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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 al... | Final IC-38 - Corporate Agent _Composite _ English.md | a138 | Participating (Par) and Non-Participating (Non-Par)Plans | Final IC-38 - Corporate Agent _Composite _ English_074 | {
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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)139Pension plans are designed on group (usually employer driven) or individual basis. A
group pension may be a "defined benefit plan", where a ... | Final IC-38 - Corporate Agent _Composite _ English.md | o4353 | Saral Pension: | Final IC-38 - Corporate Agent _Composite _ English_075 | {
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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 ... | Final IC-38 - Corporate Agent _Composite _ English.md | e2 | Summary | Final IC-38 - Corporate Agent _Composite _ English_076 | {
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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.143**Tes... | Final IC-38 - Corporate Agent _Composite _ English.md | e2019 | Surrender value: | Final IC-38 - Corporate Agent _Composite _ English_077 | {
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|---|---|---|---|
|~~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>instrum... | Final IC-38 - Corporate Agent _Composite _ English.md | e2 | Unitising | Final IC-38 - Corporate Agent _Composite _ English_078 | {
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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 opti... | Final IC-38 - Corporate Agent _Composite _ English.md | e2 | Key Terms | Final IC-38 - Corporate Agent _Composite _ English_079 | {
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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 dire... | Final IC-38 - Corporate Agent _Composite _ English.md | t150 | Who can be a key-man? | Final IC-38 - Corporate Agent _Composite _ English_080 | {
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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 ra... | Final IC-38 - Corporate Agent _Composite _ English.md | m154 | Diagram 1: | Final IC-38 - Corporate Agent _Composite _ English_081 | {
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the premium tables. This task is performed by an actuary. The process of setting155the 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 o... | Final IC-38 - Corporate Agent _Composite _ English.md | g155 | Diagram 2: | Final IC-38 - Corporate Agent _Composite _ English_082 | {
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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 ... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Gross premium = Net premium + Loading for expenses + Loading for | Final IC-38 - Corporate Agent _Composite _ English_083 | {
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provided the contract is eligible through having run for a minimum term [say 5 years]159**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... | Final IC-38 - Corporate Agent _Composite _ English.md | m2 | Types of reversionary bonuses | Final IC-38 - Corporate Agent _Composite _ English_084 | {
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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 warran... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Proposal Form: | Final IC-38 - Corporate Agent _Composite _ English_085 | {
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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)** **Mor... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Moral Hazard report | Final IC-38 - Corporate Agent _Composite _ English_086 | {
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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 t... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Standard Provisions | Final IC-38 - Corporate Agent _Composite _ English_087 | {
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can be accomplished only under certain conditions:167**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 conti... | Final IC-38 - Corporate Agent _Composite _ English.md | e168 | Revival application within specific time period: | Final IC-38 - Corporate Agent _Composite _ English_088 | {
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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 t... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Example | Final IC-38 - Corporate Agent _Composite _ English_089 | {
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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 join... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Diagram 2: | Final IC-38 - Corporate Agent _Composite _ English_090 | {
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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 l... | Final IC-38 - Corporate Agent _Composite _ English.md | f172 | Diagram 4: | Final IC-38 - Corporate Agent _Composite _ English_091 | {
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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 commenc... | Final IC-38 - Corporate Agent _Composite _ English.md | e13 | Key Terms | Final IC-38 - Corporate Agent _Composite _ English_092 | {
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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 “Equit... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Equity among risks | Final IC-38 - Corporate Agent _Composite _ English_093 | {
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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>esp... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Methods of underwriting | Final IC-38 - Corporate Agent _Composite _ English_094 | {
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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 housewi... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Test Yourself 1 | Final IC-38 - Corporate Agent _Composite _ English_095 | {
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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.Typic... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Example | Final IC-38 - Corporate Agent _Composite _ English_096 | {
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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 lifest... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Lifestyle and habits | Final IC-38 - Corporate Agent _Composite _ English_097 | {
