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## IC - 38 **CORPORATE AGENTS** **LIFE****ACKNOWLEDGEMENT****This course is based on revised syllabus prescribed by Insurance Regulatory and**
**Development Authority of India (IRDAI) and prepared by Insurance Institute of**
**India, Mumbai.****AUTHORS/ REVIEWERS (in Alphabetical order)**Dr. R. K. Duggal
Dr. Shashidharan K. Kutty
CA P. Koteswara Rao
Dr. Pradip Sarkar
Prof. Madhuri Sharma
Dr. George E. Thomas
Prof. Archana VazeG – Block, Plot No. C-46, Bandra Kurla Complex, Bandra (E), Mumbai – 400 051.i## CORPORATE AGENTS **LIFE** **IC - 38****Year of Edition: 2023****ALL RIGHTS RESERVED**This course material is the copyright of Insurance Institute of India (III). This course
is designed for providing academic inputs for students appearing for the
examinations of Insurance Institute of India. This course material may not be
reproduced for commercial purpose, in part or whole, without prior express written
permission of the Institute.The contents are based on prevailing best practices and not intended to give
interpretations or solutions in case of disputes, legal or otherwise.This is only an indicative study material. Please note that the questions in the
examination shall not be confined to this study material only.Published by: Secretary General, Insurance Institute of India, G- Block, Plot C-46,
Bandra Kurla Complex, Bandra (E) Mumbai – 400 051 and Printed atAny communication regarding this study material may be addressed to ctd@iii.org.in
mentioning the subject title and unique publication number mentioned on the coverpageii## PREFACEInsurance Institute of India, (the Institute) has developed this course material for
Insurance Agents based on the syllabus prescribed by Insurance Regulatory and
Development Authority of India (IRDAI). Industry experts were involved in preparingthe course material.The course provides basic knowledge of Life, General and Health insurance to
enable agents in the respective line of business to understand and appreciate their
professional career in the right perspective.The course is structured as four sections. (1) Overview - a Common section that
covers Insurance Principles, Legal Principles and Regulatory matters that Insurance
agents need to know. Separate sections are provided for those aspiring to become
(2) Life Insurance Agents, (3) General Insurance Agents and (4) Health Insurance
Agents.A set of model questions are included in the course to give students an idea of the
examination format and the types of objective questions that may be asked. The
model questions will also help them in revising what they have learnt.Insurance operates in a dynamic environment. Agents need to be up to date about
changes in the market. They should actively pursue knowledge through personal
study and participation in the in-house training programmes arranged by the
respective insurers.The Institute thanks IRDAI for entrusting this work to the Institute. The Institute
wishes all interested in studying the material a successful career in insurance
marketing.iii## CONTENTS|Chapter no.|Title|Page no.|
|---|---|---|
|**SECTION**|**LIFE INSURANCE **|**LIFE INSURANCE **|
|L-01|What Life Insurance Involves|2|
|L-02|Financial Planning|8|
|L-03|Life Insurance Products: Traditional|22|
|L-04|Life insurance products: Non-Traditional|32|
|L-05|Applications of Life Insurance|38|
|L-06|Pricing and Valuation in Life Insurance|43|
|L-07|Life Insurance Documentation|52|
|L-08|Life Insurance Underwriting|65|
|L-09|Life Insurance Claims <br>|78|iv## SECTION## LIFE INSURANCE1## CHAPTER L-01## WHAT LIFE INSURANCE INVOLVES**Chapter Introduction**We have seen some aspects related to Insurance in the common chapters. However,
when it comes to Life insurance, we need to look at them more deeply. An asset
The risk insured against
The principle of pooling
The contractLet us now examine the features of life insurance. This chapter will take a brief
look at the various components of life insurance mentioned above.**Learning Outcomes**2**A.** **Life insurance business – Components, human life value, mutuality****a)** **The Asset – Human Life Value (HLV)**We have already seen that an asset is a kind of property that yields value or a return.
For most kinds of property both the value and loss of value amounts can be measured
|
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CORPORATE AGENTS
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|L-05|Applications of Life Insurance|38|
|L-06|Pricing and Valuation in Life Insurance|43|
|L-07|Life Insurance Documentation|52|
|L-08|Life Insurance Underwriting|65|
|L-09|Life Insurance Claims <br>|78|iv## SECTION## LIFE INSURANCE1## CHAPTER L-01## WHAT LIFE INSURANCE INVOLVES**Chapter Introduction**We have seen some aspects related to Insurance in the common chapters. However,
when it comes to Life insurance, we need to look at them more deeply. An asset
The risk insured against
The principle of pooling
The contractLet us now examine the features of life insurance. This chapter will take a brief
look at the various components of life insurance mentioned above.**Learning Outcomes**2**A.** **Life insurance business – Components, human life value, mutuality****a)** **The Asset – Human Life Value (HLV)**We have already seen that an asset is a kind of property that yields value or a return.
For most kinds of property both the value and loss of value amounts can be measured
in precise monetary terms.**Example**If the estimated damage of a car meeting an accident is Rs 50000, the insurer will
compensate the owner for this loss.How do we estimate the amount of loss when a person dies?Is he worth Rs. 50,000 or Rs. 5,00,000?An Agent must be able to answer the above question when meeting a customer.
Based on this the agent can determine how much insurance to recommend to the
customer. It is in fact the first lesson a life insurance agent must learn.Luckily we have a measure, developed almost seventy years ago by Prof. Hubener.
It is known as **Human Life Value (HLV)** and is used worldwide.The HLV concept considers human life as a kind of property or asset that earns an
income. It thus measures the value of human life based on an individual’s expected
net future earnings. Net earnings means the income a person expects to earn each
year in the future, less the amount he would spend on himself. It thus indicates the
economic loss a family would suffer if the wage earner were to die prematurely.
These earnings are capitalised, using an appropriate interest rate to discount them.Although there are multiple parameters used to calculate HLV including taking into
account inflation, wage rise, future earning capacity etc., a simple thumb rule to
calculate HLV is to determine the amount that would generate the annual income
the family would be needing by way of interest. In other words HLV is the annual
contribution for the family by the breadwinner divided by the prevailing rate of
interest.**Example**Mr. Rajan earns Rs. 1,20,000 a year and spends Rs. 24,000 on himself. The net
earnings his family would lose, were he to die prematurely, would be Rs. 96,000 per
year. Suppose the rate of interest is 8% (expressed as 0.08).**Human-Life-Value (HLV) = Annual Contribution for Dependents ÷ Rate of****Interest**HLV = 96000/ 0.08 = Rs. 12,00,000HLV helps to determine how much insurance one should have for full protection. It
also tells us the upper limit beyond which providing life insurance may not be
reasonable.3In general, the amount of insurance should be around 10 to 15 times one’s annual
income. Thus one should grow suspicious if Mr. Rajan was to ask insurance of Rs. 2
crores, while earning only Rs. 1.2 lakhs a year. The actual amount of insurance
purchased would depend on factors like how much insurance one can afford and
would like to buy.**B.** **Risk and Life Insurance**As we have seen above, life insurance provides protection against those risk events
that can destroy or reduce the value of human life as an asset. There are three kinds
of situations where such loss can occur. They are typical concerns which ordinary
people face.**Diagram 1:** Typical concerns faced by ordinary peopleGeneral insurance on the other hand typically deals with risks that affect property
– like fire, loss of cargo while at sea, theft and burglary and motor accidents. They
also cover events leading to loss of name and goodwill. These are covered by liability
insurance.Finally there are risks that can affect the person. Termed as personal risks, these
may also be covered by general insurance.**Example**Accident insurance which protects against losses suffered due to an accident.**a)** **How exactly does life insurance differ from general insurance?**|General Insurance|Life Insurance|
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income. Thus one should grow suspicious if Mr. Rajan was to ask insurance of Rs. 2
crores, while earning only Rs. 1.2 lakhs a year. The actual amount of insurance
purchased would depend on factors like how much insurance one can afford and
would like to buy.**B.** **Risk and Life Insurance**As we have seen above, life insurance provides protection against those risk events
that can destroy or reduce the value of human life as an asset. There are three kinds
of situations where such loss can occur. They are typical concerns which ordinary
people face.**Diagram 1:** Typical concerns faced by ordinary peopleGeneral insurance on the other hand typically deals with risks that affect property
– like fire, loss of cargo while at sea, theft and burglary and motor accidents. They
also cover events leading to loss of name and goodwill. These are covered by liability
insurance.Finally there are risks that can affect the person. Termed as personal risks, these
may also be covered by general insurance.**Example**Accident insurance which protects against losses suffered due to an accident.**a)** **How exactly does life insurance differ from general insurance?**|General Insurance|Life Insurance|
|---|---|
| Indemnity: General insurance policies,<br>with the exception of Personal Accident<br>Insurance, are usually contracts of<br>indemnity i.e. after an event like fire, the<br>insurer assesses the exact amount of loss<br>that has occurred and compensates only<br>that amount of loss – no more, no less.| **Assurance:** Life insurance policies are<br>contracts of assurance.<br> The amount of benefit to be paid in<br>the event of death is fixed at the<br>beginning of the contract.<br> An assured sum is paid to the<br>nominees or beneficiaries of the<br>insured when he dies.|
| Duration: The contract is generally short<br>period or for one year renewable basis| The contract is generally long term<br>though some one year renewable<br>contracts are also prevalent|
| Uncertainty: In general insurance<br>contracts, the concerned risk event is| There is no such question Death is<br>certain once a person is born. What is|4|uncertain. No one can be certain about<br>whether a house would catch fire or a car<br>meet an accident.|uncertain is the time of death. Life<br>insurance offers protection against<br>the risk of premature death.|
|---|---|
| Increase in probability: In case of General<br>insurance perils like fire or earthquake,<br>the probability of happening of the event<br>does not increase with time.| In life insurance the probability of<br>death increases with age.|**b)** **Nature of life insurance risk**Since probability of death increases with age, lower premiums are charged for those
who are young and higher premiums for older people. One result was that old
individuals who were in good health, tended to withdraw while unhealthy members
remained in the scheme. Insurance companies faced serious problems as a result.
Their attempts to develop life insurance policies that people could afford led to the
development of level premiums.**c)** **Level premiums**The level premium is fixed such that it does not increase with age but remains
constant throughout the contract period. This means premiums collected in early
years is more than the amount needed to cover death claims of those dying when
young, while premiums collected in later years are less than what is needed to meet
claims of those dying at higher ages. The level premium is an average of both. The
excess premiums of earlier ages compensate for the deficit of premiums in later
ages. The level premium feature is illustrated below.**Diagram 2:** **Level Premium**Level premiums are required because life insurance contracts are long term
insurance contracts that run for 10, 20 or many more years. The concept of level
premiums, do not arise for general insurance policies, which are typically short term
and expire annually.5**Example**The level premium rate is arrived at by the insurers based on the mortality
(probability of death) during the term of the policy as the age of the insured would
increase every year. The rate once decided shall be constant for the entire term of
the policy.**d)** **The Principle of Risk Pooling and Life Insurance**We have already discussed the Principle of Pooling and Mutuality earlier. The
pooling principle plays two specific roles in life insurance.i. It **provides protection against the economic loss arising as a result of one’s****untimely death** . This is done by creating a fund that pools the contributions of
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claims of those dying at higher ages. The level premium is an average of both. The
excess premiums of earlier ages compensate for the deficit of premiums in later
ages. The level premium feature is illustrated below.**Diagram 2:** **Level Premium**Level premiums are required because life insurance contracts are long term
insurance contracts that run for 10, 20 or many more years. The concept of level
premiums, do not arise for general insurance policies, which are typically short term
and expire annually.5**Example**The level premium rate is arrived at by the insurers based on the mortality
(probability of death) during the term of the policy as the age of the insured would
increase every year. The rate once decided shall be constant for the entire term of
the policy.**d)** **The Principle of Risk Pooling and Life Insurance**We have already discussed the Principle of Pooling and Mutuality earlier. The
pooling principle plays two specific roles in life insurance.i. It **provides protection against the economic loss arising as a result of one’s****untimely death** . This is done by creating a fund that pools the contributions of
many who have purchased a life insurance contract.**e)** **The Life Insurance Contract**The Policy document is the **evidence of the insurance contract** which a details all
the terms and conditions of the **insurance** .The contract states the sum assured of the life insurance policy. Life insurance is
regarded a **financial security** as the sum Insured is guaranteed by the contract. The
guarantee implies that life insurance is managed efficiently and conservatively;
strongly regulated and strictly supervised.Since Life insurance contracts involve both risk cover and savings, they are often
compared with financial products. They are also seen as a way of holding wealth
than as protection. Indeed, many life insurance products have a large cash value or
savings component which can form a significant part of an individual’s savings. Some
do argue that it may be better to buy only Term Insurance from an insurance
company and invest the balance premiums in instruments that yield higher returns.Let us consider the arguments for and against traditional cash value insurance
contracts.**a)** **Advantages**i. Insurance has historically been proven as a **safe and secure investment**
**offering** a minimum guaranteed rate of return, which may increase with
contract duration.ii. Regularity of premium payments requires compulsory planning of one’s
savings and results in savings **discipline** .iii. The Insurer takes care of professional investment management and **frees** the**individual** of this responsibilityiv. Insurance **provides liquidity** . The insured can take a loan on or surrenderthe policy and convert it into cash.v. Both cash value type life insurance and annuities may enjoy some **income**
**tax advantages.**vi. Insurance may be **safe from creditors’ claims**, generally in the event of theinsured’s bankruptcy or death.6**b)** **Disadvantages**i. As insurance gives relatively fixed and stable returns, it can be seriously
affected by inflation.ii. High marketing and other initial costs reduces the amount of cash value
accumulated in earlier years of life insurance policies.iii. The guaranteed yield may be below that of other financial instruments**Test Yourself 1**How does diversification reduce risks in financial markets?I. Collecting funds from multiple sources and investing them in one placeII. Investing funds across various asset classesIII. Maintaining time difference between investmentsIV. Investing in safe assets**Summary**a) Asset is a kind of property that yields value or a return.b) The HLV concept considers human life as a kind of property or asset that earnsan income. It thus measures the value of human life based on an individual’s
expected net future earnings.c) The level premium is a premium fixed such that it does not increase with agebut remains constant throughout the contract period.d) Mutuality is one of the important ways to reduce risk in financial markets, theother being diversification.e) The element of guarantee in a life insurance contract implies that life insuranceis subject to stringent regulation and strict supervision.**Key Terms**1. Asset2. Human Life Value3. Level premium4. Mutuality5. Diversification**Answers to Test Yourself****Answer 1** - The correct answer is II.7## CHAPTER L-02## FINANCIAL PLANNING**Chapter Introduction**In previous chapters we discussed life insurance and its role in providing financial
protection. Security is only one of the concerns of individuals who seek to allocate
their income and wealth to meet various needs of the present and the future. Life
insurance must be understood in the wider context of “Personal Financial Planning”.
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expected net future earnings.c) The level premium is a premium fixed such that it does not increase with agebut remains constant throughout the contract period.d) Mutuality is one of the important ways to reduce risk in financial markets, theother being diversification.e) The element of guarantee in a life insurance contract implies that life insuranceis subject to stringent regulation and strict supervision.**Key Terms**1. Asset2. Human Life Value3. Level premium4. Mutuality5. Diversification**Answers to Test Yourself****Answer 1** - The correct answer is II.7## CHAPTER L-02## FINANCIAL PLANNING**Chapter Introduction**In previous chapters we discussed life insurance and its role in providing financial
protection. Security is only one of the concerns of individuals who seek to allocate
their income and wealth to meet various needs of the present and the future. Life
insurance must be understood in the wider context of “Personal Financial Planning”.
The purpose of this chapter is to introduce the subject of financial planning.**Learning Outcomes**8**A.** **Financial planning and the individual life cycle****1.** **What is financial planning?**Most of us spend a major part of our lives working to make money. Financial planning
is a smart way to make money work for us.**Definition**Financial planning is a process of identifying one’s life’s goals, translating these
goals into financial goals and managing one’s finances to achieve those goals.Financial planning involves preparing a roadmap to meet both current and future
needs, which may be unforeseen. It plays a crucial role in building a life with less
worry. Careful planning can help to set one’s priorities and work to achieve your
various goals.**Diagram 1:** **Types of Goals**i. Goals may be **short term** : Buying an LCD TV set or a family vacationii. They could be **medium term** : Buying a house or a vacation abroadiii. The **long term** goals may include: Education or marriage of one’s child orpost retirement provision**2.** **Individual’s life cycle**From the day a person is born till the day of his/ her death, he/ she goes through
various stages in life, during which he/ she is expected to play a series of roles
These stages are illustrated in the diagram given below.**Diagram 2:** **The Economic Life Cycle**9**Life Stages and Priorities****a)** **Learner (till say age 20 -25)** :The stage when one is preparing for hisfuture byimproving his or her knowledge and skills. Funds are required
for financing one’s education. For instance, meeting the high cost of
fees for Medical or Management Education.**b)** **Earner (from 25 onwards)** :When one has found employment andperhaps earns enough to meet his or her needs and has some surplus to
spare.There are family responsibilities and one may also save and invest
in order to have money to meet the needs that may arise in the
immediate future.For instance, a young man takes a housing loan and
invests in a house.**c)** **Partner(on getting marriage at say 28 - 30)** : The stage when one ismarried and has a family of one’s own.This creates new needs like
having a house of one’s own, perhaps a car, consumer durables,
planning for children’s future etc.**d)** **Parent(say 28 to 35)** : The years when one becomes the parent of oneor more children.One now has to worry about their health and
education - getting them into good schools etc.**e)** **Provider(say age 35 to 55)** : The stage when children have grown intoteenagers, and includes their high school and college years. One is
concerned about the high cost of education to make the child qualified
to face the challenges of life.For instance, consider the amount that
needs to be set up to finance a medical course that runs for five years.In
many Indian homes, making provision for marriage and settlement of
girl children is a critical area of concern.Indeed, marriage and
education of children is a prime motive for savings for most Indian
families today.**f)** **Empty Nester(age 55 to 65):** The term ‘empty nester’ implies that theoffspring have flown away leaving the nest [the household] empty.This
is the period when children have married and sometimes have migrated
to other places for work, leaving the parents.Hopefully by this stage,
one has liquidated one’sliabilities [like housing loan and other
mortgages] and has built up a fund for reirement.It is also the period
when ailments like BP and Diabetes begin to manifest and plague one’s
life.Health care,financial independence and security of income become
|
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|
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concerned about the high cost of education to make the child qualified
to face the challenges of life.For instance, consider the amount that
needs to be set up to finance a medical course that runs for five years.In
many Indian homes, making provision for marriage and settlement of
girl children is a critical area of concern.Indeed, marriage and
education of children is a prime motive for savings for most Indian
families today.**f)** **Empty Nester(age 55 to 65):** The term ‘empty nester’ implies that theoffspring have flown away leaving the nest [the household] empty.This
is the period when children have married and sometimes have migrated
to other places for work, leaving the parents.Hopefully by this stage,
one has liquidated one’sliabilities [like housing loan and other
mortgages] and has built up a fund for reirement.It is also the period
when ailments like BP and Diabetes begin to manifest and plague one’s
life.Health care,financial independence and security of income become
very important at this stage.**g)** **Retirement – the twilight years (age 60 and beyond):** The age whenone has retired from active work and spends one’s savings to meet the
needs of life.The living needs of the husband and wife as long as both
are alive is the focus.One is concerned abouthealth
issues,adequateincome and loneliness.This is also the period when one
would seek to enhance the quality of life and enjoy many of the things
that one had dreamt of but could not achieve – like pursuing a hobby or
going on a vacation or a pilgrimage.Whether one ages gracefully or in
poverty would depend on how much one has provided for these years.10As we can see above, the economic life cycle has three phases: a student or Pre –
job phase; the working phase that begins between ages 18 to 25 and lasts for 35 to
40 years; and the retirement years that begin after one has stopped working.**3.** **Why does one need to save and purchase various financial assets?**The reason is that during each stage in an individual’s life, when one performs a
particular role, a number of needs come up for which funds have to be provided.**Example**When a person gets married and starts a family of his own, he may need to have his
own house. As children grow older, funds are needed for their higher education. As
an individual goes well past middle age, the concern is for having money to meet
health costs and post retirement savings so that one does not need to depend on
one’s children and become a burden. Living with independence and dignity becomes
important.The Savings – Investment process may be considered as being made of two decisions.**i.** **Postponement of consumption:** an allocation of resources between present andfuture consumption.**ii.** **Parting with liquidity** (or ready purchasing power) in exchange for less liquidassets. For instance, purchase of a life insurance policy would mean exchanging
money for a contract which is less liquid.Financial planning includes both kinds of decisions. One needs to plan in order to
save for the future and also must invest wisely in appropriate assets to meet the
various needs that will arise in future.**4.** **Individual needs**If we look at the stages of the life cycle that has been discussed above, we would
see that three types of needs can arise. These give rise to three types of financial
products.a) **Enabling future transactions**The first set of needs arise from funds for meeting a range of anticipated
expenditures that are expected to arise at different stages of the life cycle.
There are two types of such needs:**i.** **Specific transaction needs** : that are linked to specific life events whichrequire a commitment of resources. For instance making a provision for
higher education/ marriage of dependents; or purchase of a house or
consumer durables**ii.** **General transaction needs:** Amounts set aside from current consumptionwithout being earmarked for any specific purposes – these are popularly
termed as ‘future provisions’**b)** **Meeting contingencies**Contingencies are unforeseen life events that may call for large funds. These
cannot met from current income and need to be pre-funded. Some of these11events, like death and disability or unemployment, lead to a loss of income.
Others, like a fire, may result in a loss of wealth.Such needs may be addressed through insurance, if the probability of their
occurrence is low but cost impact is high. One may alternatively meet them by
setting aside a large amount of liquid assets as a reserve.**c)** **Wealth accumulation**The accumulation motive refers to an individual’s desire to invest for
accumulating wealth, taking advantage of favourable market opportunities.
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There are two types of such needs:**i.** **Specific transaction needs** : that are linked to specific life events whichrequire a commitment of resources. For instance making a provision for
higher education/ marriage of dependents; or purchase of a house or
consumer durables**ii.** **General transaction needs:** Amounts set aside from current consumptionwithout being earmarked for any specific purposes – these are popularly
termed as ‘future provisions’**b)** **Meeting contingencies**Contingencies are unforeseen life events that may call for large funds. These
cannot met from current income and need to be pre-funded. Some of these11events, like death and disability or unemployment, lead to a loss of income.
Others, like a fire, may result in a loss of wealth.Such needs may be addressed through insurance, if the probability of their
occurrence is low but cost impact is high. One may alternatively meet them by
setting aside a large amount of liquid assets as a reserve.**c)** **Wealth accumulation**The accumulation motive refers to an individual’s desire to invest for
accumulating wealth, taking advantage of favourable market opportunities.
Some individuals may take a cautious approach while investing, while some may
be willing to take more risks, with a view to earn a higher return. Higher return
is desired because it helps to increase one’s wealth or net worth more rapidly.
Wealth is linked with independence, enterprise, power and influence.**5.** **Financial products**Corresponding to the above sets of needs there are three types of products in the
financial market:|Transactional<br>products|Bank deposits and other savings instruments that enable one<br>to have adequate purchasing power (liquidity) at the right<br>time and quantum.|
|---|---|
|**Contingency**<br>**products like**<br>**insurance**|These provide protection against large losses that may be<br>suffered in the event of sudden unforeseen events.|
|**Wealth**<br>**accumulation**<br>**products**|Shares and high yielding bonds or real estate are examples of<br>such products. Here the investment is made with a view to<br>committing money for making more money.|An individual would typically have a mix of all of the above needs and thus may
need to have all three types of products. In a nutshell one may say there is:i. A need to save – For cash requirementsii. A need to insure – Against uncertaintiesiii. A need to invest – For wealth creation**6.** **Risk profile and investments**As an individual moves through various stages in the life cycle, from young earner
towards middle ages and then towards the final years of one’s work life, the risk
profile, or approach towards taking risks also changes.When one is young, one may be quite aggressive and willing to take risks in order to
accumulate as much wealth as possible. As the years pass however, one may become
more prudent and careful about investing. One is now concerned to secure and
consolidate one’s investments.Finally, as one nears retirement one may be more conservative. The focus is now to
have a corpus from which one can spend in the post retirement years. One may also
think about making donations for one’s children, for gifting to charity etc.12**One’s investment style also changes to keep pace with the risk profile.** This is
indicated below:**Diagram 3:** **Risk Profile and Investment Style****Risk Profile** **Investment Style****Test Yourself 1**Which among the following gives specific protection against unforeseen events?I. InsuranceII. Transactional products like bank Fixed DepositsIII. SharesIV. Debentures**B.** **Role of financial planning****1.** **Financial planning**Financial planning is the process of carefully evaluating a ~~c~~ lient’s current and future
needs along with his or her risk profile and income, to chart out a road map for
meeting various anticipated/ unforeseen needs through recommending appropriate
financial products.Elements of financial planning include: Investing - allocating assets based on one’s risk taking appetite, Risk management, Retirement planning, Tax and estate planning, and Financing one’s needsTo put it in a nutshell financial planning involves 360 degrees planning.13**Diagram 4:** **Elements of Financial Planning****2.** **Role of Financial planning**Financial planning is not a new discipline. It was practiced in simple form by our
fore fathers. There were limited investment options then. A few decades ago many
considered equity investment as akin to gambling. Savings were largely channelled
in bank deposits, postal savings schemes and other fixed income instruments. The
challenges facing our society and our customers are far different today. Some of
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needs along with his or her risk profile and income, to chart out a road map for
meeting various anticipated/ unforeseen needs through recommending appropriate
financial products.Elements of financial planning include: Investing - allocating assets based on one’s risk taking appetite, Risk management, Retirement planning, Tax and estate planning, and Financing one’s needsTo put it in a nutshell financial planning involves 360 degrees planning.13**Diagram 4:** **Elements of Financial Planning****2.** **Role of Financial planning**Financial planning is not a new discipline. It was practiced in simple form by our
fore fathers. There were limited investment options then. A few decades ago many
considered equity investment as akin to gambling. Savings were largely channelled
in bank deposits, postal savings schemes and other fixed income instruments. The
challenges facing our society and our customers are far different today. Some of
them are:**i.** **Disintegration of the joint family**The joint family has given way to the nuclear family, consisting of father,
mother and children. The typical head and earning member of this family has to
bear the responsibility for taking care of oneself and one’s immediate family.
This may call for a lot of proper planning and advice from a professional financial
planner.**ii.** **Multiple investment choices**A large number of investment instruments are available today for wealth
creation, each offering varying degrees of risk and return. To achieve financial
goals, one has to choose wisely and make the right investment decisions based
on one’s risk taking appetite. Financial planning can help with one’s asset
allocation.**iii.** **Changing lifestyles**Instant pleasure seems to be the order of the day. Individuals want to have the
latest mobile phones, cars, large homes, memberships of prestigious clubs, etc.
To satisfy these desires, people often borrow heavily and spend a good part of
their income to pay off loans, leaving little scope to save. Financial planning
helps to plan and one’s expenditure so that one can cut down unnecessary
expenses so as to maintain one’s present standard of living while upgrading it
over time.**iv.** **Inflation**Inflation is a rise in the general level of prices of goods and services in an
economy over a period of time. This leads to a fall in the value of money. As a
result, the purchasing power of money gets reduced. Inflation can play havoc14post retirement. Financial planning can help to ensure that one is equipped to
deal with inflation, especially in later years.**v.** **Other contingencies and needs**Financial planning also enables individuals to meet a number of other needs and
challenges like medical emergencies and tax liabilities. Individuals also need to
ensure that their estate consisting of their wealth and properties, smoothly pass
on to their loved ones after their death. There are other needs like the need to
do charity or meet certain social and religious obligations during one’s lifetime
and even thereafter. Financial planning is the means to achieve all this.3. **When is the right time to start financial planning?****Financial planning** is not meant only for the wealthy. Indeed, Planning should
ideally start one earns one’s first salary. There is no trigger point to tell when one
should begin to plan.**There is however an important principle that should guide us – the longer the**
**time period of our investments, the more they will multiply.**Hence one should start early. One’s investments would then get the maximum
benefit of time. Again, planning is not only for wealthy individuals. It is for
everyone. To achieve one’s financial goals, one must follow a disciplined approach.
An unplanned, impulsive approach to financial planning is one of the prime causes
of financial distress of individuals.**Test Yourself 2**When is the best time to start financial planning?I. Post retirement
II. As soon as one gets his first salary
III. After marriage
IV. Only after one gets rich**C.** **Financial planning - Types**Let us now look at the various types of financial planning exercises that an individual
may need to do.15**Diagram 5:** **Financial Planning Advisory Services**Consider the various advisory services that may be provided. There are six such
areas that are taken up Cash planning Investment planning Insurance planning Retirement planning Estate planning Tax planning**1.** **Cash planning**Managing cash flows has two purposes.i. To manage income and expenditures flow including establishing andmaintaining a reserve of liquid assets to meet unanticipated needs.ii. To systematically create and maintain a surplus of cash for capitalinvestment.Cash Planning involves a number of steps. One must prepare a budget and analyse
one’s income and expenditure flows to check on what regular and lump sum costs
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An unplanned, impulsive approach to financial planning is one of the prime causes
of financial distress of individuals.**Test Yourself 2**When is the best time to start financial planning?I. Post retirement
II. As soon as one gets his first salary
III. After marriage
IV. Only after one gets rich**C.** **Financial planning - Types**Let us now look at the various types of financial planning exercises that an individual
may need to do.15**Diagram 5:** **Financial Planning Advisory Services**Consider the various advisory services that may be provided. There are six such
areas that are taken up Cash planning Investment planning Insurance planning Retirement planning Estate planning Tax planning**1.** **Cash planning**Managing cash flows has two purposes.i. To manage income and expenditures flow including establishing andmaintaining a reserve of liquid assets to meet unanticipated needs.ii. To systematically create and maintain a surplus of cash for capitalinvestment.Cash Planning involves a number of steps. One must prepare a budget and analyse
one’s income and expenditure flows to check on what regular and lump sum costs
have been incurred. While fixed expenses cannot be controlled easily, one can
reduce, postpone and manage expenses that are variable. The next step is to
**predict future monthly income and expenses over the whole year and** design a
plan for managing these cash flows.Another part of the cash planning process is to design strategies for maximizing
discretionary income.**Example**One can restructure one’s outstanding debts.One can meet outstanding credit card debts through consolidating them and paying
them off through a bank loan with lower interest.16One may reallocate one’s investments to make them earn more income.**2.** **Insurance planning**There are certain risks to which individuals are exposed that can keep them from
attaining their personal financial goals. Insurance planning involves constructing a
plan of action to provide adequate insurance against such risks.The task here is to estimate how much insurance is needed and determining what
type of policy is best suited.**i.** **Life insurance** may be decided by estimating the income and expenserequirements of the dependents in the event of premature death of the
bread winner.**ii.** **Health insurance** requirements may be assessed in terms of thehospitalisation expenses that are likely to be incurred in any family medicalemergency.a. Finally **insurance for one’s assets** may be considered in terms of thetype and quantum of cover required to protect one’s home/ vehicle/
factory etc. from the risk of loss.**3.** **Investment planning**There is no one right way to invest. What is appropriate would vary from individual
to individual. Investment planning is a process of determining the most suitable
investment and asset allocation strategies based on an individual’s risk taking
appetite, financial goals and the time horizon to meet those goals.**a)** **Investment parameters****Diagram 6:** **Investment Parameters**The first step here is to define certain investment parameters. These include:17**i.** **Returns** : Returns on Investment is often the most important parameter thatpeople look for when they invest their money. The rate of return determines
how fast one’s wealth from investments would grow over time. The role of
returns can be appreciated when one considers the ‘Power of compounding’.
For instance, if an amount of Rs 1000 is invested today at 8% rate of interest,
at the end of five years, it would accumulate to Rs 1469 and at the end of
10 years it would more than double to reach Rs 2159. This expectation of
returns which helps to accumulate wealth is one of the prime motives of
investment. At the same time, one must note that higher rates of return may
be typically accompanied with higher levels of risk. One has to make a tradeoff between return and risk. This depends on an individual’s risk tolerance.**ii.** **Risk tolerance** : A measure of how much risk someone is willing to take inpurchasing an investment.**iii.** **Time horizon** : This is the amount of time available to attain a financialobjective. The longer the time horizon, the less concern is there about short
term liability. One can invest in longer term, in less liquid assets that earn
a higher return.**iv.** **Liquidity** : Individuals with limited investment capacity, or uncertain incomeand expenditure flows, or who are investing for meeting a particular
personal or business expenditure, would be concerned with liquidity [This
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For instance, if an amount of Rs 1000 is invested today at 8% rate of interest,
at the end of five years, it would accumulate to Rs 1469 and at the end of
10 years it would more than double to reach Rs 2159. This expectation of
returns which helps to accumulate wealth is one of the prime motives of
investment. At the same time, one must note that higher rates of return may
be typically accompanied with higher levels of risk. One has to make a tradeoff between return and risk. This depends on an individual’s risk tolerance.**ii.** **Risk tolerance** : A measure of how much risk someone is willing to take inpurchasing an investment.**iii.** **Time horizon** : This is the amount of time available to attain a financialobjective. The longer the time horizon, the less concern is there about short
term liability. One can invest in longer term, in less liquid assets that earn
a higher return.**iv.** **Liquidity** : Individuals with limited investment capacity, or uncertain incomeand expenditure flows, or who are investing for meeting a particular
personal or business expenditure, would be concerned with liquidity [This
refers to the ability to convert investment into cash without loss of value.]**v.** **Marketability** : The ease with which an asset can be bought or sold.**vi.** **Diversification** : The extent to which one seeks to diversify or spread theinvestments to reduce the risks.**vii.** **Taxes** : Many investments confer certain income tax benefits and one maylike to consider the post-tax returns of various investments.**b)** **Selection of appropriate investment vehicles**The next step is selection of appropriate investment vehicles based on the above
parameters. The actual selection would depend on the individual’s expectations
about return and risk.In India there are a variety of products that may be considered for the purpose of
investments. These include: Fixed deposits of banks/ corporates, Small savings schemes of post office, Public issues of shares, Debentures or other securities, Mutual funds Unit linked policies that are issued by life insurance companies etc.18**4.** **Retirement planning**It is the process of determining the amount of money that an individual needs to
meet his needs post retirement and deciding on various retirement options for
meeting these needs. Retirement planning involves three phases**a)** **Accumulation:** Accumulation of funds is done through various kinds ofstrategies to set aside money for investment with this purpose.**b)** **Conservation:** Conservation refers to the efforts made to ensure that one’sinvestments are put to hard work and that the principal gets maximised during
the individual’s working years.**c)** **Distribution:** Distribution refers to the optimal method of converting the corpusor principal into withdrawals/ annuity payments for meeting income needs
after retirement.**5.** **Estate planning**It is a plan for the devolution and transfer of one’s estate after one’s demise. There
are various processes like nomination and assignment or preparation of a will. The
basic idea is to ensure that one’s property and assets are smoothly distributed and
or utilised according to one’s wishes after one is no more.**6.** **Tax planning**Tax planning is done to determine how to gain maximum tax benefit from existing
tax laws and also for planning of income, expenses and investments taking full
advantage of the tax breaks. As per the tax laws in India, life insurance premium
paid by an individual on a life insurance policy on his/ her own life, on the life of
his/ her spouse and children is eligible for deduction under Section 80C of the
Income Tax Act for calculating the taxable income. Currently, this deduction is
allowed up to Rs.1,50,000 subject to conditions. The maturity proceeds (sum
assured plus bonus) of such policies are also exempted under Section 10 (10D).
Similarly, Death Claim amounts are exempt from Income Tax at the hands of the
recipient. One must note that the purpose here is to minimise and not evade taxes.Life insurance agents may be often required by their clients and prospective
customers to advise them not only about meeting their insurance needs but also for
support in meeting their other financial needs as well. A sound knowledge of
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or utilised according to one’s wishes after one is no more.**6.** **Tax planning**Tax planning is done to determine how to gain maximum tax benefit from existing
tax laws and also for planning of income, expenses and investments taking full
advantage of the tax breaks. As per the tax laws in India, life insurance premium
paid by an individual on a life insurance policy on his/ her own life, on the life of
his/ her spouse and children is eligible for deduction under Section 80C of the
Income Tax Act for calculating the taxable income. Currently, this deduction is
allowed up to Rs.1,50,000 subject to conditions. The maturity proceeds (sum
assured plus bonus) of such policies are also exempted under Section 10 (10D).
Similarly, Death Claim amounts are exempt from Income Tax at the hands of the
recipient. One must note that the purpose here is to minimise and not evade taxes.Life insurance agents may be often required by their clients and prospective
customers to advise them not only about meeting their insurance needs but also for
support in meeting their other financial needs as well. A sound knowledge of
financial planning would be of great value to any insurance agent.**Test Yourself 3**Which among the following is not an objective of tax planning?I. Maximum tax benefitII. Reduced tax burden as a result of prudent investmentsIII. Tax evasionIV. Full advantage of tax breaks19**Summary**Financial planning is a process of: Identifying one’s life’s goals, Translating these identified goals into financial goals and Managing one’s finances in ways that will help one to achieve those goalsBased on the individual life cycle three types of financial products are needed.
These help in: Enabling future transactions, Meeting contingencies and Wealth accumulationThe need for financial planning is further increased by the changing societal
dynamics like disintegration of the joint family, multiple investment choices
that are available today and changing lifestyles etc.The best time to start financial planning is right after one receives the first
salary.Financial planning advisory services include: Cash planning,
Investment planning,
Insurance planning,
Retirement planning,
Estate planning and
Tax planning**Key Terms**1. Financial planning
2. Life stages
3. Risk profile
4. Cash planning
5. Investment planning
6. Insurance planning
7. Retirement planning
8. Estate planning
9. Suitability information
10. Tax planning20**Answers to Test Yourself****Answer 1** - The correct option is I.
**Answer 2** - The correct option is II.
**Answer 3** - The correct option is III.21## CHAPTER L-03## LIFE INSURANCE PRODUCTS: TRADITIONAL**Chapter Introduction**The chapter introduces you to the world of life insurance products. It begins by
talking about products in general and then proceeds to discussing the need for life
insurance products and the role they play in achieving various life goals. Finally we
look at some traditional life insurance products.**Learning Outcomes**22**A.** **Overview of life insurance products****1.** **What is a product?**To begin with, let us understand what is meant by a ‘product’. In popular terms a
product is normally just considered as a commodity or good that is brought and sold
in the market.It is necessary to understand that every Product is a bundle of features or attributes
that confer certain benefits.All Companies try to differentiate their products by making them more attractive
to customers and offering different kinds of features and benefits. A life insurance
agent’s role is to understand and pitch on these features and benefits to make the
products of their companies unique and attractive compared to others.**Example**Colgate, Close up and Promise are all different brands of toothpastes. But the
features of each brand is different from the other.Products may be:**i.** **Tangible** : refers to physical objects that can be directly seen or felt by touch
(for instance a car or a television set)**ii.** **Intangible:** refers to products that can only be perceived indirectly.Life insurance is a product that is intangible.**2.** **Purpose of Life Insurance products.**Human beings possess **an immensely valuable asset** - **human capital – which is the**
**source of our productive earning capacity.** However, there is an uncertainty about
life and human well-being. Events like death and disease can destroy our Earning
capabilities and life savings. Insurance provides protection for such situations.Life insurance products offer protection against the loss of economic value of an
individual’s productive abilities, as a result of death or disability. The moment an
individual takes a life insurance policy and pays the first premium, **an immediate**
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agent’s role is to understand and pitch on these features and benefits to make the
products of their companies unique and attractive compared to others.**Example**Colgate, Close up and Promise are all different brands of toothpastes. But the
features of each brand is different from the other.Products may be:**i.** **Tangible** : refers to physical objects that can be directly seen or felt by touch
(for instance a car or a television set)**ii.** **Intangible:** refers to products that can only be perceived indirectly.Life insurance is a product that is intangible.**2.** **Purpose of Life Insurance products.**Human beings possess **an immensely valuable asset** - **human capital – which is the**
**source of our productive earning capacity.** However, there is an uncertainty about
life and human well-being. Events like death and disease can destroy our Earning
capabilities and life savings. Insurance provides protection for such situations.Life insurance products offer protection against the loss of economic value of an
individual’s productive abilities, as a result of death or disability. The moment an
individual takes a life insurance policy and pays the first premium, **an immediate**
**estate is created** in his/ her name and its proceeds are available to his/ her
dependents or loved ones.Life insurance provides peace of mind and protection to the near and dear ones of
an individual, in case of one’ unfortunate death. Beyond providing such protection,
life insurance fulfils other needs of the market, such as savings, wealth
accumulation, safety and security of investment and certain rates of return, which
are not discussed in this course.Life insurance industry has seen enormous innovations in product offerings over the
last two centuries. The journey began with death benefit products but over the
period, multiple living benefits like endowment, disability benefits, dreaded disease
covers and so on were added.23One of the major innovations of recent years was the creation of market linked
policies where the insured was invited to participate in choosing and managing his
investment assets. Another major innovation was the evolution of flexible
unbundled products, in which different benefits as well as cost components could
be varied by the policy holder as per changing needs, affordability and life-stages.**3.** **Suitability Information**In order to make insurance intermediaries including agents and brokers more
accountable and reduce instances of mis-selling, IRDAI has created a concept of
‘product suitability’. ‘Suitability information’ is the information of a prospect on
age, income, family status, life stage, financial and family goals, investment
objectives, insurance portfolio already held, etc. That is, before selling an insurance
policy to a client, an Agents should be able to justify the suitability of the product
for the client’s needs.In other words, the Agent takes into account the particular prospect’s risk profile age, income, family status, life stage, financial and family goals, investment
objectives, insurance portfolio already held, insurance needs etc. and decides
whether the product is suitable for that prospect. The nature of product, the
amount of premium, the mode of premium payment and tenure of the policy as well
as the manner of premium payment are also part of the parameters of ‘Suitability’.IRDAI mandates that the suitability information collected should be signed by the
prospect and the agent; and preserved by the Insurer as part of the policy records
and made available for inspection by the Authority.**4.** **Riders in Life Insurance Products**A rider is a provision typically added through an endorsement, which becomes part
of the contract. Riders are commonly used to provide supplementary benefits like
increasing the amount of death benefit provided by a policy, say, because of
accidents. Life insurance companies offer a number of riders through which the
value of their offerings get enhanced Riders help to customise different
requirements of a person into a single plan.Riders provide a means to provide benefits like Disability cover, accident cover and
Critical Illness cover as additional benefits in a standard life insurance contract.
Policy holders can avail of them by paying an extra premium.**Test Yourself 1**Which among the following is an intangible product?
I. CarII. HouseIII. Life insurance
IV. Soap24**B.** **Traditional life insurance products**We shall now learn about some of the traditional types of life insurance products.**Diagram 1:** **Traditional Life Insurance Products****1.** **Term insurance plans**Term insurance is a contract that is valid only during a certain time period. This
may range from the short time required to complete an airplane trip to multiple
years. Protection may extend up to age 65 or 70. One-year term policies are quite
similar to property and casualty insurance contracts. There is no savings or cash
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of the contract. Riders are commonly used to provide supplementary benefits like
increasing the amount of death benefit provided by a policy, say, because of
accidents. Life insurance companies offer a number of riders through which the
value of their offerings get enhanced Riders help to customise different
requirements of a person into a single plan.Riders provide a means to provide benefits like Disability cover, accident cover and
Critical Illness cover as additional benefits in a standard life insurance contract.
Policy holders can avail of them by paying an extra premium.**Test Yourself 1**Which among the following is an intangible product?
I. CarII. HouseIII. Life insurance
IV. Soap24**B.** **Traditional life insurance products**We shall now learn about some of the traditional types of life insurance products.**Diagram 1:** **Traditional Life Insurance Products****1.** **Term insurance plans**Term insurance is a contract that is valid only during a certain time period. This
may range from the short time required to complete an airplane trip to multiple
years. Protection may extend up to age 65 or 70. One-year term policies are quite
similar to property and casualty insurance contracts. There is no savings or cash
value element in this policy.In October 2020, IRDAI has introduced a Standard Individual Term Life Insurance
Product called, “Saral Jeevan Bima” (the Insurer’s name shall be prefixed to the
product name), a non-linked non-participating individual pure risk premium life
insurance plan, which provides for payment of Sum Assured in lump sum to the
nominee in case of the Life Assured’s unfortunate death during the policy term.Apart from certain benefits and riders specified by the Regulator, no other riders/
benefits/ options/ variants are allowed to be offered. Also, there shall be no
exclusions under the product other than the suicide exclusion. Saral Jeevan Bima is
to be offered to individuals without restrictions on gender, place of residence,
travel, occupation or educational qualifications.**a)** **Purpose**A Term Life insurance plan fulfils the main and basic idea behind life insurance,
which is to provide an assured sum of money to the dependents of the insured
on his/ her death.**The policy works as an income replacement plan also.** Here the payment of a
lump-sum amount is replaced by a series of monthly, quarterly or similar
periodical payments to the dependent beneficiaries.**b)** **Disability**
Normally a Term insurance policy covers only death. However, it is possible to
buy a Disability Protection Rider on the main policy. In such a case, if the insured
suffers from a specified disability during the term of the contract, a disability25benefit would be paid to the beneficiaries/ insured person. The benefits will
continue till the death of the insured person.**Diagram 2:** **Disability****c)** **Term insurance as a rider**Protection under Term Life is usually provided as a stand-alone policy but it
could also be provided through a rider in a policy.**Example**A rider to a pension plan provides for a death benefit to be payable if one dies
before the date when pension is to start.**d)** **Convertibility**Convertible term insurance policies allow a policyholder to change or convert a
term insurance policy into a permanent plan like “Whole Life” without providing
fresh evidence of insurability. This privilege helps those who wish to have
permanent cash value insurance but are unable to afford its high premiums.
