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due to internal pressures of such boiler and/ or pressure plant.**Since fire policy and boiler insurance policy are mutually exclusive, for adequate**
**cover, both the policies need to be taken. Sum insured under all Engineering**
**Policies should be the current replacement value.****3.** **Electronic Equipment Polic... | Final IC-38 - Corporate Agent _Composite _ English.md | o313 | Since fire policy and boiler insurance policy are mutually exclusive, for adequate | Final IC-38 - Corporate Agent _Composite _ English_174 | {
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8. Earthquake Fire and Shock (Including flood due to earthquake), Tsunami
9. Frost, avalanche, ice.**B.** **Project Policies**These policies are typically issued for the period of the project and may not be on
an annual basis.
**1.** **Contractors All Risks (C.A.R.) Policy:** This is designed to protect the interestsof... | Final IC-38 - Corporate Agent _Composite _ English.md | d315 | B. | Final IC-38 - Corporate Agent _Composite _ English_175 | {
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II. Advance Loss of Profits coverIII. Contractors All Risk cover
IV. Contractors Plant & Machinery cover**I.** **Industrial All Risks Insurance**The Industrial All Risks Policy was designed to cover, industrial properties – both
manufacturing and storage facilities, anywhere in India under one policy. It provides
indem... | Final IC-38 - Corporate Agent _Composite _ English.md | null | I. | Final IC-38 - Corporate Agent _Composite _ English_176 | {
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iii. Institute Cargo (Air) Clause – A for transport by airInstitute Cargo Clause C grants the minimum cover, which is loss or damage due to
accident to the vehicle or vessel carrying the cargo due to:i. Fire or explosion
ii. Derailment or overturning of the vehicle
iii. Stranding, grounding or sinking of the vessel (in... | Final IC-38 - Corporate Agent _Composite _ English.md | null | Important | Final IC-38 - Corporate Agent _Composite _ English_177 | {
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countries. Marine hull covers are essentially of two types:**a)** **Covering a particular Voyage: The set of clauses used here are called****Institute Voyage Clauses**
**b)** **Covering a period of time: Usually one year. The set of clauses used here****are called Institute (Time) Clauses**319**c)** War risks are gover... | Final IC-38 - Corporate Agent _Composite _ English.md | l2 | Covering a particular Voyage: The set of clauses used here are called | Final IC-38 - Corporate Agent _Composite _ English_178 | {
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per person is fixed as shown below.|Compensation payable|Col2|
|---|---|
|Fatal Accident|Rs. 25,000|
|Permanent Total Disability|Rs. 25,000|
|Permanent Partial Disability|% of Rs. 25,000 based on % of disability|
|Temporary Partial Disablement|Rs. 1000 per month, maximum 3 months|
|Actual Medical Expenses|Up to a maxim... | Final IC-38 - Corporate Agent _Composite _ English.md | l2 | Public Liability Policy (Industrial/ Non-industrial Risks) | Final IC-38 - Corporate Agent _Composite _ English_179 | {
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compensation to his employees who sustain personal injury by accident or disease
arising out of and in the course of his employment. This is also called **Workman’s**
**Compensation Insurance.**Two forms of insurance are prevalent in the market:**a)** **Table A:** Indemnity against legal liability for accidents to empl... | Final IC-38 - Corporate Agent _Composite _ English.md | s322 | Workman’s | Final IC-38 - Corporate Agent _Composite _ English_180 | {
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the possible after the loss.If he gets the money promptly, it is of maximum use to him. It is insurance
company’s duty to pay the claim amount when insured needs it most – as early
as possible after the loss.b) **Professionalism**The insurance officials consider each and every claim on its merits and do not
apply preju... | Final IC-38 - Corporate Agent _Composite _ English.md | e2 | Professionalism | Final IC-38 - Corporate Agent _Composite _ English_181 | {
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medical examination. Medical evidence is also required in support of “Workmen’s
Compensation” claims. Livestock and cattle claims are assessed on the basis of the
report of a veterinary doctor.326**Information**On receipt of intimation of loss or damage insurers check whether:1. The insurance policy is in force on the ... | Final IC-38 - Corporate Agent _Composite _ English.md | e2 | Information | Final IC-38 - Corporate Agent _Composite _ English_182 | {
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value of property at the place and time of occurrence after allowance for
depreciation, wear and tear (unless the policy in respect of building, plant and
machinery is on “reinstatement value” basis). It shall not include profit]v. Amount claimed after deduction of salvage valuevi. Situation and occupancy of the premis... | Final IC-38 - Corporate Agent _Composite _ English.md | s329 | Supporting documents | Final IC-38 - Corporate Agent _Composite _ English_183 | {
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under the policy then who decides on such matters?I. Insurer’s decision is finalII. UmpireIII. ArbitratorIV. Court of Law**Summary**a) Settling claims professionally is regarded as the biggest advertisement for aninsurance company.b) Policy conditions provide that the loss be intimated to the insurer immediately.330c) ... | Final IC-38 - Corporate Agent _Composite _ English.md | S332 | ANNEXURESThese annexures are provided so that the students get a better idea of proposal | Final IC-38 - Corporate Agent _Composite _ English_184 | {
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## IC - 38 **CORPORATE AGENTS** **SECTION-GENERAL****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.... | Final IC-38 - Corporate Agent _General _ English.md | C-46 | CORPORATE AGENTS | Final IC-38 - Corporate Agent _General _ English_000 | {
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|**SECTION **|**ANNEXURES**|**ANNEXURES**|
|A-1|Annexures – Specimen Proposal forms and Claims Forms for filling up<br>|68|iv## SECTION **GENERAL INSURANCE**1## CHAPTER G-01## GENERAL INSURANCE DOCUMENTATION**Chapter Introduction**As discussed in Chapter 7, the Proposal form contains information which are useful for
