Deekshith.bangera12.docx

A PROJECT ON COMPARATIVE STUDY OF HEALTH INSURANCE IN TATA AIG SUBMITED BY DEEKSHITH BANGERA ROLL NO - 72 FOR DEGREE OF BACHALORS IN ACCOUNT AND FINANCE SEMESTER (VI) UNDER THE GUIDENCE OF PROF. ADARSH VERMA

NCRD’S STERLING INSTITUTE OF MANAGEMENT STUDIES NCRD’S STERLING INSTITUTE OF MANAGEMENT STUDIES PLOT NO. 93/93 A , SECTOR -19A NERUL ( E ) , NAVI MUMBAI 400706. PLOT NO. 93/93 A , SECTOR -19A NERUL ( E ) , NAVI MUMBAI 400706.

ACADEMIC YEAR 2018-2019

NCRD’S STERLING INSTITUTE OF MANAGEMENT STUDIES PLOT NO. 93/93 A , SECTOR -19A NERUL ( E ) , NAVI MUMBAI 400706.

Institute Certificate

This is to certify that MR. DEEKSHITH BANGDERA ROLL NO- 72 is a bonofide student studying in B.com (Accounting and Finance) program Finance specialization , Sem- VI of the Year university of Mumbai in this institute for the year 2018-19.As a part of the university Curriculum he has completed a final project title as , “ A COMPARATIVE STUDY OF HEALTH INSURANCE IN TATA AIG” “under our guidance.

Prof- ADARDH VERMA

Faculty Guide

Place: Nerul, Navi Mumbai

Date:

Dr.MG.GONDA

Principle

NCRD’S STERLING INSTITUTE OF MANAGEMENT STUDIES PLOT NO. 93/93 A , SECTOR -19A NERUL ( E ) , NAVI MUMBAI 400706.

DECLARATION I DEEKSHITH BANGERA hereby declare that project work entitled “ A COMPARATIV STUDY OF HEALTH INSURANCE IN TATA AIG ” is the original work done by me under Prof. ADARSH VERMA faculty member,NCRD’S Sterling Institute of arts commerce and science. Without the support and encouragement making this report would have been impossible for me. I would also like to thank the respondents who provided me their best knowledge and co-operation throughout the project.

Signature

DEEKSHITH BANGERA B.com (Accounting & Finance) ROLL NO – 72 Batch:-2018-2019

ACKNOWLEDGMENT

I take this opportunity to express my profound gratitude and deep regards to my guide PROF. ADARSH VERMA for his exemplary guidance, monitoring and constant encouragement throughout the course of this thesis. The blessing, help and guidance given by him time to time shall carry me a long way in the journey of life on which I am about to embark. I Am obliged to TY BAF members of NCRD’S Sterling Institute of commerce, for the valuable information provided by the m in the ir respective fields. I am grateful for their cooperation during the period of my assignment.

Lastly, I thanks almighty friends and college faculty for their constant encouragement without which this assignment would not be possible.

EXCUTIVE SUMMARY

This report basically focuses on the “A comparative study of health insurance in TATA AIG”. This insurance company gives general insurance to customer. This insurance company provides various service to customer they have many plans in health insurance

The entire report has been prepared by us and gives opinion which is purely ours and facts which exists and seen by us and completed within the limits imposed on us in the form of time and data.

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COMPERATIVE STUDY OF HEALTH INSURANCE IN TATA AIG

INDEX 6

Chap.

Contents

No

No. 1

2

Page.