When the term policy is converted into permanent insurance the new premium
rate would be higher.**e)** **Unique Selling Proposition** ( **USP)**The unique selling proposition (USP) of term assurance is its low price, enabling
one to buy relatively large amounts of life insurance on a limited budget.**f)** **Variants**A number of variants of term assurance are possible.**Diagram 3:** **Variants of Term Assurance****i.** **Decreasing Term Assurance**
These plans typically consist of decreasing term insurance which provides an
amount of death benefit that is equal to the balance that is due on a loan, if the
borrower dies before the loan is paid. These are often marketed as Mortgage
Redemption (discussed in Chapter 15) or Credit Life Insurance. The plans are26usually sold to lending institutions as group insurance to cover the lives of their
borrowers. Purchase of mortgage redemption insurance is often a condition of
the mortgage loan. Such plans may also be available for automobile or other
personal loans.**ii.** **Increasing term assurance**
As the name suggests, the plan provides a death benefit, which increases along
with the term of the policy. Premium generally increases as the amount of
coverage increases.**iii.** **Term insurance with return of premiums**
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one to buy relatively large amounts of life insurance on a limited budget.**f)** **Variants**A number of variants of term assurance are possible.**Diagram 3:** **Variants of Term Assurance****i.** **Decreasing Term Assurance**
These plans typically consist of decreasing term insurance which provides an
amount of death benefit that is equal to the balance that is due on a loan, if the
borrower dies before the loan is paid. These are often marketed as Mortgage
Redemption (discussed in Chapter 15) or Credit Life Insurance. The plans are26usually sold to lending institutions as group insurance to cover the lives of their
borrowers. Purchase of mortgage redemption insurance is often a condition of
the mortgage loan. Such plans may also be available for automobile or other
personal loans.**ii.** **Increasing term assurance**
As the name suggests, the plan provides a death benefit, which increases along
with the term of the policy. Premium generally increases as the amount of
coverage increases.**iii.** **Term insurance with return of premiums**
Another type of policy (quite popular in India) is term assurance with return of
premiums. Though the premium paid would be much higher than for a similar
term insurance plan without return of premiums, some customers may need such
policies.**g)** **Relevant scenarios**Term insurance may have relevance in the following situations:
i. Where the need for insurance protection is purely temporary, as in case ofmortgage redemption
ii. As an additional supplement to a savings plan.
iii. As part of a “buy term and invest the rest” philosophy, where one seeks onlycheap term insurance protection from the insurance company and wants to
invest the difference of premiums in other attractive investments.**Important****Limitations of term plans:** Term Insurance plans are available only for specific
periods and one may not be able to continue the coverage beyond a certain age,
say 65 or 70.**2.** **Whole life insurance**Whole life insurance is an example of a permanent life insurance policy. Here, the
life insurer offers to pay the agreed death benefit when the insured dies, no matter
when the death might occur. The premiums can be paid throughout one’s life or for
a limited time as specified.Whole life premiums are much higher than term premiums as whole life policies are
designed to remain in force until the death of the insured, and pay the death benefit
anytime. The Plan also provides for a cash value in the policy holder’s account. He/
she can withdraw cash in the form of a policy loan from this cash value or even
redeem it by surrendering the policy for its cash value.In case of outstanding loans, the amount of loan and interest get deducted from the
pay-out to the beneficiaries upon death.**A whole life policy is a good plan for the main earner of the family who wishes**
**to protect his/ her loved ones in the event of premature death and preserve his/**
**her capital against erosion from various events like terminal illness.** One can also
use the cash value of the whole life insurance policy for retirement needs, if27required. Whole life insurance thus plays an important role in household saving and
creating wealth to be passed on to the next generation.**3.** **Endowment Assurance**It is a contract in which the sum assured is payable to the nominees of the insured
in case of the death of the insured during the term of the policy. If the insured
survives the term the sum assured is paid to the insured.**The product has both death and survival benefit components.** Endowment
Assurance links one’s insurance and savings programmes by offering a safe and
compulsory method of savings accumulation.People buy endowment plans as a sure method of providing against old age or for
meeting specific purposes like having a fund for (a) educational purposes, (b)
meeting children’s marriage expenses or(c) paying a mortgage (housing) loan.**Government usually offers tax benefits on the premiums paid, which make it**
**attractive.** Many endowment policies mature at ages 55 to 65, when the insured is
planning for his/ her retirement. In such cases such policies can supplement
retirement savings.**Variants:** Endowment assurance has certain variants - discussed below.**4.** **Money Back Policy**
The Money Back policy is a popular endowment plan in India. It has a provision for
returning some part of the sum assured in instalments during the term and the
balance sum assured at the end of the term.**Example**A Money Back policy for 20 years may provide for paying survival benefits of 20% of
the sum assured each at the end of the 5 [th], 10 [th] and 15 [th] years and the balance 40%
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compulsory method of savings accumulation.People buy endowment plans as a sure method of providing against old age or for
meeting specific purposes like having a fund for (a) educational purposes, (b)
meeting children’s marriage expenses or(c) paying a mortgage (housing) loan.**Government usually offers tax benefits on the premiums paid, which make it**
**attractive.** Many endowment policies mature at ages 55 to 65, when the insured is
planning for his/ her retirement. In such cases such policies can supplement
retirement savings.**Variants:** Endowment assurance has certain variants - discussed below.**4.** **Money Back Policy**
The Money Back policy is a popular endowment plan in India. It has a provision for
returning some part of the sum assured in instalments during the term and the
balance sum assured at the end of the term.**Example**A Money Back policy for 20 years may provide for paying survival benefits of 20% of
the sum assured each at the end of the 5 [th], 10 [th] and 15 [th] years and the balance 40%
at the end of the full term of 20 years. If the life assured dies at the end of, say 18
years, the full sum assured and bonuses (explained in the next section) accrued are
paid as death benefit, even though the insured would have been paid a benefit of
60% of the face value already, as money back.Money Back plans have been popular because of their liquidity (cash back) element,
which make them attractive for meeting short and medium term needs. Such plans
provide full death protection also, if the individual dies at any point during the term
of the policy.**5.** **Participating (Par) and Non-Participating (Non-Par)Plans**The Life Insurance products can also be classified as Participating (Par) and Nonparticipating (Non-Par) products. The term “Par” implies policies which are
participating in the profits of the life insurer. “Non–Par”, on the other hand,
represents policies which do not participate in the profits. Both kinds are present
in traditional life insurance. Under all traditional plans, the pooled life funds, which
are derived from policyholders’ premiums, are invested as per regulatory norms.
Policy holders who opt for ‘par products’ are eligible to receive, in addition to a28guaranteed sum assured, a share in the surpluses( bonuses) that are generated by
the insurer. These are known as ‘With Profit’ plans.**6.** **Non-participating products**The Policy holders who buy non-linked without profit [non par] plans are paid a
benefit that is fixed and guaranteed at the beginning of the contract and nothing
more. Non-participating products may be offered either under a ‘linked platform’
or a ‘non-linked platform’. These are known as ‘Without Profits’ plans.**Example**One may have an endowment policy of twenty years providing a guaranteed addition
of 2% of sum assured for each year of term, so that the maturity benefit is sum
assured plus a total addition of 40% of the sum assured.Under the IRDAI’s guidelines on traditional non-par policies, the benefits to be paid
on the happening of a specified event, have to be explicitly stated at the outset and
not linked to an index or benchmark. The same applies to additional benefits that
are accrued at regular intervals. This means that the return on these policies must
be disclosed at the time of taking the policy.**Important**Death benefits are subject to regulations of IRDAI issued from time to time. At
present, as per the new Regulation 9 of IRDAI (Non-linked) Products Regulation,
2019 pertaining to traditional products, the minimum death cover is as follows:For all non-linked individual life insurance products, the minimum Sum Assured on
death during the entire term of the policy shall not be less than 7 times the
annualized premium, for limited or regular premium products, and 1.25 times the
single premium for single premium products.For participating products, in addition to the sum assured on death, the bonus and
additional benefits as stated in the policy and accrued till the date of death shall
become payable on death as part of the death benefit, if not paid earlier. In
essence, there are **two variants**, participating and non-participating plans.i. For **participating polices** the bonus is linked to the investment performanceof the fund and is not declared or guaranteed before. The **bonus, once it is**
**announced, becomes a guarantee** . It is usually paid in case of death of the
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be disclosed at the time of taking the policy.**Important**Death benefits are subject to regulations of IRDAI issued from time to time. At
present, as per the new Regulation 9 of IRDAI (Non-linked) Products Regulation,
2019 pertaining to traditional products, the minimum death cover is as follows:For all non-linked individual life insurance products, the minimum Sum Assured on
death during the entire term of the policy shall not be less than 7 times the
annualized premium, for limited or regular premium products, and 1.25 times the
single premium for single premium products.For participating products, in addition to the sum assured on death, the bonus and
additional benefits as stated in the policy and accrued till the date of death shall
become payable on death as part of the death benefit, if not paid earlier. In
essence, there are **two variants**, participating and non-participating plans.i. For **participating polices** the bonus is linked to the investment performanceof the fund and is not declared or guaranteed before. The **bonus, once it is**
**announced, becomes a guarantee** . It is usually paid in case of death of the
policyholder or maturity benefit. This bonus is also called **reversionary**
**bonus** .
ii. In case of **non-participating policies**, the return on the policy is disclosed inthe beginning of the policy itself.**7.** **Pension Plans and Annuities**A pension plan is typically a fund into which money is paid during a person’s
employment years and from which money is drawn to support the person after his
[retirement from work in the form of periodic payments.](https://en.wikipedia.org/wiki/Retirement)29Pension plans are designed on group (usually employer driven) or individual basis. A
group pension may be a "defined benefit plan", where a fixed sum is paid regularly
to a person, or a "defined contribution plan", under which a fixed sum is invested
[which becomes available at retirement age. Pensions are essentially guaranteed life](https://en.wikipedia.org/wiki/Life_annuity)
[annuities, thus insuring against the risk of longevity. A pension created by an](https://en.wikipedia.org/wiki/Life_annuity)
employer for the benefit of an employee is commonly referred to as an occupational
or employer pension.On retirement, the money in the member's account is used to provide retirement
benefits, typically by purchasing an annuity which then provides a regular income.
An annuity is a long-term investment issued by an insurance company designed to
help protect one from the risk of outliving one’s income. Through annuitization,
one’s contributions are converted into periodic payments that can last for life.Individuals can avail of pension benefits by purchasing pension plans from insurance
companies. Pension plans can be **on accumulation or deferred** **basis** which allows
a person to contribute in two ways, (i) in lump sum, or (ii) over a period of time; so
that he/ she can get a pension from the desired age/ date (called as the ‘vesting’
date). One can opt to receive pensions/ annuities on monthly, quarterly, half-yearly
or annual modes. Pension plans are available on an **immediate basis** also, from the
very next month of purchase, on payment of a lump sum amount, called as
immediate annuity.The Indian insurance industry has several deferred and immediate annuity products
marketed by Life Insurers. Each product has its own features, terms, conditions and
annuity options.**Saral Pension:** To provide uniformity across Insurers, to reduce confusion in the
market about annuity schemes, and to make available a product that will broadly
meet the needs of an average customer, in January 2021, IRDAI mandated all Life
Insurers to introduce a standard, immediate annuity product, with simple features
and standard terms and conditions on an individual (not group) basis. Such a
standard product will make it easier for the customers to make an informed choice,
enhance the trust between the Insurers and the insured, and reduce mis-selling as
well as potential disputes.The standard individual immediate annuity product is called, “Saral Pension”,
prefixed by the Insurer’s name. The product offer two (and only two) annuity
options as follows:a) Life annuity with 100% Return of Purchase Price; andb) Joint Life annuity with a provision of 100% annuity to the secondary annuitant
on death of the primary annuitant and return of 100% Purchase Price on death
of last survivor.Mode of Annuity payment would be Monthly, Quarterly, Half-Yearly and Yearly.
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annuity options.**Saral Pension:** To provide uniformity across Insurers, to reduce confusion in the
market about annuity schemes, and to make available a product that will broadly
meet the needs of an average customer, in January 2021, IRDAI mandated all Life
Insurers to introduce a standard, immediate annuity product, with simple features
and standard terms and conditions on an individual (not group) basis. Such a
standard product will make it easier for the customers to make an informed choice,
enhance the trust between the Insurers and the insured, and reduce mis-selling as
well as potential disputes.The standard individual immediate annuity product is called, “Saral Pension”,
prefixed by the Insurer’s name. The product offer two (and only two) annuity
options as follows:a) Life annuity with 100% Return of Purchase Price; andb) Joint Life annuity with a provision of 100% annuity to the secondary annuitant
on death of the primary annuitant and return of 100% Purchase Price on death
of last survivor.Mode of Annuity payment would be Monthly, Quarterly, Half-Yearly and Yearly.
Details are available on IRDAI’s website at the following link
=
[https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page](https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo4353&flag=1) PageNo43
[53&flag=1](https://www.irdai.gov.in/ADMINCMS/cms/whatsNew_Layout.aspx?page=PageNo4353&flag=1)30**Test Yourself 2**The premium paid for whole life insurance is _____________ than the premium paid
for term assurance.I. Higher
II. Lower
III. Equal
IV. Substantially higher**Summary**Life insurance products offer protection against the loss of economic value of
an individual’s productive abilities, which is available to his/ her dependents or
to the self.A life insurance policy, at its core, provides peace of mind and protection to the
near and dear ones of the individual in case something unfortunate happens to
him or her.Term insurance provides valid cover only during a certain time period that has
been specified in the contract.The unique selling proposition (USP) of term assurance is its low price, enabling
one to buy relatively large amounts of life insurance on a limited budget.While term assurance policies are examples of temporary assurance, where
protection is available for a temporary period of time, whole life insurance is an- example of a permanent life insurance policy.**Key Terms**1. Term insurance2. Whole life insurance3. Endowment assurance
4. Money back policy
5. Par and non-par schemes
6. Reversionary bonus**Answers to Test Yourself****Answer 1** -The correct option is III.
**Answer 2** - The correct option is I.31## CHAPTER L-04## LIFE INSURANCE PRODUCTS: NON-TRADITIONAL**Chapter Introduction**The chapter introduces you to the world of non-traditional life insurance products.
We start by examining the limitations of traditional life insurance products and then
have a look at the appeal of non-traditional life insurance products. Finally we look
at some of the different types of non-traditional life insurance products available
in the market.**Learning Outcomes**32**A.** **Overview of non-traditional life insurance products****1.** **Non-traditional life insurance products – Purpose and need**In the previous chapters we have considered some of the traditional life insurance
products which have insurance as well as a savings element in them.People have been questioning the ability of traditional life insurance policies to
provide a rate of return comparable to other assets in the financial market. Issues
have also been raised about the way they are structured into a single package of
benefits and premiums.**2.** **Limitations of traditional products**a) A critical examination would reveal the following areas of concern:b) **Cash value component:** The savings or cash value component in traditional policies
is not well defined. This makes it less transparent about mortality, interest rates,
expenses and other parameters that are made.c) **Rate of return:** It is not easy to ascertain the rate of return on traditional policies
because the value of the benefits under “With Profit policies” can be known only
when the contract ends. This makes it difficult to compare these policies with other
financial instruments.d)e)f) **Surrender value:** The method of arriving at the cash and surrender values (at any
point of time), are set by the life insurer and not transparent.**Yield:** The yield on these policies are much lower than those from other
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products which have insurance as well as a savings element in them.People have been questioning the ability of traditional life insurance policies to
provide a rate of return comparable to other assets in the financial market. Issues
have also been raised about the way they are structured into a single package of
benefits and premiums.**2.** **Limitations of traditional products**a) A critical examination would reveal the following areas of concern:b) **Cash value component:** The savings or cash value component in traditional policies
is not well defined. This makes it less transparent about mortality, interest rates,
expenses and other parameters that are made.c) **Rate of return:** It is not easy to ascertain the rate of return on traditional policies
because the value of the benefits under “With Profit policies” can be known only
when the contract ends. This makes it difficult to compare these policies with other
financial instruments.d)e)f) **Surrender value:** The method of arriving at the cash and surrender values (at any
point of time), are set by the life insurer and not transparent.**Yield:** The yield on these policies are much lower than those from other
investments.**3.** **Features of Non-Traditional Policies:** Life insurance companies starteddesigning policies with certain innovative features, some of which are given
below:a) **Direct linkage with investment gains:** Policies with direct linkage with thecapital market were designed in an attempt to make investment gains.
b) **Policies that can beat inflation:** Policies were designed to give returnscloser to the inflation rates. The change was that insurers started thinking
that life policies need to match if not beat inflation.
c) **Policies with Flexibility:** Policies which allowed customers to decide (withincertain limits) the amount of premium they wanted to pay; and the amount
of death benefits and cash values they wanted, got designed.
d) **Surrender value:** Policies that gave better surrender values available undertraditional policies were also designed by insurers.These policies became very popular and even began to replace traditional products
in many countries, including India.33**Test Yourself 1**Which among the following is a non-traditional life insurance product?I. Term assuranceII. Universal life insuranceIII. Endowment insuranceIV. Whole life insurance**B.** **Non-traditional life insurance products****Some non-traditional products**We shall discuss some of the non-traditional products which have emerged in the
Indian market and elsewhere.**1.** **Universal Life and Variable Life**Universal Life policy was introduced in the United States in 1979 and quickly became
very popular. Its features are **flexible premiums, flexible face amount and death**
**benefit amounts.** Unlike traditional policies, where fixed premiums have to be paid
periodically to keep the contract in force, universal life policies allow the
policyholder (within limits) to decide the amount of premiums he or she wants to
pay for the coverage.Variable Life was introduced in the United States in 1977.It is a typeof “Whole Life”
policy where the death benefit and cash value of the policy fluctuates according to
the investment performance of a special investment account into which premiums
are credited.The design and sale of the above two kinds of products, both of which were called
Variable Insurance Products, have been discontinued and are not allowed in India
since2019,further to the issue of IRDAI (ULIP) Regulations, 2019.**2.** **Unit linked insurance**Unit Linked Plans, also known as ULIPs were first introduced in UK during the
1960s.They have today emerged as one of the most popular and significant products,
displacing traditional plans in many markets.Unit linked policies help to overcome the limitations of traditional products.
The premium paid by the policyholder gets divided into two major portionsthe first portion which is utilised for providing insurance cover, andthe second portion that gets invested into the fund opted by the insured.The benefits under such contracts are wholly or partially determined by the value
of units credited to the policyholder’s account at the date when payment is due.34In many markets these policies were positioned and sold as investment vehicles with
an attached insurance component.Unlike traditional savings policies that are bundled, Unit linked contracts are
unbundled. Their structure is transparent with the charges to pay for the insurance
and expenses component being clearly specified.**Diagram 1:** **Premium break-up**After deducting the charges from the premium, the balance of the account and
income are invested in **units** .**The Value of Units**The value of units is defined by a rule or formula, which is outlined in advance.
Typically the value of the units is given by the Net Asset Value (NAV), which reflects
the market value of the assets in which the fund is invested. Different persons could
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displacing traditional plans in many markets.Unit linked policies help to overcome the limitations of traditional products.
The premium paid by the policyholder gets divided into two major portionsthe first portion which is utilised for providing insurance cover, andthe second portion that gets invested into the fund opted by the insured.The benefits under such contracts are wholly or partially determined by the value
of units credited to the policyholder’s account at the date when payment is due.34In many markets these policies were positioned and sold as investment vehicles with
an attached insurance component.Unlike traditional savings policies that are bundled, Unit linked contracts are
unbundled. Their structure is transparent with the charges to pay for the insurance
and expenses component being clearly specified.**Diagram 1:** **Premium break-up**After deducting the charges from the premium, the balance of the account and
income are invested in **units** .**The Value of Units**The value of units is defined by a rule or formula, which is outlined in advance.
Typically the value of the units is given by the Net Asset Value (NAV), which reflects
the market value of the assets in which the fund is invested. Different persons could
arrive at the same benefits payable by following the formula.The Formula is as follows:Net Asset Value [NAV] = Market Value of Assets of the fund/ Number of units of the
fundsThus, Policyholder benefits do not depend on the assumptions of the life insurancecompany.Unit linked policies allow policy holders to choose between different kinds of funds.
Each fund would have a different portfolio mix. The investor gets to choose between
a broad option of debt, balanced and equity funds, defined below. Even within these
broad categories there may be other types of options.|Equity Fund|Debt Fund|Balanced Fund|Money Market Fund|
|---|---|---|---|
|~~This fund invests~~<br>the major portion of<br>the money in equity<br>and equity related<br>instruments.<br>|~~This fund invests~~<br>major portion of the<br>money in Govt.<br>Bonds, Corporate<br>Bonds, Fixed<br>Deposits etc.<br>|~~This fund~~<br>invests in a mix<br>of equity and<br>debt<br>instruments<br>|~~This fund invests~~<br>money mainly in<br>instruments such as<br>Treasury Bills,<br>Certificates of Deposit,<br>Commercial Paper etc.<br>|There is also provision to switch from one kind of fund to another if performance of
one or more funds is not found to be up to the mark.35Some of the specific features of ULIP Policies are given below:**i.** **Unitising**Benefits under ULIP policies are determined by the value of units credited to the
policyholder’s account at the date when the claim payment is due to be made. A
unit is created by dividing an investment fund into a number of equal parts.**ii.** **Transparent structure**The charges for insurance cover and expenses in ULIPs are clearly specified. Once
these charges are deducted from the premium, the balance of the account and
income from it are invested in units.**iii.** **Pricing**Under ULIPs, the insured decides the amount of premium that he/ she can
contribute at regular intervals.In all Life Insurance policies, the initial costs are very high. Under traditional
policies, the premium charges for meeting these costs are spread throughout the
policy term.In the case of ULIPs, they are deducted from the initial premiums itself. This
significantly reduces the amount allocated for investment. This is why the value of
the benefits, vis-à-vis the premiums paid, would be very low and even less than the
premiums paid in the early years of the contract.**iv.** **Death Benefit**Unlike in traditional policies, the amount of death benefit in ULIP policies is a
multiple of the premiums paid. In case of death during the term of the policy, the
beneficiary would be paid the higher of the Sum Assured [which is a multiple of the
premium] or the Fund Value (unit price multiplied by the number of units) standing
to his or her account.**v.** **The bearing of investment risk**The value of the units depends on the value of the life insurer’s investments, which
are not guaranteed.The life insurer, though expected to manage the portfolio efficiently, does not give
any guarantee about unit values. Hence, the investment risk is borne by the
policyholder/ unit holder.36**Test Yourself 2**Which of the following statements is/ are incorrect?I. Variable life insurance is a temporary life insurance policy
II. Variable life insurance is a permanent life insurance policy
III. The policy has a cash value account
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the benefits, vis-à-vis the premiums paid, would be very low and even less than the
premiums paid in the early years of the contract.**iv.** **Death Benefit**Unlike in traditional policies, the amount of death benefit in ULIP policies is a
multiple of the premiums paid. In case of death during the term of the policy, the
beneficiary would be paid the higher of the Sum Assured [which is a multiple of the
premium] or the Fund Value (unit price multiplied by the number of units) standing
to his or her account.**v.** **The bearing of investment risk**The value of the units depends on the value of the life insurer’s investments, which
are not guaranteed.The life insurer, though expected to manage the portfolio efficiently, does not give
any guarantee about unit values. Hence, the investment risk is borne by the
policyholder/ unit holder.36**Test Yourself 2**Which of the following statements is/ are incorrect?I. Variable life insurance is a temporary life insurance policy
II. Variable life insurance is a permanent life insurance policy
III. The policy has a cash value account
IV. The policy provides a minimum death benefit guarantee**Summary**A critical concern with respect to life insurance policies was giving a competitive
rate of return comparable to other assets in the financial marketplace.Some of the trends that led to the increase in non-traditional life products
include unbundling, investment linkage and transparency.Universal life insurance is a form of permanent life insurance characterised by
its flexible premiums, flexible face amount and death benefit amounts, and the
unbundling of its pricing factors.ULIPs became one of the most popular and significant products, replacing
traditional plans in many markets.ULIPs provide the means for directly and immediately cashing on the benefits of
a Life Insurer’s investment performance.**Key Terms**1. Universal life insurance2. Variable life insurance3. Unit linked insurance4. Net asset value**Answers to Test Yourself****Answer 1** -The correct option is II.**Answer 2** - The correct option is I.37## CHAPTER L-05## APPLICATIONS OF LIFE INSURANCE**Chapter Introduction**Life insurance does not merely seek to protect individuals from premature death. It
has other applications as well. It can be applied to the creation of trusts with
resultant insurance benefits; it can be applied for creating a policy covering key
personnel of industries and also for redeeming mortgages. We shall briefly describe
these various applications of life insurance.**Learning Outcomes**38N’s
**A.** **Applications of Life insurance****1.** **Married Women’s Property Act**Section 6 of the Married Women’s Property Act, 1874 tries to ensure that the
benefits under a life insurance policy will pass on in a secure manner to the wife
and children through creation of a trust for the purpose.**Diagram 1:** **Beneficiaries under MWP Act**The section provides that when a married man takes a policy on his own life and
clearly expresses on the face of such policy that it is for the benefit of his wife or
his wife and children, and to be held in a trust for their benefit only, the proceeds
of such a policy shall not, so long as the objects of the trust remains, be subject to
the control of the husband or to his creditors or form part of his estate.**Features of a policy under the MWP Act**i. Each policy will remain a separate Trust. Either the wife or child (over 18years of age) can be a trustee.ii. The policy shall be beyond the control of court attachments, creditors andeven the life assured.iii. The claim money shall be paid to the trustees.iv. The policy cannot be surrendered and neither nomination nor assignment isallowed.v. If the policyholder does not appoint a special trustee to receive andadminister the benefits under the policy, the sum secured under the policy
becomes payable to the Official Trustee of the State in which the office at
which the insurance was effected is situated.39**Benefits**The Trust is set up under a deed that cannot be revoked or amended. It can contain
one or more insurance policies. It is important to appoint a trustee who would be
responsible for administering the trust property, including investing the insurance
proceeds, on behalf of the beneficiaries. These benefits are secured from passing
to future creditors**2.** **Key-man Insurance**Keyman insurance is an important form of business insurance.**Definition**Key-man Insurance can be described as an insurance policy taken out by a business
to compensate that business for financial losses that would arise from the death or
extended incapacity of an important member of the business.Many businesses have key persons responsible for a major part of its profits or has
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becomes payable to the Official Trustee of the State in which the office at
which the insurance was effected is situated.39**Benefits**The Trust is set up under a deed that cannot be revoked or amended. It can contain
one or more insurance policies. It is important to appoint a trustee who would be
responsible for administering the trust property, including investing the insurance
proceeds, on behalf of the beneficiaries. These benefits are secured from passing
to future creditors**2.** **Key-man Insurance**Keyman insurance is an important form of business insurance.**Definition**Key-man Insurance can be described as an insurance policy taken out by a business
to compensate that business for financial losses that would arise from the death or
extended incapacity of an important member of the business.Many businesses have key persons responsible for a major part of its profits or has
knowledge and skills that are vital to the organisation and difficult to replace. Key
man insurance is taken by employers on the life of such key persons to facilitate
business continuity and offset the costs and losses which are likely to be suffered in
the event of the loss of a key person. Keyman insurance does not indemnify the
actual losses incurred but compensates with a fixed monetary sum as specified on
the insurance policy.Keyman insurance is allowed as a term insurance policy where the sum assured is
linked to the profitability of the company rather than the key person’s own income.
The premium is paid by the company. In case the key person dies, the benefit is
paid to the company. The proceeds of Keyman insurance is taxable at the hands of
the company.**a)** **Who can be a key-man?**A key person can be anyone directly associated with the business whose loss can
cause financial strain to the business. For example, the person could be a
director of the company, a partner, a key sales person, key project manager, or
someone with specific skills or knowledge which is especially valuable to thecompany.**b)** **Insurable losses**The following are the losses for which key person insurance can provide
compensation:i. Losses related to the extended period when a key person is unable to work,to provide temporary personnel and, if necessary to finance the recruitment
and training of a replacement40ii. Insurance to protect profits. For example, offsetting lost income from lostsales, losses resulting from the delay or cancellation of any business project
that the key person was involved in, loss of opportunity to expand, loss of
specialised skills or knowledge**3.** **Mortgage Redemption Insurance (MRI)**A person taking a loan to buy a property, may be required to pay for mortgage
redemption insurance by the bank, as part of the loan arrangement. “Mortgage
Redemption Insurance” is popularly referred to “Credit Life Insurance policy”.**a)** **What is MRI?**It is an insurance policy that provides financial protection for home loan
borrowers. It is basically a decreasing term life insurance policy taken by
mortgagor to repay the balance on a mortgage loan if he/ she dies before its full
repayment. It can be called a loan protector policy. This plan is suitable for
people whose dependents may need assistance in clearing their debts in case of
the unexpected demise of the policyholder.**b)** **Features**The insurance cover under this policy decreases each year unlike a term
insurance policy where insurance cover is constant during the policy period.**Test Yourself 1**What is the objective behind Mortgage Redemption Insurance?I. Facilitate cheaper mortgage rates
II. Provide financial protection for home loan borrowers
III. Protect value of the mortgaged property
IV. Evade eviction in case of default**Summary**Section 6 of the Married Women’s Property Act, 1874 provides for security of
benefits under a life insurance policy to the wife and children.The policy effected under MWP Act shall be beyond the control of court
attachments, creditors and even the life assured.Keyman insurance is an important form of business insurance. It can be
described as an insurance policy taken out by a business to compensate at for
financial losses that would arise from the death or extended capacity of an
important member of the business.41Mortgage redemption insurance is basically a decreasing term life insurance
policy taken by a mortgagor to repay the balance on a mortgage loan if he/ she
dies before its full repayment.**Key Terms**1. Married Women’s Property Act
2. Keyman insurance
3. Mortgage Redemption Insurance**Answers to Test Yourself****Answer 1** - The correct option is II.42## CHAPTER L-06## PRICING AND VALUATION IN LIFE INSURANCE**Chapter Introduction**The objective of this chapter is to introduce to the learner the basic elements that
are involved in the pricing and benefits of life insurance contracts. We shall first
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IV. Evade eviction in case of default**Summary**Section 6 of the Married Women’s Property Act, 1874 provides for security of
benefits under a life insurance policy to the wife and children.The policy effected under MWP Act shall be beyond the control of court
attachments, creditors and even the life assured.Keyman insurance is an important form of business insurance. It can be
described as an insurance policy taken out by a business to compensate at for
financial losses that would arise from the death or extended capacity of an
important member of the business.41Mortgage redemption insurance is basically a decreasing term life insurance
policy taken by a mortgagor to repay the balance on a mortgage loan if he/ she
dies before its full repayment.**Key Terms**1. Married Women’s Property Act
2. Keyman insurance
3. Mortgage Redemption Insurance**Answers to Test Yourself****Answer 1** - The correct option is II.42## CHAPTER L-06## PRICING AND VALUATION IN LIFE INSURANCE**Chapter Introduction**The objective of this chapter is to introduce to the learner the basic elements that
are involved in the pricing and benefits of life insurance contracts. We shall first
discuss the elements that constitute the premium and then discuss the concept of
surplus and bonus.**Learning Outcomes**43**A.** **Insurance pricing – Basic elements****1.** **Premium**In ordinary language, the term premium denotes the price that is paid by an insured
for purchasing an insurance policy. It is normally expressed as a rate of premium
per thousand rupees of sum assured. The premium rates depend on the age of the
prospect and the plan.These premium rates are available in the form of tables of rates that are available
with insurance companies.**Diagram 1:** PremiumThe rates printed in these tables are known as “Office Premiums”. They are in most
cases the same throughout the term and are expressed as an annual rate.**Example**If the premium for a twenty year endowment policy for a given age is Rs. 4,800, it
means that Rs. 4,800 has to be paid each year for twenty years.However it is possible to have some policies in which the premiums are payable only
in the first few years. Companies also have single premium contracts in which only
one premium is payable at the beginning of the contract. These policies are usually
investment oriented.**2.** **Rebates**Life insurance companies may also offer certain types of rebates on the premium
that is payable. Two such rebates are: For sum assured
For mode of premum44**Rebate for sum assured**The rebate **for sum assured** is offered to those who buy policies with higher
amounts of sum assured. It is offered as a way of passing on to the customer,
the gains that the insurer may make when servicing higher value policies. The
logic is that the effort and cost required to process a policy of Rs 50,000 or
5,00,000 remains the same. But higher sum assured policies yield more premium
and so more profits.**Rebate for mode of premium**Similarly a rebate may be offered **for the mode of premium** . Life insurance
companies may allow premiums to be paid on annual, half yearly, quarterly or
monthly basis. More frequent the mode, more the administrative costs for
collecting and accounting the premium. Again, in the yearly mode, the insurer
can utilise this amount during the entire year and earn interest on it. Insurers
would hence encourage payment via yearly and half yearly modes by allowing a
rebate on these. They may also charge a little extra for monthly mode of
payments, to cover additional administrative expenses involved.**3.** **Extra charges**The tabular premium is charged for those individuals who are not subject to any
significant factors that would pose an extra risk. They are known as **standard**
**lives** and the rates charged are known as ordinary rates.If a person proposing for insurance suffers from certain health problems like
heart ailments or diabetes that can pose a hazard to his life, he or she is
considered to be sub-standard. The insurer may decide to impose an extra
premium by way of a health extra. Similarly an occupational extra may be
imposed on those engaged in a hazardous occupation, like a circus acrobat.
These extras would result in the premium being more than the tabular premium.Again, an insurer may offer certain extra benefits under a policy, which are
available on payment of an extra premium.**Example**A life insurer may offer a Double Accident Benefit or DAB (where double the sum
assured is payable as a claim if death is a result of accident). For this it may
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would hence encourage payment via yearly and half yearly modes by allowing a
rebate on these. They may also charge a little extra for monthly mode of
payments, to cover additional administrative expenses involved.**3.** **Extra charges**The tabular premium is charged for those individuals who are not subject to any
significant factors that would pose an extra risk. They are known as **standard**
**lives** and the rates charged are known as ordinary rates.If a person proposing for insurance suffers from certain health problems like
heart ailments or diabetes that can pose a hazard to his life, he or she is
considered to be sub-standard. The insurer may decide to impose an extra
premium by way of a health extra. Similarly an occupational extra may be
imposed on those engaged in a hazardous occupation, like a circus acrobat.
These extras would result in the premium being more than the tabular premium.Again, an insurer may offer certain extra benefits under a policy, which are
available on payment of an extra premium.**Example**A life insurer may offer a Double Accident Benefit or DAB (where double the sum
assured is payable as a claim if death is a result of accident). For this it may
charge an extra premium of one rupee per thousand sum assured.Similarly a benefit known as Permanent Disability Benefit (PDB) may be availed
by paying an extra per thousand sum assured.**4.** **Determining the premium**Let us now examine how life insurers arrive at the rates that are presented in
the premium tables. This task is performed by an actuary. The process of setting45the premium in case of traditional life insurance policies like term insurance,
whole life and endowment considers following elements: Mortality
Interest
Expenses of management
Reserves
Bonus loading**Diagram 2:** **Components of Premium**The first two elements give us the Net premium. By adding [also called ‘loading’]
the other elements to the net premium we get the gross or office premium**a)** **Mortality and Interest**Mortality is the first element in premiums. It is the chance or likelihood that a
person of a certain age would die during a given year. To find out the expected
Mortality of a person, “Mortality Tables” are used.**Example**If the mortality rate for age 35 is 0.0035 it implies that out of every 1000 people
who are alive as on age 35, 3.5 (or 35 out of 10,000) are expected to die between
age 35 and 36.The table may be used to calculate mortality cost for different ages. For
example the rate of 0.0035 for age 35 implies a cost of insurance of 0.0035 x
1000 (sum assured) = Rs. 3.50 per thousand sum assured.The above cost may be also called the “Risk Premium”. For higher ages the risk
premium would be higher.46**Example**If we need to have Rs. 5 per thousand to meet the cost of insurance after five
years and if we assume a rate of interest of 6%, the present value of Rs. 5 payable
after five years would be 5 x 1/ (1.06) [5 ] = 3.74.If instead of 6% we were to assume 10%, the present value would be only 3.10.
In other words the higher the rate of interest assumed, the lower the present
value.From our study of mortality and interest there are two major conclusions we can
derive Higher the mortality rate in the mortality table, higher the premiumswould be
Higher the interest rate assumed, lower the premium**Net premium**
The estimates of mortality and interest give the “Net Premium”**Gross premium**
Gross premium is the net premium plus an amount called loading. There are
three considerations or guiding principles that needs to be borne in mind when
determining the amount of loading:**b)** **Expenses and reserves**Life insurers have to incur various types of operating expenses including: Agents training and recruitment,
Commissions of agents,
Staff salaries,
Office accommodation,
Office stationery,
Electricity charges,
Other miscellaneous etc.All these have to be paid from premiums that are collected by insurers.
These expenses are suitably loaded to the net premium.**c)** **Lapses and contingencies**In addition to expenses, there are other factors that can make the calculations
of life insurers go wrong.One source of risk is that of lapses and withdrawals. A lapse means that the
policyholder discontinues payment of premiums. In case of withdrawals, the
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derive Higher the mortality rate in the mortality table, higher the premiumswould be
Higher the interest rate assumed, lower the premium**Net premium**
The estimates of mortality and interest give the “Net Premium”**Gross premium**
Gross premium is the net premium plus an amount called loading. There are
three considerations or guiding principles that needs to be borne in mind when
determining the amount of loading:**b)** **Expenses and reserves**Life insurers have to incur various types of operating expenses including: Agents training and recruitment,
Commissions of agents,
Staff salaries,
Office accommodation,
Office stationery,
Electricity charges,
Other miscellaneous etc.All these have to be paid from premiums that are collected by insurers.
These expenses are suitably loaded to the net premium.**c)** **Lapses and contingencies**In addition to expenses, there are other factors that can make the calculations
of life insurers go wrong.One source of risk is that of lapses and withdrawals. A lapse means that the
policyholder discontinues payment of premiums. In case of withdrawals, the
policyholder surrenders the policy and receives an amount from the policy’s
acquired cash value.47Lapses usually happen within the first three years, especially in the first year of
the contract.**d)** **With Profit (participating) policies and Bonus loading**The concept of ‘With Profit’ policies originated when Life insurers started the
practice of charging a high loading in advance to create a buffer to keep them
solvent even in adverse situations. If subsequent experience proved to be more
favourable, the life insurer would share some of the profits it made as a result
with policy holders by way of bonus.In sum we can say that:**Gross premium = Net premium + Loading for expenses + Loading for**
**contingencies + Bonus loading****Test Yourself 1**What does a policy lapse mean?I. Policyholder completes premium payment for a policy
II. Policyholder discontinues premium payment for a policy
III. Policy attains maturity
IV. Policy is withdrawn from the market**B.** **Surplus and bonus****1.** **Determination of surplus and bonus**Every life insurance company is expected to undertake a periodic valuation of its
assets and liabilities. Such a valuation has two purposes:i. To assess the financial state of the life insurer and determine if it is solventor insolvent
ii. To determine the surplus available for distribution among policyholders/share holders**Definition**Surplus is the excess of value of assets over value of liabilities. If it is negative, it is
known as a strain.Let us now see how the concept of surplus in life insurance is different from that of
profit of a firm.48Firms in general look at profits in two ways. Firstly, profit is the **excess of income**
**over outgo** for a given accounting period, as it appears in the profit and loss
account. Profit also forms part of the balance sheet of a firm - it may be defined as
the **excess of assets over liabilities** . In both instances, profits are determined at
the end of the accounting period.**Surplus = Assets - Liabilities**Let us understand what liabilities mean in life insurance. For a given block of life
insurance policies, the life insurer has to make provision for meeting future claims,
expenses and other expected pay-outs that may arise. The insurer also expects to
receive premiums in future for these policies.Liabilities are thus the present value of all payments that have to be made less the
present value of premiums expected to be received on these policies. The present
value is arrived at by applying a suitable rate of discount [the interest rate]
Surplus arises as a result of the life insurer’s actual experience being better than
what it had assumed. Life insurers are obliged to share the benefits arising as a
result with holders of it’s with profit policies.**Example**The profits of XYZ firm as on 31 [st] March 2013, is given as its income less expenses or
its assets less liabilities as on that date.In both instances, the profit is clearly defined and is known.**2.** **Bonus**Insurers have to declare and distribute its divisible surplus among the policy holders
and shareholders of the company [if any] in the form of a bonus. In India, the United
Kingdom and many other countries, distribution of surplus is popular.Bonus is paid as an addition to the basic benefit payable under a contract. Typically
it may appear as an addition to basic sum assured or basic pension per annum. It is
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receive premiums in future for these policies.Liabilities are thus the present value of all payments that have to be made less the
present value of premiums expected to be received on these policies. The present
value is arrived at by applying a suitable rate of discount [the interest rate]
Surplus arises as a result of the life insurer’s actual experience being better than
what it had assumed. Life insurers are obliged to share the benefits arising as a
result with holders of it’s with profit policies.**Example**The profits of XYZ firm as on 31 [st] March 2013, is given as its income less expenses or
its assets less liabilities as on that date.In both instances, the profit is clearly defined and is known.**2.** **Bonus**Insurers have to declare and distribute its divisible surplus among the policy holders
and shareholders of the company [if any] in the form of a bonus. In India, the United
Kingdom and many other countries, distribution of surplus is popular.Bonus is paid as an addition to the basic benefit payable under a contract. Typically
it may appear as an addition to basic sum assured or basic pension per annum. It is
expressed, for example, as Rs. 60 per thousand sum assuredThe most common form of bonus is the **reversionary bonus** . Once declared these
bonus additions, made each year, get attached to the policy and cannot be taken
away. They are called ‘Reversionary’ bonuses because they are received only at the
time of a claim by death or maturity. Bonuses may also be payable on surrender
provided the contract is eligible through having run for a minimum term [say 5 years]49**Types of reversionary bonuses****Diagram 3:** **Types of Reversionary Bonuses****i.** **Simple Reversionary Bonus**This is a bonus expressed as a percentage of the basic cash benefit under the
contract. In India for example, it is declared as amount per thousand sum
assured.**ii.** **Compound Bonus**Here the company expresses a bonus as a percentage of basic benefit and
already attached bonuses. It is thus a bonus on a bonus. A way to express it may
be as @ 8% of basic sum assured plus attached bonus.**iii.** **Terminal Bonus**As the name suggests, this bonus attaches to the contract only at the time of its
termination [by death or maturity]. It is applicable only for the claims arising in
the ensuing year. Thus terminal bonus declared for 2013 would only apply to
claims that have arisen during 2013-14 and not for subsequent years. Terminal
bonuses depend on the time duration of the contract and increase with it. A
contract that has run for 25 years would have higher terminal bonus than one
which has run for 15 years.**3.** **The Contribution Method**Another method of distribution of surplus adopted in North America is the
“Contribution” method. Here, the surplus, i.e. the difference between what was
expected to happen and what actually happened over the year with respect to
mortality, interest and expenses is declared and distributed as dividends.The dividends can be paid in cash, by way of adjustments/ reductions in future
premiums, by allowing purchase of non-forfeitable paid up additions to the policy
or as accumulations to the credit of the policy.50**4.** **Unit Linked Policies**The Principles of Pricing and other features of ULIP Policies have already been
covered in an earlier chapter.**Summary**In ordinary language, the term premium denotes the price that is paid by an
insured for purchasing an insurance policy.The process of setting the premium for life insurance policies involves
consideration of mortality, interests, expense management and reserves.Gross premium is the net premium plus an amount called loading.A lapse means that the policyholder discontinues payment of premiums. In case
of withdrawals, the policyholder surrenders the policy and receives an amount
from the policy’s acquired cash value.Surplus arises as a result of the life insurer’s actual experience being better than
what it had assumed.Surplus allocation could be towards maintaining solvency requirements,
increasing free assets etc.The most common form of bonus is the reversionary bonus.**Key Terms**1. Premium2. Rebate3. Bonus
4. Surplus
5. Reserve
6. Loading
7. Reversionary bonus**Answers to Test Yourself****Answer 1** - The correct option is II.51## CHAPTER L-07## LIFE INSURANCE DOCUMENTATION**Chapter Introduction**We have seen that the insurance industry deals with a large number of forms and
documents in Chapter 7. There are some documents specific to life insurance, which
are discussed in this chapter. Here, we are also discussing the main provisions
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insured for purchasing an insurance policy.The process of setting the premium for life insurance policies involves
consideration of mortality, interests, expense management and reserves.Gross premium is the net premium plus an amount called loading.A lapse means that the policyholder discontinues payment of premiums. In case
of withdrawals, the policyholder surrenders the policy and receives an amount
from the policy’s acquired cash value.Surplus arises as a result of the life insurer’s actual experience being better than
what it had assumed.Surplus allocation could be towards maintaining solvency requirements,
increasing free assets etc.The most common form of bonus is the reversionary bonus.**Key Terms**1. Premium2. Rebate3. Bonus
4. Surplus
5. Reserve
6. Loading
7. Reversionary bonus**Answers to Test Yourself****Answer 1** - The correct option is II.51## CHAPTER L-07## LIFE INSURANCE DOCUMENTATION**Chapter Introduction**We have seen that the insurance industry deals with a large number of forms and
documents in Chapter 7. There are some documents specific to life insurance, which
are discussed in this chapter. Here, we are also discussing the main provisions
incorporated in a policy document. Provisions related to grace period, policy lapse
and non-forfeiture and certain other privileges are also discussed.**Learning Outcomes**52**A. Proposal stage documentation**Further to the common points discussed about the Prospectus and the Proposal Form
in Chapter 7, there are some additional points that Life Insurers need to understand.**Prospectus:** In insurance, ‘Prospectus’ means a document in physical, electronic or
any other format issued by the insurer to sell or promote the insurance product.