th... | Final IC-38 - Corporate Agent _General _ English.md | A-1 | SECTION | Final IC-38 - Corporate Agent _General _ English_001 | {
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profession, occupation or business are of importance as they could have a
material bearing on the risk.**iv.** **Details and identity of the subject matter of insurance**The proposer is required to clearly state the subject matter that is proposed forinsurance.**Example**The proposer is required to state if it is:**i.*... | Final IC-38 - Corporate Agent _General _ English.md | t-1938 | Details and identity of the subject matter of insurance | Final IC-38 - Corporate Agent _General _ English_002 | {
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company has to process the proposal within 15 days’ time. 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. This entire
process of scrutinizing the proposal and deciding about acceptance is known as
un... | Final IC-38 - Corporate Agent _General _ English.md | t-1938 | Test Yourself 1 | Final IC-38 - Corporate Agent _General _ English_003 | {
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of the steamer, number of packages, or exact value etc. are not known. Even in
respect of exports, a cover note may be issued e.g. a certain quantity of cargo
meant for shipment is sent by the exporter to the docks. It may happen that, owing
to difficulty of securing adequate shipping space, shipment of the cargo by th... | Final IC-38 - Corporate Agent _General _ English.md | n7 | Clauses: | Final IC-38 - Corporate Agent _General _ English_004 | {
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d) Date of expiry of insurance
e) Persons or classes of persons entitled to drive
f) Limitations as to use
g) Additional risks, if anyThe Motor Cover Note incorporates a certificate to the effect that it is issued in
accordance with the provisions of Chapters X and XI of the Motor Vehicles Act, 1988.**Important**The va... | Final IC-38 - Corporate Agent _General _ English.md | e9 | Important | Final IC-38 - Corporate Agent _General _ English_005 | {
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e) Sums insured;
f) Perils covered and exclusions ;
g) Any excess/ deductible applicable;
h) Premium payable and where the premium is provisional subject toadjustment, the basis of adjustment of premium ;
i) Policy terms, conditions and warranties;
j) Action to be taken by the insured upon occurrence of a contingency l... | Final IC-38 - Corporate Agent _General _ English.md | null | Test Yourself 1 | Final IC-38 - Corporate Agent _General _ English_006 | {
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continue to be the same only if the warranties attached to the policy are
complied with.**Test Yourself 2**Which of the following statements is correct with regards to a warranty?I. A warranty is a condition which is never stated in the policy
II. A warranty forms part of a policy document
III. A warranty is always com... | Final IC-38 - Corporate Agent _General _ English.md | null | Test Yourself 2 | Final IC-38 - Corporate Agent _General _ English_007 | {
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d) Clauses in italics over-ride the ordinary printed wording where they areinconsistent.13e) Clauses printed or typed in the margin of the policy are to be given moreimportance than the wording within the body of the policy.
f) Clauses attached or pasted to the policy override both marginal clauses andthe clauses in th... | Final IC-38 - Corporate Agent _General _ English.md | e14 | Important | Final IC-38 - Corporate Agent _General _ English_008 | {
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IV. As per regulations there is no legal obligation on insurers to send a renewalnotice to insured before the expiry of the policy**Summary**a) The first stage of documentation is essentially the proposal forms through whichthe insured informs about himself/ herself
b) The duty of disclosure of material information ari... | Final IC-38 - Corporate Agent _General _ English.md | G-02 | Summary | Final IC-38 - Corporate Agent _General _ English_009 | {
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2. Appreciate Underwriting as a function
3. Methods used by underwriters to reduce the risk
4. Understand how the Sum Insured is fixed.17**A.** **Physical Hazards**A thorough knowledge of various hazards to which property and persons are exposed
is most essential for underwriting.Physical hazard can be ascertained from... | Final IC-38 - Corporate Agent _General _ English.md | null | A. | Final IC-38 - Corporate Agent _General _ English_010 | {
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may decide to charge an extra premium before acceptance of the same. By loading
the premium the higher probability of claims or occurrence of large claims is taken
into consideration.**Example**Normal rate of premium is charged for cargo shipped by liners or other vessels,
which comply with the prescribed standards. Ho... | Final IC-38 - Corporate Agent _General _ English.md | null | Example | Final IC-38 - Corporate Agent _General _ English_011 | {
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to the maximum bonus that can be availed. It is allowed by way of deduction on the
total premium at renewal only, depending upon the incurred claim ratio for the
entire group or to Motor vehicle Own damage policy holders for claim free years.**No claim bonus is a powerful strategy to improve underwriting experience and... | Final IC-38 - Corporate Agent _General _ English.md | null | No claim bonus is a powerful strategy to improve underwriting experience and | Final IC-38 - Corporate Agent _General _ English_012 | {
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refund is made keeping the premium on short period scale for the period Insurer
was in risk.22**Minimum premium**It is the practice to charge minimum premium under each policy so that
administrative expenses of issuing the policy are covered.**Test Yourself 1**What is expected of an agent when she detects a moral hazar... | Final IC-38 - Corporate Agent _General _ English.md | d23 | Minimum premium | Final IC-38 - Corporate Agent _General _ English_013 | {
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the market to replace the damaged raw material, after the loss.**e)** **Marine cargo insurance:** It is an agreed valued policy and the sum insured is asper the agreement between insurer and insured at the time of contract. Normally
it would consist of the sum of cost of the commodity plus Insurance + freight i.e.