Introduction 1.1

Introduction to general insurance

1.2

Introduction to Tata AIG

1.3

Meaning of health insurance

1.4

Definition

1.5

What is Health insurance

1.6

Features of Tata AIG insurance

1.7

Importance of health insurance

1.8

Advantages of health insurance

Research Methodology

6-24

25-45

2.1 Objectives 2.2 situation where your policy wont work in Tata AIG 2.3 benefits to make policy stronger in tata aig 2.4 purpose of health insurance 2.5 dispute in insurance claims 2.6 the indemnity principal of general insurance 2.7 financial statement of general insurance 2.8 Limitation

3

Literature Review

46-48

3.1 Literature review

4

Plans of health insurance in Tata AIG

49-69

4.1 TATA AIG medicare health insurance 4.2 medicare premium health insurance 4.3 wellsurance executive policy 7

4.4 critical illness 4.5 wellsurance family 4.6 mediraksha 4.7 wellsurance woman

5

Plans of health insurance in Tata AIG

70-72

4.1 TATA AIG medicare health insurance 4.2 medicare premium health insurance 4.3 wellsurance executive policy 4.4 critical illness 4.5 wellsurance family 4.6 mediraksha 4.7 wellsurance woman

6

Bibliography

73-74s

8

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CHAPTER NO. 1 INTRODUCTION

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1.1 INTRODUCTION OF GENERAL INSURANCE

There are two type of insurance one is life insurance and second is general insurance. Health insurance comes under general insurance. Insurance industry has always been a growth-oriented industry globally. On the Indian scene too, the insurance has always recorded noticeable growth vis-à-vis other Indian industries. The most important reason to get general insurance is to protect your valuable assets and your health against any kind of financial loss. Most of the general insurance products like motor insurance and health insurance are yearly contracts . General Insurance helps us protect ourselves and the things we value, such as our homes, our cars and our valuables, from the financial impact of risks, big and small – from fire, flood, storm and earthquake, to theft, car accidents, travel mishaps – and even from the costs of legal action against us. And we can choose the types of risks we wish to cover by choosing the right kind of policy with the features we need. In general, insurance works by spreading the cost of unexpected risks among a large number of people in the same region who share similar risks. When you take out an insurance policy, you pay a monthly or annual premium. That money joins the premiums of many thousands of other policyholders and goes into a big pool of funds. For more information on how premiums work.

With any luck, you will never need to draw on that pool. But if you happen to be one of the unlucky ones affected by an unexpected calamity, perhaps through severe weather or accident, that pool of funds can be used to help you up to the limit you have selected in your policy. If things go wrong, your insurer may either repair or replace the items that have been lost or damaged, depending on the terms of your policy. You may also have the choice of receiving a cash settlement for the amount of money agreed in your policy. The Indian insurance industry saw a new sun when the Insurance Regulatory & Development Authority (IRDA) invited the application for registration as insurers in August, 2000. With the liberalisation and opening up of the sector to private players, the

industry has presented promising prospects for the coming future

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The Indian Insurance industry is featured by the attributes: 

Low market penetration;



Ever-growing middle-class component in population.



Growth of consumer movement with an increasing demand for better Insurance products;



Adequate fillip from the government in the form of tax incentives to the insured, etc

Inadequate application of information technology for business

Insurance Classification:

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1.2 INTRODUCTION TO TATA AIG LIFE

History : Tata AIG General Insurance Company Limited (Tata AIG General) is a business collaboration of the Tata Group and American International Group, Inc. (AIG). Tata AIG General merges two major finance organizations: the Tata Group's prominent headship place in India and AIG's global presence as the world's leading international insurance and financial services organization. This joint venture has started its operations in India from 22 January 2001. The company provides corporate and personal insurance services. The organization offers an array of general insurance covers which are well thought-out under commercial and consumer demands. The commercial sector covers Energy, Marine, Property and specialized Financial covers. The consumer insurance service offers a variety of general Insurance products such as insurance for Automobiles, personal accident, casualty, home, health and travel. The company has made the availability for its services from end to end channels of distribution like agents, banks (through bancassurance tie ups), brokers and direct channels like tele-marketing, e-commerce, website, etc. The headquarters is in Mumbai. The company has provided the employment to more than 2000 qualified professionals across the country in more than 160 locations. Tata AIG Life Insurance was rechristened as Tata AIA Life Insurance Company following the exit of American International Group (AIG) from the Hong Kong-based insurer AIA Group.

