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GOVERNMENT OF INDIA
MINISTRY OF FINANCE
LOK SABHA
STARRED QUESTION NO: 578
ANSWERED ON:  06.04.2018
Non-Life/Health Insurance Policies
BHARTRUHARI MAHTAB
RAHUL RAMESH SHEWALE
Will the Minister of



FINANCE be pleased to state:-


(a) whether the cases of having differences between the amount claimed and the amount settled under Non-Life Insurance and Health Insurance Policies by the insurance companies have increased in the country during each of the last three years and the current year, if so, the details thereof and the reasons therefor, company-wise;
(b) whether the Government has noticed irregularities/corruption in settlement of such claims on the part of the surveyor or the insurance company during the said period;
(c) if so, the details thereof along with the action taken/being taken thereon, company-wise;
(d) the number of onsite visits/ inspections undertaken by the Insurance Regulatory and Development Authority of India and the regulatory action initiated during the said period; and
(e) the other steps taken/being taken by the Government to make the process of claim easier under Non-Life/Health Insurance?




ANSWER
(a) to (e) A Statement is laid on the Table of the House.


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STATEMENT REFERRED TO IN REPLY TO PART (a) to (e) OF LOK SABHA STARRED QUESTION NO. *578 FOR 6TH APRIL, 2018 REGARDING “NON-LIFE/HEALTH INSURANCE POLICIES” TABLED BY SHRI BHARTRUHARI MAHTAB AND SHRI RAHUL SHEWALE.

(a) The company-wise details of amount claimed under non-life insurance and health insurance and claims paid during the last three years is at Annexure I and Annexure II respectively.
(b) and (c): In Non-Life Insurance, no irregularities / corruption in settlement of claims have come to the notice of Insurance Regulatory and Development Authority of India (IRDAI). However, in the area of Health Insurance, the Authority has taken regulatory action on noticing excess deductions from health insurance policy claims as per details given in Annexure-III.
(d) The number of onsite visits/ inspections undertaken by the Insurance Regulatory and Development Authority of India and the number of regulatory actions initiated during the said period are at Annexure-III.
(e) The other steps taken to make the process of claim easier under Non-Life/Health Insurance inter-alia also includes:-
The IRDAI (Health Insurance) Regulations, 2016 (HIR 2016) and the IRDAI (Protection of Policyholders’ Interests) Regulations, 2017 have been issued by IRDAI which stipulate various provisions to protect the interest of the Policyholders of Health Insurance Policies/ General Insurance Policies including making the process of claims easier. Towards this, the Authority, inter-alia, has put in place the following provisions in these regulations:-
• The insurance claims shall be settled or rejected within 30 days from the receipt of the last “necessary” document.
• Except in cases where a fraud is suspected, ordinarily no document not listed in the policy terms and conditions shall be deemed ‘necessary’.
• The insurer shall ensure that all the documents required for claims processing are called for at one time and that the documents are not called for in a piece-meal manner.
• Insurer may stipulate a period within which all necessary claim documents should be furnished by the policyholder/insured to make a claim. However, claims filed even beyond such period should be considered if there are valid reasons for any delay.
• Every Insurance Claim shall be disposed of in accordance to the Terms and Conditions of the policy contract.
• Regulation (33) (d) (iv) of HIR 2016 specifies that where a claim is repudiated, the communication about the repudiation shall be made only by the Insurer by specifically stating the reasons for repudiation, necessarily referring to the corresponding policy conditions.
• The insurer shall also furnish the grievance redressal procedures available with the Insurance Company and with the Insurance Ombudsman along with the detailed addresses of the respective offices.
• Subject to the terms of a policy, General Insurers and Health insurers shall extend to all policy holders a cashless facility for treatment at specific establishments.
• To ensure that interests of insurance policyholders’ are protected.
• To ensure that insurers, distribution channels and other regulated entities fulfill their obligations towards policyholders and have in place standard procedures and best practices in sale and service of insurance policies.
• To ensure policyholder-centric governance by insurers with emphasis on grievance redressal.


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