The prospectus of an insurance product shall clearly state(a) the Unique Identification Number (UIN) allotted by the Authority for theconcerned insurance product:
(b) the scope of benefits;
(c) the extent of insurance cover;
(d) the warranties, exclusions/exceptions and conditions of the insurance coveralong with explanations.
The prospectus should also provide:(a) a description of the contingency or contingencies to be covered by insurance;
(b) the class or classes of lives or property eligible for insurance under the termsof such prospectus.
In Life insurance, the prospectus should also mention about the Riders (also called
Add-on covers in Health and General Insurance) allowable on the product and their
benefits.**Proposal Form:** In respect of Life insurance, the details of the proposers’ family
members (including parents) indicating their longevity, status of health and
ailments suffered by any of them, are collected through the Proposal form.
Depending on the product, the medical details of the life proposed for insurance,
his/ her personal history of disease and personal characteristics may also be asked
for. The Proposal Form is the document by which insurers get all the information
that they need from the prospect.Section 45 of the Insurance Act, provides that the Policy shall not be called in
question on the ground of mis-statement after three years. Agents have an
important role in guiding the prospect to give answers to all the questions in the
Proposal Form/ Medical Forms etc. truthfully and advising them of the implications
of not doing so in terms of Section 45.Proposal Forms for Life Insurance should state the requirements of Section 45 of the
Act. While answering the questions in the Proposal Form for obtaining life insurance
cover, the prospect is to be guided by the provisions of Section 45 of the Act.Similarly, Section 39 of the Act is about the provision of nomination. Wherever the
facility of Nomination is available to the proposer, the Agent shall inform him/ her
of the provisions of Section 39 of the Act and encourage the proposer to avail the
facility.Aspects related to the personal financial planning of the life proposed including his/
her work span, projected income and expenses, as well as needs for savings and
investment, health, retirement and insurance may also be asked in the Life
Insurance Proposal Form.53**Age Proof:** Age being an important factor for assessing the risk profile of the life to
be insured, Life insurers collect documentary evidence to verify correct age. Valid
age proofs may be standard or non-standard, as discussed in Chapter 7.Life insurers look into the following documents as well.**a)** **Agent’s Confidential Report**The agent is the primary underwriter. All material facts and particulars about the
policyholder, relevant to risk assessment, need to be revealed by the agent in his/
her report. This means that matters of health, habits, occupation, income and
family details need to be mentioned in the report.**b)** **Medical Examiner’s report**In many cases, the life to be insured has to be medically examined by a doctor who
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facility of Nomination is available to the proposer, the Agent shall inform him/ her
of the provisions of Section 39 of the Act and encourage the proposer to avail the
facility.Aspects related to the personal financial planning of the life proposed including his/
her work span, projected income and expenses, as well as needs for savings and
investment, health, retirement and insurance may also be asked in the Life
Insurance Proposal Form.53**Age Proof:** Age being an important factor for assessing the risk profile of the life to
be insured, Life insurers collect documentary evidence to verify correct age. Valid
age proofs may be standard or non-standard, as discussed in Chapter 7.Life insurers look into the following documents as well.**a)** **Agent’s Confidential Report**The agent is the primary underwriter. All material facts and particulars about the
policyholder, relevant to risk assessment, need to be revealed by the agent in his/
her report. This means that matters of health, habits, occupation, income and
family details need to be mentioned in the report.**b)** **Medical Examiner’s report**In many cases, the life to be insured has to be medically examined by a doctor who
is empanelled by the insurance company. Details of physical features like height,
weight, blood pressure, cardiac status etc. are recorded and mentioned by the
doctor in his report called the medical examiner’s report. The underwriter of the
insurance company thereby gets an account of the current health position of the
life to be insured.Many proposals are underwritten and accepted for insurance without calling for a
medical examination. They are known as non–medical cases. The medical
examiner’s report is required typically when the proposal cannot be considered
under non-medical underwriting because the sum proposed or the age of the
proposed life is high or there are certain characteristics which are revealed in the
proposal, which call for examination and report by a medical examiner.**c)** **Moral Hazard report**Moral Hazard is the likelihood that a client's behaviour might change as a result of
purchasing a life insurance policy and such a change would increase the chance of
a loss. This is one factor that Life insurance underwriters take into account seriously
when assessing the risk.Life insurance companies seek to guard against the possibility of individuals seeking
to make a profit from the purchase of life insurance through actions like ending
one’s own life or the life of another. Life insurance underwriters would thus look
for any factors which might suggest such hazard. For this purpose, the company may
require that a Moral Hazard Report has to be submitted by an official of the
insurance company.**Example**Vikas recently purchased a life insurance policy. He then decided to go on a skiing
expedition at a site which was touted to be one of the most dangerous skiing places
on earth. In the past he had refused to undertake such expeditions.54**B. Policy Stage Documentation****1.** **First Premium Receipt**An insurance contract commences when the life insurance company issues a first
premium receipt (FPR).
**The FPR is the evidence that the policy contract has begun.** The first premium
receipt contains the following information:i. Name and address of the life assured
ii. Policy number
iii. Premium amount paid
iv. Method and frequency of premium payment
v. Next due date of premium payment
vi. Date of commencement of the risk
vii. Date of final maturity of the policy
viii.Date of payment of the last premium
ix. Sum assuredAfter the issue of the FPR, the insurance company will issue subsequent premium
receipts when it receives further premiums from the proposer. These receipts are
known as renewal premium receipts (RPR). The RPRs act as proof of payment in the
event of any disputes related to premium payment.**2.** **Policy Document**The policy document is the most important document associated with insurance. **It**
**is evidence of the contract between the assured and the insurance company.** It
is not the contract itself. If the policy document is lost by the policy holder, it does
not affect the insurance contract. The insurance company will issue a duplicate
policy without making any changes to the contract. The policy document has to be
signed by a competent authority and should be stamped according to the Indian
Stamp Act. Life insurers are very careful while designing the policy document
because they bear onus of responsibility for any ambiguity or confusion that may
arise in the interpretation of its wordings.The standard policy document typically has three parts:**a)** **Policy Schedule**The policy schedule forms the first part. It is usually found on the face page of
the policy. The schedules of life insurance contracts would be generally similar.
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receipts when it receives further premiums from the proposer. These receipts are
known as renewal premium receipts (RPR). The RPRs act as proof of payment in the
event of any disputes related to premium payment.**2.** **Policy Document**The policy document is the most important document associated with insurance. **It**
**is evidence of the contract between the assured and the insurance company.** It
is not the contract itself. If the policy document is lost by the policy holder, it does
not affect the insurance contract. The insurance company will issue a duplicate
policy without making any changes to the contract. The policy document has to be
signed by a competent authority and should be stamped according to the Indian
Stamp Act. Life insurers are very careful while designing the policy document
because they bear onus of responsibility for any ambiguity or confusion that may
arise in the interpretation of its wordings.The standard policy document typically has three parts:**a)** **Policy Schedule**The policy schedule forms the first part. It is usually found on the face page of
the policy. The schedules of life insurance contracts would be generally similar.
They would normally contain the following information:55**Diagram 1:** **Policy document components**i. Name of the insurance companyii. Some common details of a policy are: Policy owner’s name and address
Date of birth and age last birthday
Plan and term of policy contract
Sum assured
Amount of premium
Premium paying term
Date of commencement, date of maturity and due date of last premium
Whether policy is with or without profits
Name of nominee
Mode of premium payment – yearly; half yearly; quarterly; monthly; viadeduction from salary
The policy number – which is the unique identity number of the policycontractiii. The insurer’s promise to pay. The events on the happening of which and theamounts that are promised to be paid. This forms the heart of the insurance
contractiv. The signature of the authorised signatory and policy stampv. The address of the local Insurance Ombudsman.**b)** **Standard Provisions**The second component of the policy document is made up of standard policy
provisions, such as relating to proof of age, premium payment grace period etc.
which are normally present in all life insurance contracts. Some of these
provisions may not be applicable in the case of certain kinds of contracts, like
term, single premium or non-participating (with profits) policies. These standard
provisions define the rights and privileges and other conditions, which are
applicable under the contract.**c)** **Specific Policy Provisions**The third part of the policy document consists of specific policy provisions that
are specific to the individual policy contract. These may be printed on the face
of the document or inserted separately in the form of an attachment.56While standard policy provisions, like days of grace or non-forfeiture in case of
lapse, are often statutorily provided under the contract, specific provisions are
generally linked to the particular contract between the insurer and the insured.**Example**A clause precluding death due to pregnancy for a lady who is expecting at the time
of writing the contract.**Test Yourself 1**What does a first premium receipt (FPR) signify? Choose the most appropriate
option.I. Free-look period has ended
II. It is evidence that the policy contract has begun
III. Policy cannot be cancelled now
IV. Policy has acquired a certain cash value.**C. Policy conditions and privileges****Grace Period**As mentioned in Chapter 4, the Grace Period provision enables a policy that would
otherwise have lapsed for non-payment of premium, to continue in force during the
grace period. Every life insurance contract undertakes to pay the death benefit on
the condition that the premiums have been paid up to date and the policy is in
force. The “Grace Period” clause grants the policyholder an additional period of
time to pay the premium after it has become due.The premium however remains due and if the policyholder dies during this period,
the insurer deducts the premium from the death benefit. If premiums remain unpaid
even after the grace period is over, the policy would then be considered lapsed and
the company is not under obligation to pay the death benefit. The only amount
payable would be whatever is applicable under the non-forfeiture provisions.**Important****Lapse and Reinstatement/ Revival**We have already seen that a policy may be said to be in lapse condition if premium
has not been paid even during the days of grace. The good news is that most lapsed
life insurance policies can be reinstated [revived]. As per IRDAI Product Regulations,
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otherwise have lapsed for non-payment of premium, to continue in force during the
grace period. Every life insurance contract undertakes to pay the death benefit on
the condition that the premiums have been paid up to date and the policy is in
force. The “Grace Period” clause grants the policyholder an additional period of
time to pay the premium after it has become due.The premium however remains due and if the policyholder dies during this period,
the insurer deducts the premium from the death benefit. If premiums remain unpaid
even after the grace period is over, the policy would then be considered lapsed and
the company is not under obligation to pay the death benefit. The only amount
payable would be whatever is applicable under the non-forfeiture provisions.**Important****Lapse and Reinstatement/ Revival**We have already seen that a policy may be said to be in lapse condition if premium
has not been paid even during the days of grace. The good news is that most lapsed
life insurance policies can be reinstated [revived]. As per IRDAI Product Regulations,
a Non-Linked Policy can be revived within 5 years from the date of unpaid premium,
whereas a Linked Policy can be revived within 3 years.**Definition**Reinstatement is the process by which a life insurance company puts back into force
a policy that has either been terminated because of non-payment of premiums or
has been continued under one of the non-forfeiture provisions.A revival of the policy cannot however be an unconditional right of the insured. It
can be accomplished only under certain conditions:57**i.** **Revival application within specific time period:** The policy owner must
complete the revival application within the time frame stated in the
provision for such reinstatement, say five years from the date of lapsation.**ii.** **Satisfactory evidence of continued insurability:** The insured must presentto the insurance company satisfactory evidence of continued insurability of
the insured. Not only must her health be satisfactory but other factors such
as financial income and morals must not have deteriorated substantially.**iii.** **Payment of overdue premiums with interest:** The policy owner is requiredto make payment of all overdue premiums with interest from due date of
each premium.**iv.** After having evaluated the evidence of continued insurability the insurermay decide to revive the policy as per existing terms and premium or even
offer revival with increase in premium or reduced risk cover or both.**Perhaps the most significant of the above conditions is that which requires**
**evidence of insurability at revival.** The type of evidence called for would depend
on the circumstances of each individual policy. If the policy has been in a lapsed
state for a very short period of time, the insurer may reinstate the policy without
any evidence of insurability or may only require a simple statement from the insured
certifying that he is in good health.The company may however require a medical examination or other evidence of
insurability under certain circumstances:i. If the grace period has expired since long and the policy is in a lapsedcondition for say, nearly a year.ii. If the insurer has reason to suspect that a health or other problem may bepresent. Fresh medical examination may also be required if the sum assured
or face amount of the policy is large.**Important**Revival of lapsed policies is an important service function that life insurers seek to
actively encourage since policies in lapsed state may do little good to either insurer
or policyholder.**Non-forfeiture provisions**The Insurance Act, 1938 (Section 113) protects policies (which have acquired
surrender value), from lapsation, by keeping them alive to the extent of paid-up
sum assured even without payment of further premiums. This is because the
policyholder has a claim to the cash value accumulated under the policy.**a)** **Surrender values**Surrender value is the amount you stand to get when you decide to make a
premature exit from the plan, i.e. when you have decided to completely withdraw
or terminate the policy before its maturity.Life insurers normally have a chart that lists the surrender values at various times
and also the method that will be used for calculating the surrender values. The58formula takes into account the type and plan of insurance, age of the policy and
the length of the policy premium-paying period.The actual amount of cash one gets in hand on surrender may be different from the
surrender value amount prescribed in the policy. The actual amount may differ on
account of any accrued bonuses, recoveries etc.**Guaranteed Surrender Value [GSV]:** The law in India as per IRDAI Guidelines
(revised in 2019) provides for a Guaranteed Surrender Value [GSV] to be payable if
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surrender value), from lapsation, by keeping them alive to the extent of paid-up
sum assured even without payment of further premiums. This is because the
policyholder has a claim to the cash value accumulated under the policy.**a)** **Surrender values**Surrender value is the amount you stand to get when you decide to make a
premature exit from the plan, i.e. when you have decided to completely withdraw
or terminate the policy before its maturity.Life insurers normally have a chart that lists the surrender values at various times
and also the method that will be used for calculating the surrender values. The58formula takes into account the type and plan of insurance, age of the policy and
the length of the policy premium-paying period.The actual amount of cash one gets in hand on surrender may be different from the
surrender value amount prescribed in the policy. The actual amount may differ on
account of any accrued bonuses, recoveries etc.**Guaranteed Surrender Value [GSV]:** The law in India as per IRDAI Guidelines
(revised in 2019) provides for a Guaranteed Surrender Value [GSV] to be payable if
all premiums have been paid for at least two consecutive years. This Value arrived
as a percentage (say 30%) of premiums paid is called Guaranteed Surrender Value.
The value depends on the duration of premium paid. The GSV is required to be
mentioned in the policy document.**b)** **Policy loans**Life insurance policies that accumulate a cash value also have a provision to grant
the policyholder the right to borrow money from the insurer by using the cash value
of the policy as a security for the loan. The policy loan is usually limited to a
percentage of the policy’s surrender value (say 90%). Note that the policyholder
borrows from his own account. He or she would have been eligible to get the amount
if the policy had been surrendered. In that case the insurance would have been
terminated.Insurers charge interest on policy loans, which are payable semi-annually or
annually. Although loan and interest are repayable periodically, If the loan has not
been repaid, the insurer deducts the amount of outstanding (unpaid) loan and
interest from the policy benefit that is payable. A loan provides relief to
policyholder in case of financial emergencies while keeping the insurance alive.Since the loan is granted on the policy being kept as security, the policy has to be
assigned (explained in later para) in favour of the insurer. Where the policyholder
has nominated (explained in later para) someone to receive the money in the event
of death of the insured, this nomination shall not be cancelled but the nominee’s
right will be affected to the extent of the insurer’s interest in the policy.**Example**Arjun bought a life insurance policy wherein the total death claim payable under
the policy was Rs. 2.5 lakhs. Arjun’s total outstanding loan and interest under the
policy amounts to Rs. 1.5 lakhs. Hence in the event of Arjun’s death, the nominee
will be eligible to get the balance of Rs. 1 lakh.**Special policy provisions and endorsements****a)** **Nomination**i. Under Section 39 of the Insurance Act 1938, the holder of a policy on his/her own life may nominate the person or persons to whom the money secured
by the policy shall be paid in the event of his/her death.
ii. The life assured can **nominate one or more than one person** as nominees.
iii. Nominees are entitled for **valid discharge** and have to **hold the money as a****trustee** on behalf of those entitled to it.
iv. Nomination can be done either **at the time the policy is bought or later** atany time before the maturity of the Policy.59v. Nomination may be incorporated in the text of the Policy itself or by anendorsement on the Policy. Nominations need be communicated to the
insurer and registered by the insurer in the records relating to the Policy.
vi. Nomination can be cancelled or changed at any time before Policy matures,by an endorsement or a further endorsement or a will as the case may be.**Important**Nomination only gives the nominee the right to receive the policy monies from
the insurer in the event of the death of the life assured. However, the money
would be belonging to the legal heir only. **A nominee does not have any right**
**to the whole (or part) of the claim.** However vide Section 39(7) of Insurance
Act,1938, in respect of all policies maturing for payment after 26 [th] December,
2014, nomination in favour of parents, spouse, children or spouse and children
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iv. Nomination can be done either **at the time the policy is bought or later** atany time before the maturity of the Policy.59v. Nomination may be incorporated in the text of the Policy itself or by anendorsement on the Policy. Nominations need be communicated to the
insurer and registered by the insurer in the records relating to the Policy.
vi. Nomination can be cancelled or changed at any time before Policy matures,by an endorsement or a further endorsement or a will as the case may be.**Important**Nomination only gives the nominee the right to receive the policy monies from
the insurer in the event of the death of the life assured. However, the money
would be belonging to the legal heir only. **A nominee does not have any right**
**to the whole (or part) of the claim.** However vide Section 39(7) of Insurance
Act,1938, in respect of all policies maturing for payment after 26 [th] December,
2014, nomination in favour of parents, spouse, children or spouse and children
by the owner of the policy on his/ own life makes the nominees beneficially
entitled to the amount payable by the insurance company.Where the nominee is a minor, the policy holder needs to appoint an appointee.
The appointee needs to sign the policy document to show his or her consent to
acting as an appointee. The appointees lose their status when the nominee
reaches majority age. The policy holder can change the appointee at any time.
If no appointee is given, and the nominee is a minor, then on the death of the
life assured, the death claim is paid to the legal heirs of the policyholder.Where more than one nominee is appointed, the death claim will be payable to
them jointly, or to the survivor or survivors. Nominations made after the
commencement of the policy have to be intimated to the insurers to be
effective.Section 39(11) of the Insurance Act says that where a policyholder dies after the
maturity of the policy but the proceeds and benefit of his policy has not been
made to him because of his death, his nominee shall be entitled to the proceeds
and benefit of his policy.**Diagram 2:** **Provisions related to nomination****b)** **Assignment**Since life insurance policy carries a promise or a debt that the insurance
company owes the insured, it is considered a security for money or property.60We have seen that loan is advanced against by the insurers against the surrender
value of the policy. Similarly, many financial institutions including banks
advance loan against the security of the insurance policy by having it assigned
it in their favour.The term assignment ordinarily refers to transfer of property by writing in favour
of another person.The assignment of a life insurance policy implies the act of transferring the
rights, title and interest in the policy (as property) from one person to another.
The person who transfers the rights is called **assignor** and the person to whom
property is transferred is called **assignee** . On assignment, the ownership of the
policy changes and hence nomination is cancelled, except when assignment is
made to the insurance company for a policy loan.There are two types of assignments.**Diagram 3:** **Types of Assignment**|Conditional Assignment|Absolute Assignment|
|---|---|
|Conditional assignment<br>provides that the policy<br>shall revert back to the<br>life assured on his or<br>her surviving the date of<br>maturity or on death of<br>the assignee.| Absolute assignment provides that all rights, title and<br>interest which the assignor has in the policy are<br>transferred to the assignee without reversion to the<br>former or his/ her estate in any event.<br> The policy thus vests absolutely with the assignee. The<br>latter can deal with the policy in whatever manner he or<br>she likes without the consent of the assignor.|Absolute assignment is more commonly seen in many commercial situations
where the policy is typically mortgaged against a debt assumed by the
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The person who transfers the rights is called **assignor** and the person to whom
property is transferred is called **assignee** . On assignment, the ownership of the
policy changes and hence nomination is cancelled, except when assignment is
made to the insurance company for a policy loan.There are two types of assignments.**Diagram 3:** **Types of Assignment**|Conditional Assignment|Absolute Assignment|
|---|---|
|Conditional assignment<br>provides that the policy<br>shall revert back to the<br>life assured on his or<br>her surviving the date of<br>maturity or on death of<br>the assignee.| Absolute assignment provides that all rights, title and<br>interest which the assignor has in the policy are<br>transferred to the assignee without reversion to the<br>former or his/ her estate in any event.<br> The policy thus vests absolutely with the assignee. The<br>latter can deal with the policy in whatever manner he or<br>she likes without the consent of the assignor.|Absolute assignment is more commonly seen in many commercial situations
where the policy is typically mortgaged against a debt assumed by the
policyholder, like a housing loan.**Conditions for valid assignment**Let us now look at the conditions that are necessary for a valid assignment.i. The assignor must have **absolute right and title or assignable interest** tothe policy being assigned.ii. The assignment should **not be opposed to any law in force** .iii. Assignee can do another assignment, but cannot do nomination becauseassignee is not the life assured.**Important** : A life insurance policy can be assigned wholly or partially The assignment must be signed by the transferor or assignor or dulyauthorized agent and attested by at least one witness.61 The transfer of title has to be specifically set forth in the form of anendorsement on the policy or a separate instrument.
The policyholder must give notice of the assignment to the insurer,without which the assignment will not be valid. Section 38(2) specifies that an insurer may accept the assignment, ordecline the same, if it has sufficient reason to believe that such
assignment is not bona fide or is not in the interest of the policyholder
or in public interest or is for the purpose of trading of insurance policy. However, the insurer shall, before refusing to act upon the endorsement,record in writing the reasons for such refusal and communicate the same
to the policyholder not later than thirty days from the date of the
policyholder giving notice of such transfer or assignment.**Diagram 4:** **Provisions related to assignment of insurance policies****Commonly extended privileges to policyholders**a) **Duplicate Policy:**A life insurance policy document is only an evidence of a promise. Loss or
destruction of the policy document does not in any way absolve the company of
its liability under the contract. Life insurance companies generally have
standard procedures to be followed in case of loss of the policy document.Normally the office would examine the case to see if there is any reason to doubt
the alleged loss. Satisfactory proof may need to be produced that the policy has
been lost and not dealt with in any manner. Generally the claim may be settled
on the claimant furnishing an indemnity bond with or without surety.If payment is shortly due and the amount to be paid is high, the office may also
insist that an advertisement be placed in a national paper with wide circulation,
reporting the loss. A duplicate policy may be issued on being sure that there is
no objection from anyone else.b) **Alteration**Policyholders may seek to effect alterations in policy terms and conditions.
There is provision to make such changes subject to consent of both the insurer
and assured. Normally alterations may not be permitted during the first year of62the policy, except for change in the mode of premium or alterations which are
of a compulsory nature – like change in name or/ address;
readmission of age in case it is proved higher or lower;
request for grant of double accident benefit or permanent disabilitybenefit etc.Alterations may be permitted in subsequent years. Some of these alterations
may be affected by placing a suitable endorsement on the policy or on a separate
paper. Other alterations, which require a material change in policy conditions,
may require the cancellation of existing policies and issue of new policies.Some of the main types of alterations that are permitted arei. Change in certain classes of insurance or term [where risk is not increased]
ii. Reduction in the sum assured
iii. Change in the mode of payment of premium
iv. Change in the date of commencement of the policy
v. Splitting up of the policy into two or more policies
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no objection from anyone else.b) **Alteration**Policyholders may seek to effect alterations in policy terms and conditions.
There is provision to make such changes subject to consent of both the insurer
and assured. Normally alterations may not be permitted during the first year of62the policy, except for change in the mode of premium or alterations which are
of a compulsory nature – like change in name or/ address;
readmission of age in case it is proved higher or lower;
request for grant of double accident benefit or permanent disabilitybenefit etc.Alterations may be permitted in subsequent years. Some of these alterations
may be affected by placing a suitable endorsement on the policy or on a separate
paper. Other alterations, which require a material change in policy conditions,
may require the cancellation of existing policies and issue of new policies.Some of the main types of alterations that are permitted arei. Change in certain classes of insurance or term [where risk is not increased]
ii. Reduction in the sum assured
iii. Change in the mode of payment of premium
iv. Change in the date of commencement of the policy
v. Splitting up of the policy into two or more policies
vi. Removal of an extra premium or restrictive clause
vii. Change from without profits to with profits plan
viii. Correction in name
ix. Settlement option for payment of claim and grant of double accident benefitThese alterations generally do not involve an increase in the risk. There are
other alterations in policies that are not allowed. These may be alterations that
have the effect of lowering the premium. Examples are extension of the
premium paying term; change from with profit to without profit plans; change
from one class of insurance to another, where it increases the risk: and increase
in the sum assured.**Test Yourself 2**Under what circumstances would the policyholder need to appoint an appointee?I. Insured is minorII. Nominee is a minor
III. Policyholder is not of sound mind
IV. Policyholder is not married**Summary**Matters of health, habits and occupation, income and family details need to be
mentioned by the agent in the agent’s report.Details pertaining to physical features like height, weight, blood pressure,
cardiac status etc. are recorded and mentioned by the doctor in his/ her report
called the medical examiner’s report.Moral hazard is the likelihood that a client's behaviour might change as a result
of purchasing a life insurance policy and such a change would increase the
chance of a loss.An insurance contract commences when the life insurance company issues a first
premium receipt (FPR). The FPR is the evidence that the policy contract has
begun.63The policy document is the most important document associated with insurance.
It is the evidence of the contract between the assured and the insurancecompany.The standard policy document typically has three parts which are the policy
schedule, standard provisions and the policy’s specific provisions.The grace period clause grants the policyholder an additional period of time to
pay the premium after it has become due.Reinstatement is the process by which a life insurance company puts back into
force a policy that has either been terminated because of non-payment of
premiums or has been continued under one of the non-forfeiture provisions.A policy loan is different from an ordinary commercial loan in two respects,
firstly the policy owner is not legally obligated to repay the loan and the insurer
need not perform a credit check on the insured.Nomination is where the life assured proposes the name of the person(s) to
which the sum assured should be paid by the insurance company after their
death.The assignment of a life insurance policy implies the act of transferring the
rights right, title and interest in the policy (as property) from one person to
another. The person who transfers the rights is called assignor and the person
to whom property is transferred is called assignee.Alteration is subject to consent of both the insurer and assured. Normally
alterations may not be permitted during the first year of the policy, except for
some simple ones.**Key Terms**1. Agents Confidential Report
2. Medical Examiner’s Report
3. Moral Hazard Report
4. First Premium Receipt (FPR)
5. Policy document
6. Policy schedule
7. Standard provisions
8. Special Provisions
9. Grace period
10. Policy lapse
11. Policy revival
12. Surrender value13. Nomination
14. Assignment**Answers to Test Yourself****Answer 1** - The correct option is II.**Answer 2** - The correct option is II.64## CHAPTER L-08## LIFE INSURANCE UNDERWRITING**Chapter Introduction**A life insurance agent’s work does not stop once a proposal is secured from a
prospective customer. The proposal must also be accepted by the insurance
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death.The assignment of a life insurance policy implies the act of transferring the
rights right, title and interest in the policy (as property) from one person to
another. The person who transfers the rights is called assignor and the person
to whom property is transferred is called assignee.Alteration is subject to consent of both the insurer and assured. Normally
alterations may not be permitted during the first year of the policy, except for
some simple ones.**Key Terms**1. Agents Confidential Report
2. Medical Examiner’s Report
3. Moral Hazard Report
4. First Premium Receipt (FPR)
5. Policy document
6. Policy schedule
7. Standard provisions
8. Special Provisions
9. Grace period
10. Policy lapse
11. Policy revival
12. Surrender value13. Nomination
14. Assignment**Answers to Test Yourself****Answer 1** - The correct option is II.**Answer 2** - The correct option is II.64## CHAPTER L-08## LIFE INSURANCE UNDERWRITING**Chapter Introduction**A life insurance agent’s work does not stop once a proposal is secured from a
prospective customer. The proposal must also be accepted by the insurance
company and result in a policy.Every life insurance proposal has to pass through a gateway where the life insurer
decides whether to accept the proposal and if so, on what terms. In this chapter we
shall know more about the process of underwriting and the elements involved in theprocess.**Learning Outcomes**65**A.** **Underwriting – Basic concepts****1.** **Underwriting purpose**Underwriting has two purposesi. To assess the risk, classify the risk and decide the terms of acceptance or todecline the risk.
ii. To prevent anti-selection against the insurer**Definition**The term **underwriting** refers to the process of evaluating each proposal for life
insurance in terms of the degree of risk it represents and then deciding whether or
not to grant insurance and on what terms.**Anti-selection** is the tendency of people, who suspect or know that their chance of
experiencing a loss is high, to seek out insurance with a view to gain in the process.**Example**If life insurers were to be not selective about whom they offered insurance, there
is a chance that people with serious ailments like heart problems or cancer, who
did not expect to live long, would seek to buy insurance.In other words, if an insurer did not exercise underwriting discretion, it would be
selected against and may suffer losses in the process.**2.** **Equity among risks**The term “Equity” means that applicants who are exposed to similar degrees of risk
must be placed in the same premium class. The Mortality table, used to determine
premiums, represents the mortality experience of standard lives or average risks.
They include the vast majority of individuals who propose to take life insurance.**a)** **Risk classification**To usher equity, the underwriter engages in a process known as **risk classification**
i.e. individual lives are categorised and assigned to different risk classes depending
on the degree of risks they pose. There are four such risk classes.**Diagram 1:** **Risk classification**66**i.** **Standard lives**
These consist of those whose anticipated mortality corresponds to the standard
lives represented by the mortality table.**ii.** **Preferred risks**
These are the ones whose anticipated mortality is significantly lower than
standard lives and hence could be charged a lower premium.**iii.** **Substandard lives**
These are the ones whose anticipated mortality is higher than the average or
standard lives, but are still considered to be insurable. They may be accepted
for insurance with higher (or extra) premiums or subjected to certain
restrictions.**iv.** **Declined lives**
These are the ones whose impairments and anticipated extra mortality are so
great that they could not be provided insurance coverage at an affordable cost.
Sometimes an individual’s proposal may also be temporarily declined if he or
she has been exposed to a recent medical event, like an operation.**3.** **Underwriting process**Underwriting process takes place at two levels: At Field level
At Underwriting department level**a)** **Field or Primary level**Field level underwriting is also known as **primary underwriting** . It includes
information gathering by an agent or company representative to decide whether
an applicant is suitable for granting insurance coverage. The agent plays a
critical role as primary underwriter. He is in the best position to know the life
to be insured.Many insurance companies may require that agents complete a statement or a
confidential report, asking for specific information, opinion and
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Key Terms
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|
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These are the ones whose anticipated mortality is higher than the average or
standard lives, but are still considered to be insurable. They may be accepted
for insurance with higher (or extra) premiums or subjected to certain
restrictions.**iv.** **Declined lives**
These are the ones whose impairments and anticipated extra mortality are so
great that they could not be provided insurance coverage at an affordable cost.
Sometimes an individual’s proposal may also be temporarily declined if he or
she has been exposed to a recent medical event, like an operation.**3.** **Underwriting process**Underwriting process takes place at two levels: At Field level
At Underwriting department level**a)** **Field or Primary level**Field level underwriting is also known as **primary underwriting** . It includes
information gathering by an agent or company representative to decide whether
an applicant is suitable for granting insurance coverage. The agent plays a
critical role as primary underwriter. He is in the best position to know the life
to be insured.Many insurance companies may require that agents complete a statement or a
confidential report, asking for specific information, opinion and
recommendations to be provided by the agent with respect to the proposed life.**Fraud monitoring and role of agent as primary underwriter**Much of the decision with regard to acceptance of a risk depends on the facts
that have been disclosed by the proposer in the proposal form. It may be difficult
for an underwriter who is sitting in the underwriting department to know
whether these facts are untrue and have been fraudulently misrepresented with
deliberate intent to deceive.The agent plays a significant role here. He or she is in the best position to ensure
that the facts that have been represented are true, due to his/ her direct and
personal contact with the proposed life.67**b)** **Underwriting at the Department level**The main level of Underwriting is at the Department or Office level. It involves
specialists and persons who consider all the relevant data on the case to decide
whether to accept a proposal for Life insurance and on what terms.**4.** **Methods of underwriting****Diagram 2:** **Methods of Underwriting**Underwriters may use two types of methods for the purpose:|Judgment Method|Numerical Method|
|---|---|
|~~Under~~<br>~~this~~<br>~~method~~<br>subjective judgment is used,<br>especially when deciding on<br>a case that is complex.<br>|~~Under this method underwriters assign positive~~<br>rating points for all negative or adverse factors<br>(negative points for any positive or favourable<br>factors).<br>|
|~~**Example:**Deciding whether~~<br>life insurance can be given to<br>a <br>person<br>staying<br>in<br>a <br>disturbed country/ area.<br>|~~**Example:** A person with history of cardiac~~<br>ailments and/ or early deaths in the family may<br>be assigned positive points. The total number of<br>points so assigned will help an underwriter in<br>deciding the extent of risk involved.<br>|
|~~In such situations, the~~<br>department may get the<br>expert opinion of a medical<br>doctor who is also called a<br>medical referee.|~~The sum total of these positive/negative points,~~<br>and/or is referred to as Extra Mortality Rating<br>(EMR). Higher EMR indicates that the life is<br>substandard.<br>If<br>the<br>EMR<br>is<br>very<br>high,<br>underwriters may decline insurance.|**Underwriting Decisions**Let us now consider the various kinds of decisions that underwriters may take with
regard to a life proposed for underwriting.**a)** **Acceptance at ordinary rates (OR)** is the most common decision. This ratingindicates that the risk is accepted at the same rate of premium as would
apply to an ordinary or standard life.68**Diagram 3:** **Underwriting decisions****b)** **Acceptance with an extra:** This is the most common way of dealing with thelarge majority of sub-standard risks. It involves charging an extra over the
tabular rate of premium.**c)** **Acceptance with a lien on the sum assured:** A lien is a kind of hold whichthe life insurance company can exercise (in part or whole) on the amount of
benefit it has to pay in the event of a claim.
**Example: Consider the case of an insured who** has suffered and recovered
from a certain disease like TB. Imposition of Lien would imply that if this
person were to die from a relapse of the TB, within a given period, only a
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Declined lives
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|
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regard to a life proposed for underwriting.**a)** **Acceptance at ordinary rates (OR)** is the most common decision. This ratingindicates that the risk is accepted at the same rate of premium as would
apply to an ordinary or standard life.68**Diagram 3:** **Underwriting decisions****b)** **Acceptance with an extra:** This is the most common way of dealing with thelarge majority of sub-standard risks. It involves charging an extra over the
tabular rate of premium.**c)** **Acceptance with a lien on the sum assured:** A lien is a kind of hold whichthe life insurance company can exercise (in part or whole) on the amount of
benefit it has to pay in the event of a claim.
**Example: Consider the case of an insured who** has suffered and recovered
from a certain disease like TB. Imposition of Lien would imply that if this
person were to die from a relapse of the TB, within a given period, only a
decreased amount of death benefit may be payable.**d)** **Acceptance with a restrictive clause:** For certain kinds of hazards arestrictive clause may be applied which limits death benefit in the event of
death under certain circumstances.**Example** is a pregnancy clause imposed on pregnant ladies that limits
insurance payable in the event of pregnancy related deaths occurring within
say three months of delivery.
**e)** **Decline or postpone:** Finally, a life insurance underwriter may decide todecline or reject a proposal for insurance. This would happen when there
are certain health/ other features which are so adverse that they
considerably increase the risk.
**Example:** An individual who suffers from cancer and has little chance of
remission, would be a candidate for rejection,Similarly in some cases it may be prudent to postpone acceptance of the risk
until such time as the situation has improved and become more favourable.69**Example**A lady who has just had a hysterectomy operation may be asked to wait for a few
months before insurance on her life is allowed, to allow any post operation
complications that may have arisen to disappear.**Test Yourself 1**Which of the following cases is likely to be declined or postponed by a life insurer?I. A healthy 18 year old
II. A sports person
III. A person suffering from AIDS
IV. A housewife with no income of her own**B.** **Non-medical underwriting****1.** **Non-medical underwriting**A large number of life insurance proposals may typically get selected for insurance
without conducting a medical examination to check the insurability of a life to be
insured. Such cases are termed as **non-medical proposals** .In view of multiple reasons including the costs involved, in some types of policies,
Life insurers grant insurance without insisting on a medical examination**2.** **Conditions for non-medical underwriting**However non-medical underwriting calls for conditions like applicability to certain
class of lives, certain plans of insurance, certain upper limits of sum insured, entry
age limits, maximum term of insurance etc.to be followed.
**3.** **Rating factors in underwriting**Rating factors refer to various aspects related to financial situation, life style,
habits, family history, personal history of health and other personal circumstances
in the prospective insured’s life that may pose a hazard and increase the risk.
Underwriting involves identifying these hazards and their likely impact and
classifying the risk accordingly.Rating factors may be broadly divided into two – those which contribute to moral
hazard and those which contribute to physical [medical] hazards. Life insurance
companies often divide their underwriting into categories accordingly. Factors like
income, occupation, lifestyle and habits, which contribute to moral hazard, are
assessed as part of **financial underwriting**, while medical aspects of health fall
under **medical underwriting** .**a)** **Female insurance**Women generally have greater longevity than men. However they may face some
problems with respect to moral hazard. This is because many women in Indian
society are victims of male domination and social exploitation. Evils like dowry
deaths exist even today. Longevity of women can also be affected from problems
connected with pregnancy.70Insurability of women is governed by need for insurance and capacity to pay
premiums. Insurance companies may thus decide to grant full insurance only to
those who have earned income of their own and may impose limits on other
categories of women. Similarly some conditions may be levied on pregnantwomen.**b)** **Minors**
Minors have no contracting power of their own. Hence a proposal on the life of
a minor has to be submitted by another person who is related to the minor in
the capacity of a parent or legal guardian. It would also be necessary to ascertain
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Acceptance at ordinary rates (OR)
|
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companies often divide their underwriting into categories accordingly. Factors like
income, occupation, lifestyle and habits, which contribute to moral hazard, are
assessed as part of **financial underwriting**, while medical aspects of health fall
under **medical underwriting** .**a)** **Female insurance**Women generally have greater longevity than men. However they may face some
problems with respect to moral hazard. This is because many women in Indian
society are victims of male domination and social exploitation. Evils like dowry
deaths exist even today. Longevity of women can also be affected from problems
connected with pregnancy.70Insurability of women is governed by need for insurance and capacity to pay
premiums. Insurance companies may thus decide to grant full insurance only to
those who have earned income of their own and may impose limits on other
categories of women. Similarly some conditions may be levied on pregnantwomen.**b)** **Minors**
Minors have no contracting power of their own. Hence a proposal on the life of
a minor has to be submitted by another person who is related to the minor in
the capacity of a parent or legal guardian. It would also be necessary to ascertain
the need for insurance, since minors usually have no earned income of their
own. Three conditions would generally be sought when considering insurance for
minors:**i.** **Whether they have a properly developed physique**Poor physique can be a result of malnutrition or other health problems posing
grave risks.
**ii.** **Proper family history and personal history**If there are adverse indicators here, it may pose risks.
**iii.** **Whether the family is adequately insured**It is necessary to check if the family has a culture of insurance. One must be
on guard if no other member of the minor’s family has been insured. Amount
of insurance is generally linked to that of parents.
**c)** **Large sums assured**
An underwriter needs to be wary when the amount of insurance is very large
relative to annual income of the proposed insured. Generally sum assured may
be assumed to be around ten to twelve times one’s annual income. If the ratio
is much higher than this, it raises the possibility of selection against the insurer.**Example**
If an individual has an annual income of Rs. 5 lakhs and proposes for a life
insurance cover of Rs. 3 crores, it raises a cause for concern.Typically concerns can arise in such instances because of the possibility that
such a large amount of insurance is being proposed in anticipation of suicide or
as a result of expected deterioration in health. A third reason for such large
sums could be excessive misselling by the sales person.Large sums assured would also mean premiums increasing in proportion and raise
the question of whether the payment of such premiums would be continued. In
general, the premium payable should be within one third of an individual’s
annual income**d)** **Age**
Mortality risk is closely related to age. The underwriter needs to be careful when
considering insurance for people of advanced ages.**Example**
If the insurance is being proposed for the first time after age 50, there is a need
to suspect moral hazard and enquire about why such insurance was not taken
earlier.71We must also note that chances of occurrence of degenerative diseases like
diseases of the heart and kidney failure increase with age and become higher at
older ages. Life insurers may also seek for some special reports when proposals
are submitted for high sums assured/ advanced ages or a combination of both.**Example**
Examples of such reports are ECG; EEG; X-Ray of the chest and Blood Sugar test.
These tests may reveal deeper insights about the health of the proposed life
than the answers given in the proposal or an ordinary medical examination can
provide.**Examples**
When a proposal is submitted at a branch located far away from the place of
residence of the proposed insuredA medical examination is done elsewhere even when a qualified medical
examiner is available near one’s place of residence.A third case is when a proposal is made on the life of another without having
clear insurable interest, or when the nominee is not the near dependent of the
life proposed.In each such case an enquiry may be made. Finally, when the agent is related
to the life assured a moral hazard report may be called from a branch official
like the agency manager/ development officer.**e)** **Occupation**Occupational hazards can arise from three sources: Accident
Health hazard
Moral hazard**Diagram 4:** **Sources of Occupational Hazards****i.** **Accidental hazards** arise because certain kinds of jobs expose one to the
risk of accident. There is any number of jobs in this category – like circus
|
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Female insurance
|
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These tests may reveal deeper insights about the health of the proposed life
than the answers given in the proposal or an ordinary medical examination can
provide.**Examples**
When a proposal is submitted at a branch located far away from the place of
residence of the proposed insuredA medical examination is done elsewhere even when a qualified medical
examiner is available near one’s place of residence.A third case is when a proposal is made on the life of another without having
clear insurable interest, or when the nominee is not the near dependent of the
life proposed.In each such case an enquiry may be made. Finally, when the agent is related
to the life assured a moral hazard report may be called from a branch official
like the agency manager/ development officer.**e)** **Occupation**Occupational hazards can arise from three sources: Accident
Health hazard
Moral hazard**Diagram 4:** **Sources of Occupational Hazards****i.** **Accidental hazards** arise because certain kinds of jobs expose one to the
risk of accident. There is any number of jobs in this category – like circus
artistes, scaffolding workers, demolition experts and film stunt artistes.**ii.** **Health hazards** arise when the nature of the job is such as to give rise to
possibility of medical impairment. There are various kinds of health hazards.72 Some jobs like that of **rickshaw pullers** involve a lot of physical strain andimpact the respiratory system. Situations where one may be exposed to **toxic substances** like mining dustor carcinogenic substances (that cause cancer) like chemicals and nuclear
radiation. Working in **high pressure environments** like underground tunnels or deepsea, can cause acute decompression sickness. Finally, **overexposure** to certain job situations (like sitting crampedbefore a computer or working in a high noise setting) can impair
functioning of certain body parts in the longer run.**iii.** **Moral hazard** can arise when a job involves proximity or can cause
predisposition towards criminal elements or to drugs and alcohol. An example
is that of a dancer in a nightclub or an enforcer in a liquor bar or the
‘bodyguard’ of a businessman with suspected criminal links. Again the job
profiles of certain individuals like superstar entertainers may lead them to
intoxicating lifestyles, which sometimes come to tragic ends.When an occupation falls under any such hazardous category, the applicant for
insurance may need to complete an occupational questionnaire that asks for
specific details of the job, duties involved and risks exposed to. A rating may
also be imposed for occupation in the form of a flat extra (for example Rupees
two per thousand sums assured.) Such extra may be reduced or removed when
the insured’s occupation changes.**f)** **Lifestyle and habits**Lifestyle and habits are terms, covering a wide range of individual lifestyle
characteristics, which may be brought out in the agent’s confidential reports
and moral hazard reports, suggesting an exposure to risk. In particular three
features are important:**Smoking and tobacco use** : Use of tobacco is not only a risk in itself but also
contributes to increasing other medical risks. Companies charge differential
rates today for smokers and non-smokers and users of other forms of tobacco
usage like _gutkha_ and _paan masala_ .**Alcohol:** Drinking alcohol occasionally or in modest quantities is not considered
a hazard. However, long term heavy drinking can impair liver functioning, affect
the digestive system and lead to mental disorders. Alcoholism is also linked with
accidents, violence, family abuse, depression and suicides.**Substance abuse** : Substance abuse refers to the use of various kinds of
substances like drugs or narcotics, sedatives and other similar stimulants. Some
of these are even illegal and their use indicates criminal disposition and moral
hazard.73**Test Yourself 2**Which of the following is an example of moral hazard?I. Stunt artist dies while performing a stunt
II. A person drinking copious amounts of alcohol because he is insured
III. Insured defaulting on premium payments
IV. Proposer misplacing policy document**C.** **Medical underwriting****1.** **Medical underwriting**Let us now consider some of the medical factors that would influence an
underwriter’s decision. These are generally assessed through medical underwriting.