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Introduction:

Tata AIG Life insurance company limited (Tata AIG life) is a joint venture company, formed by Tata sons Ltd. and AIG group Ltd. Tata AIG life combines Tata pre-eminent leadership position in India and AIG’s as the largest, independent listed pan-Asian life insurance group in the world spanning 18 market in the Asia pacific region. Tata AIG life has written retail new business weighted premium of INR 733 crores for the first half of financial year 2018-19. For the same period, the 13th month persistency of the company was at 83.5% and, the retail claim settlement ratio was 98%. One of the fastest growing company in the insurance sector, Tata AIG Life is now ranked no 5, based on individual weighted new business premium Tata sons has 74% stake in the joint venture, while the rest is held by AIG, in which AIG had a controlling stake earlier. Tata AIG Life insurance has been renamed as Tata AIG Life insurance Company fallowing the exist of American international Group (AIG) from the Hong kong based insurer AIG Group. Tata AIG Life insurance company, operating since Aril 2001, is a joint venture and collaboration between Tata sons and the AIG group with stake of 51% and 49% respectively it is accomplished in offering customised life, health and group insurance solution to individual, business across sizes and sector, and sectors , and associations

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1.3 MEANING OF HEALTH INSURANCE

Health insurance covers medical expenses for illnesses, injuries and condition. But unlike a plan through an employer, individual health insurance is something you select and pay for on your own Health insurance, like other forms of insurance, is a form of collectivism by means of which people collectively pool their risk, in this case the risk of incurring medical expenses. The coverage that provides for the payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment" Health insurance is typically defined as any insurance that is not determined to be life insurance. It is called property and casualty insurance in the U.S and Canada and Non-Life Insurance in Continental Europe. A Health insurance is a contract that offers financial compensation on any loss other than death. It insures everything apart from life. A health insurance compensates you for financial loss due to liabilities related to your health. The insurance company promises to pay you a sum assured to cover damages to your medical treatments to cure health problems. Health insurance policies, provide payments depending on the loss from a particular financial event. General insurance is typically defined as any insurance that is not determined to be life insurance. The premium and cover of general insurance depends upon the type and extent of insurance. A health insurance policy typically has a period of a few years. In India, general insurance policies are of the following types:

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1.4 DEFINITION

Insurance contracts that do not come under the ambit of life insurance are called general insurance. The different forms of general insurance are fire, marine, accident, and other miscellaneous non-life insurance.

DEFINING GENERAL INSURANCE: General insurance or non-life insurance policies, including automobile and homeowners’ policies, provide payments depending on the loss from a particular financial event. General insurance typically comprises any insurance that is not determined to be life insurance. It is called property and casualty insurance in the U.S and Non-Life Insurance in Continental Europe

DEFINATION OF HELTH INSURANCE: A plan that covers or shares the expenses associated with health care. These plan fall into three classifications: commercial health insurance, which is provided by many different companies; Private non-commercial health insurance, which is provided by Blue Cross and Blue Shield; and social insurance, which is provided by social security

DEFINATION OF HELTH INSURANCE: “coverage that provides for the payments of benefits as a result of sickness or injury. It include insurance for losses from accident, medical expenses, disability, or accident death and dismemberment”

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1.5 Design of the study

Objective of the study The main objective of the study are to evaluate need and importance of health insurance products, to search the reason behind hesitation of people toward purchasing of health insurance, to judge the satisfaction level of customer of health insurance 

