Lok Sabha Question No. 578 (STARRED), answered on 2018-04-06
Subject: Non-Life/Health Insurance Policies
Ministry: FINANCE
Asked by: BHARTRUHARI MAHTAB, RAHUL RAMESH SHEWALE

## GOVERNMENT OF INDIA MINISTRY OF FINANCE DEPARTMENT OF FINANCIAL SERVICES

## LOK SABHA STARRED QUESTION NO. *578

TO BE ANSWERED ON 6 th  April, 2018/ Chaitra 16, 1940 (Saka)

Non-Life/Health Insurance Policies

## *578. SHRI BHARTRUHARI MAHTAB: SHRI RAHUL SHEWALE:

Will the Minister of FINANCE be pleased to state:

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

## ANSWER

## THE FINANCE MINISTER (SHRI ARUN JAITLEY)

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

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## POSITION NO. 18

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

(a)   The  company-wise  details  of  amount  claimed  under  non-life  insurance and  health  insurance  and  claims  paid  during  the  last  three  years  is  at Annexure I and Annexure II respectively.

(b) and (c): In Non-Life Insurance, no irregularities / corruption in settlement of claims  have  come  to  the  notice  of  Insurance  Regulatory  and  Development Authority  of  India  (IRDAI).  However,  in  the  area  of  Health  Insurance,  the Authority  has  taken  regulatory  action  on  noticing  excess  deductions  from health insurance policy claims as per details given in Annexure-III.

(d)  The  number  of  onsite  visits/  inspections  undertaken  by  the  Insurance Regulatory and Development Authority of India and the number of regulatory actions initiated during the said period are at Annexure-III .

(e)   The other steps taken to make the process of claim easier under NonLife/Health Insurance inter-alia also includes:-

The IRDAI (Health Insurance) Regulations, 2016 (HIR 2016) and the IRDAI (Protection of Policyholders' Interests) Regulations, 2017   have been issued by  IRDAI  which  stipulate  various  provisions  to  protect  the  interest  of  the Policyholders of Health Insurance Policies/ General Insurance Policies including  making  the  process  of  claims  easier.  Towards  this,  the  Authority, inter-alia, has put in place the following provisions in these regulations:-

-  The insurance claims shall be settled or rejected within 30 days from the receipt of the last 'necessary' document.
-  Except  in  cases  where  a  fraud  is  suspected,  ordinarily  no  document  not listed in the policy terms and conditions shall be deemed 'necessary'.
-  The  insurer  shall  ensure  that  all  the  documents  required  for  claims processing are called for at one time and that the documents are not called for in a piece-meal manner.
-  Insurer may stipulate a period within which all necessary claim documents should be furnished by the policyholder/insured to make a claim. However, claims  filed  even  beyond  such  period  should  be  considered  if  there  are valid reasons for any delay.
-  Every  Insurance  Claim  shall  be  disposed  of  in  accordance  to  the  Terms and Conditions of the policy contract.
-  Regulation  (33)  (d)  (iv)  of  HIR  2016  specifies  that  where  a  claim  is repudiated, the communication about the repudiation shall be made only by
- the Insurer by specifically stating the reasons for repudiation, necessarily referring to the corresponding policy conditions.
-  The insurer shall also furnish the grievance redressal procedures available with  the  Insurance  Company  and  with  the  Insurance  Ombudsman  along with the detailed addresses of the respective offices.
-  Subject to the terms of a policy, General Insurers and Health insurers shall extend  to  all  policy  holders  a  cashless  facility  for  treatment  at  specific establishments.  To ensure that interests of insurance policyholders' are protected.  To ensure that insurers, distribution channels and other regulated entities fulfill  their  obligations  towards  policyholders  and  have  in  place  standard procedures and best practices in sale and service of insurance policies. To  ensure  policyholder-centric  governance  by  insurers  with  emphasis  on

**********

-  grievance redressal.

## Annexure-I referred to in reply of part (a) of Lok Sabha Starred Question no. *578  for 06.04.2018

Company- wise Non-life insurance amount claimed and Claims paid (in terms of amount):

