HEALTH INSURANCE GRIEVANCES,REDRESSAL

&RELATED ISSUES

R.SRINIVASANOSD, 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

8367

23925

0

5000

10000

15000

20000

25000

30000

Policy Related

Total Complaints35%

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 complaintAn 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.

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