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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 ... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Personal characteristics | Final IC-38 - Corporate Agent _Composite _ English_098 | {
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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 pa... | Final IC-38 - Corporate Agent _Composite _ English.md | L-09 | Test Yourself 3 | Final IC-38 - Corporate Agent _Composite _ English_099 | {
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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 a... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Diagram 1: | Final IC-38 - Corporate Agent _Composite _ English_100 | {
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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 ri... | Final IC-38 - Corporate Agent _Composite _ English.md | s191 | II. | Final IC-38 - Corporate Agent _Composite _ English_101 | {
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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 Insuran... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Section 45: Indisputability Clause | Final IC-38 - Corporate Agent _Composite _ English_102 | {
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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, surviva... | Final IC-38 - Corporate Agent _Composite _ English.md | N195 | Summary | Final IC-38 - Corporate Agent _Composite _ English_103 | {
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leading to good health; leading to diseases such as cancer, aids, hypertension
and diabetes, to name a few.**b)** **Environmental factors**Communicable diseases like Influenza and Chickenpox etc. are spread due to
bad hygiene, diseases like Malaria and Dengue are spread due to bad
environmental sanitation, while certai... | Final IC-38 - Corporate Agent _Composite _ English.md | y199 | Environmental factors | Final IC-38 - Corporate Agent _Composite _ English_104 | {
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with patient. It includes acute care requiring treatment for a short period for a
serious illness, often (but not necessarily) as an in-patient, including Intensive Care
services, ambulance facilities, pathology, diagnostic and other relevant medical
services.**3.** **Tertiary healthcare**Tertiary Health care is specia... | Final IC-38 - Corporate Agent _Composite _ English.md | y199 | Tertiary healthcare | Final IC-38 - Corporate Agent _Composite _ English_105 | {
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introduced which will be discussed in later chapters.200**Test Yourself 3**The first standardised health insurance product for individuals and their families
was launched in the Indian market by all the four nationalized non-life insurance
companies in the year _____.I. 1948II. 1954III. 1986IV. 2001**E.** **Health Insu... | Final IC-38 - Corporate Agent _Composite _ English.md | r202 | Test Yourself 3 | Final IC-38 - Corporate Agent _Composite _ English_106 | {
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insurance companies.g) The health insurance market is made up of many players some providing theinfrastructure, with others providing insurance services, intermediaries such as
brokers, agents and third party administrators servicing health insurance
business and also other regulatory, educational as well as legal enti... | Final IC-38 - Corporate Agent _Composite _ English.md | r202 | Answers to Test Yourself | Final IC-38 - Corporate Agent _Composite _ English_107 | {
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complete a detailed questionnaire relating to diseases such as Diabetes, Hypertension,
Chest pain or Coronary Insufficiency or Myocardial Infarction.These have to be supported by a form completed by a consulting physician. This form
is scrutinised by company’s panel doctor, based on whose opinion, acceptance,
exclusion... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Standard form of Declaration | Final IC-38 - Corporate Agent _Composite _ English_108 | {
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a limb, or loss of sight due to an accident.**a)** **Previous and Present insurance**The proposer is required to inform the details about his previous insurances to the
insurer. This is to understand his insurance history. In some markets there are
systems by which insurers confidentially share data about the insured.T... | Final IC-38 - Corporate Agent _Composite _ English.md | D-19 | Previous and Present insurance | Final IC-38 - Corporate Agent _Composite _ English_109 | {
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Insurance Policy document should contain:a) The name(s) and address(es) of the insured and any other person havinginsurable interest in the subject matter
b) Full description of the persons or interest insured
c) The sum insured under the policy person and/ or peril wise
d) UIN of the product, name, code number, contac... | Final IC-38 - Corporate Agent _Composite _ English.md | y207 | E. | Final IC-38 - Corporate Agent _Composite _ English_110 | {
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material to the risk or not.**Test Yourself 1**Which of the below statement is correct with regards to a warranty?I. A warranty is a condition which is implied without being stated in the policy
II. A warranty forms part of a policy document208III. A warranty is always communicated to the insured separately and cannot ... | Final IC-38 - Corporate Agent _Composite _ English.md | t208 | Test Yourself 1 | Final IC-38 - Corporate Agent _Composite _ English_111 | {
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of products offered by almost all general Insurance companies, standalone health
insurers and life insurers. However, the basic benefit structure of the Mediclaim
policy i.e. cover against hospitalization expenses still remains the most popular form
of insurance.**2.** **Broad classification of health insurance product... | Final IC-38 - Corporate Agent _Composite _ English.md | s211 | Broad classification of health insurance products | Final IC-38 - Corporate Agent _Composite _ English_112 | {
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definitions of various terms and exclusions, confusion arose in the market. It became
difficult for the customer to compare products and take a considered decision.