(Amount in Rs. Crore)

|                               | Claims Data 2014-15                             | Claims Data 2014-15                     | Claims Data 2014-15   | Claims Data 2015-16                             | Claims Data 2015-16                     | Claims Data 2015-16   | Claims Data 2016-17                             | Claims Data 2016-17                     | Claims Data 2016-17   |
|-------------------------------|-------------------------------------------------|-----------------------------------------|-----------------------|-------------------------------------------------|-----------------------------------------|-----------------------|-------------------------------------------------|-----------------------------------------|-----------------------|
| Name of the Gen. Ins. Company | Claims Outstanding at the beginning of the year | New claims registered during the period | Claims paid           | Claims Outstanding at the beginning of the year | New claims registered during the period | Claims paid           | Claims Outstanding at the beginning of the year | New claims registered during the period | Claims paid           |
| Bajaj Allianz                 | 2480.7                                          | 3655.1                                  | 3476.4                | 3242.6                                          | 3998.7                                  | 3397.1                | 3587.0                                          | 3506.5                                  | 3261.7                |
| Bharti AXA General            | 674.1                                           | 1425.7                                  | 927.2                 | 926.9                                           | 1736.4                                  | 965.9                 | 1400.8                                          | 884.8                                   | 1251.1                |
| Cholamandalam                 | 1390.5                                          | 1738.0                                  | 983.9                 | 1892.7                                          | 1830.0                                  | 1289.9                | 2241.0                                          | 4821.2                                  | 1517.6                |
| Future Generali               | 488.4                                           | 925.8                                   | 852.1                 | 600.5                                           | 1244.3                                  | 1050.4                | 780.2                                           | 1115.8                                  | 1040.1                |
| HDFC ERGO General #           | 1005.1                                          | 2468.2                                  | 1700.4                | 1349.3                                          | 2857.3                                  | 2156.2                | 1533.5                                          | 3260.8                                  | 2269.4                |
| ICICI-lombard                 | 2912.3                                          | 4924.1                                  | 4058.9                | 3054.1                                          | 6383.7                                  | 4881.3                | 3890.9                                          | 6880.9                                  | 5141.7                |
| IFFCO-Tokio                   | 1494.9                                          | 1895.8                                  | 1737.8                | 1655.4                                          | 2372.7                                  | 2595.8                | 1516.9                                          | 3270.8                                  | 2546.0                |
| Kotak Mahindra                | -                                               | -                                       | -                     | 0.0                                             | 6465.0                                  | 1010.0                | 0.0                                             | 12.1                                    | 6.2                   |
| HDFC Gen. (L&T)               | 106.3                                           | 234.1                                   | 131.6                 | 164.0                                           | 340.2                                   | 239.3                 | 223.2                                           | 390.2                                   | 268.9                 |
| Liberty Videocon              | 13.3                                            | 174.4                                   | 123.6                 | 49.8                                            | 468.6                                   | 217.7                 | 106.3                                           | 323.5                                   | 229.6                 |
| Magma HDI                     | 66.7                                            | 300.8                                   | 247.2                 | 169.2                                           | 370.0                                   | 225.8                 | 217.0                                           | 202.3                                   | 209.5                 |
| Raheja QBE                    | 3.6                                             | 4.9                                     | 3.3                   | 2.7                                             | 1.4                                     | 2.2                   | 2.1                                             | 5.8                                     | 2.0                   |
| Reliance General              | 1955.1                                          | 1540.3                                  | 1750.7                | 2132.2                                          | 1802.9                                  | 2041.0                | 2361.3                                          | 1767.5                                  | 2238.3                |
| Royal Sundaram                | 900.3                                           | 878.0                                   | 1001.1                | 907.8                                           | 957.0                                   | 1058.7                | 1041.2                                          | 1113.2                                  | 1240.6                |
| SBI General                   | 321.2                                           | 2181.7                                  | 485.9                 | 699.4                                           | 1936.4                                  | 995.7                 | 940.8                                           | 1466.7                                  | 1174.7                |
| Shriram General               | 714.0                                           | 1873.5                                  | 371.5                 | 1209.2                                          | 1660.9                                  | 951.0                 | 2356.6                                          | 1817.4                                  | 1348.4                |
| Tata-AIG                      | 948.5                                           | 1787.6                                  | 1302.5                | 1172.3                                          | 2495.7                                  | 1778.3                | 1552.6                                          | 2441.3                                  | 1991.2                |
| Universal Sompo               | 352.5                                           | 580.7                                   | 355.0                 | 473.7                                           | 814.8                                   | 703.4                 | 482.8                                           | 1020.5                                  | 600.0                 |
| National                      | 6718.2                                          | 12059.1                                 | 8232.4                | 6958.8                                          | 23089.5                                 | 9175.8                | 7473.1                                          | 32256.9                                 | 12542.7               |
| New India                     | 7995.6                                          | 17474.3                                 | 9739.6                | 9873.7                                          | 12396.1                                 | 11579.7               | 9968.7                                          | 16782.7                                 | 13834.5               |
| United India                  | 11151.2                                         | 12487.9                                 | 7707.3                | 12126.0                                         | 16655.6                                 | 9663.2                | 14151.5                                         | 22675.3                                 | 11826.9               |
| Oriental                      | 6453.8                                          | 7643.8                                  | 5566.8                | 7254.7                                          | 7213.9                                  | 5953.1                | 7481.2                                          | 8152.3                                  | 7544.8                |
| Total                         | 48146.3                                         | 76253.8                                 | 50755.2               | 55915                                           | 97091.1                                 | 61931.5               | 63308.7                                         | 114168.5                                | 72085.9               |