Following are the objective of the study



Try to judge and create awareness about need of health insurance



To judge trust towards health insurance and health insurers, among people



Recognize the way to solve issues between insure and customer



Evaluate the contribution of this industry toward economic growth

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1.6 WHAT IS HEALTH INSURANCE? Health insurance is an insurance that covers the whole or a part of the risk of a person incurring medical expenses, spreading the risk over a large number of persons. By estimating the overall risk of the health care and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as government agency, private business, or not-for-profit entity. According to the health insurance Association of America, health insurance defined as “coverage that provides for the payments of benefits as a result of sickness or injury. It include insurance for losses from accident, medical expenses, disability, or accident death and dismemberment

A HEALTH INSURANCE POLICY IS : A contract between an insurance provider (e.g. an insurance company or a government ) and an individual or his/her sponsor ( e.g. an employer or a community organization ). The contract can be renewable ( e.g. annually, monthly ) or lifelong in the case of private insurance , or be a mandatory for all citizen in the case of national plans. The type and amount of health insurance provider are specified in writing, in a member contract or “Evidence of coverage” booklet for private insurance, or in a national health policy for public insurance The individual person’s obligation may take several forms: 

Premium: the amount the policy holder or the sponsor (e.g. an employer) pay to the health plan to purchase health coverage.



Deductible: the amount that the insured must pay out-of-pocket before the health insurer pay its share. For example, policy holders might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor’s visits or prescription refill before the insured person reaches the deductible and the insurance company starts to pay for care. Furthermore most policies do not apply co-pays for doctors visit or prescription against you deductible.



Co-payment: the amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service. For example, an insured person might pay a $40 co-payment for a doctor visit, or obtain a prescription. A co-payment must be paid each time a particular service is obtained . 18



Coinsurance: instead of, or in addition to, paying a fixed amount up front (a co-payment) the coinsurance is a percentage of the total cost that insured person may also pay. For example, the member might have to pay 20% of the cost of surgery over and above a co-payment while the insurance company pay the other 80%. If there is an upper limit on coinsurance the policy holder could end up owing very little or a great deal depending on the actual costs of the services they obtain.



Exclusions: not all services are covered. Billed items like use-and-throw, taxes, etc. are excluded from admission claim. The insured are generally expected to pay the full cost of non-covered services out of their own pocket



Coverage limits: some health insurance policies only pay for health care up to certain amount. The insured person may be expected to pay any charge in excess of the health plan’s maximum payment for the specific service. In addition some insurance company scheme have annual or life time coverage maxima. In these cases, the health plan will stop payment when they reach the benefit maximum and the policy holder must pay all remaining cost.



Out-of-pocket maximum: similar to coverage limits except that in this case, the insured person payment obligation ends when they reach the out-of-pocket maximum and health insurance pay all further covered costs. Out-of=pocket maximum can be limited to a specific benefit category (such as prescription drug) or can apply to all coverage provide during a specific benefit year.



Capitation: an amount paid by an insurer to a health care provider for which the provider agrees to treat all members of the insurer.

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1.7 Features of Tata AIG Health insurance



Coverage: Each of the health insurance plans offered by Tata AIG has varied features and offer coverage for hospitalisation, pre-hospitalisation, post-hospitalisation, domiciliary treatment, critical illnesses and so on. Some plans also provide the benefit of hospital cash wherein an amount that ranges from Rs.500 to Rs.5,000 is provided to the insured for daily expenses when hospitalised.



Critical illness: The insurer offers a critical illness plan that provides coverage for the expenses incurred on availing treatment for certain critical illnesses such as heart attack, kidney failure, bone marrow transplant, coma, paralysis, multiple sclerosis and so on. The required amount is provided as a lump sum to help individuals manage all their expenses. In case the insured wishes to take a second opinion from another doctor, the expenses incurred for the same will be covered by the plan.



Special plans for women, working executives: Tata AIG has come out with a dedicated health insurance plan to address the healthcare needs of working women in today’s age and working executives who are always on the go. These plans are designed in such a way that they address the needs of these groups of people.