They may often call for a medical examiner’s report. Let us look at some of the
factors that are checked.**Diagram 5:** **Medical Factors that influence an Underwriter’s Decision****a)** **Family history**The impact of family history on mortality risk has been studied from three
angles.**i.** **Heredity** : Certain diseases can be transmitted from one generation to
|
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Examples
|
Final IC 38 - CA_Life - English_037
|
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accidents, violence, family abuse, depression and suicides.**Substance abuse** : Substance abuse refers to the use of various kinds of
substances like drugs or narcotics, sedatives and other similar stimulants. Some
of these are even illegal and their use indicates criminal disposition and moral
hazard.73**Test Yourself 2**Which of the following is an example of moral hazard?I. Stunt artist dies while performing a stunt
II. A person drinking copious amounts of alcohol because he is insured
III. Insured defaulting on premium payments
IV. Proposer misplacing policy document**C.** **Medical underwriting****1.** **Medical underwriting**Let us now consider some of the medical factors that would influence an
underwriter’s decision. These are generally assessed through medical underwriting.
They may often call for a medical examiner’s report. Let us look at some of the
factors that are checked.**Diagram 5:** **Medical Factors that influence an Underwriter’s Decision****a)** **Family history**The impact of family history on mortality risk has been studied from three
angles.**i.** **Heredity** : Certain diseases can be transmitted from one generation to
another, say from parents to children.**ii.** **Average longevity of the family** : When the parents have died early onaccount of certain diseases like heart trouble or cancer, it may be a pointer
that the offspring may also not live long.**iii.** **Family environment** : Thirdly, the environment in which the family lives cancause exposure to infection and other risks.Life insurers have thus to be careful when entertaining cases of individuals with
adverse family history. They may call for other reports and may impose an extra
mortality rating in such cases.74**b)** **Personal history**Personal history refers to past impairments of various systems of the human body
which the life to be insured has suffered from. The proposal form for life
insurance typically contains a set of questions which enquire whether the life to
be insured has been under treatment for any of these.The major kinds of ailments that are considered by the underwriters include
Cardiovascular diseases, diseases of the respiratory system, malignant tumours/
cancer, ailments of the renal system, impairments of the endocrine system,
diseases of the digestive system like gastric ulcers and cirrhosis of the liver and
diseases of the nervous system.**c)** **Personal characteristics**These can also be significant indicators of the tendency to disease.**i.** **Build**A person’s build consists of his height, weight, chest and girth of the abdomen.
For given age and height, there is a standard weight that has been defined and
if the weight is too high or low in relation to this standard weight, we can say
that the person is overweight or underweight.Similarly, it is expected that the chest should be expanded at least by four
centimetres in a normal person and that the abdominal girth should not be more
than one’s expanded chest.**ii.** **Blood pressure**Another indicator is a person’s blood pressure. There are two measures of this Systolic DiastolicWhen the actual readings are much higher than the normal values, we say that
the person has high blood pressure or hypertension. When it is too low, it is
termed as hypotension. The former can have serious consequences.**iii.** **Urine – Specific gravity**Finally, a reading of the specific gravity of one’s urine can indicate the balance
among various salts in the urinary system. It can indicate any malfunctioning of
the system.**d)** **Backdating:**Backdating means changing the start date of the policy to an earlier one. For
example, you bought a Life insurance policy on 1st June, 2013 but later you
think that the policy would have generated better returns if you had bought it
in April 2013. You and your insurance company agree to change the policy to
officially start it from April, 2013. In this case, you have backdated the policy.
Usually, no interest is charged if the policy is backdated by less than a month.Backdating is done for the following purposes:75(i) **Getting a lower premium based on age:** While issuing the policy, insurersconsider the nearest age of the policyholder. It means if you are 32 years
and 7 months old, the insurer will consider your age as 33 years. This nearest
age may put you in a higher premium slab. However, if you backdate the
policy by 2 months, the insurer will consider your age as 32 years and 5
months only. Now you will be paying lower premiums based on a plan for a
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Substance abuse
|
Final IC 38 - CA_Life - English_038
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the system.**d)** **Backdating:**Backdating means changing the start date of the policy to an earlier one. For
example, you bought a Life insurance policy on 1st June, 2013 but later you
think that the policy would have generated better returns if you had bought it
in April 2013. You and your insurance company agree to change the policy to
officially start it from April, 2013. In this case, you have backdated the policy.
Usually, no interest is charged if the policy is backdated by less than a month.Backdating is done for the following purposes:75(i) **Getting a lower premium based on age:** While issuing the policy, insurersconsider the nearest age of the policyholder. It means if you are 32 years
and 7 months old, the insurer will consider your age as 33 years. This nearest
age may put you in a higher premium slab. However, if you backdate the
policy by 2 months, the insurer will consider your age as 32 years and 5
months only. Now you will be paying lower premiums based on a plan for a
32-year old.(ii) **Set the timing of payment:** There are specific professions where theincome flow is not steady. In such a scenario if an individual accidently buys
a life insurance policy in its off-season then the policy can be backdated to
the period of maximum earnings. For instance, a farmer may have a
seasonal income. He would prefer to make insurance payments only after
he has received his crop proceedings. In this case, a farmer could backdate
the policy to start it in the harvest season.(iii) **To coincide with special dates:** You can backdate the policy to coincidewith your important dates, such as birthday and anniversary. It keeps easy
for you to remember your premium due date.(iv) **Early maturity claims** : Backdating reduces the tenure of a policy andfacilitates early maturity. For instance, if a 30-year life insurance cover
bought on March 2000 is backdated to April 1999, the policy would mature
on April, 2029 instead of March 2030. In case of endowment policies, this
could be beneficial as maturity benefits accrue earlier.**Test Yourself 3**Why is heredity history of importance in medical underwriting?I. Rich parents have healthy kids
II. Certain diseases can be passed on from parents to children
III. Poor parents have malnourished kids
IV. Family environment is a critical factor**Summary**To bring equity, the underwriter engages in risk classification where individual
lives are categorised and assigned to different risk classes depending on the
degree of risks they pose.Underwriting process may be said to take place at two levels: At field level and At underwriting department levelUnderwriting decisions made by underwriters include acceptance of standard
risk at standard rates or charging extra for sub-standard risks. Sometimes there
is acceptance with lien on sum assured or acceptance is based on restrictive
clauses. Where the risk is large the proposal is declined or postponed.76A large number of life insurance proposals may typically get selected for
insurance without conducting a medical examination. Such cases are termed as
non-medical proposals.Some of the rating factors for non-medical underwriting include Age Large sum assured Moral hazard etc.Some of the factors considered in medical underwriting include Family history, Heredity and personal history etc.**Key Terms**1. Underwriting
2. Standard life
3. Non-medical underwriting
4. Rating factor
5. Medical underwriting
6. Anti-selection**Answers to Test Yourself****Answer 1** - The correct option is III.**Answer 2** - The correct option is II.**Answer 3** - The correct option is II.77## CHAPTER L-09## LIFE INSURANCE CLAIMS**Chapter Introduction**This chapter explains the concept of claim and how claims are ascertained. The
chapter then explains the types of claims. In the end you will learn about the forms
to be submitted for a death claim and the safeguards in place to protect a
beneficiary from claim rejection by the insurer, provided no material information
has been suppressed by the insured.**Learning Outcomes**78**A.** **Types of claims and claims procedure****Concept of claims**The real test of an insurance company and an insurance policy comes when a policy
results into a claim. The true value of life insurance is judged by the way a claim is
settled and benefits are paid.IRDAI’s Protection of Policyholders’ Interests Regulations, 2017 prescribes that life
insurers, shall process death claims without delay and call for all requirements
|
Final IC 38 - CA_Life - English.md
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L-09
|
Backdating:
|
Final IC 38 - CA_Life - English_039
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3. Non-medical underwriting
4. Rating factor
5. Medical underwriting
6. Anti-selection**Answers to Test Yourself****Answer 1** - The correct option is III.**Answer 2** - The correct option is II.**Answer 3** - The correct option is II.77## CHAPTER L-09## LIFE INSURANCE CLAIMS**Chapter Introduction**This chapter explains the concept of claim and how claims are ascertained. The
chapter then explains the types of claims. In the end you will learn about the forms
to be submitted for a death claim and the safeguards in place to protect a
beneficiary from claim rejection by the insurer, provided no material information
has been suppressed by the insured.**Learning Outcomes**78**A.** **Types of claims and claims procedure****Concept of claims**The real test of an insurance company and an insurance policy comes when a policy
results into a claim. The true value of life insurance is judged by the way a claim is
settled and benefits are paid.IRDAI’s Protection of Policyholders’ Interests Regulations, 2017 prescribes that life
insurers, shall process death claims without delay and call for all requirements
together, within 15 days of the receipt of the death intimation.A death claim shall be paid, rejected or repudiated giving all the relevant reasons,
within 30 days from the date of receipt of all relevant papers/ clarifications.If, in the opinion of the insurer, the claim warrants investigation, it shall complete
the same expeditiously, within 90 days from the date of intimation and settle the
claim within 30 days thereafter.IRDAI specifies that in respect of Maturity clams, Survival Benefit claims and
Annuities, the Life Insurer shall initiate the claim process by sending advance
intimation, by sending post-dated cheque or by giving direct credit to the bank
account of the claimant through any electronic mode approved by RBI, so as to pay
the claim on or before the due date.**Definition**A claim is a demand that the insurer should make good the promise specified in the
contract.A claim under a life insurance contract is triggered by the happening of one or more
of the events covered under the insurance contract. While in some claims, the
contract continues, in others, the contract is terminated.Claims can be of two types:**i.** survival claims payable when the life assured is alive and**ii.** death claim**Diagram 1:** **Types of claims**While a **death claim** arises only upon the death of the life assured, **survival claims**
are payable on happening of events specified in the policy.79**Important**In all claims situations, the insurer has to ensure that the identity of the claimant
is proven and well documented as per KYC norms.**Example**Such specified events where the claims are paid to the insured.i. The insured reaching the maturity period of the policy;
ii. The insured reaching the pre-decided duration(s) under a money-backpolicy, when instalment(s) become payable; or under annuity plans.
iii. Occurrences of Critical illnesses covered under the policy (as a rider benefitor otherwise);
iv. Surrender of the policy either by the policyholder or assignee;**B.** **Ascertaining whether a claim situation has occurred****i.** **Survival claim** is payable to the insured on reaching the period of maturityor fulfilling conditions stipulated in the policy.**ii.** **Maturity claims and money-back instalment claims** are easily establishedas they are based on dates which are determined at the beginning of the
contract itself. For instance, the date of maturity and the dates when the
instalments of survival benefits may be paid under a money back policy are
clearly laid out at the time of preparing the contract.**iii.** **Surrender value payments** are different from other claim payments. Here,unlike other claims, the event is triggered by the decision of the policy
holder or assignee to cancel the contract and withdraw what is due to him
or her under the contract. There is typically a penalty for premature
withdrawal. The amount paid would be less than what would be due under
a full claim and hence would be less than what would have been due if the
full claim were to be paid.**iv.** **Critical illness** claims are ascertained based on the medical and otherrecords provided by the policyholder in support of his claim.**v.** **Annuities:** In case of annuity payments (pension plans), insured need toprovide life certificates periodically.The purpose of a critical illness benefit is to enable a policy holder to defray his/
her expenses in the event of a critical illness. If this policy were to be assigned, all
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Answers to Test Yourself
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Final IC 38 - CA_Life - English_040
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contract itself. For instance, the date of maturity and the dates when the
instalments of survival benefits may be paid under a money back policy are
clearly laid out at the time of preparing the contract.**iii.** **Surrender value payments** are different from other claim payments. Here,unlike other claims, the event is triggered by the decision of the policy
holder or assignee to cancel the contract and withdraw what is due to him
or her under the contract. There is typically a penalty for premature
withdrawal. The amount paid would be less than what would be due under
a full claim and hence would be less than what would have been due if the
full claim were to be paid.**iv.** **Critical illness** claims are ascertained based on the medical and otherrecords provided by the policyholder in support of his claim.**v.** **Annuities:** In case of annuity payments (pension plans), insured need toprovide life certificates periodically.The purpose of a critical illness benefit is to enable a policy holder to defray his/
her expenses in the event of a critical illness. If this policy were to be assigned, all
the benefits would be payable to the assignee and it would not meet the intended
purpose of the critical illness benefit. To avoid this situation, policy holders need
to be educated about the extent of benefits they may assign by way of a conditional
assignment.A **maturity or death claim** or a surrender leads to termination of the insurance
cover under the contract and no further insurance cover is available.80**Types of claims:** The following payments may occur during the policy term:
**a)** **Survival Benefit Payments**Periodical payments are made by the insurer to the insured at specified times
during the term of the policy.**I.** **Surrender of Policy**Surrender value reflects the value of investments and depends on various factors
such as sum assured, bonuses, policy term and premiums paid. Premature closing
of a life insurance policy is a voluntary termination of the policy contract. A
policy can be surrendered only if it has acquired paid-up value. The amount
payable to the insured is the **surrender value** which is usually a percentage of
the premiums paid. The actual surrender value paid to the insured is more than
the Guaranteed Surrender Value (GSV).**II.** **Rider Benefit**A payment under a rider is made by an insurance company on the occurrence of
a specified event according to the terms and conditions.
Under a **critical illness rider**, in the event of diagnosis of a critical illness, a
specified amount is paid as per terms. The illness should have been covered in
the list of critical illnesses specified by the insurance company.Under **hospital care rider**, the insurer pays the treatment costs in the event of
hospitalisation of the insured, subject to terms and conditions.The policy contract continues even after the rider payments are made.The following claim payments are made at the end of the policy term specified
in the insurance contract.**III.** **Maturity Claim**In such claims, the insurer promises to pay the insured a specified amount at
the end of the term, if the insured survives the plan’s entire term. This is known
as a **maturity claim.****i.** **Participating Plan:** The maturity claim amount payable under a participatingplan is the sum assured plus accumulated bonuses less dues such as
outstanding premium and policy loans and interests thereon.
**ii.** **Return of Premium (ROP) Plan:** In some cases premiums paid over the termperiod are returned when the policy matures.
**iii.** **Unit Linked Insurance Plan (ULIP):** In case of ULIPs, the insurer pays thefund value as the maturity claim.**iv.** **Money-back Plan:** In case of money-back policy, the insurer pays thematurity claim minus the survival benefits already paid during the term of
the policy.The insurance contact terminates after the claim is paid.**b)** **Death Claim**If the insured expires during the term of his/ her policy, accidentally or
otherwise, the insurer pays the sum assured plus accumulated bonuses, if
participating, less dues to be recovered by the insurer [like outstanding policy
loan and interest or premiums plus interest]. This is the **death claim**, which is81paid to the nominee or assignee or legal heir whatever the situation may be. A
death claim generally marks the end of the contract as a result of death.A death claim may be: Early (less than three years policy duration) or
Non-early (more than three years)The nominee or assignee or legal heir has to intimate the insurer of the cause,
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Surrender value payments
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**iii.** **Unit Linked Insurance Plan (ULIP):** In case of ULIPs, the insurer pays thefund value as the maturity claim.**iv.** **Money-back Plan:** In case of money-back policy, the insurer pays thematurity claim minus the survival benefits already paid during the term of
the policy.The insurance contact terminates after the claim is paid.**b)** **Death Claim**If the insured expires during the term of his/ her policy, accidentally or
otherwise, the insurer pays the sum assured plus accumulated bonuses, if
participating, less dues to be recovered by the insurer [like outstanding policy
loan and interest or premiums plus interest]. This is the **death claim**, which is81paid to the nominee or assignee or legal heir whatever the situation may be. A
death claim generally marks the end of the contract as a result of death.A death claim may be: Early (less than three years policy duration) or
Non-early (more than three years)The nominee or assignee or legal heir has to intimate the insurer of the cause,
date and place of death.**i.** **Forms to be submitted for death claim**Usually, the following forms are to be submitted by the beneficiary to the insurer
to facilitate processing of the claim: Claim form by nominee
Certificate of burial or cremation
Treating physician’s certificate
Hospital’s certificate
Employer’s certificate
Death certificate issued by municipal authorities etc., as proof of death
Certified court copies of police reports like First Information Report(FIR), Inquest Report, Post-Mortem Report, and Final Report - these
reports are required in case of death by accident.**Diagram 2:** **Forms to be submitted for Death Claim****ii.** **Repudiation of death claim**The death claim may be paid or repudiated. If, while processing the claim, the
insurer detects that the proposer had made any incorrect statements or had
suppressed material facts relevant to the policy, the contract would be declared
as void. All benefits under the policy are forfeited.**iii.** **Section 45: Indisputability Clause**However this penalty is subject to **Section 45** of the Insurance Act, 1938.82**Important****Section 45 states:**“No policy of life insurance shall be called in question on any ground whatsoever
after the expiry of three years from the date of the policy, i.e. from the date of
issuance of the policy or the date of commencement of risk or the date of revival
of the policy or the date of the rider to the policy, whichever is later”.**C.** **Claim Procedure for Life Insurance Policy****Although there is no laid down standard claims procedure for all insurers,**
**the IRDAI has laid down guidelines for insurers in the matter of claim**
**settlement.****Regulation 8: Claims procedure in respect of a life insurance policy**i. A life insurance policy shall state the **primary documents** which are normallyrequired to be submitted by a claimant in support of a claim.ii. A life insurance company, upon receiving a claim, shall process the claimwithout delay. Any queries or requirement of additional documents, to the
extent possible, shall be raised all at once and not in a piece-meal manner,
within a period of 15 days of the receipt of the claim.iii. As per the IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, adeath claim under a life insurance policy shall be paid, rejected or
repudiated giving all the relevant reasons, within 30 days from the date of
receipt of all relevant papers and required clarifications. However, if the
insurer needs the claim to be investigated, it shall initiate and complete the
investigation at the earliest, in any case not later than 90 days from the date
of receipt of claim intimation. The claim should be settled within 30 days of
completing the investigation.iv. Where a claim is ready for payment but the payment cannot be made due toany reasons of proper identification of the payee, the life insurer shall hold
the amount for the benefit of the payee and it shall earn interest at the rate
applicable to a savings bank account with a scheduled bank (effective from
30 days following the submission of all papers and information).v. Where there is a delay on the part of the insurer in processing a claim for areason other than the one covered by sub-regulation (iv), the life insurance
company shall pay **interest on the claim amount at a rate which is 2%**
**above the bank rate** prevalent at the beginning of the financial year in
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Unit Linked Insurance Plan (ULIP):
|
Final IC 38 - CA_Life - English_042
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repudiated giving all the relevant reasons, within 30 days from the date of
receipt of all relevant papers and required clarifications. However, if the
insurer needs the claim to be investigated, it shall initiate and complete the
investigation at the earliest, in any case not later than 90 days from the date
of receipt of claim intimation. The claim should be settled within 30 days of
completing the investigation.iv. Where a claim is ready for payment but the payment cannot be made due toany reasons of proper identification of the payee, the life insurer shall hold
the amount for the benefit of the payee and it shall earn interest at the rate
applicable to a savings bank account with a scheduled bank (effective from
30 days following the submission of all papers and information).v. Where there is a delay on the part of the insurer in processing a claim for areason other than the one covered by sub-regulation (iv), the life insurance
company shall pay **interest on the claim amount at a rate which is 2%**
**above the bank rate** prevalent at the beginning of the financial year in
which the claim is reviewed by it.**Role of an agent**An agent shall render all possible service to the nominee/ legal heir or the
beneficiary in filling up of claim forms accurately and assisting in submission of
these at the insurer’s office.83Apart from discharging obligations, goodwill is generated from such a situation
whereby there exists ample opportunity for the agent to procure business or
referrals in future from the family of the deceased.**Test Yourself 1**Which of the below statement best describes the concept of claim? Choose the most
appropriate option.I. A claim is a request that the insurer should make good the promise specified inthe contract
II. A claim is a demand that the insurer should make good the promise specified inthe contract
III. A claim is a demand that the insured should make good the commitmentspecified in the agreement
IV. A claim is a request that the insured should make good the promise specified inthe agreement**Summary**A claim is a demand that the insurer should make good the promise specified in
the contract.A claim can be survival claim or death claim. While a death claim arises only
upon the death of the life assured, survival claims can be caused by one or more
eventsFor payment of a survival claim, the insurer has to ascertain that the event has
occurred as per the conditions stipulated in the policy.The following payments may occur during the policy term:
Survival Benefit Payments
Surrender of Policy
Rider Benefit
Maturity Claim
Death ClaimSection 45 (Indisputability Clause) of the Insurance Act offers protection against
rejection of claim by the insurer on flimsy grounds provided and sets a time limit
of 3 years for the Insurer for calling a policy into question.Under the IRDAI (Protection of Policyholders Interests) Regulations, 2017, the
IRDAI has laid down regulations to safeguard/ protect the insured or beneficiary
in case of claims.**Answers to Test Yourself****Answer 1** The correct option is II.84
|
Final IC 38 - CA_Life - English.md
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Role of an agent
|
Final IC 38 - CA_Life - English_043
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## IC - 38 **INSURANCE AGENTS** **SECTION - COMMON****ACKNOWLEDGEMENT****This course is based on revised syllabus prescribed by Insurance Regulatory and**
**Development Authority of India (IRDAI) and prepared by Insurance Institute of**
**India, Mumbai.****AUTHORS/ REVIEWERS (in Alphabetical order)**Dr. R. K. Duggal
Dr. Shashidharan K. Kutty
CA P. Koteswara Rao
Dr. Pradip Sarkar
Prof. Madhuri Sharma
Dr. George E. Thomas
Prof. Archana VazeG – Block, Plot No. C-46, Bandra Kurla Complex, Bandra (E), Mumbai – 400 051.i## INSURANCE AGENTS **SECTION-COMMON** **IC - 38****Year of Edition: 2023****ALL RIGHTS RESERVED**This course material is the copyright of Insurance Institute of India (III). This course
is designed for providing academic inputs for students appearing for the
examinations of Insurance Institute of India. This course material may not be
reproduced for commercial purpose, in part or whole, without prior express written
permission of the Institute.The contents are based on prevailing best practices and not intended to give
interpretations or solutions in case of disputes, legal or otherwise.This is only an indicative study material. Please note that the questions in the
examination shall not be confined to this study material only.Published by: Secretary General, Insurance Institute of India, G- Block, Plot C-46,
Bandra Kurla Complex, Bandra (E) Mumbai – 400 051 and Printed atAny communication regarding this study material may be addressed to ctd@iii.org.in
mentioning the subject title and unique publication number mentioned on the coverpageii## PREFACEInsurance Institute of India, (the Institute) has developed this course material for
Insurance Agents based on the syllabus prescribed by Insurance Regulatory and
Development Authority of India (IRDAI). Industry experts were involved in preparingthe course material.The course provides basic knowledge of Life, General and Health insurance to
enable agents in the respective line of business to understand and appreciate their
professional career in the right perspective.The course is structured as four sections. (1) Overview - a Common section that
covers Insurance Principles, Legal Principles and Regulatory matters that Insurance
agents need to know. Separate sections are provided for those aspiring to become
(2) Life Insurance Agents, (3) General Insurance Agents and (4) Health Insurance
Agents.A set of model questions are included in the course to give students an idea of the
examination format and the types of objective questions that may be asked. The
model questions will also help them in revising what they have learnt.Insurance operates in a dynamic environment. Agents need to be up to date about
changes in the market. They should actively pursue knowledge through personal
study and participation in the in-house training programmes arranged by the
respective insurers.The Institute thanks IRDAI for entrusting this work to the Institute. The Institute
wishes all interested in studying the material a successful career in insurance
marketing.iii## CONTENTS|Chapter no.|Title|Page no.|
|---|---|---|
|**SECTION **|**COMMON CHAPTERS **|**COMMON CHAPTERS **|
|C-01|Introduction to Insurance|2|
|C-02|Core Elements of Insurance|18|
|C-03|Principles of Insurance|27|
|C-04|Features of Insurance Contracts|40|
|C-05|Underwriting and Rating|48|
|C-06|Claims Processing|56|
|C-07|Documentation|63|
|C-08|Customer Service|72|
|C-09|Grievance Redressal Mechanism|87|
|C-10|Regulatory Aspects for Insurance Agents<br>|95|iv## SECTION **AN OVERVIEW**1## CHAPTER C-01## INTRODUCTION TO INSURANCE**Chapter Introduction**This chapter aims to introduce the basics of insurance, trace its evolution and how
it works. It intends to teach how insurance provides protection against economic
|
Final IC 38 - IA_English Common.md
|
C-46
|
INSURANCE AGENTS
|
Final IC 38 - IA_English Common_000
|
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wishes all interested in studying the material a successful career in insurance
marketing.iii## CONTENTS|Chapter no.|Title|Page no.|
|---|---|---|
|**SECTION **|**COMMON CHAPTERS **|**COMMON CHAPTERS **|
|C-01|Introduction to Insurance|2|
|C-02|Core Elements of Insurance|18|
|C-03|Principles of Insurance|27|
|C-04|Features of Insurance Contracts|40|
|C-05|Underwriting and Rating|48|
|C-06|Claims Processing|56|
|C-07|Documentation|63|
|C-08|Customer Service|72|
|C-09|Grievance Redressal Mechanism|87|
|C-10|Regulatory Aspects for Insurance Agents<br>|95|iv## SECTION **AN OVERVIEW**1## CHAPTER C-01## INTRODUCTION TO INSURANCE**Chapter Introduction**This chapter aims to introduce the basics of insurance, trace its evolution and how
it works. It intends to teach how insurance provides protection against economic
losses arising as a result of unforeseen events and serves as an instrument of risktransfer.2**A.** **Insurance – History and Evolution**We live in a world of uncertainty. We hear about: Trains colliding Floods destroying entire communities Earthquakes destroying buildings Young people dying unexpectedly**Diagram 1:** **Events happening around us**Why do these events make people anxious and afraid?The reason is simple.**i.** Firstly these **events are unpredictable.** If one can anticipate and predict anevent, one can prepare for it.**ii.** Secondly, such unpredictable and untoward events are often a **cause of****economic loss and grief** .The people around can come to the aid of individuals who are affected by such
events, by having a system of sharing and mutual support. The idea of insurance is
thousands of years old. Yet, the present form of insurance, is only two or threecenturies old.**1.** **History of insurance**Insurance has existed in some form or other since 3000 BC. Many civilisations, have
practiced the concept of pooling and sharing among themselves, all the losses
suffered by some members of the community. Let us take a look at some of the
ways in which this concept was applied.3**2.** **Insurance through the ages – Some instances**|Bottomry Loans|Traders of Babylon paid extra money to their lenders to write off<br>their loans if shipment was lost or stolen.<br>Traders of Bharuch and Surat also had similar practices.|
|---|---|
|**Benevolent**<br>**Societies/**<br>**Friendly**<br>**Societies**|Greeks of 7th Cy. AD, used to pay in advance to take care of the<br>family of members who died and also the funeral expenses of the<br>member.<br>Similar practices were followed in England as well.|
|**Rhodes**|Traders of Rhodes who were sending goods by sea, were sharing<br>losses if any of them lost their goods due to jettison1.|
|**Chinese Traders**|**Chinese traders**in ancient days used to send their goods in<br>different ships, so that even if some boats sank, their loss would be<br>partial.|**3.** **Modern concepts of insurance**In India the principle of life insurance was reflected in the joint-family system.
Losses arising from the demise of a member were shared by various family
members so that each member of the family continued to feel secure.The break-up of the joint family system and emergence of the nuclear family in
the modern era, coupled with the stress of daily life has made it necessary to
evolve alternative systems for security. This highlights the importance of lifeinsurance to an individual.**i.** **Lloyds** : The origins of modern commercial insurance started at Lloyd’sCoffee House in London, where traders agreed to share losses they suffered
due to various perils at sea.**ii.** **Amicable Society for a Perpetual Assurance** founded in 1706 in London isconsidered to be the first life insurance company in the world.**4.** **History of insurance in India****a)** **India** : Modern insurance in India began in early 1800 or thereabouts, with
agencies of foreign insurers starting marine insurance business.|The Oriental Life<br>Insurance Co. Ltd|The first life insurance company to be set up in India<br>was an English company|
|---|---|
|
Final IC 38 - IA_English Common.md
|
C-01
|
CONTENTS|Chapter no.|Title|Page no.|
|
Final IC 38 - IA_English Common_001
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Losses arising from the demise of a member were shared by various family
members so that each member of the family continued to feel secure.The break-up of the joint family system and emergence of the nuclear family in
the modern era, coupled with the stress of daily life has made it necessary to
evolve alternative systems for security. This highlights the importance of lifeinsurance to an individual.**i.** **Lloyds** : The origins of modern commercial insurance started at Lloyd’sCoffee House in London, where traders agreed to share losses they suffered
due to various perils at sea.**ii.** **Amicable Society for a Perpetual Assurance** founded in 1706 in London isconsidered to be the first life insurance company in the world.**4.** **History of insurance in India****a)** **India** : Modern insurance in India began in early 1800 or thereabouts, with
agencies of foreign insurers starting marine insurance business.|The Oriental Life<br>Insurance Co. Ltd|The first life insurance company to be set up in India<br>was an English company|
|---|---|
|**Triton Insurance Co. Ltd.**|The first non-life insurer to be established in India|
|**Bombay Mutual**<br>**Assurance Society Ltd.**|The first Indian insurance company. It was formed<br>in 1870 in Mumbai|1 Jettison/ Jettisoning’ refers to throwing away some of the cargo to reduce the weight of the ship while at sea.4Many other Indian companies were set up subsequently as a result of the Swadeshi
movement at the turn of the century.**Important**a) The **Insurance Act 1938** was the first legislation to regulate the conduct ofinsurance companies in India. This Act, as amended from time to time continuesto be in force.b) Life insurance business was nationalised on 1st September 1956 and the **Life****Insurance Corporation of India (LIC)** was formed. From 1956 to 1999, the LIC
held exclusive rights to do life insurance business in India.c) In 1972, the non-life insurance business was also nationalised and the **General****Insurance Corporation of India (GIC) and its four subsidiaries** were set up.d) **The Malhotra Committee, in its report submitted in 1994, recommended**opening of the market for competitione) The Insurance market was liberalised in 2000, with the passing of the InsuranceRegulatory & Development Act, 1999 (IRDAI), which also established the
Insurance Regulatory and Development Authority of India (IRDAI) in April 2000 as
a statutory regulatory body for the insurance industry.f) An amendment of the Insurance Act in 2021, has allowed Foreign investors, tohold up to 74% of the paid up equity capital in an Indian Insurance company.
Foreign insurers can now establish branches in India to do reinsurance.**a.** **Insurance industry today (As on 30** **[th]** **September 2021)**a) There are 24 Life insurance companies operating in India. Of these, LifeInsurance Corporation (LIC) of India is a public sector company (PSU) and the
remaining 23 life insurance companies are in the private sector.b) There are 34 General Insurance companies of which 4 - National InsuranceCo. Ltd, The New India Assurance Co. Ltd., The Oriental Insurance Co. Ltd
and United India Insurance Co. Ltd. are PSU Companies dealing with all lines
of general insurance. 26 Private Companies also deal with all lines of general
insurance. 6General Insurers deal only in Health insurance. 2 are specialised
insurers - Agricultural Insurance Company [AIC] and Export Credit and
Guarantees Corporation [ECGC], both set up as Public sector entities.c) There is one Reinsurance Company – The General Insurance Corporation ofIndia [GIC Re] and 11 foreign Reinsurers that operate through branch offices.5d) The Department of Posts (called as India Post) of the Government of India,also transacts life insurance known as Postal Life Insurance. India post is
exempt from the purview of the Insurance Regulator.**Test Yourself 1**Which among the following is the regulatory body for the insurance industry in India?I. Insurance Authority of IndiaII. Insurance Regulatory and Development Authority of IndiaIII. Life Insurance Corporation of IndiaIV. General Insurance Corporation of India**How insurance works**Modern commerce was founded on the principle of ownership of property. When an
asset loses value (by loss or destruction), the owner of the asset suffers an economic
loss. This loss can be compensated from a common fund made up of small
contributions from many similar asset owners. This process of transferring the
|
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| null |
Lloyds
|
Final IC 38 - IA_English Common_002
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insurance. 6General Insurers deal only in Health insurance. 2 are specialised
insurers - Agricultural Insurance Company [AIC] and Export Credit and
Guarantees Corporation [ECGC], both set up as Public sector entities.c) There is one Reinsurance Company – The General Insurance Corporation ofIndia [GIC Re] and 11 foreign Reinsurers that operate through branch offices.5d) The Department of Posts (called as India Post) of the Government of India,also transacts life insurance known as Postal Life Insurance. India post is
exempt from the purview of the Insurance Regulator.**Test Yourself 1**Which among the following is the regulatory body for the insurance industry in India?I. Insurance Authority of IndiaII. Insurance Regulatory and Development Authority of IndiaIII. Life Insurance Corporation of IndiaIV. General Insurance Corporation of India**How insurance works**Modern commerce was founded on the principle of ownership of property. When an
asset loses value (by loss or destruction), the owner of the asset suffers an economic
loss. This loss can be compensated from a common fund made up of small
contributions from many similar asset owners. This process of transferring the
chance and consequence of a loss making event is insurance.This mechanism of pooling risks works differently in the case of death and disabilityas there is no loss/ destruction of a commercial asset.**Definition**Insurance may thus be considered as a process by which the losses of a few are
shared amongst many of those exposed to similar uncertain events/ situations.**Diagram 2:** **How insurance works**There are however some questions that need to be answered.i. Would people agree to part with their hard earned money, to create such acommon fund?ii. How could they trust that their contributions are actually being used for thedesired purpose?6iii. How would they know if they are paying too much or too little?iv. Who would take the responsibility of managing these funds and paying thosewho suffer the loss?The need for an Insurer comes as an answer to all these questions. The Insurer
assesses the risk, decides and collects the individual contributions (called premium),
pools the risks and premiums, and arranges to pay to those who suffer the loss. The
insurer must also win the trust of the individuals and the community.**1.** **Insurance is about value**a) Firstly, there must be an asset which has an economic value. The **Asset** may be:i. P **hysical** (like a car or a building) orii. N **on-physical** (like reputation, goodwill, liability to pay to someone) oriii. P **ersonal** (like one’s eyes, limbs, body and physical capabilities).b) The asset may lose its value if a certain event happens. This chance of loss iscalled as **risk** . The cause of the risk event is known as **peril** .c) There is a principle known as **pooling** . This consists of collecting numerousindividual contributions (known as premiums) from various persons. These
persons have similar assets which are exposed to similar risks. Their assets are
also referred to as ‘risks’ in many contexts.d) This pool of funds is used to compensate the few who might suffer the lossescaused by a **peril** .e) This process of pooling funds and compensating the unfortunate few is carriedout through an institution known as the **insurer** (Insurance Company).f) The insurer enters into an insurance **contract** with each person who seeks toparticipate in this mechanism of pooling. The persons who participate are known
as **insured.****2.** **Insurance reduces Risk Burden**The burden of risk refers to the costs, losses and disabilities one has to bear as a
result of being exposed to a given loss situation/ event.**Diagram 3:** **Risk burdens that one carries**There are two types of risk burdens that one carries – **primary and secondary** .7**a)** **Primary burden of risk**The **primary burden of risk** consists of losses that are actually suffered by
households (and business units), as a result of pure risk events. These losses are
often direct and measurable; and can be easily compensated for by insurance.**Example**When a factory gets destroyed by fire, the actual value of goods damaged or
destroyed can be estimated and the compensation can be paid to the owner of
the factory who has suffered the loss.Similarly, if an individual undergoes a heart surgery, the medical cost of the
same is known and compensated. In addition there may be some indirect losses.**Example**A fire may interrupt business operations and lead to loss of profits which also
can be estimated and the compensation can be paid to the one who suffers sucha loss.Someone whose scooter hits a pedestrian is liable to pay the victim the
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result of being exposed to a given loss situation/ event.**Diagram 3:** **Risk burdens that one carries**There are two types of risk burdens that one carries – **primary and secondary** .7**a)** **Primary burden of risk**The **primary burden of risk** consists of losses that are actually suffered by
households (and business units), as a result of pure risk events. These losses are
often direct and measurable; and can be easily compensated for by insurance.**Example**When a factory gets destroyed by fire, the actual value of goods damaged or
destroyed can be estimated and the compensation can be paid to the owner of
the factory who has suffered the loss.Similarly, if an individual undergoes a heart surgery, the medical cost of the
same is known and compensated. In addition there may be some indirect losses.**Example**A fire may interrupt business operations and lead to loss of profits which also
can be estimated and the compensation can be paid to the one who suffers sucha loss.Someone whose scooter hits a pedestrian is liable to pay the victim the
compensation that the Court decides.**b)** **Secondary burden of risk**Even when no such event occurs and there is no loss, the people who are exposed
to the peril carry some burden. That is, apart from the primary burden, one also
carries a secondary burden of risk.The **secondary burden of risk** consists of costs and strains that one has to bear,
even if the said event does not occur, from the mere fact that one is exposedto a loss situation.Let us understand some of these burdens:i. Firstly there is **physical and mental strain caused by fear and anxiety** . This
can cause stress and affect a person’s wellbeing.ii. Secondly when one is **uncertain about whether a loss would occur or not**,it would be prudent to keep a reserve fund to meet such an eventuality.
Such funds may be held in liquid form and yield low returns.By transferring the risk to an insurer, it becomes possible to enjoy peace of mind
and also invest one’s funds more effectively. It is precisely for these reasons thatinsurance is needed.In India, one must purchase third party insurance if he/ she owns a vehicle because
it is mandatory if one wants to drive on a public road. At the same time it would be
prudent to cover the possibility of loss of own damage to the car though it is not8mandatory. It is also compulsory to have a Personal Accident cover for the Owner
Driver.**Test Yourself 2**Which among the following is a secondary burden of risk?
I. Business interruption cost
II. Goods damaged cost
III. Setting aside reserves as a provision for meeting potential losses in the future
IV. Hospitalisation costs as a result of heart attack**B.** **The Principle of Risk Pooling**Insurance companies enter into contracts with different entities – policyholders,
who can be individuals or corporates. The benefits they pay to policyholders are
contractual obligations. Insurance contracts are meaningful only if the Insurers are
financially capable of taking over the risks and compensating for the losses, if and
when they occur. The structure arises from application of the mutuality or the
pooling principle.**Mutuality** and Diversification are two important ways to reduce risk in financial
markets. They are fundamentally different.|Diversification|Mutuality|
|---|---|
|Here the funds are spread out among<br>various assets (eggs are placed in different<br>baskets).|Under mutuality or pooling, the funds of<br>various individuals are combined (all eggs<br>are placed in one basket).|
|Funds flow from one source to many<br>destinations.|Funds flow from many sources to one.|**Diagram 4:** **Mutuality -** Mutuality (Funds flow from many sources to one)The Principle of Mutuality is what gives insurance contracts their power and
uniqueness. By paying a small contribution (the premium), an insured immediately
creates a large quantity of funds ( corpus)that is available to him/ her in the event
of a loss arising due to the insured risk. This potential corpus of money is what
makes insurance unique and without any substitutes among all financial products.9**C.** **Risk Management Techniques**One may also ask whether insurance is the right solution to all kinds of risksituations. The answer is ‘No’.Insurance is only one of the methods by which individuals may seek to manage their
risks. Here they transfer the risks they face to an insurance company. However there
are other methods of dealing with risks, which are explained below:**1.** **Risk avoidance**Reducing risk by avoiding a loss situation is known as risk avoidance. Thus one may
try to avoid activities or situations, or avoid dealing with property or persons due
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|Funds flow from one source to many<br>destinations.|Funds flow from many sources to one.|**Diagram 4:** **Mutuality -** Mutuality (Funds flow from many sources to one)The Principle of Mutuality is what gives insurance contracts their power and
uniqueness. By paying a small contribution (the premium), an insured immediately
creates a large quantity of funds ( corpus)that is available to him/ her in the event
of a loss arising due to the insured risk. This potential corpus of money is what
makes insurance unique and without any substitutes among all financial products.9**C.** **Risk Management Techniques**One may also ask whether insurance is the right solution to all kinds of risksituations. The answer is ‘No’.Insurance is only one of the methods by which individuals may seek to manage their
risks. Here they transfer the risks they face to an insurance company. However there
are other methods of dealing with risks, which are explained below:**1.** **Risk avoidance**Reducing risk by avoiding a loss situation is known as risk avoidance. Thus one may
try to avoid activities or situations, or avoid dealing with property or persons due
to which there can be an exposure.**Example**i. One may avoid certain manufacturing risks by contracting out the manufacturingto someone else.ii. One may not venture outside the house for fear of meeting with an accident ormay not travel at all for fear of falling ill when abroad.Risk avoidance is considered a negative way to handle risk. Individuals and societies
need to take some risks for doing activities for their progress. Avoiding such risk
taking activities would lead to losing the benefits from such activity.**2.** **Risk retention**One tries to manage the impact of risk and decides to bear the risk and its effects
by oneself. This is known as self-insurance.**Example**A business house may decide, based on experience about its capacity to bear small
losses upto a certain limit, to retain the risk with itself.**3.** **Risk reduction and control**This is a more practical and relevant approach than risk avoidance. It means taking
steps to lower the chance of occurrence of a loss and/ or to reduce severity of its
impact if such loss should occur.**Important**Measures to reduce the chance of occurrence of loss causing events are known as
‘ **Loss Prevention** ’. The measures to reduce the degree of loss, in case a loss
happens, are called ‘ **Loss Reduction** ’/ Loss Minimisation.Risk reduction involves reducing the frequency and/ or sizes of losses through:10**a)** **Education and training of various types of employees in proper risk****practices – e.g.** (i) participating in ‘fire drills’; (ii)wearing of seatbeltshelmets on cars.**b)** **Making Environmental changes –** like improving physical conditions - e.g. (i)installing fire alarms; (ii) spraying chemicals to kill mosquitoes to reduce
spread of Malaria.**c)** **Changes made in dangerous or hazardous operations,** while usingmachinery and equipment or in the performance of other task - e.g. (i)
wearing helmets inside construction sites; (ii) wearing gloves and face shields
while handling chemicals.**d)** **Leading a healthy lifestyle** - helps in reduce the incidence of falling ill - e.g.(i) undergoing regular medical check-ups; (ii) practicing yoga regularly.**e)** **Separation**, or spreading out various items of property into varied locationsrather than concentrating them, to reduce impact of mishap in any one
location - e.g. (i) storing large quantities of flammable substances at separate
locations; (ii) fixing fire proof doors in hazardous areas of factories.**4.** **Risk financing**This refers to the provision of funds to meet losses that may occur.**a)** **Risk retention through self-financing** involves bearing losses oneself as theyoccur. The firm assumes and finances its own risk, either through its own or
borrowed funds, this is known as **self-insurance** .**b)** **Risk retention within a bigger group:** If the risk is part of a bigger group,like a parent company, the risk can be retained within the larger group which
would finance the losses. This can be a group formed by mutual consent aswell.**c)** **Risk transfer** is an alternative to risk retention. It involves transferring theresponsibility for losses to another party.**Insurance is one of the major forms of risk transfer. Instead of facing the**
**uncertainty of many of the other forms, people prefer Insurance as it**
**provides certainty and peace of mind.****5.** **Insurance vs Assurance**Insurance is used for most General insurance contracts which provide protection
against an event that may or may not happen, and where the loss amount can
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locations; (ii) fixing fire proof doors in hazardous areas of factories.**4.** **Risk financing**This refers to the provision of funds to meet losses that may occur.**a)** **Risk retention through self-financing** involves bearing losses oneself as theyoccur. The firm assumes and finances its own risk, either through its own or
borrowed funds, this is known as **self-insurance** .**b)** **Risk retention within a bigger group:** If the risk is part of a bigger group,like a parent company, the risk can be retained within the larger group which
would finance the losses. This can be a group formed by mutual consent aswell.**c)** **Risk transfer** is an alternative to risk retention. It involves transferring theresponsibility for losses to another party.**Insurance is one of the major forms of risk transfer. Instead of facing the**
**uncertainty of many of the other forms, people prefer Insurance as it**
**provides certainty and peace of mind.****5.** **Insurance vs Assurance**Insurance is used for most General insurance contracts which provide protection
against an event that may or may not happen, and where the loss amount can
be assessed only after the event.Assurance refers to financial coverage for extended periods or until death. In
the case of life, the happening of death (the loss making event), is certain. Only
the timing is uncertain. Further, it is not possible to estimate the amount of
economic loss suffered when a person dies. The loss amount that is to be paid,11must be fixed in advance. This is why people use the term ‘Assurance’ in caseof Life insurance.**Though there are such subtle technical differences, the terms ‘Insurance’**
**and ‘Assurance’ are used interchangeably in most markets, including India.**_[One of the biggest general insurers in India carries the name – New India_
_**Assurance**_ _Company Ltd. and no life company in India is using the word_
_**‘Assurance’**_ _in its name!]_**Diagram 5:** **How insurance indemnifies the insured****Test Yourself 3**Which among the following is a method of risk transfer?