Source:IRDAI

Note: The amount settled against a policy is based on the final assessment and also as per the terms and conditions under which a specific policy has been issued. The data pertaining to just concluded Financial Year (2017-18) is not readily available with IRDAI .

## Annexure-II referred to in reply of part (a) of Lok Sabha Starred Question no. *578  for 06.04.2018

Company- wise Health Insurance (Excluding Personal Accident and Travel) amount claimed and Claims paid (in terms of amount): (Amount in Rs. Crore)

|                               | Claims Data 2014-15                             | Claims Data 2014-15                     | Claims Data 2014-15   | Claims Data 2015-16                             | Claims Data 2015-16                     | Claims Data 2015-16   | Claims Data 2016-17                             | Claims Data 2016-17                     | Claims Data 2016-17   |
|-------------------------------|-------------------------------------------------|-----------------------------------------|-----------------------|-------------------------------------------------|-----------------------------------------|-----------------------|-------------------------------------------------|-----------------------------------------|-----------------------|
| Name of the Gen. Ins. Company | Claims Outstanding at the beginning of the year | New claims registered during the period | Claims paid           | Claims Outstanding at the beginning of the year | New claims registered during the period | Claims paid           | Claims Outstanding at the beginning of the year | New claims registered during the period | Claims paid           |
| Bajaj                         | 41                                              | 494                                     | 498                   | 21                                              | 733                                     | 548                   | 29                                              | 801                                     | 694                   |
| Bharti                        | 16                                              | 224                                     | 175                   | 18                                              | 119                                     | 99                    | 12                                              | 98                                      | 62                    |
| Cholamandalam                 | 28                                              | 111                                     | 91                    | 11                                              | 97                                      | 71                    | 15                                              | 99                                      | 72                    |
| Future                        | 5                                               | 128                                     | 119                   | 7                                               | 148                                     | 127                   | 2                                               | 160                                     | 145                   |
| HDFC                          | 26                                              | 327                                     | 247                   | 24                                              | 334                                     | 225                   | 27                                              | 398                                     | 269                   |
| ICICI                         | 181                                             | 1314                                    | 1039                  | 186                                             | 1156                                    | 851                   | 202                                             | 1690                                    | 1195                  |
| IFFCO                         | 16                                              | 312                                     | 229                   | 23                                              | 537                                     | 388                   | 43                                              | 608                                     | 482                   |
| Kotak                         | -                                               | -                                       | -                     | -                                               | -                                       | -                     | 0                                               | 2                                       | 1                     |
| Liberty                       | 0                                               | 27                                      | 17                    | 4                                               | 63                                      | 50                    | 4                                               | 72                                      | 49                    |
| L&T                           | 3                                               | 36                                      | 23                    | 4                                               | 39                                      | 24                    | 3                                               | 43                                      | 31                    |
| Magma                         | 0                                               | 0                                       | 0                     | 0                                               | 0                                       | 0                     | 0                                               | 0                                       | 0                     |
| Raheja                        | 0                                               | 0                                       | 0                     | 0                                               | 0                                       | 0                     | 0                                               | 0                                       | 0                     |
| Reliance                      | 63                                              | 472                                     | 524                   | 48                                              | 483                                     | 466                   | 90                                              | 292                                     | 331                   |
| Royal                         | 17                                              | 140                                     | 117                   | 18                                              | 153                                     | 127                   | 14                                              | 162                                     | 134                   |
| SBI                           | 1                                               | 34                                      | 13                    | 5                                               | 98                                      | 42                    | 10                                              | 121                                     | 54                    |
| Shriram                       | 0                                               | 0                                       | 0                     | 0                                               | 0                                       | 0                     | 0                                               | 0                                       | 0                     |
| Tata                          | 4                                               | 72                                      | 60                    | 5                                               | 94                                      | 72                    | 8                                               | 90                                      | 69                    |
| Universal                     | 7                                               | 159                                     | 100                   | 8                                               | 170                                     | 120                   | 8                                               | 117                                     | 107                   |
| National                      | 388                                             | 6182                                    | 4525                  | 513                                             | 5047                                    | 4476                  | 572                                             | 6025                                    | 5302                  |
| New India                     | 190                                             | 3877                                    | 3467                  | 225                                             | 5764                                    | 5204                  | 210                                             | 6900                                    | 6365                  |
| Oriental                      | 236                                             | 2908                                    | 2250                  | 272                                             | 3485                                    | 2534                  | 300                                             | 3639                                    | 3363                  |
| United                        | 333                                             | 5885                                    | 3356                  | 513                                             | 6432                                    | 4399                  | 745                                             | 8742                                    | 6155                  |
| Aditya Birla                  | -                                               | -                                       | -                     | -                                               | -                                       | -                     | 0                                               | 14                                      | 8                     |
| Apollo                        | 35                                              | 569                                     | 407                   | 47                                              | 725                                     | 528                   | 52                                              | 925                                     | 680                   |
| Cigna                         | 0                                               | 3                                       | 1                     | 0                                               | 43                                      | 37                    | 1                                               | 111                                     | 84                    |
| Max Bupa                      | 11                                              | 267                                     | 169                   | 16                                              | 295                                     | 210                   | 9                                               | 338                                     | 266                   |
| Religere                      | 15                                              | 191                                     | 98                    | 18                                              | 339                                     | 173                   | 35                                              | 466                                     | 235                   |
| Star                          | 84                                              | 836                                     | 703                   | 102                                             | 1264                                    | 987                   | 102                                             | 1976                                    | 1372                  |
| Industry total                | 1700                                            | 24568                                   | 18228                 | 2088                                            | 27618                                   | 21758                 | 2493                                            | 33889                                   | 27525                 |