CIF ... | Final IC-38 - Corporate Agent _General _ English.md | e24 | Marine cargo insurance: | Final IC-38 - Corporate Agent _General _ English_014 | {
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that deal with personal lines of insurance as the buyers also are essentially from the
same consumer segment.**B.** **'All Risks' and ‘Named Perils’ Insurance Policy**Non-life insurance policies can be broadly classified into two categories: Named peril policies
All risk policiesi. "All risks" typically means that a... | Final IC-38 - Corporate Agent _General _ English.md | null | B. | Final IC-38 - Corporate Agent _General _ English_015 | {
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**v.** **Baggage** : Compensates for loss of baggage while on travel for official purposes
**vi.** **Fixed Plate Glass and Sanitary Fittings covers accidental loss of damage to:** Fixed plate glass
Sanitary fittings
Neon Sign/ Glow Sign/ Hoarding
**vii.** **Personal Accident**
**viii.** **Infidelity/ Dishonesty of... | Final IC-38 - Corporate Agent _General _ English.md | null | Baggage | Final IC-38 - Corporate Agent _General _ English_016 | {
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declared by a policyholder is less than what ought to have been declared for the
property in question, the policyholder’s claim will not be settled proportionately
but upto the Sum Insured that is declared.29**F.** **Sum Insured and Premium**Industrial units or offices will maintain books of accounts showing therein va... | Final IC-38 - Corporate Agent _General _ English.md | null | F. | Final IC-38 - Corporate Agent _General _ English_017 | {
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synonymous with ‘larceny’.**Test Yourself 2**Under the shopkeeper package policy, the insured may opt for an additional ‘Fixed plate
glass and sanitary fittings’ cover. This will cover accidental loss of damage to which of the
following?I. Fixed plate glass
II. Sanitary fittings
III. Neon signs
IV. All of the above**G.... | Final IC-38 - Corporate Agent _General _ English.md | null | Test Yourself 2 | Final IC-38 - Corporate Agent _General _ English_018 | {
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party. Third-party insurance is purchased by the insured (first party) from an
insurance company (second party) for protection against another party's claims
(third party) for liability arising out of the action of the insuredThird party insurance is called ‘Liability Insurance’ as well.**Two important types of covers ... | Final IC-38 - Corporate Agent _General _ English.md | null | Two important types of covers that are popular in the market are discussed | Final IC-38 - Corporate Agent _General _ English_019 | {
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from Regional Transport Authority
III. In the name of any family member of the vehicle owner, including the vehicleowner, subject to approval from the Regional Transport Authority
IV. If the vehicle will be driven by anyone other than the owner, then primary policyshould be in the name of the vehicle owner and addition... | Final IC-38 - Corporate Agent _General _ English.md | y34 | Summary | Final IC-38 - Corporate Agent _General _ English_020 | {
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stocks and stock in process, including stocks at suppliers/ customer's premises,Stocks held in trust, if specifically declared, machinery temporarily removed from
the premises for repairs can be insured. Monetary relief is essential to rebuild and
renew the property damaged to bring back the business to its normal cour... | Final IC-38 - Corporate Agent _General _ English.md | e37 | What does the Standard Fire policy cover? | Final IC-38 - Corporate Agent _General _ English_021 | {
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storage risks and so on. The policy underinsurance to the extent of 15% is waived.
Bharat Sookshma Udyam Policies allow increase in Sum Insurer during the policy
tenure by endorsement.38**ii.** **Bharat Laghu Udyam Suraksha(meant for enterprises where the total value****at risk is more than Rs. 5 Crore and upto Rs. 50 ... | Final IC-38 - Corporate Agent _General _ English.md | null | Bharat Laghu Udyam Suraksha(meant for enterprises where the total value | Final IC-38 - Corporate Agent _General _ English_022 | {
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fire floater policies as the sum insured ‘floats’ over multiple locations.**vi.** **Premium rating depends on:**a) The type of occupancy, whether industrial or otherwise.
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through means of force. This is generally known as “key clause”.b) A complete list of the amounts of cash in safe is kept secure in some place otherthan the safe. The liability of the insurer is limited to the amount actually shown
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are normally the same as of burglary insurance (of business premises) that this
was discussed under Learning Outcome C above.**2.** **Important exclusions**These include:a) Shortage due to error or omission,b) Loss of money that has been entrusted to other than authorized person andc) Riot, strike and terrorism**3.** *... | Final IC-38 - Corporate Agent _General _ English.md | m43 | Important exclusions | Final IC-38 - Corporate Agent _General _ English_025 | {
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organization makes adequate enquiries into the antecedents of employees.