Free-look period: The insurer offers a 15-day free-look period during which time the policyholder can go through the terms and conditions thoroughly. If he/she finds the plan unsatisfactory or is unhappy with it for any other reason, he/she may return the policy during this 15-day period and demand a refund of the premium amount paid. The insurer may deduct certain charges like medical check-up charges or stamp duty charges.



Discounts: The company offers discounts on the premium payable towards the policy on certain grounds like if more than two people are covered under the plan or if one opts for a two-year policy. Including more than two family members in the policy will give the policyholder a discount of 10% on the premium. Also, if an individual opts for a policy that needs to be renewed every two years, he/she will get a 7.5% discount on the premium amount payable.



e-services: Policyholders can avail an array of services through the official website of the insurance company. One can buy a policy, renew a policy, notify a claim, track a claim, and so on with just a few clicks. The company also has the SMS option wherein a policyholder can inform the insurer about the hospitalization by sending a simple SMS. 20



Tax benefit: The premium paid towards any of the health insurance plans offered by the company can be claimed as a tax benefit under section 80D of the Income Tax Act, 1961.



Policy cancellation: If a policyholder wishes to cancel the health insurance policy, he/she may do so anytime during the policy period.



Policy changes: If an individual wishes to make a certain change in the policy, he/she may request to make such changes to the insurance company at the time of renewal of the policy.



Additional benefits: Tata AIG health insurance policies comes with a wide range of benefits including features such as the Health Portal, the E-newsletter and other discounts on premium and sum insured.

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1.8 IMPORTANCE OF HELTH INSURANCE

THE FOLLOWING POINT SHOWS THE IMPORTANCE OF HEALTH INSURANCE: Insurance has evolved as a process of safeguarding the interest of people from loss and uncertainty. It may be described as a social device as a social device to reduce or eliminate risk of loss to life Insurance contributes a lot to the general economic growth of the society by providing stability to the functioning of process. The insurance industries develop financial institutions and reduce uncertainties by improving financial resources.

1.

PROVIDE SAFETY AND SECURITY: Health Insurance provides financial support and reduces uncertainties in human life. It provides safety

and security against particular event. There is always a fear of sudden loss. Insurance provides a cover against any sudden loss. For example, in case of health insurance financial assistance is provided to the family. In case of other insurance security is provided against the loss due to fire, marine, accidents, etc.

2.

GENERATES FINANCIAL RESOURCES: Insurance generates funds by collecting premium. These funds are invested in government securities

and stock. These funds are gainfully employed in industrial development of a country for generating more funds and utilised for the economic development of the country. Employment opportunities are increased by big investments leading to capital formation.

3.

HEALTH INSURANCE ENCOURAGES SAVINGS: Insurance does not only protect against risks and uncertainties, but also provides an investment

channel too. Health insurance enables systematic savings due to payment of regular premium. Health insurance provides a mode of investment. It develops a habit of saving money by paying premium. The insured get the lump sum amount at the time of any health problem. Thus, health insurance encourages savings.

4.

PROMOTES ECONOMIC GROWTH: Insurance generates significant impact on the economy by mobilising domestic saving. Insurance turn

accumulated capital into productive investments. Insurance enables to mitigate loss, financial stability and

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promotes trade and commerce activities those results into economic growth and development. Thus, insurance plays a crucial role in sustainable growth of an economy

5.

MEDICAL SUPPORT: A medical insurance considered essential in managing risk in health. Anyone can be victim of critical

illness unexpectedly. And rising medical expense is of great concern. Medical Insurance is one of the insurance policies that cater for different type of health risks. The insured gets a medical support in case of medical insurance policy.

6.

SPREADING OF RISK: Insurance facilitates spreading of risk from the insured to the insured. The basic principle of insurance

is to spread risk among a large number of people. A large number of persons get insurance policies and pay premium to the insurer. Whenever a loss occurs, it is compensated out of funds of the insurer.

7.

