HEALTH INSURANCE GRIEVANCES, REDRESSAL & RELATED ISSUES

1. HEALTH INSURANCE GRIEVANCES,REDRESSAL &RELATED ISSUES R.SRINIVASAN OSD, I.R.D.A.

2. 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.

3. 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.

4. HEALTH INS.COMPLAINTS VS TOTAL COMPLAINTS 32% 36%

5. BROAD CLASSIFICATION OF HEALTH INSURANCE COMPLAINTS 81% 60%

6. Main parties involved • Insurer vs Individual Insured; • Insurer vs Group Organizer • TPA vs Insured • TPA vs Hospital

7. REFINED CLASSIFICATION OF COMPLAINTS RELATE TO… • POLICY DOCUMENT • CLAIM • PREMIUM • PROPOSAL • INSURANCE COVERAGE • REFUNDS • PRODUCT • OTHERS

8. 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);

9. 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.

10. Policy Related complaints vis-à-vis Total Complaints – 1.4.2011 to 31.12.2011-IGMS DATA 35%

11. 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;

12. 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;

13. 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.

14. Claim Related complaints vis-à-vis Total Complaints – 1.4.2011 to 31.12.2011 37%

15. 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

16. Premium Related complaints vis-à-vis Total Complaints – 1.4.2011 to 31.12.2011 4%

17. 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

18. Proposal Related complaints vis-à-vis Total Complaints – 1.4.2011 to 31.12.2011 4%

19. 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.

20. 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

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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.

32. THANK YOU!