The references that the employer obtains must be available to the insurers in
the event of a claim. The policy is granted only to large firms of repute.**3.** **Premium**The rate of premium depends upon the type of business occupation, status of t... | Final IC-38 - Corporate Agent _General _ English.md | s45 | Premium | Final IC-38 - Corporate Agent _General _ English_026 | {
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especially diamonds. Imported raw diamonds are cut, polished and exported. It
takes care of all risks of a jeweller whose business involves sale of articles of high
value in small bulk like jewellery gold &silver articles, diamonds and precious
stones, wrist watches etc. The trade involves stocking these expensive item... | Final IC-38 - Corporate Agent _General _ English.md | y47 | Coverage of Jeweller’s Block Policy | Final IC-38 - Corporate Agent _General _ English_027 | {
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machine; the industry in which it is used and its value. Discounts are offered based
on factors such as stand-by facilities, spares available and claims experience.**2.** **Boiler and Pressure Plant Policy:** This covers boilers and pressure vessels,against:a) Damage, other than by fire, to the boilers and/ or other pr... | Final IC-38 - Corporate Agent _General _ English.md | o48 | Boiler and Pressure Plant Policy: | Final IC-38 - Corporate Agent _General _ English_028 | {
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Dry docks, Harbours, Jetties Railway lines, Rock Filled dams, Concrete dams,
Earthen dams, Canals, Irrigation system are considered under this policy. Risks
covered are –1. Fire
2. Lightning
3. Explosion/ Implosion494. Riot, Strike, Malicious Damage
5. Impact by any Rail/ Road or water borne vehicle or animal
6. Storm ... | Final IC-38 - Corporate Agent _General _ English.md | n494 | B. | Final IC-38 - Corporate Agent _General _ English_029 | {
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actual commencement of project.The policy also covers financial losses in the form of continuing expenses such as
interest on term loan, debentures, wages and salaries etc. and on the anticipated
net profit which the business could have earned if it had commenced on the
scheduled date.Premium rating depends on various ... | Final IC-38 - Corporate Agent _General _ English.md | null | Test Yourself 8 | Final IC-38 - Corporate Agent _General _ English_030 | {
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between the insurer and insured and is not subject to revaluation later unless fraud
is suspected. The convention for the Sum Insured is CIF + 10% (Cost Insurance &
Freight + 10%). Another unique feature is that the policy is freely assignable.52The cover normally commences from the time the goods leave the warehouse a... | Final IC-38 - Corporate Agent _General _ English.md | null | Important | Final IC-38 - Corporate Agent _General _ English_031 | {
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protection to cover a large number of shipments/ despatches. The premium
on the consignments would be adjusted from the respective cash deposit
account maintained by the Insured. Open covers are issued to large exporters
and importers who have continuous tradeOpen covers set out the terms of cover and rates of premium ... | Final IC-38 - Corporate Agent _General _ English.md | l2 | Duty and increased value insurance | Final IC-38 - Corporate Agent _General _ English_032 | {
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existence of such a liability and the amount of compensation to be paid would be
decided by a civil court which would go into the aspect of alleged negligence/ fraud.
Liability insurance policies provide coverage of such liabilities. Let us look at some
of the liability policies.**Statutory liability**55There are certa... | Final IC-38 - Corporate Agent _General _ English.md | l2 | Statutory liability | Final IC-38 - Corporate Agent _General _ English_033 | {
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accident and any one year.5. **Professional Liability**Professional indemnities are designed to provide insurance protection to
professional people against their legal liability to pay damages arising out of
negligence in the performance of their professional duties. Such covers are available
for doctors hospitals; eng... | Final IC-38 - Corporate Agent _General _ English.md | s57 | Professional Liability | Final IC-38 - Corporate Agent _General _ English_034 | {
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policyholders on the happening of a loss event. Insurer fulfils this promise by
providing prompt, fair and equitable service in either paying the policyholder or
paying claims made against the insured by a third party.One of the non-life insurance companies had the inscription “Pay if you can;
repudiate if you must” in... | Final IC-38 - Corporate Agent _General _ English.md | null | Settling claims professionally is regarded the biggest advertisement for an | Final IC-38 - Corporate Agent _General _ English_035 | {
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investigation to determine the cause and extent of loss is done, by an officer of theinsurers.**The investigation** of other claims is entrusted to independent licensed professional
surveyors who are specialists in loss assessment. The assessment of loss by
independent surveyors is based on the principle that since bot... | Final IC-38 - Corporate Agent _General _ English.md | e2 | The investigation | Final IC-38 - Corporate Agent _General _ English_036 | {
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Rules 1939 and specific regulations issued by IRDAI.Claims made outside the country in case of ‘Travel Policy’ or ‘Marine Open Cover’
for exports, are assessed by the claims settling agents abroad named in the policy.