Moreover, in critical illness policies, there is no clear understanding as to what is
meant by critical illness and what is not.To remove the confusion amo... | Final IC-38 - Corporate Agent _Composite _ English.md | s10 | C. | Final IC-38 - Corporate Agent _Composite _ English_113 | {
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injection administration charges and similar expensesii. Intensive Care Unit (ICU) expensesiii. Surgeon, anaesthetist, medical practitioner, consultants, specialists feesiv. Anaesthetic, blood, oxygen, operation theatre charges, surgical appliances,v. Medicines and drugs,vi. Dialysis, chemotherapy, radiotherapyvii. Cos... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Day Care Procedures | Final IC-38 - Corporate Agent _Composite _ English_114 | {
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**of three to five days** meaning that treatment costs for the first three to five
days have to be borne by the insured. The cover excludes domiciliary treatments
for certain chronic or common ailments such as Asthma, Bronchitis, Diabetes
Mellitus, Hypertension, Influenza Cough, Cold, and fevers etc.**Example**Mira had... | Final IC-38 - Corporate Agent _Composite _ English.md | f216 | Example | Final IC-38 - Corporate Agent _Composite _ English_115 | {
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fresh policy is to be issued every year, Lifelong renewability has been made
compulsory by IRDAI for all policies.**SPECIAL FEATURES**In order to provide new features in the product as also to maintain the pricing,
insurance companies have come out innovative modifications in the products. For
example, the Mediclaim Po... | Final IC-38 - Corporate Agent _Composite _ English.md | null | SPECIAL FEATURES | Final IC-38 - Corporate Agent _Composite _ English_116 | {
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policies for making any claim. This however will not be applied for hospitalization
due to an accident.**v.** **Waiting periods for specific diseases**This is applicable for diseases for which treatment can be delayed and planned.
Depending on the product waiting periods of one/ two/ four years are imposed by
the insur... | Final IC-38 - Corporate Agent _Composite _ English.md | d219 | Waiting periods for specific diseases | Final IC-38 - Corporate Agent _Composite _ English_117 | {
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to insured patient during the period of hospitalization. Lump sum payment or
reimbursement payment as per the policy terms is paid, up to the limit specified
in the schedule of the policy. **Family definition:** Definition of family has undergone changes in few healthproducts. Earlier, primary insured, spouse, depende... | Final IC-38 - Corporate Agent _Composite _ English.md | d219 | Family definition: | Final IC-38 - Corporate Agent _Composite _ English_118 | {
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based high deductible plans or Super top-up cover as known in the Indian market. A
super top-up plan covers the total of all hospitalisation bills (up to the super top-up
plan limit) above the deductible amount, that is, the deductible is applied to the
total claims in one year. Hence, once the deductible is paid, the ... | Final IC-38 - Corporate Agent _Composite _ English.md | null | E. | Final IC-38 - Corporate Agent _Composite _ English_119 | {
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The hospital daily cash policy is available as a standalone policy as offered by
some insurers while, in other cases, it is an add-on cover to a regular indemnity
policy. These policies help the insured to cover incidental expenses as the payout is a fixed sum and not related to the actual cost of treatment. This also
... | Final IC-38 - Corporate Agent _Composite _ English.md | d-19 | Supplementary cover | Final IC-38 - Corporate Agent _Composite _ English_120 | {
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indemnity-based standard COVID-19 product, _Corona Rakshak,_ offering the benefitbased product, is optional for all insurers. Both products have a waiting period of
15 days.223_Corona Rakshak_ is a standard benefit based health insurance designed for providing
lump sum benefit to insured individuals affected by COVID-1... | Final IC-38 - Corporate Agent _Composite _ English.md | D-19 | Corona Kavach | Final IC-38 - Corporate Agent _Composite _ English_121 | {
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hours.
