Slide 1

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


Slide 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.


Slide 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.


Slide 4

HEALTH INS.COMPLAINTS VS TOTAL
COMPLAINTS

32%

36%


Slide 5

BROAD CLASSIFICATION OF HEALTH
INSURANCE COMPLAINTS
81%

60%


Slide 6

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

vs Insured

• TPA

vs Hospital


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REFINED CLASSIFICATION OF
COMPLAINTS RELATE TO…
•
•
•
•
•
•
•
•

POLICY DOCUMENT
CLAIM
PREMIUM
PROPOSAL
INSURANCE COVERAGE
REFUNDS
PRODUCT
OTHERS


Slide 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 telemarketing business);


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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.


Slide 10

Policy Related complaints vis-à-vis Total Complaints –
1.4.2011 to 31.12.2011-IGMS DATA
30000

23925

25000

20000

15000

10000

5000

0

35%

8367

Policy Related

Total Complaints


Slide 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;


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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;


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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.


Slide 14

Claim Related complaints vis-à-vis Total
Complaints – 1.4.2011 to 31.12.2011

37%


Slide 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


Slide 16

Premium Related complaints vis-à-vis
Total Complaints – 1.4.2011 to 31.12.2011

4%


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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


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Proposal Related complaints vis-à-vis
Total Complaints – 1.4.2011 to 31.12.2011

4%


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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.


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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


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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.


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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.


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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.


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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.


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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.


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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


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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


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Regulatory Framework for
Grievances
Protection of Policyholders Interests
Regulations 2002;
Grievance Redressal Guidelines;
Board Approval of Grievance Redressal
Policy of Insurers;
Mandating Policyholders Protection SubCommittee of the Board;
Public Disclosure of Grievance Information.
Board


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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


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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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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.


Slide 32

THANK YOU!