These agents may assess the loss and make payment, which is reimbursed by the62insurers along with the... | Final IC-38 - Corporate Agent _General _ English.md | e62 | Important | Final IC-38 - Corporate Agent _General _ English_037 | {
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comprehensive policy. Which among the following is most appropriate for Raj to do?I. Notify the insurer of the loss as soon as reasonably possibleII. Notify the insurer at the time of insurance renewalIII. Damage the car further so as to receive a bigger compensationIV. Ignore the damage**Test Yourself 3**Which of the ... | Final IC-38 - Corporate Agent _General _ English.md | s64 | ANNEXURESThese annexures are provided so that the students get a better idea of proposal | Final IC-38 - Corporate Agent _General _ English_038 | {
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## IC - 38 **CORPORATE AGENTS** **SECTION-HEALTH****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. ... | Final IC-38 - Corporate Agent _Health_ English.md | C-46 | CORPORATE AGENTS | Final IC-38 - Corporate Agent _Health_ English_000 | {
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what healthcare is, levels of healthcare and types of healthcare. You will also learn
about the healthcare system in India and factors affecting it. Finally, it will explain
how health insurance evolved in India and also the various players in the health
insurance market in India.**Learning Outcomes**After studying thi... | Final IC-38 - Corporate Agent _Health_ English.md | null | Learning Outcomes | Final IC-38 - Corporate Agent _Health_ English_001 | {
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The health care facilities should be based upon the probability of the incidence of
disease for the population. For example, a person may get fever, cold, cough, skin
allergies etc. many times a year, but the probability of him/ her suffering from
Hepatitis B is less as compared to cold and cough.Hence, the need to set... | Final IC-38 - Corporate Agent _Health_ English.md | y5 | C. | Final IC-38 - Corporate Agent _Health_ English_002 | {
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"Secondary healthcare",
"Employees’ State Insurance Scheme",
"Central Government Health Scheme",
"Evolution of Health Insurance in India",
"Tertiary healthcare"
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State Insurance Scheme, introduced vide the ESI Act, 1948, shortly after the
country’s independence in 1947. This scheme was introduced for blue-collar
workers employed in the formal private sector and provides comprehensive
health services through a network of its own dispensaries and hospitals.ESIC (Employees State I... | Final IC-38 - Corporate Agent _Health_ English.md | null | Central Government Health Scheme | Final IC-38 - Corporate Agent _Health_ English_003 | {
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insurance services. Stand Alone Health Insurance (SAHI) Companies are allowed to
transact all types of Health Insurances, while Life Insurance Companies are also
permitted to transact certain types of Health Insurances.**2.** **Intermediaries:**A number of people and organizations providing services as part of the insu... | Final IC-38 - Corporate Agent _Health_ English.md | r8 | Intermediaries: | Final IC-38 - Corporate Agent _Health_ English_004 | {
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below are some of the details of the proposal form for a health insurance policy:1. The proposal form incorporates a prospectus which gives details of the cover, suchas coverage, exclusions, provisions etc. The prospectus forms part of the proposal
form and the proposer has to sign it as having noted its contents.
2. T... | Final IC-38 - Corporate Agent _Health_ English.md | null | Medical Questionnaire | Final IC-38 - Corporate Agent _Health_ English_005 | {
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has been submitted but before communication of the risk acceptance by thecompany.4. I/ We declare and consent to the company seeking medical information from anydoctor or from a hospital who at any time has attended on the life to be insured/
proposer or from any past or present employer concerning anything which affec... | Final IC-38 - Corporate Agent _Health_ English.md | null | Nature of questions in a proposal form | Final IC-38 - Corporate Agent _Health_ English_006 | {
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Details of the subject matter
Type of cover required
Details of the physical features both positive and negative
Previous history of insurance and claim experienceIn the case of a health insurance proposal, the insurer may also refer the prospective
customer e.g. above 45 years of age to a doctor and/ or for me... | Final IC-38 - Corporate Agent _Health_ English.md | D-19 | C. | Final IC-38 - Corporate Agent _Health_ English_007 | {
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insurer in the circumstances
p) Any special conditions
q) Provision for cancellation of the policy on grounds of misrepresentation,fraud, non-disclosure of material facts or non-cooperation of the insured
r) The details of the Add-on covers, if any
s) Details of Grievance Redressal mechanism and address of Ombudsman
t)... | Final IC-38 - Corporate Agent _Health_ English.md | t14 | E. | Final IC-38 - Corporate Agent _Health_ English_008 | {
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e) Change in risk, e.g. change of destinations in the case of an overseas travelpolicy
f) Cancellation of insurance
g) Change in name or address etc.**Test Yourself 2**If certain terms and conditions of the policy need to be modified at the time of issuance,
it is done by setting out the amendments through __________.I... | Final IC-38 - Corporate Agent _Health_ English.md | H-03 | Test Yourself 2 | Final IC-38 - Corporate Agent _Health_ English_009 | {
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population.The benefit structures, pricing, underwriting and marketing for each segment are
quite distinct.**Regulations for Health Insurance** : Some important changes have been brought in
Health Regulations, 2016 regarding Health Products, some of which have been given
below:1. Life Insurance Companies can offer long... | Final IC-38 - Corporate Agent _Health_ English.md | s10 | Regulations for Health Insurance | Final IC-38 - Corporate Agent _Health_ English_010 | {
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8. standard File and Use format for getting IRDAI for new policies
9. Standardisation of exclusions10. Exclusions not allowed**C.** **Hospitalization indemnity** **product**Hospitalization indemnity products protect individuals from the expenditure they
may need to incur in the event of hospitalisation. In most of the ... | Final IC-38 - Corporate Agent _Health_ English.md | s10 | C. | Final IC-38 - Corporate Agent _Health_ English_011 | {
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regular medical tests, dental and pharmacy costs.20**4.** **Pre and post hospitalization expenses****i.** **Pre hospitalization expenses**Hospitalization could be either emergency hospitalization or planned. If a
patient goes in for a planned surgery, there would be expenses incurred by him
prior to the hospitalization... | Final IC-38 - Corporate Agent _Health_ English.md | null | Pre and post hospitalization expenses | Final IC-38 - Corporate Agent _Health_ English_012 | {
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dependent insured’s under a single policy with a separate sum insured chosen
for each insured person. In such covers, each person insured under the policy
can claim up to the maximum amount of his sum insured during the currency of
the policy. Premium will be charged for each individual insured according to his
age and... | Final IC-38 - Corporate Agent _Health_ English.md | f22 | Family floater: | Final IC-38 - Corporate Agent _Health_ English_013 | {
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insurance policy that provides that the policyholder/ insured will bear a specified
percentage of the admissible claims amount. A co-payment does not reduce the Sum
Insured.