I. Bank Fixed DepositII. InsuranceIII. Equity sharesIV. Real Estate**D.** **Insurance as a tool for managing risk**The term ‘Risk’ refers not to a loss that has actually been suffered but a loss that is
likely to occur. It is thus an expected loss. The cost of this expected loss is the
product of two factors:i. The **probability** that the peril being insured against may happen, leading tothe lossii. The **severity (impact)** or the amount of loss that may be suffered as a result.12The cost of risk would increase in direct proportion with both the **probability** and
the **severity** (amount of loss). This works in different ways – (a) If the amount of
loss is very high, and the probability of its occurrence is small, the cost of the risk
would be low as such instances may be very few. (b) Even if the amount of loss is
small, if the probability of its occurrence is very high, the cost of the risk would be
high, as there would be many such occurrences. Insurance can be seen as a powerful
tool for managing one’s risk. It protects one from the financial impact of losingone’s assets/ wealth due to an insured loss.**Diagram 6:** **Considerations before opting for insurance****E.** **Considerations before opting for Insurance**When deciding whether to insure or not, one needs to evaluate the cost of
transferring the risk [the insurance premium] against the cost of bearing it oneself.
Insurance would be most required where the loss impact could be very high, but the
probability (and hence the premium), is very low. E.g. (i) the chance of an
earthquake; (ii) the chance of a ship sinking.**a)** **Do not risk a lot for a little** : A reasonable relationship must be there betweenthe cost of transferring the risk and the value derived.Would it make sense to insure an ordinary ball pen?**b)** **Do not risk more than one can afford to lose:** If the loss that can arise as aresult of an event is large enough to cause bankruptcy, retention of the risk
would not be appropriate.If a large oil refinery gets destroyed, the owners cannot afford to bear the loss.**c)** **Consider the likely outcomes of the risk carefully:** It is best to insure thoseassets for which the probability of occurrence (frequency) of a loss is low but
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transferring the risk [the insurance premium] against the cost of bearing it oneself.
Insurance would be most required where the loss impact could be very high, but the
probability (and hence the premium), is very low. E.g. (i) the chance of an
earthquake; (ii) the chance of a ship sinking.**a)** **Do not risk a lot for a little** : A reasonable relationship must be there betweenthe cost of transferring the risk and the value derived.Would it make sense to insure an ordinary ball pen?**b)** **Do not risk more than one can afford to lose:** If the loss that can arise as aresult of an event is large enough to cause bankruptcy, retention of the risk
would not be appropriate.If a large oil refinery gets destroyed, the owners cannot afford to bear the loss.**c)** **Consider the likely outcomes of the risk carefully:** It is best to insure thoseassets for which the probability of occurrence (frequency) of a loss is low but
the possible impact (severity), is high.The loss of a space satellite can be so costly that it has to be insured.13**Test Yourself 4**Which among the following scenarios needs insurance?I. The sole bread winner of a family might die untimely
II. A person may lose his wallet
III. Stock prices may fall drastically
IV. A house may lose value due to natural wear and tear**F.** **Insurance Market Players**The Insurance Companies (Insurers) are the major players in the insurance industry.
In addition to insurers, there are multiple parties who are part of the Insurance
value chain. There is the Insurance Regulator, which regulates the entire market.Intermediaries like Agents, Brokers, Banks (through Bancassurance) Insurance
Marketing Firms and Point of Sales Persons are in the field of interacting with the
prospects/ insured finding out their needs, giving them information about the
policies available for covering their needs.Surveyors and Loss Assessors/ Adjusters go into assessing claims and ancillary work.
Third Party Administrators deal with Health and Travel Insurance Claims.
Regulations provides that all intermediaries have a responsibility towards thecustomer.Agents, being intermediaries between the insurance company and the insured have
the responsibility to ensure all material information about the risk is provided bythe insured to insurer.**Important****Duty of an Insurance Agent/ Intermediary towards the Prospect (Customer)**IRDAI regulations provides that intermediaries have certain responsibilities towards
the prospect. The intermediary has a responsibility towards the insurer as well.The regulation states that where the prospect depends upon the advice of the
insurer or his agent or an insurance intermediary, such a person must advise the
prospect in a fair manner. It also says that “An insurer or its agent or other
intermediary shall provide all material information in respect of a proposed cover
to the prospect to enable the prospect to decide on the best cover that would be inhis or her interest”.If the proposal and other connected papers are not filled by the customer, a
certificate may be incorporated at the end of proposal form from the customer that
the contents of the form and documents have been fully explained to him and that
he has fully understood the importance of the proposed contract.When the customer pays the insurer towards premium, the insurer is bound to issue
a receipt. That is, even if the premium is paid in advance.14**G.** **Role of Insurance in the Society**Insurance companies play an important role in a country’s economic development.
They ensure that the wealth of the country is protected and preserved. Some of
their contributions are given below.a) Insurance is founded on the principle of Mutuality, in which the collectivepower of the community is brought together to support its unfortunate fewmembers who suffer an economic loss. There are no substitutes forinsurance.b) Insurance companies collect small amounts of premium and pool themtogether as huge funds. These funds are held and invested for the interests
of policyholders and the benefit of the community. They are not unduly
invested in speculative ventures.c) Insurance provides the benefit of protection to numerous insured - bothindividuals and enterprises –against losses caused by accidents or fortuitous
events. It preserves capital and releases it for development of business and
industry, which helps the country’s growth.d) Insurance enables investment of capital leading to commercial and industrialdevelopment. It also helps in removing the fear, worry and anxiety
associated with entrepreneurship.e) Many Banks and Financial institutions do not advance loans on propertyunless it is insured against loss or damage. Many of them insist on assigning
the policy as collateral security.f) Before accepting large complicated risks, general insurers arrange forinspection of the property by qualified engineers/ other experts. They assess
the risk and suggest risk management measures to reduce the risk and help
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their contributions are given below.a) Insurance is founded on the principle of Mutuality, in which the collectivepower of the community is brought together to support its unfortunate fewmembers who suffer an economic loss. There are no substitutes forinsurance.b) Insurance companies collect small amounts of premium and pool themtogether as huge funds. These funds are held and invested for the interests
of policyholders and the benefit of the community. They are not unduly
invested in speculative ventures.c) Insurance provides the benefit of protection to numerous insured - bothindividuals and enterprises –against losses caused by accidents or fortuitous
events. It preserves capital and releases it for development of business and
industry, which helps the country’s growth.d) Insurance enables investment of capital leading to commercial and industrialdevelopment. It also helps in removing the fear, worry and anxiety
associated with entrepreneurship.e) Many Banks and Financial institutions do not advance loans on propertyunless it is insured against loss or damage. Many of them insist on assigning
the policy as collateral security.f) Before accepting large complicated risks, general insurers arrange forinspection of the property by qualified engineers/ other experts. They assess
the risk and suggest risk management measures to reduce the risk and help
in rating.g) Insurance earns foreign exchange for the country like trade, shipping andbanking services.h) Insurers are associated with institutions engaged in fire loss prevention,cargo loss prevention, industrial safety and road safety.i) Entrepreneurs get the confidence to invest in new or relatively unknownfields with the protection offered by Insurance.**Information****Insurance and Social Security**a) Social security is an obligation of the State. Social security schemes of theState involve the use of compulsory or voluntary insurance, as a tool of social
security. The Employees State Insurance Act, 1948 provides for **Employees**
**State Insurance Corporation** to pay for the expenses of sickness,15disablement, maternity and death for industrial employees and their families,who are covered.b) Insurers play an important role in social security schemes sponsored by theGovernment such as1. PMJJBY –Pradhan Mantri Jeevan Jyoti Bima Yojana
2. PMSBY – Pradhan Mantri Suraksha Bima Yojana
3. PMFBY- Pradhan Mantri Fasal Bima Yojana
4. PMJAY – Pradhan Mantri Jan Arogya Yojana (Ayushmaan Bharat)
5. PMVVY - Pradhan Mantri Vaya Vandana Yojana – a Pension plan
6. APY - Atal Pension YojanaThese, and other Government schemes have been benefiting the Indian
society/ community.c) In addition to supporting Government schemes, the insurance industry offersinsurance covers on a commercial basis which have the ultimate objective of
providing social security. The **rural insurance schemes**, operated on a
commercial basis, are designed to provide social security to the rural families.**Test Yourself 5**Which of the following insurance schemes are sponsored by the Government of
India?I. PM Jan Arogya Yojana - Ayushmaan Bharat
II. PM Fasal Bima Yojana
III. PM Suraksha Bima Yojana
IV. All of the above**Summary**Insurance is risk transfer through risk pooling.Commercial insurance business as practiced today started at the Lloyd’s CoffeeHouse in London.An insurance arrangement involves the following: Asset,
Risk,
Peril,
Contract,
Insurer and
InsuredWhen persons having similar assets, exposed to similar risks, contribute into a
common pool of funds it is known as pooling.Apart from insurance, other risk management techniques include: Risk avoidance,16 Risk control,
Risk retention,
Risk financing and
Risk transfer- The thumb rules of insurance are: Do not risk more than one can afford to lose,
Consider the likely outcomes of the risk carefully and
Do not risk a lot for a little**Key Terms**1. Risk2. Pooling3. Asset4. Burden of risk5. Risk avoidance6. Risk control7. Risk retention8. Risk financing9. Risk transfer**Answers to Test Yourself****Answer 1** - The correct option is II.
**Answer 2** - The correct option is III.
**Answer 3** - The correct option is II.
**Answer 4** - The correct option is I.
**Answer 5** - The correct option is IV.17## CHAPTER C-02## CORE ELEMENTS OF INSURANCE**Chapter Introduction**In this chapter, we shall learn about the various key elements and principles of
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common pool of funds it is known as pooling.Apart from insurance, other risk management techniques include: Risk avoidance,16 Risk control,
Risk retention,
Risk financing and
Risk transfer- The thumb rules of insurance are: Do not risk more than one can afford to lose,
Consider the likely outcomes of the risk carefully and
Do not risk a lot for a little**Key Terms**1. Risk2. Pooling3. Asset4. Burden of risk5. Risk avoidance6. Risk control7. Risk retention8. Risk financing9. Risk transfer**Answers to Test Yourself****Answer 1** - The correct option is II.
**Answer 2** - The correct option is III.
**Answer 3** - The correct option is II.
**Answer 4** - The correct option is I.
**Answer 5** - The correct option is IV.17## CHAPTER C-02## CORE ELEMENTS OF INSURANCE**Chapter Introduction**In this chapter, we shall learn about the various key elements and principles of
insurance that govern the working of insurance.**Learning Outcomes**After studying this chapter, one should be able to:1. Understand Assets are2. Understand Risk, Hazards and Perils3. Appreciate Risk Management4. Understand Risk Pooling in insurance18**A.** **Elements of insurance**We have seen that the process of insurance has four elements Asset Risk Risk poolingLet us now look at the various elements of the insurance process in some detail.**1.** **Asset****Definition**An asset may be defined as ‘anything that confers some benefits and has aneconomic value to its owner’.An asset must have the following features: **Economic value:** An asset must have economic value. Value can arise in twoways.**a)** **Income generation** : Asset may be productive and generate income.**Example**A machine used to manufacture biscuits, or a cow that yields milk, both generate
income for their owner. A healthy worker is an asset to an organization.**b)** **Serving needs** : An asset could also add value by satisfying one or a group ofneeds.**Example**A refrigerator cools and preserves food while a car provides comfort and
convenience in transportation, similarly a body free of illness adds value to oneself
and family also. **Scarcity and Ownership**What about air and sunlight? Are they not assets? - **The answer is ‘No’.**Few things are as valuable as air and sunlight. We cannot live without them. Yet
they are not considered as assets in the economic sense of the term.There are two reasons for this: Their supply is abundant and not scarce.
They are not owned by any one individual but are freely available to all.This implies that an asset must satisfy two more conditions to qualify as such - its
scarcity and its ownership or possession by someone.19 **Insurance of assets**Insurance provides protection only against financial losses arising from unexpected
events and not natural wear and tear, of assets due to usage over time.We must note that **insurance cannot protect an asset from loss or damage** . An
earthquake will destroy a house whether it is insured or not. The insurer can only
pay a sum of money, which would reduce the economic impact of the loss.Losses can arise in the event of breach of an agreement.**Example**An exporter would lose a great deal if the importer on the other side refused to
accept the goods or defaulted on payments. **Life insurance**What about our lives? There is indeed nothing as valuable to us as our own lives and
those of our loved ones. Our lives can be seriously affected when subjected to anaccident or an illness.This can impact in two ways: Firstly there are costs of treatment of a particular disease.
Secondly there may be loss of economic earnings, both due to death or disability.These kinds of losses are covered by insurances of the person or personal lines of
insurance. Insurance is possible for anyone who has assets that have value [i.e.
which generate income or meet some needs]; the loss of which [due to fortuitous
or accidental events] cause financial loss that can be [measured in terms of money].Thus these assets are commonly referred to as subject matter of insurance in
insurance parlance.**2.** **Risk**The second element in the process of insurance is the concept of risk. Risk can be
defined as the **chance of a loss** . Risk thus refers to the likely loss or damage that
can arise on account of happening of an event. [Risk is sometimes used to refer the
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accept the goods or defaulted on payments. **Life insurance**What about our lives? There is indeed nothing as valuable to us as our own lives and
those of our loved ones. Our lives can be seriously affected when subjected to anaccident or an illness.This can impact in two ways: Firstly there are costs of treatment of a particular disease.
Secondly there may be loss of economic earnings, both due to death or disability.These kinds of losses are covered by insurances of the person or personal lines of
insurance. Insurance is possible for anyone who has assets that have value [i.e.
which generate income or meet some needs]; the loss of which [due to fortuitous
or accidental events] cause financial loss that can be [measured in terms of money].Thus these assets are commonly referred to as subject matter of insurance in
insurance parlance.**2.** **Risk**The second element in the process of insurance is the concept of risk. Risk can be
defined as the **chance of a loss** . Risk thus refers to the likely loss or damage that
can arise on account of happening of an event. [Risk is sometimes used to refer the
subject matter of insurance, as well.] One do not usually expect one’s house to burn
or one’s car to have an accident. Yet it can happen.Examples of risks are the possibility of economic loss arising from the burning of a
house or a burglary or an accident which results in the loss of a limb.This has two implications.**i.** **Firstly,** it means that that the loss may or may not happen.**ii.** **Secondly,** the event, the occurrence of which actually leads to the loss, isknown as a **peril** . It is the cause of the loss.20**Example**Examples of perils are fire, earthquakes, floods, lightning, burglary, heart attacketc.**Natural wear and tear**It is true that nothing lasts forever. Every asset has a finite lifetime during which it
is functional and yields benefits. This is a natural process and one discards or
changes one’s mobiles, washing machines and clothes when they are worn out.
Therefore losses arising out of normal wear and tear are not covered in insurance.**Exposure to risk** : Occurrence of a peril need not necessarily lead to a loss. A person
staying in Mumbai does not suffer any loss due to a flood in coastal Andhra. For loss
to happen the asset must be exposed to the peril. Exposure to risk alone is not
enough ground for insurance compensation.ExampleA fire may break out in factory premises without causing actual damage. Insurance
comes into play only if there is an actual economic (financial) loss as a result of a
peril.**Degree of Risk Exposure:**Two assets may be exposed to the same peril but the likelihood of loss or the amount
of loss may vary greatly. A vehicle carrying explosives can yield far greater loss from
fire than tanker carrying water.**3.** **Risk Management** **Extent of damage likely to be suffered**This is given by the degree of loss and its impact on an individual or business.
On this basis one may identify three types of risk events or situations: **Critical**Where losses are of such a magnitude; that may result in total loss or
bankruptcy. Losses can be critical when the accident results in significant and
severe impact, disability, damage to equipment and the environment, which
may be reversible to some extent. Critical losses would include those resulting
in serious financial losses, compelling a firm to borrow to continue operations.**Example: Critical** A fire in the plant of a large multinational company at Gurgaon destroysinventory worth Rs 1 crore. The loss is heavy but not so high as to lead to
bankruptcy.21 A torpedo from a pirate ship sinks an entire passenger ship but most passengersare saved. A major accident resulting in a kidney damage necessitating a kidney transplantoperation entailing prohibitive costs. **Catastrophic**Catastrophic losses signify death or total disability for a large number of people,
widespread loss of assets, having significant environmental impact which are
practically irreversible. Catastrophic losses usually signify disasters that are
sudden, widespread and unstoppable.**Example: Catastrophic** An earthquake or flood that completely destroys a few villages
A major fire that completely destroys a multi crore installation over a largeterritory
The terrorist attack of 9/ 11 on World Trade Centre which caused injuries to alarge number of people
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Life insurance
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Final IC 38 - IA_English Common_010
|
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may be reversible to some extent. Critical losses would include those resulting
in serious financial losses, compelling a firm to borrow to continue operations.**Example: Critical** A fire in the plant of a large multinational company at Gurgaon destroysinventory worth Rs 1 crore. The loss is heavy but not so high as to lead to
bankruptcy.21 A torpedo from a pirate ship sinks an entire passenger ship but most passengersare saved. A major accident resulting in a kidney damage necessitating a kidney transplantoperation entailing prohibitive costs. **Catastrophic**Catastrophic losses signify death or total disability for a large number of people,
widespread loss of assets, having significant environmental impact which are
practically irreversible. Catastrophic losses usually signify disasters that are
sudden, widespread and unstoppable.**Example: Catastrophic** An earthquake or flood that completely destroys a few villages
A major fire that completely destroys a multi crore installation over a largeterritory
The terrorist attack of 9/ 11 on World Trade Centre which caused injuries to alarge number of people
A pandemic like Covid – 19 causing disease to people across the globe. **Marginal/ Insignificant**Where the possible losses are insignificant and can be easily met from an
individual or a firm’s existing assets or current income without imposing anyundue financial strain.**Example** A minor car accident results in the side being slightly grazed due to which someof the paint is damaged and a fender is slightly bent.
An individual suffering from common cold and cough..**4.** **Hazards and Perils**The condition or conditions which increase the probability of a loss or its severity,
and thus impact(s) the risk is known as hazard. When insurers make an assessment
of the risk, it is generally with reference to the hazards to which the asset is subject.The term hazard in insurance language refers to those conditions or features or
characteristics which create or increase the chance of loss arising from a given peril.
A thorough knowledge of various hazards to which a risk is exposed to is most
essential for underwriting. Examples of the link between assets, peril and hazards
are given below.22|Asset|Peril|Hazard|
|---|---|---|
|**Life**|Cancer|Excessive Smoking|
|**Factory**|Fire|Explosive material left Unattended|
|**Car**|Car Accident|Careless driving by driver|
|**Cargo**|Storm|Water seeping in cargo and spoiling; Cargo not packaged in<br>waterproof containers|**Important** **Types of hazards****a)** **Physical hazard** is a physical condition that increases the chance of loss.**Example**i. Defective wiring in a building
ii. Indulging in water sports
iii. Leading a sedentary lifestyle**b)** **Moral hazard** refers to dishonesty or character defects in an individual thatinfluence the frequency or severity of the loss. A dishonest individual may
attempt to commit fraud and make money by misusing the facility of insurance.**Example**If one deliberately sets a fire to one’s property and collects claims against losses
under the policy, such claims are clearly fraudulent and could be justifiably rejectedA classic instance of moral hazard is purchasing insurance for a factory and then
burning it down to collect the insurance amount or buying health insurance after
onset of a major ailment.**c)** **Legal hazard** is more prevalent in cases involving a liability to pay for damages.It arises when certain features of the legal system or regulatory environment
can increase the incidence or severity of losses.**Example**The enactment of law governing workmen’s compensation in the case of accidents
can raise the amount of liability payable considerably.A major concern in insurance is the relationship between risks and associated
hazards. Assets are classified into various risk categories on this basis and the price[premiums] charged for insurance coverage would increase if the susceptibility to
loss, arising as a result of the presence of associated hazards, is high.23**5.** **Mathematical Principle of Insurance (Risk pooling)**The third element in insurance is a mathematical principle that makes insurance
possible. It is known as the principle of risk pooling.**Example**Suppose there are 100000 RCC houses exposed to the risk of fire that can cause an
average loss of Rs. 50000. If the chance of a house catching fire is 2 in 1000 [or 2/
1000 = 0.002] it would mean that the total amount of loss suffered would be Rs
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Example: Critical
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Final IC 38 - IA_English Common_011
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onset of a major ailment.**c)** **Legal hazard** is more prevalent in cases involving a liability to pay for damages.It arises when certain features of the legal system or regulatory environment
can increase the incidence or severity of losses.**Example**The enactment of law governing workmen’s compensation in the case of accidents
can raise the amount of liability payable considerably.A major concern in insurance is the relationship between risks and associated
hazards. Assets are classified into various risk categories on this basis and the price[premiums] charged for insurance coverage would increase if the susceptibility to
loss, arising as a result of the presence of associated hazards, is high.23**5.** **Mathematical Principle of Insurance (Risk pooling)**The third element in insurance is a mathematical principle that makes insurance
possible. It is known as the principle of risk pooling.**Example**Suppose there are 100000 RCC houses exposed to the risk of fire that can cause an
average loss of Rs. 50000. If the chance of a house catching fire is 2 in 1000 [or 2/
1000 = 0.002] it would mean that the total amount of loss suffered would be Rs
10000000 [= 50000x 0.002 x 100000].If an insurer were to get the owners of each of the 100000 houses to contribute Rs
100 and if these contributions (100000 x 100 = Rs.10000000) were to be pooled into
a single fund, it would be enough to pay for the loss of the unfortunate few whosuffered from the fire.To ensure that there is equity [fairness] among all those being insured, it is
necessary that the houses should all be similarly exposed to the risk. In the above
example risk exposure to mud houses will be different.**a)** **How exactly does the principle work in insurance?**It is by pooling number of risks of all the insured similarly placed and exposed
to possibility of loss due to a peril that the insurer is able to assume that risk
and its financial impact.|Large<br>number<br>of people|Paying<br>Premium|Premium|Paying Claims to a<br>few who suffered<br>loss|
|---|---|---|---|
|**Many**<br>**people**<br>**pay**|**Small**<br>**amounts of**<br>**money as**<br>**Premiums**|**These small amounts are pooled**<br>**together as a Common Pool, big**<br>**enough to pay a statistically**<br>**estimated number of claims**|**Big amounts are**<br>**paid to those who**<br>**suffer a loss**|**b)** **Risk pooling and the law of large numbers**The probability of damage [derived as 2 out of 1000 or 0.002 in the example
above] forms the basis on which the premium is determined. The insurer would
face no risk of loss if the actual experience was as expected. In such a situation
the premiums of the numerous insured would be sufficient to completely
compensate for the losses of those who have been affected by the peril. The
insurer would however face a risk if the actual experience was more adverse
than expected and the premiums collected were not sufficient to pay the claims.How can the insurer be sure about its predictions? This becomes possible because
of a principle known as the “Law of large numbers”. It states that the larger the
size of the pool of risks, the actual average of losses would be closer to the
estimated or expected average loss.24**c)** **Insurance Companies to remain Solvent:**If the pools of risks and the premium pools created are not sufficient to meet
the liabilities towards paying claims (in case they occur), the system of risk
pooling and insurance may fail. Insurers need to have sufficient money with
them to honour their promises to all the members of the pool. If they have the
sufficient money, they are considered solvent and if they do not have money to
meet their obligations, they become insolvent.In other words, Insurers need to keep with them some surplus money (or solvency
margin) to meet unforeseen deviations between expected and actual claims
situations. Solvency Ratio assesses the extent to which assets are available to
cover the insurers’ commitments towards future payments. Different countries
use different measures to assess Solvency Ratio. In India, IRDAI has mandated
that insurers are required to maintain a minimum solvency ratio of 1.5.**Example**To give a simple illustration, the probability of getting heads on a toss of the coin
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Legal hazard
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Final IC 38 - IA_English Common_012
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size of the pool of risks, the actual average of losses would be closer to the
estimated or expected average loss.24**c)** **Insurance Companies to remain Solvent:**If the pools of risks and the premium pools created are not sufficient to meet
the liabilities towards paying claims (in case they occur), the system of risk
pooling and insurance may fail. Insurers need to have sufficient money with
them to honour their promises to all the members of the pool. If they have the
sufficient money, they are considered solvent and if they do not have money to
meet their obligations, they become insolvent.In other words, Insurers need to keep with them some surplus money (or solvency
margin) to meet unforeseen deviations between expected and actual claims
situations. Solvency Ratio assesses the extent to which assets are available to
cover the insurers’ commitments towards future payments. Different countries
use different measures to assess Solvency Ratio. In India, IRDAI has mandated
that insurers are required to maintain a minimum solvency ratio of 1.5.**Example**To give a simple illustration, the probability of getting heads on a toss of the coin
is 1 out of 2. But one cannot be sure to actually get 2 heads if a coin is tossed fourtimes.Only when the number of tosses gets very large and closer to infinity, the chance of
getting heads once for every two tosses will become closer to one.It follows that insurers can be sure of their ground only when they have been able
to insure a large number of insured. An insurer who has insured only a few hundred
houses, likely would be worse affected than one who has insured several thousandhouses.**Important****Conditions for insuring a risk**When does it make sense to insure a risk from the insurer’s point of view?Six broad requirements for a risk to be considered insurable are given below.**i.** **A sufficiently large number of homogenously [similar] exposed units** to makethe losses reasonably predictable. This follows from the **law of large numbers** .
Without this it would be difficult to make predictions.**ii.** **Loss produced by the risk must be definite and measurable** . It is difficult todecide the compensation if one cannot say for sure that a loss has occurred andhow much it is.**iii.** **Loss must be fortuitous or accidental** . It must be the result of an event thatmay or may not happen. The event must be beyond the control of insured. No
insurer would cover a loss that is intentionally caused by the insured.25**iv.** **Sharing of losses of the few by many** can work only if a small percentage of theinsured group suffers loss at any given period of time.**v.** **Economic feasibility:** The cost of insurance must not be high in relation to thepossible loss; otherwise the insurance would be economically unviable.**vi.** **Public policy:** Finally the contract should not be contrary to public policy andmorality.**Test Yourself 1**Which one of the following does not represent an insurable risk?I. FireII. Stolen goods
III. Burglary
IV. Loss of goods due to ship capsizing**Summary**a) The process of insurance has four elements (asset, risk, risk pooling and aninsurance contract).b) An asset may be anything that confers some benefit and is of economic value toits owner.c) A chance of loss represents risk.d) Condition or conditions that increase the probability or severity of the loss arereferred to as hazards.e) The mathematical principle, that makes insurance possible is known as principleof risk pooling.**Key terms**a) Asset
b) Risk
c) Hazard
d) Risk pooling
e) Offer and acceptance
f) Lawful consideration**Answers to Test Yourself****Answer 1** - The correct option is II.26## CHAPTER C-03## PRINCIPLES OF INSURANCE**Chapter Introduction**In this chapter, we discuss the principles, based on which the mechanism ofinsurance works.a) Utmost Good Faith or "Uberrima fides" is defined as involving “a positive duty
to voluntarily disclose, accurately and fully, all facts material to the risk being
proposed, whether requested or not". All insurance contracts are based on the
principle of Uberrima Fidesb) The existence of ‘Insurable Interest’ is an essential ingredient of every
insurance contract and is considered as the legal pre-requisite for insurance.c) Indemnity ensures that the insured is compensated to the extent of his loss on
the occurrence of the contingent event.d) Subrogation means the transfer of all rights and remedies, with respect to the
subject matter of insurance, from the insured to the insurer.e) The principle of contribution implies that if the same property is insured with
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Final IC 38 - IA_English Common.md
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C-03
|
Insurance Companies to remain Solvent:
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Final IC 38 - IA_English Common_013
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b) Risk
c) Hazard
d) Risk pooling
e) Offer and acceptance
f) Lawful consideration**Answers to Test Yourself****Answer 1** - The correct option is II.26## CHAPTER C-03## PRINCIPLES OF INSURANCE**Chapter Introduction**In this chapter, we discuss the principles, based on which the mechanism ofinsurance works.a) Utmost Good Faith or "Uberrima fides" is defined as involving “a positive duty
to voluntarily disclose, accurately and fully, all facts material to the risk being
proposed, whether requested or not". All insurance contracts are based on the
principle of Uberrima Fidesb) The existence of ‘Insurable Interest’ is an essential ingredient of every
insurance contract and is considered as the legal pre-requisite for insurance.c) Indemnity ensures that the insured is compensated to the extent of his loss on
the occurrence of the contingent event.d) Subrogation means the transfer of all rights and remedies, with respect to the
subject matter of insurance, from the insured to the insurer.e) The principle of contribution implies that if the same property is insured with
more than one insurance company, the compensation paid by all the insurers
together cannot exceed the actual loss suffered.f) Proximate cause is a key principle of insurance and is concerned with how the
loss or damage actually occurred and whether it is indeed as a result of an
insured peril.27**A.** **Uberrima Fides**Insurance contracts have various special features that are discussed below:**1.** **Utmost Good Faith or** _**‘Uberrima Fides’**_Utmost Good Faith or "Uberrima fides", one of the fundamental principles of an
insurance contract, is defined as “a positive duty to voluntarily disclose, accurately
and fully, all facts material to the risk being proposed, whether requested or not".All commercial contracts are based on Good Faith in so much as there shall be nofraud or deceit when giving information or doing the transaction. The rule observed
here is that of **“Caveat Emptor”** which means **Buyer Beware** . The parties to the
contract are expected to examine the subject matter of the contract and so long as
one party does not mislead the other and the answers are given truthfully, there is
no question of the other party avoiding the contract.Insurance contracts stand on a different footing as the subject matter of the
contract is intangible and cannot be easily known to the insurer. Again, there are
many facts, which may be known only to the proposer. The insurer has to rely
entirely on the proposer for information. Hence the proposer has a legal duty to
disclose all material information about the subject matter of insurance to the
insurers. That is, the insured should not make any misrepresentation regarding any
fact that is material for the insurance contract. This higher obligation of full
representation and full disclosure in respect of Insurance contracts makes themcontracts of Utmost Good Faith.**If Utmost Good Faith is not observed by either party, the contract may be**
**avoided by the other.** This follows from the logic that no one should be allowed to
take advantage of his own wrong especially while entering into a contract ofinsurance.**a)** **Material fact** has been defined as a fact that would affect the judgment of aninsurance underwriter in deciding whether to accept the risk and if so, the rate
of premium and the terms and conditions. The insured has an obligation to fully
and accurately disclose all facts that are material to an insurance contract.Whether an undisclosed fact was material or not would depend on the
circumstances of the individual case and could be decided ultimately only in a
court of law. The insured **has to disclose** facts that affect the risk.Material facts denote the information which enables the insurers to decide: Whether they will accept the risk? If so, at what rate of premium and subject to what terms and conditions?This legal duty of utmost good faith arises under common law. The duty applies
not only to material facts which the proposer knows, but also extends to material28facts which he ought to know. There is a corresponding duty of the insurer not to
withhold any information about the policy to the insured.**Example**The following are some examples of material information that the proposer should
disclose while making a proposal:**i.** **Life Insurance:** One’s own medical history, family history of hereditaryillnesses, habits like smoking and drinking, absence from work, age, hobbies,
financial information like income details of proposer, pre-existing life
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C-03
|
Answers to Test Yourself
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Final IC 38 - IA_English Common_014
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of premium and the terms and conditions. The insured has an obligation to fully
and accurately disclose all facts that are material to an insurance contract.Whether an undisclosed fact was material or not would depend on the
circumstances of the individual case and could be decided ultimately only in a
court of law. The insured **has to disclose** facts that affect the risk.Material facts denote the information which enables the insurers to decide: Whether they will accept the risk? If so, at what rate of premium and subject to what terms and conditions?This legal duty of utmost good faith arises under common law. The duty applies
not only to material facts which the proposer knows, but also extends to material28facts which he ought to know. There is a corresponding duty of the insurer not to
withhold any information about the policy to the insured.**Example**The following are some examples of material information that the proposer should
disclose while making a proposal:**i.** **Life Insurance:** One’s own medical history, family history of hereditaryillnesses, habits like smoking and drinking, absence from work, age, hobbies,
financial information like income details of proposer, pre-existing life
insurance policies, occupation etc.**ii.** **Fire Insurance:** Construction, location/ situation of risk and usage ofbuilding, age of the building, nature of goods in premises etc.**iii.** **Marine Insurance:** Description of goods, method of packing and mode oftransit etc.**iv.** **Motor Insurance:** Description of vehicle, date of purchase and RegionalRegistration authority etc.**v.** **Health Insurance:** Pre-existing disease, age etc.**b)** **When a Fact becomes ‘Material’: Some types of material facts that one** needsto disclose are those indicating that the particular risk represents a greater
exposure than can be normally expected.**Example**Hazardous nature of cargo being sent by a ship, past history of illness, past history
burglary of a house.i. Existence of policies taken from all insurers and their present statusii. All questions in the proposal form or application for insurance are consideredto be material, as these relate to various aspects of the subject matter of
insurance and its exposure to risk. They need to be answered truthfully and
be full in all respects.The following are some scenarios wherein material facts need not be disclosed.**Information**a. **Material Facts that need not be disclosed:** Unless there is a specific enquiry byunderwriters, the proposer has no obligation to disclose facts like:**i.** **Measures implemented to reduce the risk. E.g.:** The presence of a fireextinguisher**ii.** **Facts which the insured does not know or is unaware of. E.g.:** Anindividual, who had high blood pressure but was not aware about the same29at the time of taking the policy, cannot be charged with non-disclosure ofthis fact.**iii.** **Which could be discovered, by reasonable diligence.** It is not necessary todisclose every minute material fact. The underwriters must be conscious
enough to ask for the same if they require further information. E.g.: When
insuring a textile shop one does not need to specifically say that some of the
synthetic clothes in the shop are highly combustible.**iv.** **Matters of law** : Everybody is supposed to know the law of the land. **E.g.:**Municipal laws about storing of explosives**v.** **About which insurer appears to be indifferent (or has waived the need****for further information)**In such cases, the insurer cannot later disclaim responsibility on grounds that the
answers were incomplete.**b.** **Duty to Disclose:** In the case of insurance contracts, the duty to disclose ispresent throughout the entire period of negotiation until the proposal is accepted
and a Life Insurance policy is issued.Once the Life Insurance policy is accepted, there is no further need to disclose any
material facts that may come up during the term of the policy.**Example**Mr. Rajan has taken a Life insurance policy for a term of fifteen years. Six years
after taking the policy, Mr. Rajan has some heart problems and has to undergo some
surgery. Mr. Rajan does not need to disclose this fact to the insurer._[However, if the policy is in a lapsed condition because of failure to pay the_
_premiums when due and the policy holder seeks to revive the policy contract and_
_bring it back in force, he may, at the time of such revival, have the duty to disclose_
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answers were incomplete.**b.** **Duty to Disclose:** In the case of insurance contracts, the duty to disclose ispresent throughout the entire period of negotiation until the proposal is accepted
and a Life Insurance policy is issued.Once the Life Insurance policy is accepted, there is no further need to disclose any
material facts that may come up during the term of the policy.**Example**Mr. Rajan has taken a Life insurance policy for a term of fifteen years. Six years
after taking the policy, Mr. Rajan has some heart problems and has to undergo some
surgery. Mr. Rajan does not need to disclose this fact to the insurer._[However, if the policy is in a lapsed condition because of failure to pay the_
_premiums when due and the policy holder seeks to revive the policy contract and_
_bring it back in force, he may, at the time of such revival, have the duty to disclose_
_all facts that are material and relevant, as though it is a new policy.]_In the case he has Health Insurance, at the time of renewing the policy, Mr. Rajanhas to inform the insurer about this health issue.Similarly, in the case of General Insurance, at the time of renewing the Fire policy
for an enterprise/ factory, the insured has to inform the insurer if a change was
made in the occupancy of the building.At the time of renewing the Hull policy for a ship, the insured has to inform the
insurer if the ship was modified to carry a different type cargo; say, hazardous
chemicals instead of pulses.c. **Situations of Non-Disclosure** may arise when the insured is silent about materialfacts because the insurer has not raised any specific enquiry. Such situations may
also arise through evasive answers to queries raised by the insurer.30Often non-disclosure may be inadvertent (meaning that it may be made without
one’s knowledge or intention) or because the proposer thought that a fact wasnot material. In such a case it is innocent.When a fact is intentionally suppressed it is treated as concealment. Here, thereis the intent to deceive.d. **Misrepresentation:** Any statement made during negotiation of a contract ofinsurance is called representation. A representation may be a definite statement
of fact or a statement of belief, intention or expectation. It is expected that the
statement must be substantially correct. Representations that concern matters
of belief or expectation must be made in good faith. Misrepresentation is of twokinds:**i.** **Innocent Misrepresentation** relates to inaccurate statements, which aremade without any fraudulent intention.**ii.** **Fraudulent Misrepresentation** on the other hand refers to false statementsthat are made with deliberate intent to deceive the insurer or are maderecklessly without due regard for truth.An insurance contract generally becomes void when there is a clear case of
concealment with intent to deceive, or when there is fraudulent
misrepresentation.Amendments (March, 2015) to Insurance Act, 1938 have provided certain
guidelines about the conditions under which a policy can be called into question
for fraud. The new provisions are as followse. **Fraud:** The term “Fraud” has been specified under **Section 45 (2) of the****Insurance Act (amended in 2015).** Accordingly, a Life Insurance policy can be
called in question on the ground of Fraud by the insurer only within a time period
and not later. However, Insurers can do so only within three years from (a) the
date of issuance of the policy (b) the date of commencement of risk, (c) the date
of revival of the policy or (d) the date of the rider to the policy, whichever islater.The insurer needs to communicate the reasons on which the policy is questioned
in writing to the insured or his/ her legal representatives, nominees or assignees.The expression "fraud" means any act committed by the insured, with the intent
to deceive the insurer or to induce the insurer to issue an insurance policy. It is
also provided that in case the policyholder is not alive, the onus of disproving
fraud, lies upon the beneficiaries.**B.** **Insurable interest**The existence of ‘insurable interest’ is an essential ingredient of every insurance
contract and is considered as the legal pre-requisite for insurance.31**Three essential elements of insurable interest:**i. There must be property, right, interest, life or potential liability capable ofbeing insured.ii. Such property, right, interest, life or potential liability must be the subjectmatter of insurance.iii. The insured must bear a legal relationship to the subject matter such that hestands to benefit by the safety of the property, right, interest, life or freedom
|
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of revival of the policy or (d) the date of the rider to the policy, whichever islater.The insurer needs to communicate the reasons on which the policy is questioned
in writing to the insured or his/ her legal representatives, nominees or assignees.The expression "fraud" means any act committed by the insured, with the intent
to deceive the insurer or to induce the insurer to issue an insurance policy. It is
also provided that in case the policyholder is not alive, the onus of disproving
fraud, lies upon the beneficiaries.**B.** **Insurable interest**The existence of ‘insurable interest’ is an essential ingredient of every insurance
contract and is considered as the legal pre-requisite for insurance.31**Three essential elements of insurable interest:**i. There must be property, right, interest, life or potential liability capable ofbeing insured.ii. Such property, right, interest, life or potential liability must be the subjectmatter of insurance.iii. The insured must bear a legal relationship to the subject matter such that hestands to benefit by the safety of the property, right, interest, life or freedom
of liability. By the same token, he must stand to lose financially by any loss,
damage, injury or creation of liability.Let us see how insurance differs from a gambling or wager agreement.**a)** **Gambling and insurance:** Unlike a card game, where one could win or lose, afire can have only one consequence – loss to the owner of the house.The owner takes insurance to ensure that the loss suffered is compensated for
in some way.In other words, Insurable Interest is the interest the insured has in the subjectmatter of insurance. Insurable interest makes an insurance contract valid andenforceable under the law.**Example**If Mr. Patel has brought a house with a mortgage loan of Rs 15 lakhs from a bank
and he has repaid 12 lakhs of this amount, the bank’s interest would be only to the
tune of the balance three lakhs which is outstanding.Thus the bank also has an insurable interest financially in the house for the balance
amount of loan that is unpaid and would ensure that it is made a co insured in the
policyMr. Patel owns a house for which he has taken a mortgage loan of Rs. 15 lakhs from
a bank. Ponder over the questions below: Does he have an insurable interest in the house? Does the bank have an insurable interest in the house? What about his neighbour?Mr. Dass has a family consisting of spouse, two kids and old parents. Ponder over
the below questions: Does he have an insurable interest in their well-being? Does he stand to financially lose if any of them are hospitalised? What about his neighbour’s kids? Would he have an insurable interest in them?32It would be relevant here to make a distinction between the subject matter of
insurance and the subject matter of an insurance contract.**The subject matter of insurance** relates to property being insured against, whichhas an intrinsic value of its own.**The subject matter of an insurance contract** on the other hand is the insured’s
financial interest in that property. It is only when the insured has such an interest
in the property that he/ she has the legal right to insure. The insurance policy in
the strictest sense covers not the property per se, but the insured’s financial
interest in the property.**Diagram 1:** **Insurable interest according to common law****b)** **Time when insurable interest should be present:** In life insurance, insurableinterest should be present at the time of taking the policy. In general insurance,
insurable interest should be present both at the time of taking the policy and at
the time of claim with some exceptions like marine policies in which case itmust exist at the time of claim.In case of fire and accident insurance, insurable interest should be present both
at the time of taking the policy and at the time of loss.In case of health and personal accident insurance apart from self, family can
also be insured by the proposer since he/ she stands to incur financial losses if
the family meets with an accident or undergoes hospitalisation. However, in
marine cargo insurance, insurable interest is required only at the time of loss as
the ownership of the goods would change hands when the cost is paid, which
can happen during the period of transit.**C.** **Proximate Cause**Proximate cause is a key principle of insurance and is concerned with how the loss
or damage actually occurred and whether it is as a result of an insured peril. If the
loss has been caused by the insured peril, the insurer is liable. If the immediate
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insurable interest should be present both at the time of taking the policy and at
the time of claim with some exceptions like marine policies in which case itmust exist at the time of claim.In case of fire and accident insurance, insurable interest should be present both
at the time of taking the policy and at the time of loss.In case of health and personal accident insurance apart from self, family can
also be insured by the proposer since he/ she stands to incur financial losses if
the family meets with an accident or undergoes hospitalisation. However, in
marine cargo insurance, insurable interest is required only at the time of loss as
the ownership of the goods would change hands when the cost is paid, which
can happen during the period of transit.**C.** **Proximate Cause**Proximate cause is a key principle of insurance and is concerned with how the loss
or damage actually occurred and whether it is as a result of an insured peril. If the
loss has been caused by the insured peril, the insurer is liable. If the immediate
cause is an insured peril, the insurer is bound to make good the loss, otherwise he
is not. This application of principle is practically more in respect of non-lifeinsurance claims.33When a loss occurs, there can often be a series of events leading up to the incident
and so it is sometimes difficult to determine the nearest or proximate cause. Under
this rule, the insurer looks for the predominant cause which sets into motion the
chain of events producing the loss. This may not necessarily be the last event that
immediately preceded the loss i.e. it is not necessarily an event which is closest to,
or immediately responsible for causing the loss. For example, a fire might cause a
water pipe to burst. Despite the resultant loss being water damage, the fire would
still be considered the proximate cause of the incident. Other causes may be
classified as remote causes, which are separate from proximate causes. Remote
causes may be present but are not effectual in causing an event.**Definition**Proximate cause is defined as the active and efficient cause that sets in motion achain of events which brings about a result, without the intervention of any force
started and working actively from a new and independent source.How does the principle of proximate cause apply to insurance contracts? Since
insurance provides for payment of a death benefit, regardless of the cause of death,
the principle of proximate cause would not usually apply. However many insurance
contracts may also have an accident benefit add-on wherein an additional sum
assured is payable in the event of accidental death. In such a situation, it becomes
necessary to ascertain the cause - whether the death occurred as a result of an
accident. The principle of proximate cause would become applicable in suchinstances.To understand the principle of proximate cause, consider the following situation:**Example****Scenario 1:** Mr. Ajay had parked his car in the garage and gone on a long vacation.