Source:IRDAI

Note: The amount settled against a policy is based on the final assessment and also as per the terms and conditions under which a specific  policy  has  been  issued.  The  data  pertaining  to  just  concluded  Financial  Year  (2017-18)  is  not  readily  available  with  IRDAI .

## for 06.04.2018

## Regulatory action taken by IRDAI on noticing excess deductions from health insurance policy claims :

| Order dated                             | Licensed entity                              | Observation                                                                                                          | Details of Direction                                                                                                                                                                                                                                                                 |
|-----------------------------------------|----------------------------------------------|----------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Charge 38 of Order dated 30-07-2015     | L&T General Insurance Company Limited        | Deduction of other hospitalization expenses in the proportion to the eligibility of the room rent.                   | Penalty of Rs.5 lacs has been imposed and insurer is directed to refund the excess deductions along with penal interest. Compliance: Insurer submitted that it has identified 350 health claims and refunded an amount of Rs.34,30,718 including penal interest.                     |
| Charge 3 of Order dated 16/05/2016      | Vidal Third Party Administrator              | Deduction was wrongly made toward co-pay.                                                                            | Direction was given to re-examine all such cases and to refund the excess recovered amount Compliance: Insurer submitted that it has refunded Rs.3,72,000 with regard to 11 cases where co-pay was wrongly recovered.                                                                |
| Charge 2 of Order dated 28/06/2016      | United India Insurance Company Limited       |                                                                                                                      |                                                                                                                                                                                                                                                                                      |
| Charge 5,6& 7 of Order dated 20/07/2016 | Bharti Axa General Insurance Company Limited | Wrongful deduction from the associated charges and other medical charges in the proportion to room rent eligibility. | Penalty of Rs.5 lacs imposed and insurer is directed to ensure that no claim is settled based on the product features and conditions that is not filed and approved under F&U procedure of Authority. Compliance: Insurer agreed to the direction and remitted penalty of Rs.5 lacs. |

## The year-wise break up of onsite visits/inspections Non-Life and Health insurance companies:

| Financial Year   |   No. of Non-Life Insurance Companies inspected in FY |   No. of Health Insurance Companies inspected in FY |
|------------------|-------------------------------------------------------|-----------------------------------------------------|
| 2017-18          |                                                     9 |                                                   2 |
| 2016-17          |                                                     7 |                                                   0 |
| 2015-16          |                                                     4 |                                                   2 |
| 2014-15          |                                                    11 |                                                   2 |

## The year-wise break-up of the number of regulatory actions initiated against the Insurance Companies as a result of onsite visit/inspection:

| Financial Year                                    |   2014-15 |   2015-16 |   2016-17 |   2017-18 |   Total |
|---------------------------------------------------|-----------|-----------|-----------|-----------|---------|
| General insurers and Stand alone Health insurers. |         5 |        16 |        10 |         6 |      37 |