Co-payment is the concept of the insured bearing a portion of each and every claim
under a health policy. These could be compulsory or voluntary d... | Final IC-38 - Corporate Agent _Health_ English.md | null | Deductible/ Excess | Final IC-38 - Corporate Agent _Health_ English_014 | {
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"Maternity cover:",
"Coverage for Day care procedure",
"Deductible/ Excess",
"Cost of pre policy check up",
"Add on covers"
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of the insurers. Some of them are:24 **Maternity cover:** Maternity was not offered earlier under retail policies but isnow offered by most insurers, with varying waiting periods.
**Critical illness cover:** Available as an option under the high end version productsfor certain ailments which are life threatening and... | Final IC-38 - Corporate Agent _Health_ English.md | d25 | Maternity cover: | Final IC-38 - Corporate Agent _Health_ English_015 | {
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in the market and customers were not able to compare them, causing confusion.]The following two types of plans are available under Arogya Sanjeevani Insurance
Policy:- **Individual Plan** : A single policyholder will be the beneficiary of ArogyaSanjeevani policy.**Family Floater Plan** : Multiple family members of the ... | Final IC-38 - Corporate Agent _Health_ English.md | null | Individual Plan | Final IC-38 - Corporate Agent _Health_ English_016 | {
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sub limit whichever is higher. In some policies they follow the typical indemnity
plans such as expenses falling within specified period of 30/ 60 days or 60/ 90 days.IRDAI has mandated that all health insurers and TPAs shall establish a separate
channel to address the health insurance related claims and grievances of ... | Final IC-38 - Corporate Agent _Health_ English.md | null | F. | Final IC-38 - Corporate Agent _Health_ English_017 | {
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treatment as well as for living expenses post treatment. Onset of critical illness
threatens the financial security of a person. A basic health insurance policy may not
be sufficient to cover all medical costs in such cases.Critical illness policy has a provision to pay a lump sum amount on diagnosis of
certain named c... | Final IC-38 - Corporate Agent _Health_ English.md | d-19 | Disease Specific Products | Final IC-38 - Corporate Agent _Health_ English_018 | {
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admissible.)a. Room, Boarding, Nursing Expenses as provided by the Hospital / NursingHome.
b. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist Fees
c. Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances,ventilator charges, medicines and drugs, costs towards diagnostics,
diagno... | Final IC-38 - Corporate Agent _Health_ English.md | m14 | Standard Vector Borne Disease Health Policy: | Final IC-38 - Corporate Agent _Health_ English_019 | {
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insurance but also accidental death/ disability benefits along with Medical expenses
due to illness/ accident and the coverages like Loss of or delay in arrival of checked
in baggage, Loss of passport and documents, Third party liability for property/
personal damages, Cancellation of trips and even Hijack cover tradit... | Final IC-38 - Corporate Agent _Health_ English.md | null | H. | Final IC-38 - Corporate Agent _Health_ English_020 | {
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savings bank account on the prescribed forms will be required to be given by 31 [st]
May of every year,Joining subsequently on payment of full annual premium may be possible on
specified terms. Individuals who exit the scheme at any point may re-join the
scheme in future years through the above modality.Benefits under ... | Final IC-38 - Corporate Agent _Health_ English.md | r2 | Premium | Final IC-38 - Corporate Agent _Health_ English_021 | {
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at the time of claim. Thus, if a person has more than one policy with different
insurers, claims would be paid under all the policies.**4.** **Scope of cover**These policies are often extended to cover medical expenses, i.e. reimbursement
of hospitalization/ medical costs incurred following the accident.**5.** **Value ... | Final IC-38 - Corporate Agent _Health_ English.md | a35 | Scope of cover | Final IC-38 - Corporate Agent _Health_ English_022 | {
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can be paid in Indian rupees except in the case of the employment plan where
premium has to be paid in dollars. The plans are usually of two types: World-wide excluding USA/ Canada35 World-wide including USA/ CanadaSome products provide cover for a group of countries. Examples are travel to Asian
countries only, Euro... | Final IC-38 - Corporate Agent _Health_ English.md | a35 | Corporate Frequent Flyer plans | Final IC-38 - Corporate Agent _Health_ English_023 | {
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family member. In such situations, if the buffer cover is opted for it brings relief,
whereby the excess expenses over and above the family sum insured are met from
this buffer amount.Amounts are drawn from the buffer, once a family’s sum insured is exhausted.