SOURCE OF COLLECTING FUNDS: Large funds are collected by the way of premium. These funds are utilised in the industrial

development of a country, which accelerates the economic growth. Employment opportunities are increased by such big investment. Thus, insurance has become an important source of capital formation.

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1.9 ADVANTAGES OF HEALTH INSURANCE



The expenses of medical treatment are compensated by the policies of health and medical insurance



Health insurance typically covers other essential health benefits like emergency services, prescription

drugs and maternity care 

Health insurance can help protect you from high medical costs, whether expected or not through co-

payments and co-insurance 

Having private health insurance is an important and cost effective method of protecting against

unexpected health issues and providing with you more control over your health care choise of services and choice of doctor 

Health insurance company covers the incurred recovery expenses for the insured under the loss of

income benefit the insurer provider covers lump sum in case there is a prolonged hospitalization

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CHAPTER NO.2 RESEARCH METHODOLOGY

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Type of research: Descriptive research Descriptive research can be explained as a statement of affairs as they are at present with the researcher having no control over variable. Moreover, “descriptive studies may be characterized as simply the attempt to determine, describe or identify what is, while analytical research attempts to establish why it is that way or how it came to be. It is Random Research in which all the questionnaires are distributed among the customers who have taken the health insurance service, by ensuring that all the answered answers will be kept confidential. Through this type of Research it made easy to analysis

Research method: Survey, Personal Interview and Questionnaire

Type of data: The sources of data include both primary and secondary data  PRIMARY DATA: Primary data is collected with specific objective, especially to address the research problem. The data is gathered by distributing a questionnaire to the customer who have taken the health insurance in Tata AIG health insurance  SECONDARY DATA: Books, Journal &Internet.

Sample size: The sample size taken for the study is 20 .

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Sample Method: To obtain the representative sample, a non probability sample can be drawn. In this study the method of selecting sample is random i.e. it is non probable. Non-probability sampling is a sampling technique where the samples are gathered in a process that does not give all the individuals in the population equal chances of being selected.

Data Collection Method: The tools used for analysing data are rating method; graphs, pie chart etc. Questionnaire is distributed to the individual respondent and special care has been taken to make him/ her feel comfortable so that, he/she could answer all the questions. This method is followed to get unbiased answers.

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2.1 OBJECTIVES OF STUDY

1)

To know what are the trends in Tata AIG Health Insurance

Self-Service Dashboards. Ah – the beauty of the self-service model. We've seen it in grocery store lines and restaurants and now we are finally seeing it in insurance. As we have learned people want to use their phones to get life done as quickly and easily as possible. They have also started to get more comfortable with doing serious things such as taking out mortgages and buying cars at the click of a button. It makes sense they would want to do the same thing with their insurance managing everything from finding the right policy and making a claim to tracking their car repair all from one place.

Easier – Faster - Claims Process. In the past, when we got rear- ended we’d have to move to the side of the road, fish out our insurance and AAA cards and start the agonizing process of information everyone under the sun about our accident. Today, we can do all of that via mobile, all without ever needing to talk to an agent.

And Purchase Options. What Kayak has done for plane tickets, companies like Tata AIG can do for insurance customers helping to compare often complicated policy coverage and costs at the click of a button. Even better: you can enrol on the spot, having insurance in minutes without ever needing to speak to a sales agent.

More Seamless Experience. We have all had the excruciating experience of explaining our accident to one service agent, and then getting transferred to another agent, only to tell the same story all over again. Now, Tata AIG insurance company are making better use of technology to store customer history and data so all agents whether contacted by a bot, text or phone will have access to the same information.

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2)

To find out the procedure of claims.

The claims process. Tata AIG Insurance company try to make the claims process as smooth as possible, but the policyholder must go through a few steps in the claims process.