a) Dengue fever
b) Malaria
c) Filaria (Lymphatic Filariasis)
d) Kala-azar
e) Chikungunya
f) Japanese Encephalitis
g) Zika Virus2. **Diagnosis Cover:** 2% of the sum insured shall be payable on positive diagnosis(through laboratory examination and confirmed by the medical practitioner) of
every covered vector bor... | Final IC-38 - Corporate Agent _Composite _ English.md | s2 | Diagnosis Cover: | Final IC-38 - Corporate Agent _Composite _ English_122 | {
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flagship scheme of to achieve the vision of Universal Health Coverage (UHC). Also
known as Pradhan Mantri Jan Arogya Yojana (PMJAY) Ayushman Bharat came with a
Sum Insured of Rs. 5,00,000.It subsumed the then existing Rashtriya Swasthya Bima Yojana (RSBY). PM-JAY is
fully funded by the Government and cost of implementa... | Final IC-38 - Corporate Agent _Composite _ English.md | r2 | K. | Final IC-38 - Corporate Agent _Composite _ English_123 | {
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would be payable.**1.** **Types of disability covered**Types of disability which are normally covered under the policy are:**i.** **Permanent total disability (PTD):** means becoming totally disabled forlifetime viz. paralysis of all four limbs, comatose condition, loss of both
eyes/ both hands/ both limbs or one hand ... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Types of disability covered | Final IC-38 - Corporate Agent _Composite _ English_124 | {
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financial problems.**Scope of coverage**Such policies are primarily meant for accident and sickness benefits, but most
products available in the market package a range of covers within one product.The usual covers offered are:**a) Medical and sickness section:**i. Accidental death/ disability
ii. Medical expenses due t... | Final IC-38 - Corporate Agent _Composite _ English.md | a229 | Scope of coverage | Final IC-38 - Corporate Agent _Composite _ English_125 | {
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restricted to a certain amount within the overall sum insured of the family.**4.** **Child cover**Coverage is given to babies from day one, sometimes restricted to the
maternity cover limit and sometimes extended to include the full sum insured
of the family.**5.** **Pre-existing diseases covered, waiting period waived... | Final IC-38 - Corporate Agent _Composite _ English.md | d-19 | Child cover | Final IC-38 - Corporate Agent _Composite _ English_126 | {
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tie-up with an insurer/ TPA for providing cashless treatment to insured patients.
Patients are free to go to out-of-network providers but there they are generally
charged much higher fees.**2.** **Preferred provider network (PPN)**An insurer has the option to create a preferred network of hospitals to ensure quality
tr... | Final IC-38 - Corporate Agent _Composite _ English.md | s232 | Preferred provider network (PPN) | Final IC-38 - Corporate Agent _Composite _ English_127 | {
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compensation of expenses that would be deemed to be reasonable for treatment of
a particular ailment and in a particular geographical area.**8.** **Notice of claim**Every insurance policy provides for immediate intimation of claim and specified
time limits for document submission. In health insurance policies, wherever... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Notice of claim | Final IC-38 - Corporate Agent _Composite _ English_128 | {
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misrepresentation, fraud, and non-disclosure of material fact or non-cooperation by
the insured.When policies are cancelled by the insurer, a proportion of the premium
corresponding to the unexpired period of insurance, is returned to the insured
provided no claim has been paid under the policy. This is usually on pro-... | Final IC-38 - Corporate Agent _Composite _ English.md | H-04 | Grace period for renewal | Final IC-38 - Corporate Agent _Composite _ English_129 | {
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Insurance companies try to insure people who are expected to pay adequate
premium in proportion to the risk they bring to the insurance pool. This process of
collecting and analysing information from a proposer is known as underwriting. On
the basis of information collected through this process, they decide whether the... | Final IC-38 - Corporate Agent _Composite _ English.md | m237 | Definition | Final IC-38 - Corporate Agent _Composite _ English_130 | {
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morbidity and should be taken into consideration while accepting risk.
**f)** **Build:** Stout, thin or average build may also be linked to morbidity in certaingroups.
**g)** **Past illness or surgery:** It has to be ascertained whether the past illness hasany possibility of causing increased physical weakness or even ... | Final IC-38 - Corporate Agent _Composite _ English.md | o240 | Build: | Final IC-38 - Corporate Agent _Composite _ English_131 | {
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and/or accept them subject to certain conditions and restrictions.**iv.** **Declined risks**There are some persons who have certain medical or other conditions, which
make them highly prone to sicknesses and making claims. It is highly probable
that such persons fall sick and cause a disproportionate degree of liabilit... | Final IC-38 - Corporate Agent _Composite _ English.md | o240 | Declined risks | Final IC-38 - Corporate Agent _Composite _ English_132 | {
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has prescribed standard forms to be filled up by the insured which forms part of
the policy document.