However this utilization is usually restricted to major ill... | Final IC-38 - Corporate Agent _Health_ English.md | d-19 | O. | Final IC-38 - Corporate Agent _Health_ English_024 | {
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independent organizations for managing health insurance claims. These agencies
are known as the TPAs. In India, a TPA is engaged by an insurer for provision of
health services which includes among other things:i. Providing an identity card to the policyholder which is proof of his insurancepolicy and can be used for ad... | Final IC-38 - Corporate Agent _Health_ English.md | s38 | Hospital | Final IC-38 - Corporate Agent _Health_ English_025 | {
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Moreover, if a claim is made in any particular year, the cumulative bonus accrued
can only be reduced at the same rate at which it is accrued.**Example**A person takes a policy for Rs. 3 lacs at a premium of Rs. 5,000. In the second year,
in case of no claims in the first year, he gets a sum insured of Rs. 3.15 lacs (5... | Final IC-38 - Corporate Agent _Health_ English.md | H-04 | Example | Final IC-38 - Corporate Agent _Health_ English_026 | {
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insurance. Underwriting is a very important aspect of any type of insurance and
plays a vital role in issuance of an insurance policy. In this chapter, you will get an
understanding about basic principles, tools, methods and process of underwriting.
It will also provide you the knowledge about group health insurance un... | Final IC-38 - Corporate Agent _Health_ English.md | n42 | Learning Outcomes | Final IC-38 - Corporate Agent _Health_ English_027 | {
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sickness usually comes much before death and could be frequent. Hence, it is quite
logical that the underwriting norms and guidelines are much tighter for health
coverage than death coverage.**3.** **Underwriting – Risk Assessment**In health insurance, there is a higher focus on medical or health findings than
financia... | Final IC-38 - Corporate Agent _Health_ English.md | null | Underwriting – Risk Assessment | Final IC-38 - Corporate Agent _Health_ English_028 | {
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insurance just to collect a claim.**Test Yourself 1**Underwriting is the process of ___________.
I. Marketing insurance products
II. Collecting premiums from customers
III. Risk assessment and risk pricing
IV. Selling various insurance products**B.** **Underwriting – Basic concepts****1.** **Purposes of Underwriting**
... | Final IC-38 - Corporate Agent _Health_ English.md | o46 | Test Yourself 1 | Final IC-38 - Corporate Agent _Health_ English_029 | {
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by an agent or company representative to decide whether an applicant is suitable
for granting insurance coverage. The agent plays this critical role of **primary**
**underwriting** . He is in the best position to know whether prospective client is
insurable.Some insurance companies require the agents to provide a state... | Final IC-38 - Corporate Agent _Health_ English.md | e48 | Moral Hazard report | Final IC-38 - Corporate Agent _Health_ English_030 | {
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decided by the new insurance company. Procedurally, the request for porting should
be made by the insured to the old insurer at least 45 days before the renewal,
specifying the company to which the policy has to be ported. The policy has to be
renewed without a break (there is a 30 day grace period if porting is under ... | Final IC-38 - Corporate Agent _Health_ English.md | e48 | E. | Final IC-38 - Corporate Agent _Health_ English_031 | {
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Knowing the financial status of the proposer is particularly relevant for benefit
products and to reduce the moral hazard. However, normally the financial
documents are only asked for in cases of:a) Personal accident covers or
b) High sum assured coverage or
c) When the stated income and occupation as compared to the c... | Final IC-38 - Corporate Agent _Health_ English.md | d50 | Medical reports | Final IC-38 - Corporate Agent _Health_ English_032 | {
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The process is speedy but the premiums may be relatively higher.**3.** **Numerical rating method**This is a process adopted in underwriting, wherein numerical or percentage
assessments are made on each component of the risk.
Factors like age, sex, race, occupation, residence, environment, build, habits,
family and pers... | Final IC-38 - Corporate Agent _Health_ English.md | null | Numerical rating method | Final IC-38 - Corporate Agent _Health_ English_033 | {
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i) Preference of the group holder for administration of the group insurance bya third party administrator (of his choice or one selected by the insurer) or
by the insurer itself
j) Past claims experience of the proposed group**Example**A group of members working in mines or factories is at higher health risk than a
gro... | Final IC-38 - Corporate Agent _Health_ English.md | null | Example | Final IC-38 - Corporate Agent _Health_ English_034 | {
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The minimum and maximum age for being covered and renewed varies from
company to company.**Family Package Cover**The Personal accident policy also has a family package cover wherein Children and
Non-earning spouse are covered for to death and permanent disablement (total or
partial) only.**Premium Discount in Group Pol... | Final IC-38 - Corporate Agent _Health_ English.md | H-05 | Family Package Cover | Final IC-38 - Corporate Agent _Health_ English_035 | {
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to that promise. The occurrence of an insured event leading to a claim under the
policy is the true test of that promise. How well an insurer performs is evaluated by
how well it keeps its claims promises. One of the key rating factors in insurance is
the claims paying ability of the insurance company.**1.** **Stakehol... | Final IC-38 - Corporate Agent _Health_ English.md | null | Stakeholders in claim process | Final IC-38 - Corporate Agent _Health_ English_036 | {
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business.