Steps in making your claim in Tata AIG. If you are well prepared and organised, and you have all the information that the company needs to see, making a claim is usually straight forward and quick. The first thing you must do is contact to company as soon as practical after the event happens You may choose to review the Product Disclosure Statement (PDS) for your insurance policy to see if you have a valid claim and that the event is not on the list of exclusions for your policy. Your insurer will do this anyway once you lodge a claim. You can make your claim progress much more smoothly if you take an organise, step by step approach. The following guidelines will help you to make sure that you don't overlook any of the important steps in the process.



Before you claim



Making a claim



Working through your claim 29



Finalising your claim



More information

Before you claim.

Review your product disclosure statement. You may choose to review the Product Disclosure Statement (PDS) and your policy schedule for your insurance policy to see if you have a valid claim and that the event is not on the list of exclusion for your policy. Your insurer will do this anyway once you lodge a claim. At this time, you can check on the amount of excess you may need to pay.

Claims handling standards. Through each insurance company has its own processes for handling claims, insurance companies that are members of the Insurance Council of Australia are required to meet or exceed the standards for claims handling laid down in the General Insurance Code of Practice. The code describes how insurer must handle their customers, including the time it takes to handle and make decisions on claims. Compliance is monitored by the Financial Ombudsmen Service.

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Paying claims Insurance companies are expected to promptly assess all of the claims that are made, and to pay out all claims that are covered by the wording in their policies. Under the General Insurance Business Code of Practice, insurance companies promise to respond to your claim within 10 business days and tell you whether they will accept or deny your claim based on the information you have provided. When you make a claim, you will need to provide enough proof of your financial loss under the policy. This may include proof of ownership of claimed items, police or medical reports, and receipts or invoices. If the insurance company needs more detailed information before making a decision, it will let you know what information it needs from you within 10 business days of receiving your claims. If your claim is complex, the insurance company will negotiate with you to arrange a different timeframe for settling the claim. You can have access to any information about you that was used by the insurance company to access your claim, unless the company is investigating your claim. Insurance companies are not allowed to be unreasonable in denying your request for information and reports about your claim. If mistake is identified in dealing with your claim the insurance company promises to correct that information straight away. If insurance claim is denied, the insurance company must provide written reasons for the decision to deny the claim and information about its complaints handling procedures. If you ask for them, the insurance company will also supply you with copies of any reports from service providers that were used in assessing your claim.

The objectives of this code are: a.

to commit us to high standards of service.

b.

to promote better, more informed relations between us and you.

c.

to maintain and promote trust and confidence in the general insurance industry.

d.

to provide fair and effective mechanisms for the resolution of Complaints and disputes between us

and you.

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e.

to promote continuous improvement of the general insurance industry through education and

training.

What you should do file your claim quickly 

You should file your claim as soon as you have gathered the information you need.



By making a claim and getting a claim number, your insurer is made aware of your loss and can start

assessing your claim. You can provide the relevant information later. 

If you delay reporting your claim, your insurer may not pay for any additional loss or damage caused

by your delay. 

Some types of policies may also have time limit to lodge a claim so check your policy.

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2.2 Situation where your policy wont work in Tata AIG

Medical Exclusions: 

Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment certified by the attending Medical Practitioner for reconstruction following an Accident, Cancer or Burns.



Rest cure, sanatorium treatment, rehabi litation measures, private duty nursing, respite care, long-term nursing care or custodial care.



All preventive care, vaccination including inoculation and immunizations (except in case of post- bite treatment and other vaccines explicitly covered);



Hospitalization purely for enteral feedings (infusion formulae via a tube into the upper gastrointestinal tract) and other nutritional and electrolyte supplements, unless certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.



Experimental and Unproven treatments, Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Chelation therapy, Hyperbaric Oxygen therapy

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Non-Medical Exclusions: 

Charges incurred at a Hospital primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness or Injury, for which confinement is required at a Hospital.



Items of personal comfort and convenience like television (wherever specifically charged for), charges for access to telephone and telephone calls, internet, foodstuffs (except patient’s diet), cosmetics, hygiene articles, body care products and bath additive, barber or beauty service, guest service.