c. Insurers have come out with various mechanisms to reward policyholders forearly entry, continued renewals, favourable claims experience etc. with the
same insurer and disclose upfront such mechanism or incentives in... | Final IC-38 - Corporate Agent _Composite _ English.md | e242 | D. | Final IC-38 - Corporate Agent _Composite _ English_133 | {
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may result in the insurer deciding to avoid the liability. (These principles have been
discussed in the common chapters.)**2.** **Tools for underwriting**These are the sources of information for the underwriter and the basis on which the
risk classification is done and premiums finally decided. The following are the ke... | Final IC-38 - Corporate Agent _Composite _ English.md | d244 | Tools for underwriting | Final IC-38 - Corporate Agent _Composite _ English_134 | {
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have a high probability of future hospitalization for diseases of the heart, kidney
and the nervous system. So, these conditions should be carefully considered while
assessing the risk for medical underwriting.Medical underwriting guidelines may also require a signed declaration of the
proposer’s health status by his/ ... | Final IC-38 - Corporate Agent _Composite _ English.md | g245 | Non-medical underwriting | Final IC-38 - Corporate Agent _Composite _ English_135 | {
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III. Proposers have to undergo medical and pathological investigations to assesstheir health risk profile.
IV. Percentage assessment is made on each component of the risk.**H.** **Health Insurance at Group Level**While accepting a group for health insurance, the insurers take into consideration
the possibility of exist... | Final IC-38 - Corporate Agent _Composite _ English.md | null | H. | Final IC-38 - Corporate Agent _Composite _ English_136 | {
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insured. The risks associated with profession or occupation varies in accordance
with the nature of work performed. For example, an office manager is less exposed
to risk at work than a civil engineer working at a site where a building is being
constructed. To fix a rate, occupations are classified into groups, each gr... | Final IC-38 - Corporate Agent _Composite _ English.md | H-05 | Classification of Risk | Final IC-38 - Corporate Agent _Composite _ English_137 | {
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**Answer 2** **-** The correct option is III.
**Answer 3** **-** The correct option is I.
**Answer 4** **-** The correct option is IV.
**Answer 5** **-** The correct option is IV.250## CHAPTER H-05## HEALTH INSURANCE CLAIMS**Chapter Introduction**In this chapter we will discuss about claim management process in Health ... | Final IC-38 - Corporate Agent _Composite _ English.md | H-05 | Answer 2 | Final IC-38 - Corporate Agent _Composite _ English_138 | {
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Reserves are usually are actuarial estimates of the amounts that will be paid on
outstanding claims.Reserving refers to the amount of provision made for all claims in the books of the
insurer based on the status of the claims.**Test Yourself 1**Who among the following is not a stakeholder in Health insurance claim proc... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Test Yourself 1 | Final IC-38 - Corporate Agent _Composite _ English_139 | {
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medical consultation is allowed, in the terms and conditions of medical insurance
policies.This will help policy holders who may prefer to consult medical practitioners online
or telephonically to avoid going out of their homes or if they are in quarantine
themselves due to the coronavirus infection.**Arriving at the f... | Final IC-38 - Corporate Agent _Composite _ English.md | l2 | Arriving at the final claim payable: | Final IC-38 - Corporate Agent _Composite _ English_140 | {
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investigations shall be initiated and completed 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. (Pl refer to IRDAI
(Protection of policyholder’s), 2017 Regulations and updated accordingly)**f)**... | Final IC-38 - Corporate Agent _Composite _ English.md | l2 | Cashless settlement process by TPA | Final IC-38 - Corporate Agent _Composite _ English_141 | {
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options available where cashless facility for such treatment is available.ii. He/ she needs to make sure that the correct details are entered into thepre-authorization form. This form has been standardized by IRDAI as per
Guidelines on Standardization in Health Insurance issued in 2013. If the case
is not clear, the TP... | Final IC-38 - Corporate Agent _Composite _ English.md | t258 | C. | Final IC-38 - Corporate Agent _Composite _ English_142 | {
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has been stated above. These are:a) Accident claims, where FIR or Medico-legal certificate issued by the hospitalto the registered police station, may be required.b) Case indoor papers in case of complicated or high value claims.c) Dialysis/ Chemotherapy/ Physiotherapy charts where applicable.d) Hospital registration c... | Final IC-38 - Corporate Agent _Composite _ English.md | e259 | Test Yourself 2 | Final IC-38 - Corporate Agent _Composite _ English_143 | {
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investigator for verification.**Example**Example of case guideline:
**Road traffic accident**i. When did the incident take place – exact time and date place? Date and time
ii. Was the insured a pedestrian, traveling as passenger/ pillion rider or drivingthe vehicle involved in accident?**Some examples of possible fraud... | Final IC-38 - Corporate Agent _Composite _ English.md | e262 | Example | Final IC-38 - Corporate Agent _Composite _ English_144 | {
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i. Medical service provider referrals
ii. Arrangement of hospital admission
iii. Arrangement of Emergency Medical Evacuation
iv. Arrangement of Emergency Medical Repatriation
v. Mortal remains repatriation
vi. Compassionate visit arrangements
vii. Minor children assistance/ escort
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**Answer 2** - The correct option is II.