Six months later, when he came back and started the car, he noticed that the airconditioning of the car was not working. Mr. Ajay filed a claim with the insurance
company for the cost of repairing the air-conditioning and the insurance company
rejected the claim. The reason given by the insurance company was that the damage
was due to the ‘normal wear and tear’ of the car and the air-conditioning system,
which was an excluded peril in the insurance policy. Mr Ajay approached the Court
and after examining the survey report which said that the car was 12 years old and
neither the car nor the air-conditioning had been serviced/ repaired during the
previous 6 years, the damage was due to the ‘normal wear and tear’ and the
insurance company was not liable to pay the claim.**Scenario 2:** Mr. Pinto, while riding a horse, fell on the ground and had his leg
broken, he was lying on the wet ground for a long time before he was taken to
hospital. Because of lying on the wet ground, he had fever that developed into
pneumonia, finally dying of this cause. Though pneumonia might seem to be the34immediate cause, in fact it was the accidental fall that emerged as the proximate
cause and the claim was paid under personal accident insurance.There are certain losses which are suffered by the insured as a result of fire but
which cannot be said to be proximately caused by fire. In practice, some of these
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was due to the ‘normal wear and tear’ of the car and the air-conditioning system,
which was an excluded peril in the insurance policy. Mr Ajay approached the Court
and after examining the survey report which said that the car was 12 years old and
neither the car nor the air-conditioning had been serviced/ repaired during the
previous 6 years, the damage was due to the ‘normal wear and tear’ and the
insurance company was not liable to pay the claim.**Scenario 2:** Mr. Pinto, while riding a horse, fell on the ground and had his leg
broken, he was lying on the wet ground for a long time before he was taken to
hospital. Because of lying on the wet ground, he had fever that developed into
pneumonia, finally dying of this cause. Though pneumonia might seem to be the34immediate cause, in fact it was the accidental fall that emerged as the proximate
cause and the claim was paid under personal accident insurance.There are certain losses which are suffered by the insured as a result of fire but
which cannot be said to be proximately caused by fire. In practice, some of these
losses are customarily paid by business under fire insurance policies.Example of such losses can be – Damage to property caused by water used to extinguish fire Damage to property caused by fire brigade in execution of their duty Damage to property during its removal from a burning building to a safe place**Test Yourself 1**Mr. Pinto contracted pneumonia as a result of lying on wet ground after a horse
riding accident. The pneumonia resulted in death of Mr. Pinto. What is the
proximate cause of the death?I. PneumoniaII. HorseIII. Horse riding accidentIV. Bad luck**D.** **Indemnity**The Principle of Indemnity is applicable to Non-life insurance policies. **It means that**
**the policyholder, who suffers a loss, is compensated so as to put him or her in**
**the same financial position as he or she was before the occurrence of the loss**
**event** . The insurance contract guarantees that the insured would be indemnified or
compensated up to the amount of loss and no more.The philosophy is that one should not make a profit through insuring one’s assets
and recovering more than the loss. The insurer would assess the economic value of
the loss suffered and compensate accordingly.**Example**Ram has insured his house, worth Rs. 10 lakhs, for the full amount. He suffers loss
on account of fire estimated at Rs. 70,000. The insurance company would pay him
an amount of Rs. 70,000. The insured can claim no further amount.The indemnity to be paid would depend on the type of insurance one
takes.Indemnity might take one or more of the following modes of settlement: Cash payment
Repair of a damaged item
Replacement of the lost or damaged item
Reinstatement (Restoration). E.g. Rebuilding a house destroyed by fire35**Diagram 2:** **Indemnity****a)** **Agreed Value:** However, there is some subject matter whose value cannot beeasily estimated or ascertained at the time of loss. For instance, it may be
difficult to put a price in the case of family heirlooms or rare artefacts. Similarly
in marine insurance policies it may be difficult to estimate the extent of loss
suffered in a ship accident half way around the world.In such instances, a principle known as the ‘Agreed Value’ is adopted. The
insurer and insured agree on the value of the property to be insured, at the
beginning of the insurance contract. In the event of total loss, the insurer agrees
to pay the agreed amount of the policy. This type of policy is known as “ **Agreed**
**Value Policy** ”.**b)** **Underinsurance:** Consider a situation now where the property has not been
insured for its full value. One would then be entitled to indemnity for loss only
in the same proportion as one’s insurance.Suppose the house, worth Rs. 10 lakhs has only been insured for a sum of Rs. 5
lakhs. If the loss on account of fire is Rs. 60,000, one cannot claim this entire
amount. It is deemed that the house owner has insured only to the tune of half
its value and he is thus entitled to claim just 50% [Rs. 30,000] of the amount ofloss. This is known as underinsurance.In most types of non-life insurance policies, which deal with insurance of
property and liability, the insured is compensated to the extent of actual
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insurer and insured agree on the value of the property to be insured, at the
beginning of the insurance contract. In the event of total loss, the insurer agrees
to pay the agreed amount of the policy. This type of policy is known as “ **Agreed**
**Value Policy** ”.**b)** **Underinsurance:** Consider a situation now where the property has not been
insured for its full value. One would then be entitled to indemnity for loss only
in the same proportion as one’s insurance.Suppose the house, worth Rs. 10 lakhs has only been insured for a sum of Rs. 5
lakhs. If the loss on account of fire is Rs. 60,000, one cannot claim this entire
amount. It is deemed that the house owner has insured only to the tune of half
its value and he is thus entitled to claim just 50% [Rs. 30,000] of the amount ofloss. This is known as underinsurance.In most types of non-life insurance policies, which deal with insurance of
property and liability, the insured is compensated to the extent of actual
amount of loss i.e. the amount of money needed to replace lost or damaged
property at current market prices less depreciation.**E.** **Subrogation**Subrogation means the transfer of all rights and remedies with respect to the
subject matter of insurance, from the insured to the insurer. Subrogation follows
from the principle of Indemnity. Hence, it is often called a ‘corollary’ of Indemnity.In other words, if an insured suffers a loss and the loss has been indemnified by the
insurer, the insured’s right to get compensated by any third party for that loss,36would get shifted to the insurer. Note that the amount of damage that can be
collected by the insurance company is only to the extent of the amount paid by the
insurance company.**Important****Subrogation:** It is the process an insurance company uses to recover claim amounts
paid to a policy holder from a negligent third party.Subrogation can also be defined as surrender of rights by the insured to an insurance
company that has paid a claim against the third party.**Example**Mr. Kishore’s household goods were being carried in Sylvain Transport service. They
got damaged due to driver’s negligence, to the extent of Rs. 45,000 and the insurer
paid an amount of Rs. 30,000 to Mr. Kishore. The insurer stands subrogated to the
extent of only Rs. 30,000 and collect that amount from Sylvain Transports.In case the matter went into litigation and the Court directed Sylvain Transports to
pay Rs.35,000 as compensation to Mr. Kishore, he is liable to pay the insurer the
claim amount of Rs 30,000 under the subrogation clause, and to keep the balance
amount of Rs 5,000 with himself.The Subrogation Clause prevents the insured from collecting more than the loss from the insurance company and from any third party. Subrogation arises only in
case of contracts of indemnity and not against benefit policies like Life Insurance
Policy or Personal Accident Policy.**Example**Mr. Suresh dies in an air crash. His family is entitled to collect the full Sum Assured
of Rs 50 lakhs from the insurer who has issued a Personal Accident Policy plus the
compensation paid by the airline, say, Rs 15 lakhs.**F.** **Contribution:**Like Subrogation, ‘Contribution’ also follows from the Principle of Indemnity.
Hence, it is also called a ‘corollary’ of Indemnity. Contribution is a principle that
arises in general insurance contracts. It tells us how the liability is to be met when
the insured has taken insurance from more than one insurer. Contribution implies
that if the same property is insured with more than one insurance company, the
compensation paid by all the insurers together cannot exceed the actual loss
suffered. The policy holder can claim from each of the insurers only a portion of the
loss in proportion to the amount insured with each.Example: If Mr Srinivas has taken a fire policy on his house with two insurance
companies, with both of whom, he insured for the full value of Rs.12 lakhs. Suppose37a fire breaks out and he suffers a loss of Rs 3 lakhs as a result, he can claim anamount of Rs 1.5 lakhs from each of the insurers.The Principle of Contribution applies only to indemnity policies. It does not arise in
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Hence, it is also called a ‘corollary’ of Indemnity. Contribution is a principle that
arises in general insurance contracts. It tells us how the liability is to be met when
the insured has taken insurance from more than one insurer. Contribution implies
that if the same property is insured with more than one insurance company, the
compensation paid by all the insurers together cannot exceed the actual loss
suffered. The policy holder can claim from each of the insurers only a portion of the
loss in proportion to the amount insured with each.Example: If Mr Srinivas has taken a fire policy on his house with two insurance
companies, with both of whom, he insured for the full value of Rs.12 lakhs. Suppose37a fire breaks out and he suffers a loss of Rs 3 lakhs as a result, he can claim anamount of Rs 1.5 lakhs from each of the insurers.The Principle of Contribution applies only to indemnity policies. It does not arise in
the case of Life Insurance, because there is no upper limit that can be placed onthe losses suffered when there is a loss of life.**Test Yourself 2**Which among the following is an example of coercion?I. Ramesh signs a contract without having knowledge of the fine print
II. Ramesh threatens to kill Mahesh if he does not sign the contract
III. Ramesh uses his professional standing to get Mahesh to sign a contract
IV. Ramesh provides false information to get Mahesh to sign a contract**Test Yourself 3**Which among the following options cannot be insured by Ramesh?I. Ramesh’s houseII. Ramesh’s spouseIII. Ramesh’s friendIV. Ramesh’s parents**Test Yourself 4**What is the significance of the principle of contribution?I. It ensures that the insured also contributes a certain portion of the claim alongwith the insurerII. It ensures that all the insured who are a part of the pool, contribute to the claimmade by a participant of the pool, in the proportion of the premium paid bythemIII. It ensures that multiple insurers covering the same subject matter; cometogether and contribute the claim amount in proportion to their exposure to the
subject matter
IV. It ensures that the premium is contributed by the insured in equal instalmentsover the year.**Summary**The special features of insurance policies include:i. Uberrima fides,
ii. Insurable interest,
iii. Proximate cause,
iv. Indemnity
v. Subrogation38vi. Contribution**Key Terms**1. Non-Disclosure2. Misrepresentation3. Material facts4. Agreed Value5. Under Insurance**Answers to Test Yourself****Answer 1** - The correct option is III
**Answer 2** - The correct option is II
**Answer 3** - The correct option is III
**Answer 4** - The correct option is III39### CHAPTER C-0 4 **FEATURES OF INSURANCE CONTRACTS****Chapter Introduction**In this chapter, we discuss the elements that govern the working and specialfeatures of an insurance contract.40**A.** **Insurance contracts – Legal aspects and special features.**The chapter also deals with the legal aspects and special features of an insurancecontract.**1.** **The Insurance Contract**Insurance involves a contractual agreement in which the insurer agrees to
provide financial protection against certain specified risks for a price or
consideration known as the premium. The contractual agreement takes the form
of an insurance policy.**2.** **Legal aspects of an insurance contract**This section looks at some features of an insurance contract and considers thelegal principles that govern insurance contracts in general.**Important**A contract is an agreement between parties, enforceable at law. The provisions of
the Indian Contract Act, 1872 govern all contracts in India, including insurancecontracts.An insurance policy is a contract entered into between two parties, viz., the
company, called the **insurer**, and the policy holder, called the **insured** and fulfils
the requirements enshrined in the Indian Contract Act, 1872.**Diagram 1:** **Insurance contract**41**B.** **Elements of a valid contract****Diagram 2:** **Elements of a valid contract**The elements of a valid contract are:**1.** **Offer and acceptance**When one person signifies to another his willingness to do or to abstain from doing
anything with a view to obtaining the assent of the other to such act, he is said to
make an offer or proposal. Usually, the offer is made by the proposer, and
acceptance made by the insurer.When a person to whom the offer is made signifies his assent thereto, this is deemed
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the Indian Contract Act, 1872 govern all contracts in India, including insurancecontracts.An insurance policy is a contract entered into between two parties, viz., the
company, called the **insurer**, and the policy holder, called the **insured** and fulfils
the requirements enshrined in the Indian Contract Act, 1872.**Diagram 1:** **Insurance contract**41**B.** **Elements of a valid contract****Diagram 2:** **Elements of a valid contract**The elements of a valid contract are:**1.** **Offer and acceptance**When one person signifies to another his willingness to do or to abstain from doing
anything with a view to obtaining the assent of the other to such act, he is said to
make an offer or proposal. Usually, the offer is made by the proposer, and
acceptance made by the insurer.When a person to whom the offer is made signifies his assent thereto, this is deemed
to be an acceptance. Hence, when a proposal is accepted, it becomes a promise.
The acceptance needs to be communicated to the proposer which results in theformation of a contract.When a proposer accepts the terms of the insurance plan and signifies his/ her
assent by paying the deposit amount, which, on acceptance of the proposal, gets
converted to the first premium, the proposal becomes a policy. If any condition is
put, it becomes a counter offer. The policy bond becomes the evidence of thecontract.**2.** **Consideration**This means that the contract must contain some mutual benefit for the parties. The
premium is the consideration from the insured, and the promise to indemnify, is theconsideration from the insurers.**3.** **Agreement between the parties (Consensus Ad-Idem)**Both the parties, the insurer and the policyholder, should agree to the same thing
in the same sense. In other words, there should be “ **consensus ad-idem** ” between
both parties.42**4.** **Free consent**There should be free consent while entering into a contract. Consent is said to
be free when it is not caused by Coercion/ By Force
Undue influence Fraud Misrepresentation
MistakeWhen consent to an agreement is caused by coercion, fraud or
misrepresentation, the agreement is voidable.**5.** **Capacity of the parties**Both the parties to the contract must be legally competent to enter into the
contract. The policyholder must be legally an adult at the time of signing the
proposal and should be of sound mind and not disqualified under law. For
example, minors cannot enter into insurance contracts.**6.** **Legality**The object of the contract must be legal, for example, no insurance can be had
for illegal acts. Every agreement of which the object or consideration is unlawful
is void. The object of an insurance contract is a lawful object.Also one’s entering into an insurance contract should be done out of one’s free
will, without any kind of force, fear or mistake.**C.** **Paying Premium in Advance**As per Indian laws, Insurers are not allowed to assume risk unless they receive the
premium in advance. In other words, insurance protection cannot be sold on creditbasis in India.Section 64 VB of the Insurance Act 1938 states, “No risk to be assumed unless
premium is received in advance”. No insurer shall assume any risk unless and until
the premium is received in advance or is guaranteed to be paid or a deposit is made
in advance in the prescribed manner. This is an important feature of the insurance
industry in India.The Insurance Rules, 1939, provide certain exceptions to this condition of advance
payment of premium, in respect of particular categories of insurances. Section 59
of the Insurance Rules allows accepting premiums in instalments in respect of
Sickness Insurance, Group Personal Accident Insurance Medical Benefits Insurance
and Hospitalisation Insurance Schemes, subject to certain conditions. Section 59 of
the Insurance Rules allows relaxations for policies issued to Government and semiGovernment bodies, Fidelity Guarantee Insurance policies covering Government and43semi-Government employees, Workmen's Compensation policies, Cash in Transit
policies, and some other categories of insurances subject to certain conditions.**Solicitation**Insurance has always been regarded as something to be purchased after a proper
understanding the product and not just bought/ sold. Hence, insurance is to be
‘solicited’ or asked for by the customer. Traditionally, insurers declare that
“Insurance is the subject matter of solicitation”. To elucidate, insurance is not
a ready-made product like a packet of biscuits or a bar of chocolate to be
bought/ sold outright. Customers have to discuss their insurance needs with a
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in advance in the prescribed manner. This is an important feature of the insurance
industry in India.The Insurance Rules, 1939, provide certain exceptions to this condition of advance
payment of premium, in respect of particular categories of insurances. Section 59
of the Insurance Rules allows accepting premiums in instalments in respect of
Sickness Insurance, Group Personal Accident Insurance Medical Benefits Insurance
and Hospitalisation Insurance Schemes, subject to certain conditions. Section 59 of
the Insurance Rules allows relaxations for policies issued to Government and semiGovernment bodies, Fidelity Guarantee Insurance policies covering Government and43semi-Government employees, Workmen's Compensation policies, Cash in Transit
policies, and some other categories of insurances subject to certain conditions.**Solicitation**Insurance has always been regarded as something to be purchased after a proper
understanding the product and not just bought/ sold. Hence, insurance is to be
‘solicited’ or asked for by the customer. Traditionally, insurers declare that
“Insurance is the subject matter of solicitation”. To elucidate, insurance is not
a ready-made product like a packet of biscuits or a bar of chocolate to be
bought/ sold outright. Customers have to discuss their insurance needs with a
person qualified for the same and based on professional advice, the right
insurance product is to be purchased. The Insurance product has to be
understood and the offering most suited to the specific needs and requirements
of the customer in terms of the policy coverage, exclusions, terms and
conditions, is to be considered.‘Solicitation’ is usually initiated when an insurer or an authorised intermediary
approaches a prospect with a view to understand his/ her insurance needs and
provides professional advice in selecting appropriate insurance products. The
prospect solicits the proper solution and provides all requisite details to the
advisor. As per regulations of IRDAI, **Insurance Agents** are appointed by an
insurer for the purpose of engaging in the solicitation process and procuring
insurance business, including business relating to the continuance, renewal or
revival of policies of insurance. Only authorised employees of insurance
companies, and specified persons of licensed intermediaries, who are trained
and authorised for the purpose can be part of the process of solicitation andsales of insurance.**D.** **Enabling Provisions****1.** **Grace Period**Grace period is the specified period of time immediately following the premium
due date during which a payment can be made to renew or continue a policy in
force without loss of continuity benefits such as waiting periods and coverage of
pre-existing diseases. Coverage is not available for the period for which no
premium is received. The days of grace are computed from the next day after the
due date fixed for payment of the premium.For **Life insurance**, if there is no grace period, a single delay in payment can
lead to a policy lapse. This would be detrimental for the policyholder, the
insurer and the insurance industry in general. IRDAI Regulations allow a grace
period of 15 days is applicable in case of Monthly mode of Premium collection and
30 days in other modes.44In respect of **Health insurance** also, certain number of days as grace period is
allowed for renewal of individual health policies. This period depends on the policy
of the company and the product offered. All continuity benefits are maintained if
the policy is renewed within the grace period. However Claims, if any, during the
break period will not be considered. As per IRDAI Regulations, the grace period is
15 days in case of Monthly mode of Premium collection and 30 days in other modes.**Motor Policies** are usually valid for a period of one year and have to be renewed
before the due date. Grace period for paying the premium do not apply. In case
a comprehensive policy lapses for more than 90 days, the accrued No Claim
Bonus (NCB) benefit would also be lost.In the interest of smooth operation of affairs during the Covid-19 pandemic,
IRDAI permitted the following relaxations:i. In case of Life insurance policies, Insurers were asked to enhance thegrace period by additional 30 days if desired by the policyholders.ii. In case of Health insurance policies, Insurers were told to condone delaysin renewal up to 30 days without deeming such condonation as a break in
policy. Insurers were requested to contact the policyholders well in
advance to avoid discontinuance in coverage.iii. As regards Motor Vehicle Third Party Insurance policies that fell due forrenewal and premiums could not be paid due to the Covid-19 situation,
IRDAI allowed a grace period till 15th May, 2020.**2.** **Free-Look Period introduced by “IRDAI”**Insurance contracts are drafted by the insurer, and the other party has to adhere to
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before the due date. Grace period for paying the premium do not apply. In case
a comprehensive policy lapses for more than 90 days, the accrued No Claim
Bonus (NCB) benefit would also be lost.In the interest of smooth operation of affairs during the Covid-19 pandemic,
IRDAI permitted the following relaxations:i. In case of Life insurance policies, Insurers were asked to enhance thegrace period by additional 30 days if desired by the policyholders.ii. In case of Health insurance policies, Insurers were told to condone delaysin renewal up to 30 days without deeming such condonation as a break in
policy. Insurers were requested to contact the policyholders well in
advance to avoid discontinuance in coverage.iii. As regards Motor Vehicle Third Party Insurance policies that fell due forrenewal and premiums could not be paid due to the Covid-19 situation,
IRDAI allowed a grace period till 15th May, 2020.**2.** **Free-Look Period introduced by “IRDAI”**Insurance contracts are drafted by the insurer, and the other party has to adhere to
it if he/ she wants the insurance. Such contracts where someone has to accept the
contract as it is and cannot make any change to it are legally called Contracts of
Adhesion. Because of this one-sided situation, the Courts always make insurers
liable for any ambiguity or confusion that may arise in interpreting these terms andconditions.To reduce this one-sidedness and make insurance transactions more customerfriendly, IRDAI has built into its regulations a consumer-friendly provision called
‘Free-Look Period’ whereby, if the customer is not satisfied with any term and
conditions of the policy, he/ she can return it and get a refund. This provision
whereby policyholders are given the option of cancelling the policy within 15 days
(30 days, in case of electronic policies and policies sourced through distance mode)
after receiving the policy document, in case they are not satisfied with the policy,
has been introduced for Life Insurance and Health Insurance policies (having a
tenure of at least one year). The company has to be intimated in writing and the
premium is refunded less, proportionate risk premium for the period of cover,
expenses and charges.45**Cancellation of Policies:** When policies are cancelled by the insurer, the proportion
of the premium corresponding to the expired period of insurance is charged/
retained by the insurer and the proportion corresponding to the unexpired period
of insurance is returned to the insured, provided no claim has been paid under the
policy. Such proportionate calculation of premium is called Pro-rata premium.When annual policies are cancelled by the insured, insurers usually charge/ retain
premiums at a higher rate and refund premiums at higher rates, instead of
calculating pro-rata premiums. This would prevent anti-selection against the
insurers and take care of the initial expenses of the insurer. Such rates are disclosed
as part of the terms and conditions of the insurance contract and referred to as
Short period scales.**Important****i.** **Coercion** - Involves pressure applied through criminal means.**ii.** **Undue influence** – using one’s position to dominate the will of another person,to obtain an undue advantage over that person.**iii.** **Fraud** – inducing another to act on a false belief that is caused by arepresentation one does not believe to be true. It can arise either from
deliberate concealment of facts or through misrepresenting them.**iv.** **Mistake** - Error in one’s knowledge or belief or interpretation of a thing or event.This can lead to an error in understanding and agreement about the subjectmatter of the contract.**Test Yourself 1**Which among the following cannot be an element in a valid insurance contract?I. Offer and AcceptanceII. CoercionIII. ConsiderationIV. Legality**Summary**i. Insurance involves a contractual agreement in which the insurer agrees toprovide financial protection against specified risks for a price or consideration
known as the premium.
ii. A contract is an agreement between parties, enforceable at law.iii. The elements of a valid contract include:Offer and acceptanceConsideration,Consensus ad-idem,- Free consentCapacity of the parties and46Legality of the object**Key Terms**1. Offer and Acceptance2. Lawful consideration3. Consensus ad idem**Test Yourself 2**During the Free-look period, if the policyholder, who has bought a policy through
an Agent, disagrees to any of its terms and conditions, he/ she can return it and get
a refund subject to the following conditions:I. He/ she can exercise this option within 15 days of receiving the policy document
II. He/ she has to communicate to the company in writing
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known as the premium.
ii. A contract is an agreement between parties, enforceable at law.iii. The elements of a valid contract include:Offer and acceptanceConsideration,Consensus ad-idem,- Free consentCapacity of the parties and46Legality of the object**Key Terms**1. Offer and Acceptance2. Lawful consideration3. Consensus ad idem**Test Yourself 2**During the Free-look period, if the policyholder, who has bought a policy through
an Agent, disagrees to any of its terms and conditions, he/ she can return it and get
a refund subject to the following conditions:I. He/ she can exercise this option within 15 days of receiving the policy document
II. He/ she has to communicate to the company in writing
III. The premium refund will be adjusted for proportionate risk premium for theperiod on cover, expenses incurred by the insurer on medical examination and
stamp duty chargesIV. All the above**Test Yourself 3**If the policyholder has bought a policy and does not want it, he/ she can return it
during the _________ period, and get a refund.I. Free evaluationII. Free-lookIII. CancellationIV. Free trial**Answers to Test Yourself****Answer 1** - The correct option is II.
**Answer 2** - The correct option is IV.
**Answer 3** - The correct option is II.47## CHAPTER C-05## UNDERWRITING AND RATING**Chapter Introduction**In this chapter you will learn the basics of underwriting and rating. You will learn
about the different methods of dealing with hazards in the process of rating of risks.
You will be able to appreciate the common aspects of underwriting, product
approval and rating.**Learning Outcomes**After studying this chapter, you should be able to:1. Define the basics of underwriting2. Understand the basics of product approvals in India3. Appreciate rating factors and the importance of ratemaking48**A.** **Basics of Underwriting**In the previous chapters, we have seen that the concept of insurance involves
managing risk through pooling. Insurers create a pool consisting of premiums that
are made by several individuals/ commercial/ industrial firms/ organizations.This process of understanding risks, classifying risks, identifying which category they
fall into, **deciding whether to accept the risk or not** and if so, how much premium
the insurer would require to accept the risk and whether any extra conditions are
to be imposed on the risk - all these are part of **underwriting** .It is also important to know what rate is to be charged and how the rates are made.**Definition**Underwriting is the process of determining whether a risk offered for insurance is
acceptable, and if so, at what rates, terms and conditions.Underwriting comprises the following steps:i. Assessment and evaluation of hazard and risk in terms of frequency andseverity of lossii. Formulation of policy coverage and terms and conditionsiii. Fixing of rates of premiumThe underwriter decides on whether or not to accept the riskThe next step would be to decide the **rates, terms and conditions** under which the
risk is to be accepted.Underwriting skills are acquired through a continuous learning process involving
adequate training, field exposure and deep insights. To be a fire insurance
underwriter one needs to have a good knowledge of the likely causes of fire, impact
of fire on various physical goods and property, the process involved in an industry,
geography, climatic conditions etc.Similarly a marine insurance underwriter must be aware about port/ road
conditions, problems encountered by cargo/ goods in transit or storage, ships andtheir seaworthiness and so on.A health underwriter needs to understand the risk profile of the insured, age,
medical aspects, fitness levels and family history and measure the effect of each
factor affecting the risk.**Sources of information for underwriting**The first stage in any numerical (or statistical) analysis is the collection of data.
When pricing a risk, an underwriter should gather as much information as possibleto aid accurate assessment.49**Sources of information are:**i. **Proposal form or underwriting presentation**ii. **Risk surveys**iii. **Historic claims experience data:** For some classes of business, such aspersonal and motor lines, underwriters often utilise historic claims
experience data to provide an indication of the likely future claims
experience, and to arrive at a suitable premium **.****Underwriting, equity and business sustainability**The need for careful underwriting and risk classification in insurance arises from the
simple fact that **all risks are not equal** . Each risk thus needs to be appropriately
assessed and priced in accordance with the likelihood of loss occurrence and
severity.Since all risks are not equal, it would not be proper to ask all those who are to be
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medical aspects, fitness levels and family history and measure the effect of each
factor affecting the risk.**Sources of information for underwriting**The first stage in any numerical (or statistical) analysis is the collection of data.
When pricing a risk, an underwriter should gather as much information as possibleto aid accurate assessment.49**Sources of information are:**i. **Proposal form or underwriting presentation**ii. **Risk surveys**iii. **Historic claims experience data:** For some classes of business, such aspersonal and motor lines, underwriters often utilise historic claims
experience data to provide an indication of the likely future claims
experience, and to arrive at a suitable premium **.****Underwriting, equity and business sustainability**The need for careful underwriting and risk classification in insurance arises from the
simple fact that **all risks are not equal** . Each risk thus needs to be appropriately
assessed and priced in accordance with the likelihood of loss occurrence and
severity.Since all risks are not equal, it would not be proper to ask all those who are to be
insured, to pay equal premium. **The purpose of underwriting is to classify risks so**
**that, depending on their characteristics and degree of risk posed, an appropriate**
**rate of premium may be charged.** It is important for the underwriter to ensure
that the risk evaluation is done properly and the premium charged is neither too
low to cover the risk nor too high to make it non-competitive.The main features of underwriting are as followsi. To **identify risk** based upon the characteristicsii. To **determine the level** of risk presented by the proposerThe objectives of underwriting are achieved, in short, by deciding the level of
acceptability, adequacy of premium and other terms.**B.** **Product Filing with IRDAI**Every Insurance product needs to be filed with IRDAI for approval before it is offered
for sale. IRDAI allots a Unique Identification number (UIN) for every insurance
product. Once products are introduced in the market, there are guidelines to be
followed for withdrawing the product as well.**1.** The Regulator asks for a clear commitment by the Board of the insurer that it iswilling to accept the risks in the policy and agrees to pay the claims. It also asks
the insurer to commit that the policy wordings are fair to the customer and that
the prices are decided on a scientific basis.**2.** The insurer should plan for the possibility of withdrawal of the products in thefuture and the options that would be available to the policyholder on such
withdrawal of the product.**3.** The withdrawn product shall not be offered to the prospective customers.50**C.** **Basics of Ratemaking**Insurance is based on transfer of risk to the insurer. By purchasing an insurance
policy, the insured is able to reduce the impact of financial losses arising from the
peril against which the property is insured. The Insurer needs to adopt a process of
calculating a price to cover the future cost of insurance claims and expenses,
including a margin for profit. This is known as **ratemaking.****A rate is the price of a given unit of insurance.** For example, a rate may be
expressed as Rs.1.00 per mile (per thousand) sum assured for earthquake coverage.
Each rate is established after looking at past trends and changes in the current
environment that may affect potential losses in the future.**Note that rates are not the same as premiums.****Premium = (Sum Insured) x (rate)****Example**Taking an example of health insurance, numerical or percentage assessments are
made on each component of the risk. Factors like age, race, occupation, habits etc.
are examined and scored numerically based on predetermined criteria.The amount of premium to be paid by each depends on a rate, which is determined
by two factors; The probability of loss due to a loss event (caused by an insured peril) and The estimated amount of loss that may arise due to the loss event**Example**Assume the average amount of a house being destroyed by fire is Rs 1,00,000.The probability of the loss of a house being destroyed by fire 1 out of 100 [or 0.01].
That is, the experience is that out of a 100 insured houses, one house gets destroyed
by fire.The expected average loss would be Rs.1,00,000 x 0.01 = Rs. 1000.So, Insurers would need to charge a minimum of Rs.1000 to insure a house of
Rs.1,00,000 value.How can the insurer ensure that the pool is sufficient to compensate for the losses
that are actually incurred?As seen earlier, the whole mechanism of insurance involves pooling of many similar
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made on each component of the risk. Factors like age, race, occupation, habits etc.
are examined and scored numerically based on predetermined criteria.The amount of premium to be paid by each depends on a rate, which is determined
by two factors; The probability of loss due to a loss event (caused by an insured peril) and The estimated amount of loss that may arise due to the loss event**Example**Assume the average amount of a house being destroyed by fire is Rs 1,00,000.The probability of the loss of a house being destroyed by fire 1 out of 100 [or 0.01].
That is, the experience is that out of a 100 insured houses, one house gets destroyed
by fire.The expected average loss would be Rs.1,00,000 x 0.01 = Rs. 1000.So, Insurers would need to charge a minimum of Rs.1000 to insure a house of
Rs.1,00,000 value.How can the insurer ensure that the pool is sufficient to compensate for the losses
that are actually incurred?As seen earlier, the whole mechanism of insurance involves pooling of many similar
risks so that the probability of the number of losses (frequency) as well as the extent
of loss (severity) becomes predictable. This principle, referred to as ‘the law of
large numbers’ states that as the sample size grows, the results come closer to the
expected value. Insurance companies need to sell more policies to more and more
people to make their expectations/ predictions work.51An example is that if a coin is tossed, the chances of getting ‘heads’ or ‘tails’ is
50:50. However, if the coin is tossed only once, the result can be 100% heads and
0% ‘tails’ or 0% ‘heads’ and or 100% tails. However, if one tosses a coin many times,
the chance of the average count of ‘heads’ and ‘tails’ being 100% and 0% reduces
and will get closer to 50:50.**Example**In the field of property insurance, the chances of a wooden structure catching fire
are more than stone structures; hence, a higher premium is required to insure thewooden structure.The same concept applies to Life and Health Insurance also. An individual suffering
from high blood pressure or diabetes has higher chances of suffering a heart attack.**Test Yourself 1**Identify the two factors that affect insurance ratemaking.I. Probability and severity of riskII. Source and nature of riskIII. Source and timing of risk
IV. Nature and impact of risk**1.** **Determining the rate of premium**The pure rate of premium is arrived at on the basis of past loss experience.
Therefore, statistical data regarding past losses is most essential for purposes of
calculating rates. To fix the rates, it is necessary to give a ‘mathematical value’ tothe risks.**Example**If loss experience of a large number of motor cycles is collected for a period of say
10 years, we will get the sum total of the losses resulting from damage to the
vehicles. By expressing this amount of loss as percentage of the total value of motor
cycles we can fix the ‘mathematical value’ of the risk. This may be expressed in the
formula given below:Let us suppose that: The Value of a motor cycle: Rs. 50,000/ Loss experience: Out of 1000 motor cycles, 50 motor cycles get stolen over10 years
On an average, 5 motor cycles become total losses due to theft every yearApplying the formula, the result will be:52Losses per year (Rs. 50,000 X 5) = Rs. 2,50,000**Total Values of 1000 motor vehicles (Rs.** 50,000 X 1000) **= Rs. 5,00,00,000**This means that average loss percentage per vehicle (L/ V) x 100= [2,50,000/
5,00,00,000] x 100 = 0.5%Therefore the rate of premium that a motor cycle owner pays is half a percent of
Rs. 50,000/ - i.e. Rs. 250/ - per year. This is called the **‘Pure’ premium,** also known
as ‘Burning Cost’.At the rate of Rs. 250 per motor cycle, Rs. 2.5 lakhs is collected which is paid outin claims on total losses of 5 vehicles.If the pure premium, which is arrived above, is collected it would constitute a fund
which will be sufficient only to pay for losses.In the example above we can see that there is no surplus. But insurance operations
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5,00,00,000] x 100 = 0.5%Therefore the rate of premium that a motor cycle owner pays is half a percent of
Rs. 50,000/ - i.e. Rs. 250/ - per year. This is called the **‘Pure’ premium,** also known
as ‘Burning Cost’.At the rate of Rs. 250 per motor cycle, Rs. 2.5 lakhs is collected which is paid outin claims on total losses of 5 vehicles.If the pure premium, which is arrived above, is collected it would constitute a fund
which will be sufficient only to pay for losses.In the example above we can see that there is no surplus. But insurance operations
also involve costs of administration (expenses of management) and costs of
procurement of business (agency commission). It is also necessary to provide a
margin for unexpected heavy losses.Finally, since insurance is transacted on a commercial basis, like any other business,
it is necessary to provide for a margin of profit which is a return on the capitalinvested in the business.**Therefore, the ‘pure premium’ is suitably loaded or increased by adding**
**percentages to provide for expenses, reserves and profits.****The final rate of premium will consist of the following components:** Loss payments
Loss expenses (e.g. survey fees)
Agency commission
Expenses of management
Margin for reserves for unexpected heavy losses e.g. 7 total losses against 5expected
Margin for profitsBy taking all the relevant rating factors into consideration, one can ensure the rates
are adequate, excessive or unfairly discriminatory as between risks of similar type
and quality.**Test Yourself 2**What is pure premium?I. Premium sufficiently big enough to pay for losses only
II. Premium applicable to marginal members of the society
III. Premium after loading for administrative costs
IV. Premium derived from the most recent loss experience period53**2.** **Deductible**‘Deductible’ or ‘excess’ is a cost-sharing provision between an insurer and insured.
Deductibles provide that only the claims in excess of a particular threshold are
payable by the insurer. In other words, the insurer will not be liable for claims below
a specified level. The level or the threshold would be set as a fixed amount, or a
percentage or even as a specified period of time (when it is called time-excess.) In
case of health policies, there could be a condition that claims would be payable
only if the hospitalization is beyond a specified number of days/ hours. Deductibles
are not used in life policies.In products such as property, motor and home insurances, deductibles are
predetermined amounts that the insured must bear towards an indemnity claim.
Deductibles can be compulsory for some policies or voluntary. Insurers generally
charge lower premiums when the insured voluntarily opt for higher deductibles. An
agent must examine how specific deductibles work and inform the insured whether
the deductible is applicable on a ‘per year’ or ‘per event’ basis.There are various reasons for having deductibles. Corporate customers covering
factories, multiple cargo consignments, large groups of employee, public liability
exposures etc. and having huge amounts of Sum Insured, may prefer to bear small
claims themselves and avoid the documentation to prove claims. For example, a
large factory owner paying lakhs or rupees as premium may not be bothered about
a minor repair cost of a machine amounting to around Rs.2,000.Some type of policies may need the insured also to bear some part of the loss to
ensure that he/ she takes due care. For instance, health insurers may insist on a
deductible so that insured would not overspend on costly hospital rooms just
because insurance is there. Some Insurers also may not prefer spending time on
processing small claims. Also, in certain situations, insurers may not want to get
exposed to the financial stress caused by accumulation of a large number of small
losses at one location. For example, a small flood in an industrial estate area can
cause many low value claims from all the warehouses in the area.**Franchise:** Franchise refers to a threshold set, usually as a percentage of the sum
insured, below which no claim is admissible, as in the case of deductibles. However,
when the claim amount is beyond the franchise limit, the entire claim is admissible
by the insurer. In other words, franchise determines the minimum threshold of the
insurance companies' financial responsibility. Franchise will apply to the policy in
the same way and for the same reasons as a deductible in case of claims below the
threshold, but in the event of a claim exceeding the franchise, the full amount of
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ensure that he/ she takes due care. For instance, health insurers may insist on a
deductible so that insured would not overspend on costly hospital rooms just
because insurance is there. Some Insurers also may not prefer spending time on
processing small claims. Also, in certain situations, insurers may not want to get
exposed to the financial stress caused by accumulation of a large number of small
losses at one location. For example, a small flood in an industrial estate area can
cause many low value claims from all the warehouses in the area.**Franchise:** Franchise refers to a threshold set, usually as a percentage of the sum
insured, below which no claim is admissible, as in the case of deductibles. However,
when the claim amount is beyond the franchise limit, the entire claim is admissible
by the insurer. In other words, franchise determines the minimum threshold of the
insurance companies' financial responsibility. Franchise will apply to the policy in
the same way and for the same reasons as a deductible in case of claims below the
threshold, but in the event of a claim exceeding the franchise, the full amount of
the loss will be paid.54**D.** **Rating factors**The relevant elements that are used to add up the rates and make the rating plan
are referred to as **rating factors** . Insurers use ‘rating factors’ to determine the risk
and to decide the price they will charge. The Insurer uses his assessments to establish a base rate. The Insurer then adjusts this rate with discounts applied for positive featuressuch as superior fire protection on property risk and loadings applied for
adverse features such as presence of inflammable materials in the premises. In Life Insurance the usual practice is to apply loading for adverse health,habits, heredity or occupational factors.**Key Terms**- Deductibles- Franchise**Answers to Test Yourself****Answer 1** - The correct option is I.**Answer 2** - The correct option is I.55### CHAPTER C-0 6## CLAIMS PROCESSING**Chapter Introduction**The insured get to taste the benefit of insurance only when they are affected by
losses. The entire insurance industry is sensitive to the losses faced by insured and
try to settle the claims that arise as amicably as possible and as fast as possible.After studying this chapter, you should be able to understand:1. Claims settlement2. Importance of claim procedures56**A.** **Loss Assessment and Claim settlement**Claims Assessment (Loss Assessment) is the process of determining whether the loss
suffered by the insured is covered by the insurance policy, i.e. the loss does not fall
under any exclusion and there is no breach of warranty.Settlement of claims has to be based on considerations of fairness. For an Insurancecompany, expeditious settlement of claim is the benchmark of efficiency for its
services. Each company has internal guidelines about time taken in claims
processing, which its employees follow.This is generally known by the term “Turnaround time” (TAT). Some insurers have
also put in place, facility for the insured to check claim status online from time to
time. Some insurance companies have also set up claims hub for speedy processingof claims.**Important aspects in an insurance claim**Although most companies are bound by their TAT it is important for an agent to
know the aspects that are looked into for settling a claim. Six of the most important
aspects for Non-life claims are given below.i. Whether the loss causing event is within the scope of the policyii. Whether the insured has complied with his part of the policy conditionsiii. Compliance with warranties. The survey report would indicate whether or notwarranties have been complied with.iv. Observance of utmost good faith by the proposer, during the currency of thepolicy.v. On the occurrence of a loss, the insured is expected to act as if he is uninsured.In other words, he has a duty to take measures to minimise the loss.vi. Determination of the amount payable. The amount of loss payable is subject tothe sum insured. However, the amount payable will also depend upon the
following: The extent of the insured’s insurable interest in the property affected
The value of salvage
Application of underinsurance
Application of contribution and subrogation conditionsIn the matter of claims relating to life insurance, the insurer checks whether1) Conditions of policy have not been breached
2) Utmost good faith has been followed and
3) No material facts have been concealed fraudulently.57**B.** **Categories of claim**Insurance Claims fall into the following categories:**i.** **Standard claims**These are claims which are clearly within the terms and conditions of the policy.
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following: The extent of the insured’s insurable interest in the property affected
The value of salvage
Application of underinsurance
Application of contribution and subrogation conditionsIn the matter of claims relating to life insurance, the insurer checks whether1) Conditions of policy have not been breached
2) Utmost good faith has been followed and
3) No material facts have been concealed fraudulently.57**B.** **Categories of claim**Insurance Claims fall into the following categories:**i.** **Standard claims**These are claims which are clearly within the terms and conditions of the policy.
The assessment of claim is done keeping in view scope and the sum insured opted
for and other methods of indemnity laid down for various classes of insurance.**ii.** **Condition of average or average clause**This is a condition in some policies which penalises the insured for insuring his
property at a sum insured less than its actual value known as underinsurance. In the
event of a claim the insured gets an amount that is proportionately reduced fromhis actual loss in accordance to the amount underinsured. Such situations occurmore in the case of non-life insurance.**iii.** **Act of God perils - Catastrophic losses**Natural perils like storm, cyclone, flood, inundation, and earthquake are termed as
“Act of God” perils. These perils may result in losses to many policies of insurer in
the affected region. Surveyors are appointed for assessment of certain categoriesof non-life insurance claims.In such major and catastrophic losses, the surveyor is asked to proceed to the loss
site immediately for an early assessment and loss minimisation efforts.
Simultaneously, insurers’ officials also visit the scene of loss particularly when the
amount involved is large. The purpose of the visit is to obtain an immediate, on the
spot idea of the nature and extent of loss.Preliminary reports are also submitted if the surveyors face some problems in
regards to the assessment and may desire guidance and instructions from insurers
who are thus given an opportunity to discuss the issues with the insured, ifnecessary.**iv.** **On account payment**In Non-life insurance claims, apart from preliminary reports, interim reports may be
submitted from time to time where repairs and/ or replacements are made over a
long period. Interim reports also give the insurer an idea of the development of
assessment of loss. It also helps in recommendation of "On account payment" of the
claim if desired by the insured. This usually happens if the loss is large and the
completion of assessment may take some time.If the claim is found to be in order, payment is made to the claimant and entries
made in the company records. Appropriate recoveries are made from the co-insurers
and reinsurers, if any. In some cases, the insured may not be the person to whom
the money is to be paid.58**v.** **Discharge vouchers**Settlement of the claim is made only after obtaining a discharge under the policy.
