of    cardiac
  impairment and resulting in the insured being
  unable to perform his usual occupation.
THANK YOU!

				
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