**Answer 3** - The correct option is III.
**Answer 4** - The correct option is IV.
**Answer 5** - The correct option is III.**Summary**a) Insurance is a ‘promise’ and the policy is a ‘witness’ to that promise. Theoccurrence of insured event leading to a claim under the policy is... | Final IC-38 - Corporate Agent _Composite _ English.md | G-01 | Answer 2 | Final IC-38 - Corporate Agent _Composite _ English_146 | {
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arranged by insurer before acceptance of the risk. Special questionnaire are
sometimes used in addition to the proposal form to gather specific information.Fire insurance proposal form seeks, among other things, the description of the
property which would include the following information: Construction of external wal... | Final IC-38 - Corporate Agent _Composite _ English.md | null | For motor insurance, | Final IC-38 - Corporate Agent _Composite _ English_147 | {
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past. Underwriters can understand the risk better from such answers and decide
on conducting risk inspections or collecting further details.**viii.** **Declaration by insured**As the purpose of the proposal form is to provide all material information to the
insurers, the form **includes a declaration by the insured tha... | Final IC-38 - Corporate Agent _Composite _ English.md | t-1938 | Declaration by insured | Final IC-38 - Corporate Agent _Composite _ English_148 | {
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or the cheque is posted as the case may be.e) Any refund of premium which may become due to an insured on account of thecancellation of policy or alteration in its terms and conditions or otherwise, shall
be paid by the insurer directly to the insured by a crossed or order cheque or by
postal/ money order or by Electro... | Final IC-38 - Corporate Agent _Composite _ English.md | o60 | D. | Final IC-38 - Corporate Agent _Composite _ English_149 | {
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shipment on board the steamer, it is hereby agreed that the basis of valuation272shall be prime cost of the goods plus charges actually incurred and for which the
assured is liable.With regard to inland transit normally all relevant data required for issue of policy
are available and therefore a cover note is rarely re... | Final IC-38 - Corporate Agent _Composite _ English.md | n272 | Motor Cover Notes | Final IC-38 - Corporate Agent _Composite _ English_150 | {
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and is not disqualified from holding or obtaining such a license. Provided also that the person
holding an effective learner's license may also drive the vehicle and such a person satisfies
the requirement of Rule 3 of Central Motor Vehicles Rules 1989.**LIMITATIONS AS TO USE**The policy covers use for any purpose othe... | Final IC-38 - Corporate Agent _Composite _ English.md | e274 | LIMITATIONS AS TO USE | Final IC-38 - Corporate Agent _Composite _ English_151 | {
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and does not, in any way, contribute to or aggravate the loss, insurers at their
discretion may process the claims according to norms and guidelines as per company
policy.275**1.** **Fire Insurances warranties (some examples) are as given below**Warranted, that no hazards goods shall be stored in the insured premises d... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Fire Insurances warranties (some examples) are as given below | Final IC-38 - Corporate Agent _Composite _ English_152 | {
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cancelled as from ………. The insurance having been in force for a period over ………….