A sample of discharge receipt for claims (under personal accident insurance) for
injuries is worded along the following lines: (may vary from company to company)Name of the InsuredClaim No. Policy No.Received from the Company Ltd.The sum of Rs. ___________ in full and final settlement of compensation due
to me/ us on account of injuries sustained by me/ us due to accident which
occurred on or about the___________ I/ we give this discharge receipt to the
Company in full and final settlement of all my/ our claim present or future
arising directly or indirectly in respect of the said claim.Date (Signature)vi. **Post settlement action**The action taken after settlement of the non-life claim in relation to underwritingvaries from one class of business to another.**Example**Sum insured under a fire policy stands reduced to the extent of the amount of
claim paid. However, it can be reinstated on payment of pro-rata premium, which
is deducted from the amount of claim paid.On payment of the capital sum insured under a personal accident policy, the policy
stands cancelled.Similarly, payment of a claim under individual fidelity guarantee policy
automatically terminates the policy.**vii.** **Salvage**Salvage generally refers to damaged property. On payment of loss, the salvage
belongs to insurers.**Example**When motor claims are settled on total loss basis, the damaged vehicle is taken over
by insurers. Salvage can also arise in other non-life insurances like fire claims,
marine cargo claims etc.Salvage is disposed of according to the procedure laid down by the companies for
the purpose. Surveyors, who have assessed the loss, will also recommend methods
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arising directly or indirectly in respect of the said claim.Date (Signature)vi. **Post settlement action**The action taken after settlement of the non-life claim in relation to underwritingvaries from one class of business to another.**Example**Sum insured under a fire policy stands reduced to the extent of the amount of
claim paid. However, it can be reinstated on payment of pro-rata premium, which
is deducted from the amount of claim paid.On payment of the capital sum insured under a personal accident policy, the policy
stands cancelled.Similarly, payment of a claim under individual fidelity guarantee policy
automatically terminates the policy.**vii.** **Salvage**Salvage generally refers to damaged property. On payment of loss, the salvage
belongs to insurers.**Example**When motor claims are settled on total loss basis, the damaged vehicle is taken over
by insurers. Salvage can also arise in other non-life insurances like fire claims,
marine cargo claims etc.Salvage is disposed of according to the procedure laid down by the companies for
the purpose. Surveyors, who have assessed the loss, will also recommend methods
of disposal.**viii.** **Recoveries**After settlement of claims, the insurers under subrogation rights applicable to
insurance contracts, are entitled to the rights and remedies of the insured and to59recover the loss paid from a third party who may be responsible for the loss under
respective laws applicable. Thus, insurers can recover the loss from shipping
companies, railways, road carriers, airlines, port trust authorities etc.**Example**In the case of non-delivery of consignment, the carriers are responsible for the loss.
Similarly, the port trust is liable for goods which are safely landed but subsequently
missing. For this purpose, a letter of subrogation duly stamped is obtained from theinsured before the settlement of the claim.**ix.** **Disputes related to claims**Despite best efforts, there could be delay in payment, non-payment (repudiation)
of the claim, or the claim being admitted for a lesser amount, which might lead to
dissatisfaction and dispute between Insurer and the insured.Apart from these, the most common reasons, to name a few are: Non-disclosure of material facts Lack of coverage Loss caused by excluded perils Lack of adequate sum insured Breach of warranty Issues regarding quantum due to underinsurance, depreciation, etc.All this could cause considerable grief to the insured at a time when he is already
suffering from financial constraints arising due to losses. In order to reduce his
sufferings, grievance redressal and dispute handling procedures are well laid out in
the policy itself. Policies of fire or property have the condition of “Arbitration” in
the policy itself.**C.** **Arbitration**Arbitration is a method of settling disputes arising out of contracts. Arbitration is
done in accordance with the provisions of the Arbitration and Conciliation Act, 1996.
The normal method of enforcing a contract or settling a dispute there under would
be to go to a court of law. Such litigation, however, involves considerable delay and
expense. The Arbitration Act allows the parties to submit disputes under a contract
to the more informal, less costly and private process of arbitration.Arbitration may be done by a single arbitrator or by more than one, chosen by the
parties to the dispute themselves. In the event of a single arbitrator, the parties
have to agree about that person. Many commercial insurance policies contain an
**arbitration clause** stating that disputes will be subject to arbitration. Fire and most
miscellaneous policies also contain an arbitration clause which provides that if the
liability under the policy is admitted by the company, and there is a difference
concerning the quantum to be paid, such a difference must be referred to60arbitration. Normally the arbitrator’s decision is considered final and binding on
both the parties.The wording of the condition varies from policy to policy. Generally, it provides asfollows:i. The dispute is submitted to the decision of a single arbitrator to be appointedby the parties, or in the event of any disagreement between them upon
appointment of a single arbitrator, to the decision of two arbitrators each
appointed by the parties.ii. These two arbitrators shall appoint an Umpire, who presides at the meetings.The procedure during these meetings resembles that of a court of law. Each
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parties to the dispute themselves. In the event of a single arbitrator, the parties
have to agree about that person. Many commercial insurance policies contain an
**arbitration clause** stating that disputes will be subject to arbitration. Fire and most
miscellaneous policies also contain an arbitration clause which provides that if the
liability under the policy is admitted by the company, and there is a difference
concerning the quantum to be paid, such a difference must be referred to60arbitration. Normally the arbitrator’s decision is considered final and binding on
both the parties.The wording of the condition varies from policy to policy. Generally, it provides asfollows:i. The dispute is submitted to the decision of a single arbitrator to be appointedby the parties, or in the event of any disagreement between them upon
appointment of a single arbitrator, to the decision of two arbitrators each
appointed by the parties.ii. These two arbitrators shall appoint an Umpire, who presides at the meetings.The procedure during these meetings resembles that of a court of law. Each
party states his case, if necessary, with the help of a counsel and witnesses areexamined.iii. If the two arbitrators do not agree on a decision, the matter is submitted beforethe Umpire, who makes his award.iv. Costs are awarded at the discretion of the arbitrator/ arbitrators or Umpiremaking the award.Disputes relating to question of liability are to be settled through litigation.**Example**If the insurers contend that the loss is not payable because it is not covered under
the policy, the matter has to be decided by a Court of Law. Again, if the insurers
refuse to pay the claim on the ground that the policy is void because it was obtained
through fraudulent non-disclosure of material facts (breach of the legal duty of
‘utmost good faith’), the issue has to be resolved through litigation.**D.** **Other dispute resolution mechanisms**As per IRDAI regulations, all policies have to mention about the grievance redressalmechanism available to the insured in the event the insured is dissatisfied with theservice of the insurer for any reason.In case of claims under personal lines of business, a dissatisfied insured can
approach Insurance Ombudsman. The procedure is discussed in detail in Chapter 9.
The Office details of Insurance Ombudsman are given in the policy. Decision of
Ombudsman is binding on Insurer but not on insured.Matters like the financial authority and the limitations of Ombudsmen are also
discussed in detail in Chapter 9.61**Test Yourself 1**Which of the following activities would not be categorised under professionalsettlement of claims?I. Seeking information relating to the cause of the loss
II. Approaching the claim with a prejudice
III. Ascertaining whether the loss was a result of an insured peril
IV. Quantifying the amount payable under the claim**Answers to Test Yourself****Answer 1** - The correct option is II.**Key Terms**Turn Around TimeSalvageRecoveriesClaims Assessment62### CHAPTER C-0 7## DOCUMENTATION**Chapter Introduction**In the insurance industry we deal with a large number of forms and documents.
These are required for the purpose of bringing clarity in the relationship between
the insured and the insurer. In this chapter, we shall deal with the various
documents that are involved at the proposal stage and their significance.**After learning this Chapter you will be able to:**Understand proposal stage documentation and its importanceFamiliarize with the purposes of the ProspectusUnderstand the importance of the Proposal formAppreciate Anti-Money Laundering (AML), Know Your Customer (KYC) norms
and the important documents, commonly applicable for practically all
policiesImportance of Age Proof and acceptable documents.63**A.** **Prospectus**Prospectus is a proposal stage document. The prospectus is a formal legal document
used by insurance companies that provides details about the product. It can mean
a document issued by the insurer in physical, electronic or any other format to sell
or promote insurance products. For this purpose, Insurance products would also
include the add-on covers/ riders offered, if any. The prospectus is like an
introductory document which helps the prospective policyholder to get familiar with
the company’s products.As per IRDAI’s (Protection of Policyholders’ Interests) Regulations, 2017 the
prospectus should contain all facts that are necessary for a prospective policyholder
to make an informed decision regarding purchase of a policy. It should contain the
following for each plan of insurance:The Unique Identification Number (UIN) allotted by the Authority for the
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and the important documents, commonly applicable for practically all
policiesImportance of Age Proof and acceptable documents.63**A.** **Prospectus**Prospectus is a proposal stage document. The prospectus is a formal legal document
used by insurance companies that provides details about the product. It can mean
a document issued by the insurer in physical, electronic or any other format to sell
or promote insurance products. For this purpose, Insurance products would also
include the add-on covers/ riders offered, if any. The prospectus is like an
introductory document which helps the prospective policyholder to get familiar with
the company’s products.As per IRDAI’s (Protection of Policyholders’ Interests) Regulations, 2017 the
prospectus should contain all facts that are necessary for a prospective policyholder
to make an informed decision regarding purchase of a policy. It should contain the
following for each plan of insurance:The Unique Identification Number (UIN) allotted by the Authority for the
concerned insurance product- The extent of insurance coverThe Scope of benefits/ entitlements – guaranteed and non-guaranteedWarranties, exclusions/ exceptions of the insurance cover with explanations- The terms and conditions of the insurance coverDescription of the contingency or contingencies to be covered by insuranceThe class or classes of lives or property eligible for insurance under the terms
of such prospectusWhether the plan is participative or non-participativeThe allowable Add-on covers (also called Riders in Life insurance) on the productand their benefits are also stated.Other important information which a Prospectus includes:1. Any differences in covers and premium. E.g. for different age groups or fordifferent entry ages
2. Renewal terms of the policy
3. Terms of cancellation of policy under certain circumstances
4. The details of any discounts or loading applicable under differentcircumstances5. The possibility of any revision or modification of the terms of the policyincluding the premium
6. Any incentives to reward policyholders for early entry, continued renewals,favourable claims experience etc. with the same insurer.
7. Prospectus shall necessarily contain the product UIN allotted by IRDAI648. IRDAI Regulations mandate that Prospectus shall contain a copy of Section 41.This section prohibits any direct or indirect inducement to any person for
buying a new insurance, continuing or renewing any kind of insurance relating
to lives or property in India, including any rebate of the whole or part of the
commission payable on the policy.In particular the prospectus informs the proposer about the availability of facilityfor nomination.**Test Yourself 1**Which of the following it not usually part of the insurance prospectus?I. Name of OmbudsmanII. Date of Scope of benefitsIII. The EntitlementsIV. The Exceptions**B.** **Proposal Form**The insurance policy is a legal contract between the insurer and the policyholder.
As required for any contract, it has a proposal and its acceptance.The “Proposal form” is the application document that is used for making a proposal.
It is a form to be filled in by the proposer in written or electronic or any other
format approved by the Authority. It contains all information required by the insurer
to decide whether to accept or reject to cover the risk. In case the risk is accepted,
the insurer can on the basis of this information, decide the rates, terms and
conditions of the cover to be granted.The Principle of Utmost Good Faith and the Duty of Disclosure of material
information begin with the Proposal Form for insurance. The proposer must provide
all information correctly and completely as this document becomes the basis of
granting insurance and any wrong or concealed information could result in denial ofclaim.This duty to disclose continues beyond the proposal stage even after finalizing the
insurance contract. That is, any material change that happens anytime during the
period of insurance needs to be disclosed in non-life policies.Information collected from the Proposal Form during the course of solicitation of an
insurance policy or issuance of an insurance policy are confidential and should not
be shared with any third party. Where a proposal deposit is refundable to a prospect
for any reason, the same shall be refunded within 15 days from the date of
underwriting decision on the proposal.65As per IRDAI guidelines, it is the duty of the insurer to furnish to the insured, free
of charge, within 30 days of the acceptance of a proposal, a copy of the proposal
submitted by the Insured. The agent is expected to keep track of these timelines,
follow up internally and communicate with the prospect/ insured as and when
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conditions of the cover to be granted.The Principle of Utmost Good Faith and the Duty of Disclosure of material
information begin with the Proposal Form for insurance. The proposer must provide
all information correctly and completely as this document becomes the basis of
granting insurance and any wrong or concealed information could result in denial ofclaim.This duty to disclose continues beyond the proposal stage even after finalizing the
insurance contract. That is, any material change that happens anytime during the
period of insurance needs to be disclosed in non-life policies.Information collected from the Proposal Form during the course of solicitation of an
insurance policy or issuance of an insurance policy are confidential and should not
be shared with any third party. Where a proposal deposit is refundable to a prospect
for any reason, the same shall be refunded within 15 days from the date of
underwriting decision on the proposal.65As per IRDAI guidelines, it is the duty of the insurer to furnish to the insured, free
of charge, within 30 days of the acceptance of a proposal, a copy of the proposal
submitted by the Insured. The agent is expected to keep track of these timelines,
follow up internally and communicate with the prospect/ insured as and when
required by way of customer service.**a)** **Proposal Form - Details**The proposal form is first stage of documentation through which the insured informsthe insurer: Who he/ she is What kind of insurance he/ she needs Details of what he/ she wants to insure and For what period of time Details of the risk (E.g., for Life and Health insurances – details of health orany ailments suffered are to be given) Details would include the monetary value proposed on the subject matter ofinsurance and all **material facts** connected with the proposed insurance.In other words, the Proposal form collects details on the proposer’s identity such as
name, father’s name, address and other identifying inputs. To determine the true
identity of their customers, documents like address proof, PAN card, photographs
etc. are collected with the proposal.In respect of Life and Health insurances, details of the proposers’ family members
(including parents) indicating their longevity, status of health and ailments suffered
by any of them are collected. Depending on the product, the medical details of the
life proposed for insurance, personal characteristics and his/ her personal history
of disease may also be asked for.Details of the monetary value proposed on the subject matter of insurance and the
material facts connected with the proposed insurance would be collected for manylines of insurance.The insurance advisor’s recommendations including the reasons for such
recommendation may also be part of the proposal form. There would be a
declaration that the recommended policy’s details have been fully explained to the
proposer and the latter has acknowledged the same.A Proposal form may have the following Sections starting with details of the Insurer,
the Agent, the details of the product, the Sum Assured, the mode of payment of
premiums etc. The form would also contain the signature of the proposer, as proof
of the fact that he/ she has filled up the form and has submitted the proposal.66Other details asked for are the Proposer’s name, date of birth, contact details,
marital status, nationality, names of parents and spouse, educational qualifications,
habits and ID Proof, family particulars, employment details, bank details, name of
nominee/ appointee; details of existing insurance and reasons for opting for the
policy.Depending on the Product, medical details of the life proposed for insurance,
personal characteristics and his/ her personal history of disease may be asked for.Aspects related to the personal financial planning of the life being proposed
including his/ her work span, projected income and expenses, as well as needs for
savings and investment, health, retirement and insurance may also be enquiredabout.The Agents recommendations including the reasons for such recommendation may
also be part of the proposal form. In compliance to the IRDAI regulations mentioned
above, the Agent would make a declaration that the recommended policy’s details
have been fully explained to the proposer and the latter has acknowledged thesame.Proposal forms are printed by insurers usually with the insurance company’s name,
logo, address and the class/ type of insurance/ product that it is used for. It is
customary for insurance companies to add a printed note in the proposal form,
though there is no standard format or practice in this regard.**b)** **Declaration in the Proposal Form**Insurance companies usually add a declaration at the end of the proposal form to
be signed by the proposer. This ensures that the insured takes the pain to fill up the
form accurately and has understood the facts given therein, so that at the time of
a claim there is no scope for disagreements on account of misrepresentation of
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including his/ her work span, projected income and expenses, as well as needs for
savings and investment, health, retirement and insurance may also be enquiredabout.The Agents recommendations including the reasons for such recommendation may
also be part of the proposal form. In compliance to the IRDAI regulations mentioned
above, the Agent would make a declaration that the recommended policy’s details
have been fully explained to the proposer and the latter has acknowledged thesame.Proposal forms are printed by insurers usually with the insurance company’s name,
logo, address and the class/ type of insurance/ product that it is used for. It is
customary for insurance companies to add a printed note in the proposal form,
though there is no standard format or practice in this regard.**b)** **Declaration in the Proposal Form**Insurance companies usually add a declaration at the end of the proposal form to
be signed by the proposer. This ensures that the insured takes the pain to fill up the
form accurately and has understood the facts given therein, so that at the time of
a claim there is no scope for disagreements on account of misrepresentation of
facts. Such declaration converts the common law principle of utmost good faith to
a contractual duty of utmost good faith.**Example**Examples of such declarations are:‘I/ We hereby declare and warrant that the above statements are true and complete
in all respects and that there is no other information which is relevant to the
application for insurance that has not been disclosed to you.’‘I/ We agree that this proposal and the declarations shall be the basis of the contract
between me/ us and (insurer’s name).’67**Test Yourself 2**Which of the following is not relevant in respect of a Proposal form?I. Utmost Good-faith
II. Amount expected to be claimed
III. Duty to Disclose material facts
IV. Confidentiality of details given**Some examples of such notes are:**‘Non-disclosure of facts material to the assessment of the risk, providing misleading
information, fraud or non-co-operation by the insured will nullify the cover under
the policy issued’.‘The company will not be on risk until the proposal has been accepted by the
Company and full premium paid’.**C.** **Know Your Customer (KYC) Norms****Anti-Money Laundering and KYC Norms**Money Laundering is the process by which criminals transfer funds to conceal the
true origin and ownership of the proceeds of criminal activities. Money laundering
processes are used by criminals to make funds obtained through illegal activities
appear legal money. In the process, they try to cover up the criminal origin of the
money and make it appear valid.Criminals attempt to use financial services, including banks and insurance, to
launder their money. They make transactions using false identities, for example, by
purchasing some form of insurance and then managing to withdraw that money and
then disappearing once their purpose is served. Governments across the world,
including India constantly try to prevent such money laundering attempts.**Definition**Money laundering is the process of bringing illegal money into an economy by hiding
its illegal origin so that it appears to be legally acquired. The Government of India
launched the PMLA, 2002 to rein in money-laundering activities.The Prevention of Money Laundering Act (PMLA), 2002 came into effect from 2005
to control money laundering activities and to provide for confiscation of property
derived from money-laundering.The Anti-Money Laundering guidelines issued by IRDAI soon after have indicated
suitable measures to determine the true identity of customers requesting for
insurance services, reporting of suspicious transactions and proper record keeping
of cases involving or suspected of involving money laundering. It is necessary to be68vigilant and ensure, right at the beginning of the contract that it is not intended to
be a tool for money laundering of any sort.The Prevention of Money Laundering Act, 2002 (PMLA) was been brought into force
by the Government of India with effect from 1st July 2005. As per the Act, every
banking company, financial institution (which includes Insurance companies) and
intermediary shall have to maintain a record of all the transactions prescribed under
the PMLA. Accordingly, IRDAI issued the Guidelines on Anti-Money laundering/
Counter Financing of Terrorism (AML/ CFT) 31st March 2006.Know your customer is the process used by a business to verify the identity of their
clients. Banks and insurers are increasingly demanding their customers provide
detailed information to prevent identity theft, financial fraud and money
laundering. The objective of KYC guidelines is to prevent financial institutions from
being used by criminal elements for money laundering activities.Insurers, hence, need to determine the true identity of their customers. Agents
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of cases involving or suspected of involving money laundering. It is necessary to be68vigilant and ensure, right at the beginning of the contract that it is not intended to
be a tool for money laundering of any sort.The Prevention of Money Laundering Act, 2002 (PMLA) was been brought into force
by the Government of India with effect from 1st July 2005. As per the Act, every
banking company, financial institution (which includes Insurance companies) and
intermediary shall have to maintain a record of all the transactions prescribed under
the PMLA. Accordingly, IRDAI issued the Guidelines on Anti-Money laundering/
Counter Financing of Terrorism (AML/ CFT) 31st March 2006.Know your customer is the process used by a business to verify the identity of their
clients. Banks and insurers are increasingly demanding their customers provide
detailed information to prevent identity theft, financial fraud and money
laundering. The objective of KYC guidelines is to prevent financial institutions from
being used by criminal elements for money laundering activities.Insurers, hence, need to determine the true identity of their customers. Agents
should ensure that proposers submit the proposal form along with the following as
part of the KYC procedure:i. Proof of identity – driving license, passport, voter ID card, PAN card,Photographs etc.ii. Proof of address – driving license, passport, telephone bill, electricity bill,bank passbook etc. Different documentation are prescribed for individuals,
corporates, partnership firms, trusts and foundationsiii. Income proof documents and financial status, esp. in case of high-valuetransactionsiv. Purpose of insurance contract**a)** **Age Proof – for Personal Lines**While dealing with person related insurances like Life, Health, Personal Accident,
etc. Insurance companies use age as an important factor to determine the risk
profile of the insured. In life business, as age assumes great importance, life insurers
used to follow more detailed norms of age related documentation. [However, the
Government, the Reserve Bank of India and the IRDAI are becoming stricter on
following KYC norms.]An important part of the underwriting process is admission of
age, after verifying the proof of age.**i.** **Standard Age Proofs**There are two types of age proofs that insurers come across as evidence of
age. Valid age proofs may be standard or non-standard. Standard **age proofs** are normally issued by a public authority, like birthcertificate issued by a municipality or other government body, school
leaving certificate, passport etc.69 Non-standard, when a standard age proof is not available (not to beaccepted readily)Some documents considered as standard age proofs are:i. School or college certificateii. Birth certificate extracted from municipal recordsiii. Passportiv. PAN cardv. Service registervi. Identity card in case of defence personnelvii. Marriage certificate issued by appropriate authority**ii.** **Non-standard age proofs**When standard age proofs like the above are not available, the life insurer
may allow submission of a non-standard age proof. Some documents
considered as non-standard age proofs are:i. Horoscopeii. Ration cardiii. An affidavit by way of self-declarationiv. Certificate from village panchayat**Test Yourself 3**Which of the following is not acceptable as valid Age Proof?I. Birth certificate extracted from municipal recordsII. Birth Certificate issued by Member of Legislative AssemblyIII. PassportIV. PAN Card**Answers to Test Yourself****Answer 1** -The correct option is I.
**Answer 2** - The correct option is II.
**Answer 3** – The correct option is II.**Summary**Prospectus is a formal legal document used by insurance companies that
provides details about the product.The application document used for making the proposal is commonly known as
the ‘proposal form’.70Some documents considered as standard age proofs include school or college
certificate, birth certificate extracted from municipal records etc.Insurers need to determine the true identity of their customers. KYC documents
like address proof, PAN card and photographs etc. need to be collected as a part
of the KYC procedure.**Key Terms**1. Prospectus
2. Proposal form
3. Moral hazard
4. Know your Customer (KYC)
5. Age Proof
6. Standard and non-standard age proofs
7. Free-look period71### CHAPTER C-0 8## CUSTOMER SERVICE**Chapter Introduction**In this chapter you will learn the importance of customer service. You will learn the
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**Answer 2** - The correct option is II.
**Answer 3** – The correct option is II.**Summary**Prospectus is a formal legal document used by insurance companies that
provides details about the product.The application document used for making the proposal is commonly known as
the ‘proposal form’.70Some documents considered as standard age proofs include school or college
certificate, birth certificate extracted from municipal records etc.Insurers need to determine the true identity of their customers. KYC documents
like address proof, PAN card and photographs etc. need to be collected as a part
of the KYC procedure.**Key Terms**1. Prospectus
2. Proposal form
3. Moral hazard
4. Know your Customer (KYC)
5. Age Proof
6. Standard and non-standard age proofs
7. Free-look period71### CHAPTER C-0 8## CUSTOMER SERVICE**Chapter Introduction**In this chapter you will learn the importance of customer service. You will learn the
role of agents in providing service to customers. You will also learn how tocommunicate and relate with customers.After studying this chapter, you should be able to:Understand the importance of customer service1. Describe quality of service2. Examine the importance of service in the insurance industry3. Discuss the role of an insurance agent in providing good service4. Explain the process of communication5. Demonstrate the importance of non-verbal communication6. Recommend ethical behaviour72**A.** **Customer Service – General concepts****1.** **Why Customer Service?**Customers are the most important part of any industry and no enterprise can afford
to treat them indifferently. The role of customer service and relationships is
important in the service sector and more so for insurance.Every enterprise has a goal to delight its customers. This can be explained by
examining how buying insurance differs from buying a car.A car can be seen, touched, test driven and experienced, whereas the Insurance of
the car is just a promise to pay if there is loss or damage to the car due to an
accident. This promise is intangible – it cannot be seen, touched or experienced.While the customer of the car will be able to understand and experience the car
easily, the customer of insurance can evaluate and experience the insurance
protection that he buys only when a loss happens and the insurance company settles
the claim. All customers do not get the chance to experience this. In insurance,
when such a situation arises, if the service exceeds expectations, the customer
would be delighted.**2.** **Quality of service**It is necessary for insurance companies and their personnel, which includes their
agents, to render high quality service and delight the customer.**But what is high quality service? What are its attributes?**The well-known SERVQUAL approach to service quality of Zeithaml, Parasuraman
and Berry highlights 5 major indicators of service quality:**a)** **Reliability** : The ability to perform the promised service dependably andaccurately is considered the most important indicator of good service. It isthe foundation on which trust is built.**b)** **Responsiveness** : Refers to the willingness and ability of service personnel tohelp customers and provide prompt response to the customer’s needs. It may
be measured by indicators like speed, accuracy, and attitude while givingthe service.**c)** **Assurance** : Refers to the knowledge, competence and courtesy displayed byan employee or agent in understanding and meeting the needs of a customer,
thus conveying trust and confidence.**d)** **Empathy** : Empathy is described as the human touch. It is reflected in thecaring attitude and individualised attention provided to customers.**e)** **Tangibles** : Represent physical environmental factors like location, layoutand cleanliness as also the sense of professionalism that a customer feels
when contacting a service provider. First impressions last long.73**3.** **Customer service and insurance**Leading sales producers in the insurance industry state that the secret of reaching
the top and staying there is in getting the patronage and support of a large number
of existing clients with whose help the business gets built. These clients are a source
of commissions from renewal of existing contracts. These can be a valuable source
for acquiring new customers.One great mantra of success in insurance selling is to be able to convert one’s
customers into one’s clients. Customers are those who buy a product. Clients, on
the other hand are people with whom an agent relates for life, who continue to buy
from him/ her as also help and possibly, support him/ her in reaching out to and
selling to other customers.Clients are built by working with deep commitment to serving one’s customers. To
understand how keeping a customer happy benefits the agent and the company, one
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Final IC 38 - IA_English Common_037
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when contacting a service provider. First impressions last long.73**3.** **Customer service and insurance**Leading sales producers in the insurance industry state that the secret of reaching
the top and staying there is in getting the patronage and support of a large number
of existing clients with whose help the business gets built. These clients are a source
of commissions from renewal of existing contracts. These can be a valuable source
for acquiring new customers.One great mantra of success in insurance selling is to be able to convert one’s
customers into one’s clients. Customers are those who buy a product. Clients, on
the other hand are people with whom an agent relates for life, who continue to buy
from him/ her as also help and possibly, support him/ her in reaching out to and
selling to other customers.Clients are built by working with deep commitment to serving one’s customers. To
understand how keeping a customer happy benefits the agent and the company, one
should understand the concept of Customer’s Lifetime Value.**Customer Lifetime Value** may be defined as the sum of economic benefits that can
be derived from building a sound relationship with a customer over a long period oftime.**Diagram 1:** **Customer Lifetime Value**An agent who renders service and builds close relationships with her customers,
builds goodwill and brand value, which helps in expanding the business.**Test Yourself 1**What is meant by customer lifetime value?I. Sum of costs incurred while servicing the customer over his lifetime
II. Rank given to customer based on business generated
III. Sum of economic benefits that can be achieved by building a long termrelationship with the customerIV. Maximum insurance that can be attributed to the customer74**4.** **Customer Relationships and Service**While customer service is a key element in creating satisfied and loyal customers,
it is also necessary to build a strong relationship with them. A Customer’s views
about an insurer depends on the service and relationships experience the insureroffers.What goes to make a healthy relationship? At its heart, of course, there is trust. At
the same time, there are other elements, which reinforce and promote that trust.Let us illustrate some of the elements.**Diagram 2:** **Elements for Trust**i. Every relationship begins with **attraction** : Attraction means being liked and beingable to build a rapport with the customer, starting with creating a great first
impression. Attraction is regarded the key to unlocking every heart. Without it a
relationship is hardly possible. A sales person cannot make much headway if he/
she is not liked by the customer.ii. The second element of a relationship is one’s presence, being there when needediii. **Communication:** Even if one is not fully present and unable to do full justice toall the expectations of one’s customers, one can still **maintain a strong**
**relationship by communicating in a manner that is assuring, full of empathy**
**and conveying a sense of responsibility.**The above dimensions of communication call for discipline and skills. They
ultimately reflect how one thinks and sees.Companies emphasise on customer relationship management, as the cost of
retaining a customer is far lower than acquiring a new customer. A customer relation
opportunity arises at various touch points e.g. while understanding customers
insurance needs, explaining coverage’s, handing over forms etc.**B.** **Insurance agent’s role in providing customer service.**Let us now consider how an agent can render great service to the customer. It is
important to realise that from the moment a customer gets contacted by a sales
person to the final point of settlement of a claim, the customer goes on a journey
of experience that we shall call the ‘ **Customer Journey’** . The agent needs to
partner with the customer through the entire duration of the contract, hand holding75him/ her in each step of the journey to create memorable experiences at everystep.Let us look at some milestones in the journey and the role played at each step.**1.** **The Sale**It is said that selling is both an art and a science. It is a science because it calls for
a set process which, if consistently and properly followed, is likely to lead to
success. It is also an art in the sense that each sales person brings his or her
distinctive beliefs, style and personality into the process and the results depend on
what each person puts into the process.- **Prospecting:** The Sales Process begins with **Prospecting**, which literally means
‘searching’ for a prospective customer. Searching is important as ‘ _**One cannot**_
_**find till one searches’,**_ it is the most important step in the process. An agent
typically begins with his or her natural market, made up of known and easily
approachable people. The challenge lies in getting across to more networks of
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Final IC 38 - IA_English Common.md
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r74
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Customer service and insurance
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Final IC 38 - IA_English Common_038
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of experience that we shall call the ‘ **Customer Journey’** . The agent needs to
partner with the customer through the entire duration of the contract, hand holding75him/ her in each step of the journey to create memorable experiences at everystep.Let us look at some milestones in the journey and the role played at each step.**1.** **The Sale**It is said that selling is both an art and a science. It is a science because it calls for
a set process which, if consistently and properly followed, is likely to lead to
success. It is also an art in the sense that each sales person brings his or her
distinctive beliefs, style and personality into the process and the results depend on
what each person puts into the process.- **Prospecting:** The Sales Process begins with **Prospecting**, which literally means
‘searching’ for a prospective customer. Searching is important as ‘ _**One cannot**_
_**find till one searches’,**_ it is the most important step in the process. An agent
typically begins with his or her natural market, made up of known and easily
approachable people. The challenge lies in getting across to more networks of
people who are outside one’s immediate circle – getting to know them and be
known by them.All the people one knows and approaches may not be proper candidates for
insurance or they may not be interested in buying. It is thus necessary to **qualify**
them so that one targets only those who are likely to buy insurance. The
prospecting process becomes successful only when an agent is able to build
strong relationships with the prospect. The first task of any sales person is thus
to **sell trust and build confidence.**_**Invite for an Interview:**_ While personal relationships are the foundation on
which insurance business is built, it is necessary to convert the goodwill one
earns into a sale. This begins when the sales person sets up a formal appointment
for a detailed sales interview. This step is critical for establishing one’s
professional credentials and also to separate business from casual discussions.- _**Determining the needs and recommending the Solution:**_ The heart of the Sales
Interview is the steps wherein the sales agent determines and makes the
prospective customer aware about the exact needs for which insurance is a
solution. A master sales person is distinguished by his/ her skill in guiding a
prospect, through asking gentle questions, to understand the gaps in protection
that give rise to the needs for insurance.The Agent has the responsibility to provide _Best Advice_ to the Prospect about the
right kind of insurance solutions to meet his/ her needs. Firstly one must determine
and make the prospective customer aware about the exact needs for which
insurance is a solution. This also includes giving proper advice on the amount of
insurance to be purchased. For example the amount of life insurance to be76purchased by an individual needs to be linked to his/ her income and paying
capacity.It is also important to keep a basic percept in mind, especially when buying non-life
insurance: Do not recommend insuring where the risk can be managed otherwise.Whether insurance is needed or not, depends on the circumstances. If the premium
payments are high compared to the loss involved, it may be advisable to just bear
the risk. On the other hand, if the loss consequences of a risk are likely to be severe,
it is wise to insure against it.**Example**To a homeowner living in a flood prone area, purchasing an add-on cover against
floods would prove to be helpful. On the other hand, if the home owner owns a
home at a place where the risk of floods is negligible it may not be necessary toobtain such cover.Many customers may not be much concerned about getting maximum insurance per
rupee spent, but would be interested in **reducing the cost of handling risk** . The
concern would be thus on identifying those risks which a customer cannot retainand hence must be insured.The agent becomes successful when he/ she renders best advice. The agent needs
to constantly ask himself/ herself about his/ her role vis-à-vis the customer. He/
she should go to the customer not just to get a sale but to relate to the customer
as a coach and partner who can help him/ her to manage his/ her risks more
effectively?_**Handling Objections and Closing the Sale:**_ It may not be enough to give best
advice and recommendations to a customer about the right products to buy. One
also needs to persuade him/ her to take the decision to buy. Quite often the
customer may have a number of questions and may raise objections that need
to be addressed before he/ she decides to commit to the purchase. Whilst
handling these objections, it is vitally important to understand that the
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Final IC 38 - IA_English Common.md
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Customer Journey’
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Final IC 38 - IA_English Common_039
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home at a place where the risk of floods is negligible it may not be necessary toobtain such cover.Many customers may not be much concerned about getting maximum insurance per
rupee spent, but would be interested in **reducing the cost of handling risk** . The
concern would be thus on identifying those risks which a customer cannot retainand hence must be insured.The agent becomes successful when he/ she renders best advice. The agent needs
to constantly ask himself/ herself about his/ her role vis-à-vis the customer. He/
she should go to the customer not just to get a sale but to relate to the customer
as a coach and partner who can help him/ her to manage his/ her risks more
effectively?_**Handling Objections and Closing the Sale:**_ It may not be enough to give best
advice and recommendations to a customer about the right products to buy. One
also needs to persuade him/ her to take the decision to buy. Quite often the
customer may have a number of questions and may raise objections that need
to be addressed before he/ she decides to commit to the purchase. Whilst
handling these objections, it is vitally important to understand that the
objections being voiced may reflect underlying concerns that need to beidentified and resolved.In sum, the role of an insurance agent is more than that of a mere sales person. He/
she also **needs to be a risk assessor, underwriter, risk management counsellor,**
**designer of customised solutions and a relationship builder** (who thrives on
building trust and long-term relationships), all rolled into one.**2.** **The Proposal stage**The agent has to support the customer in filling out the proposal for insurance. The
insured is required to take responsibility for the statements made therein. The
salient aspects of a proposal form have been discussed in a later chapter.77The agent should explain and clarify to the proposer the details to be filled as
answers to each of the questions in the proposal form. A failure to give proper and
complete information can jeopardise the customer’s claim.Sometimes, if additional information is required to complete the policy, the
company may inform the customer directly or through the agent/ advisor. The agent
should help the customer in completing such formalities, explaining why they arenecessary.IRDAI (Issuance of e-Insurance Policies) Regulations, 2016, provide for e – Proposal
forms that are similar to the physical proposal form and having a provision to the
Prospect to give his consent to the proposal, which can be validated by one time
password (mobile phone OTP).**3.** **Acceptance stage****a)** **Cover notes/ Certificates of Insurance**After underwriting is completed it may take some time before the policy is issued.
Pending the preparation of the policy or when the negotiations for insurance are
in progress and it is necessary to provide cover on a provisional basis or when the
premises are being inspected for determining the actual rate applicable, a cover
note is issued to confirm protection under the policy.As Cover notes and Certificates of Insurance are used predominantly in marine
and motor classes of business, cover note is discussed in detail under the GeneralInsurance Section.It is the agent’s responsibility to ensure that the cover note is issued by the
company, where applicable, to the insured. Promptness in this regardcommunicates to the client that his/ her interests are safe in the hands of theagent and the company.**b)** **Policy Document**The policy is a formal document which provides an evidence of the contract of
insurance. This document has to be stamped in accordance with the provisions
of the Indian Stamp Act, 1899. The insurer is duty bound to give the policydocument to the insured.**4.** **Premium Payment****Premium** is the consideration or amount paid by the insured to the insurer for
insuring the subject matter of insurance, under a contract of insurance.A good agent takes active interest in ensuring that the insured pays the premium
for taking or continuing or renewing his policy and the customer is made aware
of various options available for payment of premium.78**5.** **Method of payment of premium**The premium to be paid by any person proposing to take an insurance policy or by
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Final IC 38 - IA_English Common.md
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Handling Objections and Closing the Sale:
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Final IC 38 - IA_English Common_040
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and motor classes of business, cover note is discussed in detail under the GeneralInsurance Section.It is the agent’s responsibility to ensure that the cover note is issued by the
company, where applicable, to the insured. Promptness in this regardcommunicates to the client that his/ her interests are safe in the hands of theagent and the company.**b)** **Policy Document**The policy is a formal document which provides an evidence of the contract of
insurance. This document has to be stamped in accordance with the provisions
of the Indian Stamp Act, 1899. The insurer is duty bound to give the policydocument to the insured.**4.** **Premium Payment****Premium** is the consideration or amount paid by the insured to the insurer for
insuring the subject matter of insurance, under a contract of insurance.A good agent takes active interest in ensuring that the insured pays the premium
for taking or continuing or renewing his policy and the customer is made aware
of various options available for payment of premium.78**5.** **Method of payment of premium**The premium to be paid by any person proposing to take an insurance policy or by
the policyholder to an insurer may be made in any one or more of the followingmethods:a) Cashb) Any recognised banking negotiable instrument such as cheques, demanddrafts, pay order, banker’s cheques drawn on any schedule bank in India;c) Postal money order;d) Credit or debit cards;e) Bank guarantee or cash deposit;f) Internet;g) E-transferh) Direct credits via standing instruction of proposer or the policyholder or thelife insured through bank transfers;i) Any other method or payment as may be approved by the Authority fromtime to time;As per IRDA Regulations, in case the proposer/ policyholder opts for premium
payment through net banking or credit/ debit card, the payment must be made
only through net banking account or credit/ debit card issued on the name of
such proposer/ policyholder.**6.** **Service after issuance of Policy Document and Receipt for Premium**Once the premium is paid by the customer, the insurer is bound to issue a
receipt. A receipt is also to be issued even in case the premium is paid inadvance.The agent may approach the insured and enquire whether the Policy Document
has been received from the insurance company. It presents a great opportunity
for the agent to connect with the customer. The agent will be able to clear any
doubts and also explain the various policy provisions and policy holders’ rights
and privileges. This demonstrates commitment to the customer and provides an
opportunity to pledge continued support and service. One should also inform the
customer about the free-look period provision, during which period, the policy
can be returned and refund of premium obtained.If the policy being purchased is an Electronic insurance policy, the agent can
help the Customer to open an e-Insurance Account (e-I-A), through the
Registered Insurance Repository.79This also paves the way for the next step which is to ask the customer for the
names and particulars of other individuals he/ she knows, who can possibly
benefit from the agent’s services. It would be even better if the client itself
contacted these people and introduced the agent to them.**7.** **Policy Renewal**Most general Insurance policies have to be renewed each year. For general
insurance policies, at the time of each renewal, the customer has a choice to
continue insuring with the same company or switch to another company. In case
of Life Insurance, a policy would continue to be in force when the customer pays
the premium at regular intervals based on premium payment term. This does
not apply to one-time payments.General Insurers usually send a Renewal Notice, well in advance of the date of
expiry of the premium paying period, inviting renewal of the policy.The customer’s choice to renew or continue with the policy may often depend
on the trust and goodwill created by the agent and company and the agent needs
to be in touch to remind the customer about the renewal or continuity of policywell before the due date.High producer agents constantly keep in touch with their clients, and win their
trust and loyalty through various acts of service and relationships – like greeting
their clients on various occasions like festivals or family events and being with
them to share their joys and sorrows.**8.** **The claim stage**The crucial test comes at the time of claim settlement. The agent must ensure
that the incident giving rise to the claim is immediately informed to the insurer
and that the customer carefully follows all the formalities. The agent may also
assist in all the investigations that may need to be done to assess the loss. A
good agent assists the customers or his representatives in fulfilling the claim
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Policy Document
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Final IC 38 - IA_English Common_041
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the premium at regular intervals based on premium payment term. This does
not apply to one-time payments.General Insurers usually send a Renewal Notice, well in advance of the date of
expiry of the premium paying period, inviting renewal of the policy.The customer’s choice to renew or continue with the policy may often depend
on the trust and goodwill created by the agent and company and the agent needs
to be in touch to remind the customer about the renewal or continuity of policywell before the due date.High producer agents constantly keep in touch with their clients, and win their
trust and loyalty through various acts of service and relationships – like greeting
their clients on various occasions like festivals or family events and being with
them to share their joys and sorrows.**8.** **The claim stage**The crucial test comes at the time of claim settlement. The agent must ensure
that the incident giving rise to the claim is immediately informed to the insurer
and that the customer carefully follows all the formalities. The agent may also
assist in all the investigations that may need to be done to assess the loss. A
good agent assists the customers or his representatives in fulfilling the claim
lodgement formalities quickly, correctly and completely.**Test Yourself 2**Identify the scenario where a debate on the need for insurance is not required.I. Property insurance
II. Business liability insurance
III. Motor insurance for third party liabilityIV. Fire insurance80**C.** **Communication skills in customer service**An agent needs to possess soft skills for effective performance in the work place.S **oft skills relate to one’s ability to interact effectively with others, both at work**
**and outside. Communication skills are the most important of these soft skills.****1.** **Process of communication**What is communication?All communications require a sender, who sends a message, and a person who
received that message. The process is complete once the receiver has understood
the message of the sender.**Diagram 3:** **Forms of communication**Communication may be face to face, over the phone, or by mail or internet. It may
be formal or informal. Whatever the content or form of the message or the media
used, the effectiveness of communication depends on whether or not the recipient
has understood what was sought to be communicated.Since an insurance policy is essentially a promise, it is important that what is
promised by the insurer is clearly understood by the insured. The agent as an
intermediary has to not only provide complete, accurate and unambiguous account
of the terms of the insurance to the customer, but also seek and clarify doubts or
queries that a customer may have.**2.** **Barriers to effective communication**Different kinds of barriers to effective communication can arise at each step in the
above process, due to which communication can get distorted. The challenge is to
visualize, understand and remove the barriers.**Test Yourself 3**What does not go on to make a healthy relationship?I. AttractionII. TrustIII. CommunicationIV. Dislike81**D.** **Non-verbal Communication**Let us now look at some concepts that the agent needs to understand.**Important****1.** **Making a great first impression**The prospect judges an agent based on his appearance, body language, mannerisms,
dress and speech. As attraction is the first pillar of a relationship and first
impressions last long, some tips for making a good first impression are given below:**i.** **Be on time always** . Plan to arrive a few minutes early, allowing flexibilityfor all kinds of possible delays.**ii.** **Present yourself appropriately** . The appearance should to create the right first impression
The dress must be appropriate for the meeting or occasion
The look must be clean and tidy – with good haircut and shave, clean andtidy clothes, neat and tidy make up**iii.** **A warm, confident and winning smile** puts a person and his/ her audienceimmediately at ease with one another.**iv.** **Being open, confident and positive** body language must project confidence and self-assurance stand tall, smile, make eye contact, greet with a firm handshake remain positive even in the face of some criticism or when the meeting isnot going as well as expected**v.** **Interest in the other person** - The most important thing is about beinggenuinely interested in the other person. Take some time to find out about the customer as a person Be caring and attentive to what he or she says Be totally present and available to your customer Not engaging in one’s mobile phone during the interview?**2.** **Body language**Body language refers to movements, gestures, facial expressions. The way we talk,
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Final IC 38 - IA_English Common.md
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The claim stage
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Final IC 38 - IA_English Common_042
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The dress must be appropriate for the meeting or occasion
The look must be clean and tidy – with good haircut and shave, clean andtidy clothes, neat and tidy make up**iii.** **A warm, confident and winning smile** puts a person and his/ her audienceimmediately at ease with one another.**iv.** **Being open, confident and positive** body language must project confidence and self-assurance stand tall, smile, make eye contact, greet with a firm handshake remain positive even in the face of some criticism or when the meeting isnot going as well as expected**v.** **Interest in the other person** - The most important thing is about beinggenuinely interested in the other person. Take some time to find out about the customer as a person Be caring and attentive to what he or she says Be totally present and available to your customer Not engaging in one’s mobile phone during the interview?**2.** **Body language**Body language refers to movements, gestures, facial expressions. The way we talk,
walk, sit and stand, all says something about us, and what is happening inside us.It is often said that people listen to only a small percentage of what is actually said.