The general process and supporting documents for a claim under fixed benefit
product or critical illness or daily cash product etc. would be quite similar, except
for the fact that such products may not come with cashless facility.In both cases of indemnity as well as reimbursement type of claim, the basic st... | Final IC-38 - Corporate Agent _Health_ English.md | null | Diagram 2: | Final IC-38 - Corporate Agent _Health_ English_037 | {
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involved.Earlier every TPA/ insurer had its own list of non-payable items, now the same
has been standardized under IRDAI Health Insurance Standardization Guidelines.**c)** **Payment of claim**Once the payable claim amount is arrived at, payment is done to the customer
or the hospital as the case may be. The payment ma... | Final IC-38 - Corporate Agent _Health_ English.md | l2 | Payment of claim | Final IC-38 - Corporate Agent _Health_ English_038 | {
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|**Step 2**| The hospital compiles the necessary information such as:<br>i. Diagnosis of illness<br>ii. Treatment,<br>iii. Name of treating doctor,<br>iv. Number of days of proposed hospitalization and<br>v. The estimated cost<br> This is presented in a format, called the cashless authorization form.<br>|
|**Step 3**... | Final IC-38 - Corporate Agent _Health_ English.md | t64 | Step 2 | Final IC-38 - Corporate Agent _Health_ English_039 | {
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policy and could prejudice the approval of the subsequent request.**C.** **Documentation in Health Insurance Claims**This section explains the need for and content of each of the documents required
to be submitted by the customers:**1.** **Discharge summary**Discharge summary can be termed as the most important documen... | Final IC-38 - Corporate Agent _Health_ English.md | t64 | C. | Final IC-38 - Corporate Agent _Health_ English_040 | {
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case of insurers not using TPAs, the services are performed by in-house team.**1.** **Post sale service of health insurance**a) Once the proposal (and the premium) is accepted, the coverage commences.
b) If a TPA is to be used for servicing the policy, the insurer passes on theinformation about the customer and the pol... | Final IC-38 - Corporate Agent _Health_ English.md | d66 | Post sale service of health insurance | Final IC-38 - Corporate Agent _Health_ English_041 | {
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verification (passport/ PAN card/ Voter's ID/ Driving license) for address
verification (Telephone bill/ Bank account statement, Electricity bill/ Ration
card).
f) Legal heir certificate containing affidavit and indemnity bond both dulysigned by all legal heirs and notarized
g) Permanent disability certificate from a c... | Final IC-38 - Corporate Agent _Health_ English.md | e68 | Test Yourself 4 | Final IC-38 - Corporate Agent _Health_ English_042 | {
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travel insurance policy.v. Hospitals usually contact the assistance companies/ insurers on the callcentre numbers to check the validity of the policy and verify coverages.vi. Once the policy is accepted by the hospital the insured would undergotreatment in the hospital on a cashless basis.vii. Some basic information re... | Final IC-38 - Corporate Agent _Health_ English.md | t2 | Reimbursement of medical expenses and other non-medical claims: | Final IC-38 - Corporate Agent _Health_ English_043 | {
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## IC - 38 **INSURANCE AGENTS** **SECTION-HEALTH****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. ... | IC 38 -IA- Eng-Health.md | C-46 | INSURANCE AGENTS | IC 38 -IA- Eng-Health_000 | {
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what healthcare is, levels of healthcare and types of healthcare. You will also learn
about the healthcare system in India and factors affecting it. Finally, it will explain
how health insurance evolved in India and also the various players in the health
insurance market in India.**Learning Outcomes**After studying thi... | IC 38 -IA- Eng-Health.md | null | Learning Outcomes | IC 38 -IA- Eng-Health_001 | {
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The health care facilities should be based upon the probability of the incidence of
disease for the population. For example, a person may get fever, cold, cough, skin
allergies etc. many times a year, but the probability of him/ her suffering from
Hepatitis B is less as compared to cold and cough.Hence, the need to set... | IC 38 -IA- Eng-Health.md | y5 | C. | IC 38 -IA- Eng-Health_002 | {
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"Secondary healthcare",
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"Evolution of Health Insurance in India",
"Tertiary healthcare"
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State Insurance Scheme, introduced vide the ESI Act, 1948, shortly after the
country’s independence in 1947. This scheme was introduced for blue-collar
workers employed in the formal private sector and provides comprehensive
health services through a network of its own dispensaries and hospitals.ESIC (Employees State I... | IC 38 -IA- Eng-Health.md | null | Central Government Health Scheme | IC 38 -IA- Eng-Health_003 | {
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insurance services. Stand Alone Health Insurance (SAHI) Companies are allowed to
transact all types of Health Insurances, while Life Insurance Companies are also
permitted to transact certain types of Health Insurances.**2.** **Intermediaries:**A number of people and organizations providing services as part of the insu... | IC 38 -IA- Eng-Health.md | r8 | Intermediaries: | IC 38 -IA- Eng-Health_004 | {
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below are some of the details of the proposal form for a health insurance policy:1. The proposal form incorporates a prospectus which gives details of the cover, suchas coverage, exclusions, provisions etc. The prospectus forms part of the proposal
form and the proposer has to sign it as having noted its contents.
2. T... | IC 38 -IA- Eng-Health.md | null | Medical Questionnaire | IC 38 -IA- Eng-Health_005 | {
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