Months, no refund is due to the Insured.277The total insurance now stands at Rs …….Subject otherwise to the terms, provisions and conditions of this policy.**Test Yourself 4**If certain terms and conditions of the policy need to be modifi... | Final IC-38 - Corporate Agent _Composite _ English.md | e279 | Test Yourself 4 | Final IC-38 - Corporate Agent _Composite _ English_153 | {
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decisions and those decisions of a higher court will be binding on a lower court
decision. Technical terms must always be given their technical meaning, unless
there is an indication to the contrary.**H.** **Renewal Notice****Most of the non-life insurance policies are insured on annual basis.**Although there is no leg... | Final IC-38 - Corporate Agent _Composite _ English.md | e279 | H. | Final IC-38 - Corporate Agent _Composite _ English_154 | {
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n) If certain terms and conditions of the policy need to be modified at the time ofissuance or during the policy tenure, it is done by setting out the amendments/
changes through a document called endorsement.
o) The most important rule of construction is that the intention of the parties mustprevail and this intention... | Final IC-38 - Corporate Agent _Composite _ English.md | G-02 | Key Terms | Final IC-38 - Corporate Agent _Composite _ English_155 | {
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contents may be highly susceptible to damage in the event of fire.For example, paper, clothing etc. are susceptible not only to fire damage but
also to damage by water, heat etc.**vi.** **The process of manufacture:** If work is carried during the night, the hazardis increased due to the use of artificial lights, conti... | Final IC-38 - Corporate Agent _Composite _ English.md | null | The process of manufacture: | Final IC-38 - Corporate Agent _Composite _ English_156 | {
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examples are provided below.**Example****i.** **Marine cargo:** A warranty is inserted to the effect that goods (e.g. Tea) arepacked in tin lined cases.**ii.** **Burglary:** It is warranted that the property is guarded by a watchman for twentyfour hours.**iii.** **Fire:** In fire insurance, it is warranted the premises... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Example | Final IC-38 - Corporate Agent _Composite _ English_157 | {
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and is declined. Based on their past loss experience, knowledge of hazards and
overall underwriting policy, insurers have formulated a list of risks to be declined
in each class of insurance.**C.** **Moral hazard**Moral hazard could arise in the following ways:**a)** **Dishonesty**An extreme example of bad moral hazard... | Final IC-38 - Corporate Agent _Composite _ English.md | null | C. | Final IC-38 - Corporate Agent _Composite _ English_158 | {
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condition. An insured has to be very careful in choosing the limit of indemnity,
because that is the maximum amount that would be reimbursed at the time ofclaim.The sum insured is always fixed by the insured. It is an amount on which rate is
applied to arrive at the premium under the policy.It should be representative ... | Final IC-38 - Corporate Agent _Composite _ English.md | d288 | Deciding the sum insured | Final IC-38 - Corporate Agent _Composite _ English_159 | {
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spread. Additional legal costs and expenses may also form part of claim
compensation. The sum insured is decided by the insured based on the above
parameters.**Test Yourself 2**Suggest an insurance scheme for a doctor to protect himself from any claims of
negligence against him.I. Personal accident insuranceII. Profess... | Final IC-38 - Corporate Agent _Composite _ English.md | e289 | Test Yourself 2 | Final IC-38 - Corporate Agent _Composite _ English_160 | {
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ii. For instance there are covers such as Householder’s Policy, Shopkeeper’s Policy,Office Package Policy etc. that, under one policy, seek to cover various physical
assets including buildings, contents etc.
iii. Such policies may also include certain personal lines or liability covers.
iv. Package covers could have co... | Final IC-38 - Corporate Agent _Composite _ English.md | null | D. | Final IC-38 - Corporate Agent _Composite _ English_161 | {
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Compensation and Public Liability Polices (dealt with next chapter) can be taken
separately also.
Terrorism cover may also be extended. The exclusions are generally the same
as in householder’s insurance.293**E.** **Householder’s Insurance**The coverages under a Householder’s Insurance Policy can be quite wide. It is u... | Final IC-38 - Corporate Agent _Composite _ English.md | null | E. | Final IC-38 - Corporate Agent _Composite _ English_162 | {
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of M.V., in the event of a loss, depreciation is levied on the asset depending on
its age. Under this method, the insured is not paid amount sufficient to replace
the property.ii. In the RIV method, the insurance company will pay the cost of replacementsubject to ceiling of sum insured. Under this method, no depreciati... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Test Yourself 1 | Final IC-38 - Corporate Agent _Composite _ English_163 | {
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more than what it cost her to purchase the car. Will Revathi or similar people have that much money to pay?
Should the other party’s insurance pay for Revathi’s actions?