What we don’t say may speak a lot more about us in a louder way. Obviously, one
needs to be very careful about one’s body language.82**a)** **Confidence**Here are a few tips about how to appear confident and self-assured, giving the
impression of someone to be seriously listened to: Posture – standing tall with shoulders held back. Solid eye contact - with a "smiling" face Purposeful and deliberate gestures**b)** **Trust** Quite often, a sales person’s words fall on deaf ears because the audiencedoes not trust him/ her – his/ her body language does not give the assurance
that he/ she is sincere about what he/ she says**3.** **Listening skills**The third set of communication skills that one needs to be aware about and cultivateare listening skills. These follow from a well-known principle of personal
effectiveness – ‘first try to understand before being understood’.Active listening calls for: Allowing the speaker to finish each point before asking questions Not interrupting the speaker with any counter arguments This may require that we reflect on the message and ask questions to clarifywhat was said Another way to provide feedback is to summarize the speaker’s words andrepeat it back to him or her periodically or at the end of the conversation.**Let us look at the skills required for active listening:****a)** **Demonstrating that one is listening:** For instance one may: Give an occasional nod and smile Adopt a posture that is open and draws out the other to speak freely Have small verbal comments like "I understand", "I see", "yes" and "uh".**b)** **Paying attention**One needs to give the speaker one’s undivided attention, and acknowledge him.
Some aspects of paying attention are as follows:Look at the speaker directly Put aside distracting thoughts Don't mentally prepare a rebuttal83 Avoid all external distractions [for instance, keep your mobile on silentmode] "Listen" to the speaker's body language**c)** **Removing filters:**A lot of what we hear may get distorted by one’s personal filters, like the
assumptions, judgments, and beliefs one carries.**Not being judgemental: If the listener is judgemental,** even if he hears what
the speaker is saying, he will understand only according to his biased
interpretation.**d)** **Empathetic listening:****Empathy implies hearing and listening patiently, and with full attention, to**
**what the other person has to say, even when one does not agree with it. It**
**is important to show the speaker acceptance, not necessarily agreement.****e)** **Responding appropriately:**Active listening implies much more than just hearing what a speaker says. The
communication can be completed only when the listener responds in some way,
through word or action. Certain rules need to be followed for ensuring that the
speaker is not put down but treated with respect.These include: Being candid, open, and honest in your response Asserting one’s opinions respectfully Treating another person in a way, one would like oneself to be treated**Example****Asking for clarity** – “I realize that we have not been able to clear about the benefits
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Final IC 38 - IA_English Common.md
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A warm, confident and winning smile
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Final IC 38 - IA_English Common_043
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assumptions, judgments, and beliefs one carries.**Not being judgemental: If the listener is judgemental,** even if he hears what
the speaker is saying, he will understand only according to his biased
interpretation.**d)** **Empathetic listening:****Empathy implies hearing and listening patiently, and with full attention, to**
**what the other person has to say, even when one does not agree with it. It**
**is important to show the speaker acceptance, not necessarily agreement.****e)** **Responding appropriately:**Active listening implies much more than just hearing what a speaker says. The
communication can be completed only when the listener responds in some way,
through word or action. Certain rules need to be followed for ensuring that the
speaker is not put down but treated with respect.These include: Being candid, open, and honest in your response Asserting one’s opinions respectfully Treating another person in a way, one would like oneself to be treated**Example****Asking for clarity** – “I realize that we have not been able to clear about the benefits
of some of our health plans. Could you help us by asking us your doubts?”**Paraphrasing the speaker’s exact words** – “So, you are saying that ‘our health plans
are not attractive enough’ – Have I understood you correctly?”**Test Yourself 4**Which among the following is not an element of active listening?I. Paying good attention
II. Being extremely judgemental
III. Empathetic listening
IV. Responding appropriately84**E.** **Ethical Behavior**In recent years, there are many reports of improper conduct, and serious concerns
have been raised about ethical behaviour in business causing betrayal of trust.This has led to discussions about concepts like accountability, corporate
governance, and treating customers fairly in insurance, which form part of “Ethics”in business.It is not wrong to look after one’s interests. But it is wrong to do so at the cost ofthe interests of others. Unethical behaviour arises when there is no concern forothers and there is high concern for oneself.**Insurance is a business of trust** . Breach of trust amounts to cheating. When wrong
information is given to prospects tempting them to buy insurance, or if the insurance
given does not cater to the specific needs of the prospect, things go wrong.The Code of Ethics spelt out by the IRDAI in various regulations are directed towards
ethical behaviour. It is not enough just to know the code. What is more important
for the insurers and their representatives is to always keep the interests of the
prospect/ policy holder as primary.**Characteristics:** Some characteristics of ethical behaviour are:a) Placing the best interests of the client above one’s own direct or indirectbenefitsb) Holding in strictest confidence and considering as privileged, all business andpersonal information pertaining to client’s affairsc) Making full and adequate disclosure of all facts to enable clients make informeddecisionsThere could be a likelihood of ethics being compromised in the following situations:a) Having to choose between two plans, one giving much less premium orcommission than the otherb) Temptation to recommend discontinuance of an existing policy and taking out anew onec) Being aware of circumstances that, if known to the insurer, could adverselyaffect the interests of the client or the beneficiaries of the claim.**Test Yourself 5**Which among the following is not a characteristic of ethical behaviour?
I. Making adequate disclosures to enable the clients to make an informed decision
II. Maintaining confidentiality of client’s business and personal information
III. Placing self-interest ahead of client’s interests
IV. Placing client’s interest ahead of self interest85**Summary**a) The role of customer service and relationships is far more critical in the case ofinsurance than in other products.b) Five major indicators of service quality include reliability, responsiveness,assurance, empathy and tangibles.c) Customer lifetime value may be defined as the sum of economic benefits thatcan be derived from building a sound relationship with a customer over a long
period of time.d) The role of an insurance agent in the area of customer service is absolutelycritical.e) Active listening involves paying attention, providing feedback and respondingappropriately.f) Ethical behaviour involves placing the customer’s interest before one’s own.**Key terms**a) Quality of serviceb) Empathyc) Body languaged) Active listeninge) Ethical behavior**Answers to Test Yourself****Answer 1** -The correct option is III.
**Answer 2** - The correct option is III.
**Answer 3** - The correct option is IV.
**Answer 4** - The correct option is II.
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Not being judgemental: If the listener is judgemental,
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II. Maintaining confidentiality of client’s business and personal information
III. Placing self-interest ahead of client’s interests
IV. Placing client’s interest ahead of self interest85**Summary**a) The role of customer service and relationships is far more critical in the case ofinsurance than in other products.b) Five major indicators of service quality include reliability, responsiveness,assurance, empathy and tangibles.c) Customer lifetime value may be defined as the sum of economic benefits thatcan be derived from building a sound relationship with a customer over a long
period of time.d) The role of an insurance agent in the area of customer service is absolutelycritical.e) Active listening involves paying attention, providing feedback and respondingappropriately.f) Ethical behaviour involves placing the customer’s interest before one’s own.**Key terms**a) Quality of serviceb) Empathyc) Body languaged) Active listeninge) Ethical behavior**Answers to Test Yourself****Answer 1** -The correct option is III.
**Answer 2** - The correct option is III.
**Answer 3** - The correct option is IV.
**Answer 4** - The correct option is II.
**Answer 5** - The correct option is III.86### CHAPTER C-0 9## GRIEVANCE REDRESSAL MECHANISM**Chapter Introduction**Insurance industry is essentially a service industry where customer expectations are
constantly rising. There is dissatisfaction with the standard of services. Despite
continuous product innovation and significant improvement in the level of customer
service, aided by use of modern technology, the industry suffers badly in terms of
customer dissatisfaction and poor image. The Government and the regulator have
taken a number of initiatives to improve the situation.IRDAI Regulations on Protection of Policyholders’ Interests 2017 mandate that every
Insurer shall have their own board approved policy for protection of policyholders’
interests which shall includei. Service parameters including turnaround times for various services rendered.
ii. Procedure for speedy resolution of complaints.**Learning Outcomes**87**A.** **Grievance Redressal**The time for high priority action is when the customer has a complaint. Remember
that in the case of a complaint, the customer is angry due to a failure of service.
This is only a part of the story.Many times, Customers get upset because they understand the situation wrongly.
All service failures causes two types of feelings:1. A feeling that the insurer was unfair (a feeling of being cheated)2. A feeling of hurt ego (being made to look and feel small)The customers want to feel valued and human touch is critical in this situation. Asa professional insurance advisor first of all, the agent would not allow such a
complaint situation to happen. He would take up the matter with the appropriate
officer of the company.A complaint is a crucial “ **moment of truth** ” in the customer relationship. If the
agent/ company can use the situation to clarify the position, the situation can
actually improve customer loyalty.**Remember, no one else in the company has ownership of the client’s problems**
**as much as an agent does** .Complaints/ grievances give us the chance to show how much we care for the
customer’s interests. They are in fact the pillars on which an insurance agent builds
goodwill and business. **Word of mouth publicity (Good/ Bad) plays a significant**
**role in selling and servicing** .The procedure for grievance redressal is detailed at the end of every policy
document. This should be bought to the notice of customers. As per the regulations,
any grievance of a policy holder should be first referred to the Insurer’s Grievance
Cell. If it is not satisfactorily resolved, the complainant may approach the Regulator
through the Integrated Grievance Management System.**B.** **Integrated Grievance Management System (IGMS)**Each Insurer has its own grievance redressal mechanism. All operating/ controlling/
corporate offices of Insurance companies have Grievance Redressal Officers. A
policyholder can approach them directly for any grievance.IRDAI has launched an Integrated Grievance Management System (IGMS) which acts
as an online consumer complaints registration system. Insurers have to register all
grievances that they receive in the system which is integrated with IGMS of IRDAI.
IGMS helps IRDAI in monitoring grievance redress in the industry and also acts as a
central repository of insurance grievance data.Policyholders can approach the respective insurer first for any grievance. If he does
not receive any response from the insurer or if the response/ resolution received is88not to his satisfaction, he can approach the Regulator under the IGMS. The
complaint registration process involves two steps – (i) Registering oneself by
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Cell. If it is not satisfactorily resolved, the complainant may approach the Regulator
through the Integrated Grievance Management System.**B.** **Integrated Grievance Management System (IGMS)**Each Insurer has its own grievance redressal mechanism. All operating/ controlling/
corporate offices of Insurance companies have Grievance Redressal Officers. A
policyholder can approach them directly for any grievance.IRDAI has launched an Integrated Grievance Management System (IGMS) which acts
as an online consumer complaints registration system. Insurers have to register all
grievances that they receive in the system which is integrated with IGMS of IRDAI.
IGMS helps IRDAI in monitoring grievance redress in the industry and also acts as a
central repository of insurance grievance data.Policyholders can approach the respective insurer first for any grievance. If he does
not receive any response from the insurer or if the response/ resolution received is88not to his satisfaction, he can approach the Regulator under the IGMS. The
complaint registration process involves two steps – (i) Registering oneself by
entering one’s policy details and (ii) Registering one’s complaints and viewing the
status of the complaints. Complaints are then forwarded to the respective insurance
companies and IRDAI facilitates disposal of Grievances.IGMS tracks complaints and the time taken for their redressal. The complaints can
be registered at the following URL: http://www.policyholder.gov.in/Integrated_
Grievance_Management.aspx**C.** **Consumer Protection****The Consumer Protection Act, 2019:** This original Act of 1986 was passed _“to_
_provide for better protection of the interest of consumers and to make provision_
_for the establishment of consumer councils and other authorities for the_
_settlement of consumer’s disputes”_ . The Act was amended by the Consumer
Protection (Amendment) Act, 2002 and later on 2019.Some definitions provided in
the Act are as follows:“ **Service** ” means service of any description which is made available to potential
users and includes the provision of facilities in connection with banking, financing,
**insurance**, transport, processing, supply of electrical or other energy, board or
lodging or both, housing construction, entertainment, etc. **Insurance is included as**
**a service.** However, “Service” does not include the rendering of any service free of
charge or under a contract of personal service.“ **Consumer** ” means any person who Buys goods for a consideration. It includes any user of such goods. (It does notinclude a person who obtains such goods for resale or for any commercial
purpose) or
Hires or avails of any services for a consideration. It includes the beneficiary ofsuch services. (It does not include any person who avails of such service for any
commercial purpose.)“ **Defect** ” means any fault, imperfection, shortcoming, inadequacy in the quality,
nature and manner of performance which is required to be maintained by or under
any law or has been undertaken to be performed by a person in pursuance of a
contract or otherwise in relation to any service.**“Complaint”** means any allegation in writing made by a complainant that: an unfair trade practice or restrictive trade practice has been adopted
the goods bought by him suffer from one or more defects
the services hired or availed of by him suffer from deficiency in any respect
price charged is in excess of that fixed by law or displayed on package
goods which will be hazardous to life and safety when used are being offeredfor sale to the public in contravention of the provisions of any law requiring
trader to display information in regard to the contents, manner and effect of
use of such goods.“ **Consumer dispute** ” means a dispute where the person against whom a complaint
has been made, denies and disputes the allegations contained in the complaint.89**D.** **Consumer** **disputes redressal agencies**Consumer disputes redressal agencies are established at district, state and national
levels.**i.** **District Consumer Disputes Redressal Commission** The District Consumer Disputes Redressal Commission (District Commission),has jurisdiction to entertain complaints, where value of the goods or services
does not exceed Rs. 1 crore. The District Commission has the powers of a civil
court.**ii.** **State Consumer Disputes Redressal Commission** The State Consumer Disputes Redressal Commission (State Commission) hasoriginal jurisdiction to entertain complaints where the value of goods/ service
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B.
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price charged is in excess of that fixed by law or displayed on package
goods which will be hazardous to life and safety when used are being offeredfor sale to the public in contravention of the provisions of any law requiring
trader to display information in regard to the contents, manner and effect of
use of such goods.“ **Consumer dispute** ” means a dispute where the person against whom a complaint
has been made, denies and disputes the allegations contained in the complaint.89**D.** **Consumer** **disputes redressal agencies**Consumer disputes redressal agencies are established at district, state and national
levels.**i.** **District Consumer Disputes Redressal Commission** The District Consumer Disputes Redressal Commission (District Commission),has jurisdiction to entertain complaints, where value of the goods or services
does not exceed Rs. 1 crore. The District Commission has the powers of a civil
court.**ii.** **State Consumer Disputes Redressal Commission** The State Consumer Disputes Redressal Commission (State Commission) hasoriginal jurisdiction to entertain complaints where the value of goods/ service
and compensation, if any claimed exceeds Rs. 1 crore but does not exceed
Rs.10 crores.
It also has appellate and supervisory jurisdiction to entertain appeals fromthe District Commission.
Other powers and authority are similar to those of the District Commission.**iii.** **National Consumer Disputes Redressal Commission** The National Consumer Disputes Redressal Commission (National Commission)is the final authority established under the Act.
It has original jurisdiction to entertain disputes, where goods/ services andthe compensation claimed exceeds Rs.10 crores.
It has appellate as well as supervisory jurisdiction to hear the appeals fromthe orders passed by the State Commission.
Every order made by a District Commission, State Commission or the National
Commission shall be enforced by it in the same manner as if it were a decree
made by a Court in a suit before it. Appeals against the orders of the National
Commission have to be made only at the Supreme Court.90**Channels for Consumer Disputes Redressal**|Judicial Channels|Col2|
|---|---|
|<br> <br> <br> <br> <br>**National Consumer**<br>**Disputes Redressal**<br>**Commission** <br> <br>**State Consumer**<br>**Disputes Redressal**<br>**Commission** <br> <br>**District Consumer**<br>**Disputes Redressal**<br>**Commission** <br> <br> <br> <br> <br> <br>**Established by the**<br>**Central Government**<br> <br>**Established by the State**<br>**Government**<br> <br>**Established by the**<br>**State Government**|<br> <br> <br> <br> <br>**National Consumer**<br>**Disputes Redressal**<br>**Commission** <br> <br>**State Consumer**<br>**Disputes Redressal**<br>**Commission** <br> <br>**District Consumer**<br>**Disputes Redressal**<br>**Commission** <br> <br> <br> <br> <br> <br>**Established by the**<br>**Central Government**<br> <br>**Established by the State**<br>**Government**<br> <br>**Established by the**<br>**State Government**|
|**Established by the**<br>**Central Government**|**Established by the**<br>**State Government**|**a)** **Procedure for filing a complaint**The procedure for filing a complaint is very simple in all the above three
agencies. There is no fee for filing a complaint or filing an appeal whether before
the State Commission or National Commission. The complaint can be filed by
the complainant himself or by his authorised agent. It can be filed personally or
can even be sent by post. It may be noted that no advocate is necessary for the
purpose of filing a complaint.**b)** **Consumer Commission Orders**If the Commission is satisfied (a) that the goods in question have the defects
specified in the complaint or (b) that the allegations about the services are
proven; the Commission can issue orders directing the opposite party to do any
of the following:
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|**Established by the**<br>**Central Government**|**Established by the**<br>**State Government**|**a)** **Procedure for filing a complaint**The procedure for filing a complaint is very simple in all the above three
agencies. There is no fee for filing a complaint or filing an appeal whether before
the State Commission or National Commission. The complaint can be filed by
the complainant himself or by his authorised agent. It can be filed personally or
can even be sent by post. It may be noted that no advocate is necessary for the
purpose of filing a complaint.**b)** **Consumer Commission Orders**If the Commission is satisfied (a) that the goods in question have the defects
specified in the complaint or (b) that the allegations about the services are
proven; the Commission can issue orders directing the opposite party to do any
of the following:
i. To **return** to the complainant the **price** (or premium in case of insurance)and/ or charges paid by the complainant
ii. To award such amount as **compensation** to the consumers for any loss orinjury suffered by the consumer due to negligence of the opposite party
iii. To remove the defects or **deficiencies** in the services in question.
iv. To **discontinue the unfair trade practice** or the restrictive trade practiceor not to repeat them
v. To provide for **adequate costs** to the complainants.**c)** **Nature of complaints**The **majority of consumer disputes** with the three Commissions relating to
insurance business fall in the following main categories:91i. Delay in settlement of claims
ii. Non-settlement of claims
iii. Repudiation of claims
iv. Amount or Quantum of loss
v. Policy terms, conditions etc.**E.** **The Insurance Ombudsman**The Central Government under the powers of the Insurance Regulatory &
Development Authority Act, 1999 made **Insurance Ombudsman Rules 2017** by a
notification published in the official gazette on 25 [th] April 2017.Rules regarding Insurance Ombudsmen apply to all insurers and their agents and
intermediaries in respect of complaints on all personal lines of insurance, group
insurance policies, policies issued to sole proprietorship and micro enterprises.[‘Personal lines’ here means insurances taken in an individual capacity, in contrast
to insurances sold to corporate entities.] Complaints relating to (a) delay in
settlement of claims beyond the time specified by IRDAI, (b) partial or total
repudiation of claims by the insurer, (c) disputes about premium paid or payable in
terms of insurance policy, (d) misrepresentation of policy terms and conditions at
any time in the policy document or policy contract, (e) legal construction of
insurance policies that affect the claim; and (f) policy servicing and related
grievances against insurers and their agents and intermediaries.a) Issuance of life insurance policy, general insurance policy including healthinsurance policy which is not in conformity with the proposal form submitted
by the proposer.
b) Non issuance of insurance policy after receipt of premium in life insurance andgeneral insurance including health insurance and
c) Any other matter resulting from the violation of provisions of the InsuranceAct, 1938 or the regulations, circulars, guidelines or instructions issued by the
IRDAI from time to time or the terms and conditions of the policy contract, in
so far as they relate to issues mentioned at clauses (a) to (f)
The objective of these rules is to resolve all types of complaints mentioned above,
in a cost effective, and impartial manner.**The Ombudsman, by mutual agreement of the insured and the insurer can act as**
**a mediator and counsellor within the terms of reference.****The decision of the Ombudsman, whether to accept or reject the complaint, is**
**final.****a)** **Complaint to the Ombudsman**Any complaint made to the Ombudsman should be in writing, and must be signed
by the insured or his legal heirs, nominee or assignee, and addressed to an
Ombudsman within whose jurisdiction, the insurer has a branch/ office. It should
contain the facts giving rise to the complaint, supported by documents, the
nature and extent of the loss caused to the complainant and the relief sought.92**Complaints can be made to the Ombudsman if:**i. The complainant had made a previous written representation to theinsurance company and:
the insurance company had rejected the complaint or
the complainant had not received any reply within one month afterreceipt of the complaint by the insurer.
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The objective of these rules is to resolve all types of complaints mentioned above,
in a cost effective, and impartial manner.**The Ombudsman, by mutual agreement of the insured and the insurer can act as**
**a mediator and counsellor within the terms of reference.****The decision of the Ombudsman, whether to accept or reject the complaint, is**
**final.****a)** **Complaint to the Ombudsman**Any complaint made to the Ombudsman should be in writing, and must be signed
by the insured or his legal heirs, nominee or assignee, and addressed to an
Ombudsman within whose jurisdiction, the insurer has a branch/ office. It should
contain the facts giving rise to the complaint, supported by documents, the
nature and extent of the loss caused to the complainant and the relief sought.92**Complaints can be made to the Ombudsman if:**i. The complainant had made a previous written representation to theinsurance company and:
the insurance company had rejected the complaint or
the complainant had not received any reply within one month afterreceipt of the complaint by the insurer.
ii. The complainant is not satisfied with the reply given by the insurer
iii. The complaint is made within one year from the date of rejection by theinsurance company
iv. The complaint is not pending in any court or consumer Commission or inarbitration
v. The value of the claim including expenses claimed is not above Rs 30 lakhs.**b)** **Recommendations by the Ombudsman**The Ombudsman will send copies of complaints to both the complainant and the
insurance company. The Ombudsman will make his recommendations within one
month of the receipt of the complaint.**c)** **Award**The dispute can be settled by intermediation. If this is not possible, the
Ombudsman will pass an award to the insured which he thinks is fair within a
period of 3 months from the date of receipt of all requirements from the
complainant and sending a copy of the award to the complainant and the
insurer.The insurer shall comply with the award within 30 days of the receipt of the
award and intimate compliance of the same to the Ombudsman. The award of
the Ombudsman shall be binding on the insurer.**F.** **Right to Information**In addition to the rules and regulations that are specific for grievance redressal in
insurance, there are certain general laws common to everyone in the country. The
Right to Information (RTI) Act, 2005 enacted by the Govt. of India is an important
law that gives citizens of India access to the information available with public
authorities which promotes transparency and accountability in these organisations.
The Act provides for appointment of a Chief Public Information Officer (CPIO) to
deal with requests for information. IRDAI is obliged to provide information to
members of public in accordance with the provisions of the said Act. Agents should
be aware that as per the RTI Act, IRDAI and Insurance Companies may have to reveal
certain information to customers and others; as also allow them to inspect the work,
document, records, extracts or certified copies of documents/ records and also
information stored in electronic form. However, there are certain categories of
information that are exempt from disclosure.93**Test Yourself 1**The ______________ has jurisdiction to entertain complaints, where value of the
goods or services and the compensation claimed is up to Rs.20 lakhs.I. District CommissionII. State CommissionIII. Zilla ParishadIV. National Commission**Summary**IRDAI has launched an Integrated Grievance Management System (IGMS) which
acts as a central repository of insurance grievance data and as a tool for
monitoring grievance redress in the industry.Consumer disputes redressal agencies are established in each district and state
and at national level.As far as insurance business is concerned, the majority of consumer disputes fall
in categories such as delay in settlement of claims, non-settlement of claims,
repudiation of claims, quantum of loss and policy terms, conditions etc.The Ombudsman, by mutual agreement of the insured and the insurer can act
as a mediator and counsellor within the terms of reference.- If the dispute is not settled by intermediation, the Ombudsman will pass award
to the insured which he thinks is fair, and is not more than what is necessary
to cover the loss of the insured.**Key Terms**1. Integrated Grievance Management System (IGMS)
2. The Consumer Protection Act, 2019
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goods or services and the compensation claimed is up to Rs.20 lakhs.I. District CommissionII. State CommissionIII. Zilla ParishadIV. National Commission**Summary**IRDAI has launched an Integrated Grievance Management System (IGMS) which
acts as a central repository of insurance grievance data and as a tool for
monitoring grievance redress in the industry.Consumer disputes redressal agencies are established in each district and state
and at national level.As far as insurance business is concerned, the majority of consumer disputes fall
in categories such as delay in settlement of claims, non-settlement of claims,
repudiation of claims, quantum of loss and policy terms, conditions etc.The Ombudsman, by mutual agreement of the insured and the insurer can act
as a mediator and counsellor within the terms of reference.- If the dispute is not settled by intermediation, the Ombudsman will pass award
to the insured which he thinks is fair, and is not more than what is necessary
to cover the loss of the insured.**Key Terms**1. Integrated Grievance Management System (IGMS)
2. The Consumer Protection Act, 2019
3. District Commission4. State Commission5. National Commission6. Insurance Ombudsman**Answers to Test Yourself****Answer 1** -The correct answer is I.94### CHAPTER C- 10## REGULATORY ASPECTS FOR INSURANCE AGENTS**Chapter Introduction**In this chapter, we discuss Regulatory aspects of Insurance agents.**Learning Outcomes**95**A.** **Regulations of Insurance Agents**IRDAI (Appointment of Insurance Agents) Regulations, 2016 that came into force
with effect from 1 [st] April 2016 is discussed here.Learners are expected to read and understand the Regulations for Insurance Agents
issued by IRDAI which have defined many related terms. As Regulations are amended
from time to time, one needs to refer original and revised/ updated versions placedon the IRDAI website.**Definitions:**Many of the definitions applicable in the insurance market are defined in the
Regulations. For instance, an "Insurance Agent" is defined as _“an individual_
_appointed by an insurer for the purpose of soliciting or procuring insurance business_
_including business relating to the continuance, renewal or revival of policies of__insurance”_ .The Regulations define a “Composite Insurance Agent” as _“an individual who is_
_appointed as an insurance agent by two or more insurers subject to the condition_
_that he/ she shall not act as insurance agent for more than one life insurer, one_
_general insurer, one health insurer and one each of the mono-line insurers.”_**Important terms that an agent should know are also defined.**For example, “Appointment Letter” is defined as _“a letter of appointment issued_
_by an insurer to any person to act as an insurance agent.”_Similarly, the “Designated Official” is also defined as “an officer authorised by the
Insurer to make Appointment of an individual as an Insurance Agent.” On receipt of
the application, before appointing the Agent, the Designated Official shall satisfy
himself that the applicant (i) has furnished the Agency Application complete in all
respects; (ii) has submitted the PAN details along with the Agency Application Form;
(iii) has passed the insurance examination as specified under the Regulations; (iv)
does not suffer from any of the disqualifications mentioned in the Regulations; (v)
has the requisite knowledge to solicit and procure insurance business; and (vi)
capable of providing the necessary service to the policyholders;The designated official will verify the application form, and ascertain whether the
applicant holds agency appointment with more than one life insurer, one general
insurer, one health insurer and one of each of the mono-line insurers. He will also
verify the centralised list of agents maintained by the Authority and verify whether
the applicant is black listed. If satisfied, the designated official may appoint the
applicant as an Insurance Agent within 15 days of receipt of all documents from the
applicant, allot an agency code number and an identity card to the Agent prefixing
the abbreviation of the company name. If the applicant does not fulfil the
prescribed conditions, the designated official may refuse to grant Agency
Appointment, and communicate the reasons thereof to the applicant in writing,96within 21 days of receipt of the application. If an applicant is aggrieved by the
decision of the designated official regarding refusal of granting insurance agency
he/ she, may submit a review application to the insurer for review the decision.
The insurer shall consider the review application and communicate the final
decision within 15 days of receipt of the application.**Appeal Provision** : Insurers have “Appellate Officers” who are authorised by the
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applicant holds agency appointment with more than one life insurer, one general
insurer, one health insurer and one of each of the mono-line insurers. He will also
verify the centralised list of agents maintained by the Authority and verify whether
the applicant is black listed. If satisfied, the designated official may appoint the
applicant as an Insurance Agent within 15 days of receipt of all documents from the
applicant, allot an agency code number and an identity card to the Agent prefixing
the abbreviation of the company name. If the applicant does not fulfil the
prescribed conditions, the designated official may refuse to grant Agency
Appointment, and communicate the reasons thereof to the applicant in writing,96within 21 days of receipt of the application. If an applicant is aggrieved by the
decision of the designated official regarding refusal of granting insurance agency
he/ she, may submit a review application to the insurer for review the decision.
The insurer shall consider the review application and communicate the final
decision within 15 days of receipt of the application.**Appeal Provision** : Insurers have “Appellate Officers” who are authorised by the
Insurer to consider and dispose representations and appeals received from an
appointed Insurance Agent. If an appointment is cancelled, an aggrieved agent can
appeal to the Appellate Officer within 45 days of the order, and the Officer will give
his decision in the matter in writing within 30 days of the receipt of the appeal.The “Examination Body” is also defined as _“an Institution, which conducts pre-_
_recruitment tests for insurance agents and which is duly recognised by the_
_Authority.”_ [Note: As on 30 [th] September 2021, Insurance Institute of India is the
only ‘Examination Body’ approved by the IRDAI]**B.** **Regulatory Compliances for Agents**The procedure to become an Insurance Agent of an Insurer is discussed in detail.
The prescribed pre-qualifications that one should have before approaching an
insurer are discussed in detail. The processes involved are also stated in the
Regulations.In order to make the Agent aware of his rights, the mode and manner in which the
appointment process shall be done and the processes to be followed by the
Insurance Company are also specified.In case an Applicant is aggrieved at some stage of the process, procedures for
complaining are specified. Provisions on how such complaints have to be addressed
by the company. In case the Applicant is still aggrieved, the provisions for appealing
against the company’s decisions are also discussed.The Regulations provide details relating to appearing for the Insurance Agency
Examination conducted by the ‘Examination Body’ in the subjects of Life, General,
or Health Insurance as the case may be, as per the syllabus prescribed by the
Authority to be eligible for appointment as an insurance agent. The duties of the
insurer in providing the Applicant the necessary assistance and guidance to equip
them with adequate insurance knowledge required to qualify in the agency
examination are also spelt out.The applicant who has successfully passed the Insurance Agency Examination shall
be issued a pass certificate by the Examination Body. The pass certificate shall be
in force for a period of twelve months, for seeking appointment as an agent with
any insurer for the first time.A candidate can be eligible for appointment as an agent only after qualifying in the
Insurance Agency examination and holding a valid pass certificate issued by the
Examination Body.97**C.** **Code of Conduct for Agents**The Code of Conduct that every Agent shall adhere to are discussed in detail.
Matters like identifying oneself and one’s Insurer properly by showing the agency
identity card and the duty to disclose the agency appointment letter to the prospecton demand are discussed.The code of conduct specifies the duties of Agents in detail. Some of the important
duties that Agent Applicants need to know are listed below: Giving necessary information about insurance products offered for sale by hisinsurer and consider the needs of the prospect while recommending a specific
insurance plan; Explaining the premium to be charged by the insurer for the insurance productoffered for sale; Disclosing the scales of commission in respect of the insurance product offeredfor sale; Care to be taken when representing more than one insurer offering same line ofproducts; Explaining to the prospect the nature of information required in the proposalform by the insurer, and the importance of disclosing material information in
the purchase of an insurance contract; Obtaining the requisite documents at the time of filing the proposal form withthe insurer; and other documents subsequently asked for by the insurer for
completion of the proposal; Informing the insurer every fact about the prospect relevant to insuranceunderwriting, including any adverse habits or income inconsistency of the
|
Final IC 38 - IA_English Common.md
| null |
Appeal Provision
|
Final IC 38 - IA_English Common_051
|
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Matters like identifying oneself and one’s Insurer properly by showing the agency
identity card and the duty to disclose the agency appointment letter to the prospecton demand are discussed.The code of conduct specifies the duties of Agents in detail. Some of the important
duties that Agent Applicants need to know are listed below: Giving necessary information about insurance products offered for sale by hisinsurer and consider the needs of the prospect while recommending a specific
insurance plan; Explaining the premium to be charged by the insurer for the insurance productoffered for sale; Disclosing the scales of commission in respect of the insurance product offeredfor sale; Care to be taken when representing more than one insurer offering same line ofproducts; Explaining to the prospect the nature of information required in the proposalform by the insurer, and the importance of disclosing material information in
the purchase of an insurance contract; Obtaining the requisite documents at the time of filing the proposal form withthe insurer; and other documents subsequently asked for by the insurer for
completion of the proposal; Informing the insurer every fact about the prospect relevant to insuranceunderwriting, including any adverse habits or income inconsistency of the
prospect, within the knowledge of the agent; Advising every prospect to effect nomination under the policy; Informing the prospect about the acceptance or rejection of the proposal by theinsurer, in a prompt manner; Assisting and advising one’s customers/ policyholders on policy servicing mattersincluding assignment of policy, change of address or exercise of options under
the policy or any other policy service, as required; Assisting one’s customers/ policyholders/ claimants/ beneficiaries in claimssettlement related procedures.The code of conduct specifies what the Agents should not do as well. There are
some important prohibitions that Agent Applicants need to be aware of:**Insurance agents are prohibited from** Soliciting or procuring insurance business without being duly authorized by theinsurer98 Inducing the prospect to omit any material information or submit wronginformation in the proposal form; Resorting to multilevel marketing for soliciting and procuring insurance policiesand/ or inducting any prospect/ policyholder into multilevel marketing schemes. Offering different rates, advantages, terms and conditions other than thoseoffered by one’s insurer; Demand or receive a share of proceeds from the beneficiary under an insurancecontract; Issuing Insurance advertisements without the express approval of the InsuranceCompany.Agents should alert policyholders orally and issue notices to them so that the
business procured are conserved.**Action against Agents:**An Agent’s appointment can be cancelled or suspended for multiple reasons. Someof the serious reasons are mentioned below.The Agent would attract action if he/ she: violates relevant provisions under the Acts, Rules or Regulations as amendedfrom time to time, fails to comply with the stipulated code of conduct, violates the terms of appointment, furnishes wrong or false information, conceals or fails to disclose material facts in the application submitted forappointment of Insurance Agent does not submit periodical returns as required by the Insurer/ Authority does not co-operate with any inspection or enquiry conducted by theAuthority fails to resolve the complaints of the policyholders. either directly or indirectly involves in embezzlement of premiums/ cashcollected from policyholders/ prospects on behalf of insurer.The procedure to be followed for such Cancellation/ Suspension of Agency and the
effects thereof are given in detail in the Insurance Regulatory and Development
Authority of India (Appointment of Insurance Agents) Regulations, 2016. There is a
provision for black listing agents whose appointment is cancelled/ suspended by a
designated official of the insurer on grounds of violation of the Code of Conduct
and/ or fraud. If the agency of the insurance agent is cancelled, he/ she shall cease
to act as an insurance agent from the date of the order. The Authority maintains a
“Centralised list of black listed agents” whose appointment is cancelled/99suspended. In case the suspension is revoked, the name is removed from the black
list. The procedure in respect of resignation/ surrender of appointment by an
insurance agent is also specified.The Regulations allow IRDAI to call for any information pertaining to the insurance
business undertaken by the Insurance Agent and he/ she shall submit the same
within the time lines. IRDAI can appoint an “Investigating Officer” to undertake
inspection of the affairs of an Insurance Agent, to ascertain and see whether the
business is carried on by him/ her as per the Act, Regulations and the instructions
issued by the Authority from time to time, and also to inspect the books of accounts,
|
Final IC 38 - IA_English Common.md
|
r98
|
Insurance agents are prohibited from
|
Final IC 38 - IA_English Common_052
|
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Authority of India (Appointment of Insurance Agents) Regulations, 2016. There is a
provision for black listing agents whose appointment is cancelled/ suspended by a
designated official of the insurer on grounds of violation of the Code of Conduct
and/ or fraud. If the agency of the insurance agent is cancelled, he/ she shall cease
to act as an insurance agent from the date of the order. The Authority maintains a
“Centralised list of black listed agents” whose appointment is cancelled/99suspended. In case the suspension is revoked, the name is removed from the black
list. The procedure in respect of resignation/ surrender of appointment by an
insurance agent is also specified.The Regulations allow IRDAI to call for any information pertaining to the insurance
business undertaken by the Insurance Agent and he/ she shall submit the same
within the time lines. IRDAI can appoint an “Investigating Officer” to undertake
inspection of the affairs of an Insurance Agent, to ascertain and see whether the
business is carried on by him/ her as per the Act, Regulations and the instructions
issued by the Authority from time to time, and also to inspect the books of accounts,
records and documents of the Agent.**Key Terms**1. Regulatory Compliances for agents2. Code of Conduct for Agents**Test Yourself 1**Which of the following statements is incorrect**An insurance agent shall not -**I. Solicit or procure insurance business without being appointed to act as such
by the insurer
II. Induce the prospect to omit any material information in the proposal form;
III. Disclose the scales of commission in respect of the insurance product offered
for sale, if asked by the prospect
IV. Offer different rates, advantages, terms and conditions other than those
offered by his insurer**Test Yourself 2**Pick the right answer**An insurance agent is allowed to**
I. Interfere with any proposal introduced by any other insurance agent
II. Resort to multilevel marketing for soliciting and procuring insurance policies
III. Receive a share of proceeds from the beneficiary under an insurance contract
IV. Indicate the premium to be charged by the insurer for the insurance product
offered for sale**Answers to Test Yourself****Answer 1** - The correct option is III.**Answer 2** - The correct option is IV.100
|
Final IC 38 - IA_English Common.md
|
s2
|
Key Terms
|
Final IC 38 - IA_English Common_053
|
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## IC - 38 **WEB AGGREGATORS** **COMPOSITE****ACKNOWLEDGEMENT****This course is based on revised syllabus prescribed by Insurance Regulatory**
**and Development Authority of India (IRDAI) and prepared by Insurance**
**Institute of India, Mumbai.****AUTHORS/ REVIEWERS (in Alphabetical order)**Dr. R. K. Duggal
Dr. Shashidharan K. Kutty
CA P. Koteswara Rao
Dr. Pradip Sarkar
Prof. Madhuri Sharma
Dr. George E. Thomas
Prof. Archana VazeG – Block, Plot No. C-46, Bandra Kurla Complex, Bandra (E), Mumbai – 400 051.i## WEB AGGREGATORS **COMPOSITE** **IC - 38****Year of Edition: 2023****ALL RIGHTS RESERVED**This course material is the copyright of Insurance Institute of India (III). This
course is designed for providing academic inputs for students appearing for the
examinations of Insurance Institute of India. This course material may not be
reproduced for commercial purpose, in part or whole, without prior express
written permission of the Institute.The contents are based on prevailing best practices and not intended to give
interpretations or solutions in case of disputes, legal or otherwise.This is only an indicative study material. Please note that the questions in the
examination shall not be confined to this study material only.Published by: Secretary General, Insurance Institute of India, G- Block, Plot C-46,
Bandra Kurla Complex, Bandra (E) Mumbai – 400 051 and Printed atAny communication regarding this study material may be addressed to
ctd@iii.org.in mentioning the subject title and unique publication number
mentioned on the cover pageii## PREFACEInsurance Institute of India, (the Institute) has developed this course material for
Corporate Agents based on the syllabus prescribed by Insurance Regulatory and
Development Authority of India (IRDAI). Industry experts were involved in
preparing the course material.The course provides basic knowledge of Life, General and Health insurance to
enable agents in the respective line of business to understand and appreciate
their professional career in the right perspective.The course is structured as four sections. (1) Overview - a Common section that
covers Insurance Principles, Legal Principles and Regulatory matters that
Insurance agents need to know. Separate sections are provided for those aspiring
to become (2) Life Insurance Agents, (3) General Insurance Agents and (4) Health
Insurance Agents.A set of model questions are included in the course to give students an idea of
the examination format and the types of objective questions that may be asked.
The model questions will also help them in revising what they have learnt.Insurance operates in a dynamic environment. Agents need to be up to date about
changes in the market. They should actively pursue knowledge through personal
study and participation in the in-house training programmes arranged by the
respective insurers.The Institute thanks IRDAI for entrusting this work to the Institute. The Institute
wishes all interested in studying the material a successful career in insurance
marketing.iii## CONTENTS|Chapter no.|Title|Page no.|
|---|---|---|
|**SECTION **|**COMMON CHAPTERS **|**COMMON CHAPTERS **|
|C-01|Introduction to Insurance|2|
|C-02|Core Elements of Insurance|19|
|C-03|Principles of Insurance|29|
|C-04|Features of Insurance Contracts|43|
|C-05|Underwriting and Rating|52|
|C-06|Claims Processing|60|
|C-07|Documentation|67|
|C-08|Customer Service|76|
|C-09|Grievance Redressal Mechanism|93|
|C-10|Regulatory Aspects for Web Aggregators|101|
|**SECTION **|**LIFE INSURANCE **|**LIFE INSURANCE **|
|L-01|What Life Insurance Involves|116|
|L-02|Financial Planning|123|
|L-03|Life Insurance Products: Traditional|137|
|L-04|Life insurance products: Non-Traditional|148|
|L-05|Applications of Life Insurance|154|
|L-06|Pricing and Valuation in Life Insurance|159|
|L-07|Life Insurance Documentation|168|
|L-08|Life Insurance Underwriting|182|
|L-09|Life Insurance Claims|196|
|**SECTION **|**HEALTH INSURANCE **|**HEALTH INSURANCE **|
|H-01|Introduction to Health Insurance|205|
|
Final IC 38 - WA_Composite - English.md
|
C-46
|
WEB AGGREGATORS
|
Final IC 38 - WA_Composite - English_000
|
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|C-06|Claims Processing|60|
|C-07|Documentation|67|
|C-08|Customer Service|76|
|C-09|Grievance Redressal Mechanism|93|
|C-10|Regulatory Aspects for Web Aggregators|101|
|**SECTION **|**LIFE INSURANCE **|**LIFE INSURANCE **|
|L-01|What Life Insurance Involves|116|
|L-02|Financial Planning|123|
|L-03|Life Insurance Products: Traditional|137|
|L-04|Life insurance products: Non-Traditional|148|
|L-05|Applications of Life Insurance|154|
|L-06|Pricing and Valuation in Life Insurance|159|
|L-07|Life Insurance Documentation|168|
|L-08|Life Insurance Underwriting|182|
|L-09|Life Insurance Claims|196|
|**SECTION **|**HEALTH INSURANCE **|**HEALTH INSURANCE **|
|H-01|Introduction to Health Insurance|205|
|H-02|Health Insurance Documentation|213|
|H-03|Health Insurance Products|221|
|H-04|Health Insurance Underwriting|248|
|H-05|Health Insurance Claims|264|
|**SECTION **|**GENERAL INSURANCE **|**GENERAL INSURANCE **|
|G-01|General Insurance Documentation|281|
|G-02|Underwriting and Rate Making|297|
|G-03|Personal and Retail Insurance|307|
|G-04|Commercial Insurance|317|
|G-05|General Insurance Claims|341|
|**SECTION **|**ANNEXURES **|**ANNEXURES **|
|A-01|Annexures – Specimen Proposal forms and Claims Forms for filling up|351|iv## SECTION **AN OVERVIEW**1## CHAPTER C-01## INTRODUCTION TO INSURANCE**Chapter Introduction**This chapter aims to introduce the basics of insurance, trace its evolution and
how it works. It intends to teach how insurance provides protection against
economic losses arising as a result of unforeseen events and serves as aninstrument of risk transfer.2**A.** **Insurance – History and Evolution**We live in a world of uncertainty. We hear about: Trains colliding Floods destroying entire communities Earthquakes destroying buildings Young people dying unexpectedly**Diagram 1:** **Events happening around us**Why do these events make people anxious and afraid?The reason is simple.**i.** Firstly these **events are unpredictable.** If one can anticipate and predictan event, one can prepare for it.**ii.** Secondly, such unpredictable and untoward events are often a **cause of****economic loss and grief** .The people around can come to the aid of individuals who are affected by such
events, by having a system of sharing and mutual support. The idea of insurance
is thousands of years old. Yet, the present form of insurance, is only two or threecenturies old.**1.** **History of insurance**Insurance has existed in some form or other since 3000 BC. Many civilisations,
have practiced the concept of pooling and sharing among themselves, all the
losses suffered by some members of the community. Let us take a look at some
of the ways in which this concept was applied.3**2.** **Insurance through the ages – Some instances**|Bottomry Loans|Traders of Babylon paid extra money to their lenders to write<br>off their loans if shipment was lost or stolen.<br>Traders of Bharuch and Surat also had similar practices.|
|---|---|
|**Benevolent**<br>**Societies/**<br>**Friendly**<br>**Societies**|Greeks of 7th Cy. AD, used to pay in advance to take care of the<br>family of members who died and also the funeral expenses of the<br>member.<br>Similar practices were followed in England as well.|
|**Rhodes**|Traders of Rhodes who were sending goods by sea, were sharing<br>losses if any of them lost their goods due to jettison1.|
|**Chinese Traders**|**Chinese traders**in ancient days used to send their goods in<br>different ships, so that even if some boats sank, their loss would<br>be partial.|**3.** **Modern concepts of insurance**In India the principle of life insurance was reflected in the joint-family
system. Losses arising from the demise of a member were shared by various
|
Final IC 38 - WA_Composite - English.md
|
C-06
|
SECTION
|
Final IC 38 - WA_Composite - English_001
|
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