What if they don't have insurance?296That is why the laws of the land make it mandatory to have third-party liability
insurance. While motor insu... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Important | Final IC-38 - Corporate Agent _Composite _ English_164 | {
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damage.
The claims for compensation to third party victims in case of death or injury caused
by a motor accident are to be filed by the complainant in Motor Accident Claim
Tribunal (MACT).
**‘Compulsory Personal Accident (CPA) Insurance’**IRDAI permitted the issuance of a stand-alone Compulsory Personal Accident cover
... | Final IC-38 - Corporate Agent _Composite _ English.md | y299 | Package/ Comprehensive Policy: (Own Damage + Third Party Liability) | Final IC-38 - Corporate Agent _Composite _ English_165 | {
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contents against burglary, housebreaking, larceny and theft.
c) Package covers give, under a single document, a combination of covers.
d) For a householder’s insurance policy generally there are two methods of fixingthe sum insured: Market Value (MV) and Reinstatement Value (RIV).
e) Shopkeeper’s insurance usually cove... | Final IC-38 - Corporate Agent _Composite _ English.md | y299 | Key terms | Final IC-38 - Corporate Agent _Composite _ English_166 | {
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Impact damage
Aircraft damage
Storm, tempest, cyclone, typhoon, hurricane, tornado, flood and inundation
Subsidence and landslide including rock slide
Bursting and overflowing of water tanks, apparatus and pipes
Missile testing operations
Leakages from automatic sprinkler installation
Bush fire302There ... | Final IC-38 - Corporate Agent _Composite _ English.md | e302 | Revised Standard Fire and Special Perils (SFSP) Policies: | Final IC-38 - Corporate Agent _Composite _ English_167 | {
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by the policy for micro level enterprises mentioned above. The perils against which
insurance is offered are also similar to the policy meant for micro level enterprises.The policy, again, can be taken for all types of risks such as offices, hotels,
industries, storage risks and so on. Bharat Laghu Udyam Policies allow... | Final IC-38 - Corporate Agent _Composite _ English.md | y305 | Exclusions under Fire Policies | Final IC-38 - Corporate Agent _Composite _ English_168 | {
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II. Fire on ship
III. Explosion in factory
IV. Hospitalization due to fire**B.** **Business Interruption Insurance**Business Interruption insurance is also known as Consequential Loss Insurance or
Loss of Profit Insurance.Fire insurance provides indemnity against material or property damage or loss
suffered to building... | Final IC-38 - Corporate Agent _Composite _ English.md | y305 | B. | Final IC-38 - Corporate Agent _Composite _ English_169 | {
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immediately or the insured may take additional security measures from itsrecurrence.**2.** **Declaration cover and floater cover is also possible in respect of stocks,****similar to fire insurance.****3** . **Exclusions**The policy does not cover theft by employees, family members or other persons
who are lawfully on t... | Final IC-38 - Corporate Agent _Composite _ English.md | s307 | Declaration cover and floater cover is also possible in respect of stocks, | Final IC-38 - Corporate Agent _Composite _ English_170 | {
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company at any one time, the mode of conveyance, distance involved, safety
measures taken etc. Premium is adjustable according to actual cash carried
throughout the year based on declaration made within 30 days of expiry of the
policy.**Test Yourself 4**Which of the below is covered under a money insurance policy?I. Sh... | Final IC-38 - Corporate Agent _Composite _ English.md | m308 | Test Yourself 4 | Final IC-38 - Corporate Agent _Composite _ English_171 | {
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who deal with operations involving money, considering the special risks faced by
them regarding money and securities.**1.** **Coverage under Bankers Indemnity Insurance**
There are different variations to this policy based on the requirement of banker.a) Money securities lost or damaged whilst within the premises due t... | Final IC-38 - Corporate Agent _Composite _ English.md | s310 | Coverage under Bankers Indemnity Insurance | Final IC-38 - Corporate Agent _Composite _ English_172 | {
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there is no separate section for this cover.Risks are rated on merits of each case. Different premium rates are applied for each
section with discounts for exclusive round the clock watchman, close circuit TV/
alarm system, exclusive strong room and for any other safety expedient etc.**Test Yourself 7**In case of a Jew... | Final IC-38 - Corporate Agent _Composite _ English.md | y312 | Test Yourself 7 | Final IC-38 - Corporate Agent _Composite _ English_173 | {
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