Treatment rendered by a Medical Practitioner which is outside his discipline,



Doctor’s fees charged by the Medical Practitioner sharing the same residence as an Insured Person or who is an immediate relative of an Insured Person’s family

Waiting Period: 

Policy coverage starts 30 days from the first inception of the policy (except accident).



Any listed illnesses/treatments will be covered after a waiting period of 24 months.



Any pre-existing condition will be covered after a waiting period of 36 months.

Claim Procedure:

Claims under this policy will be administered by a specified Third Party Administrator (TPA) duly licensed by IRDAI. Intimation & Assistance: Please contact our designated TPA/Us at least 48 hours prior to an event which might give rise to a claim. For any emergency situations, kindly contact our TPA within 24 hours of the event. Claim Related Information: For any claim related query, intimation of claim and submission of claim related documents,

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2.3 Benefits to make policy stronger in Tata AIG



Tax Benefit: The premium amount paid under this policy qualifies for deduction under 80D of Income Tax (Amendment) Act, 1986. This benefit is not applicable for premium amount paid towards accidental death benefit if opted and for premium paid in cash/ or by demand draft. Tax benefits are subject to changes in Income Tax Law.



Settlement of your claims: We settle your claims hassle-free and quickly so that you can focus on quality and timely recovery rather than managing the funding of the treatment, subject to submission of all required documents.



Network of hospitals: We are equipped to offer you quality health care in your city with our strong network of hospitals across India. Kindly carry original photo identity proof along with cashless card to avail cashless hospitalization in network hospitals.



Lifelong Renewal: We offer you a lifelong renewal for your policy provided premium is paid without any break Your premiums will be basis the age and coverage. Your renewal premium will be basis your revised age band and there will be no extra loading's based on your individual claim.

35

2.4 Purpose of health insurance

Every individual should purchase an affordable health insurance plan to cover the expensive medical costs incurred for various health related expenses like serious health disorders or illnesses, routine check-ups, diagnosis tests, physical examinations, prescription drugs, doctor consultation and various other expenses. The coverage benefits and costing differ from plan to plan and varies with every insurance provider. Hence, one should perform adequate research on the web and compare the free instant quotes mailed to you within seconds before finalizing on the policy. Health insurance plans enable you to take extra care of your health. This is because, when you do routine physical examinations, if you need to pay a nominal sum to get check-ups done rather than the actual fee, you would not tend to skip these tests. Otherwise, individuals do not go for checkups in order to avoid the expenses for medical examinations. It also gives the comfort and psychological relief that in case sudden medical expenses are huge, the insurance plan will take care of most of these expenses. Individuals pay a specific amount either on a monthly or a quarterly basis. This is referred as premium and the fee is generally paid in advance to the insurance provider for future coverage benefits. Typically, while you purchase a health insurance policy, you are given a health insurance identity card which you present to the clinic, doctor or hospital for verification purposes. The card also has details of your insurance number and the insurance provider. In case you avail direct claims settlement facility, the hospital would send the medical expense bill to the insurance company directly for reimbursement. Hence, you are saved of the tedious procedure of filing claims with numerous proofs for claiming back your expenses. Every insured person should be aware of the terms and conditions of coverage of the health insurance plan they purchase. For example, pre-existing conditions, which refer to diseases, illnesses or serious health disorders which exist at the time of purchase of the insurance plan would not be covered. Similarly, the exclusions section of the policy document also list those circumstances or conditions under which the insured cannot file for claims. For instance, the insurance company would not pay you for any medical expenses that arise in case of injuries or accidents due to substance abuse or alcohol addiction. Self-inflicted injuries, medical expenses arising due to suicide attempts cannot be claimed from the insurance provider. 36

Some health insurance plans offer full reimbursement only when any medical expert, clinic or hospital that is tied up to its network is consulted. Otherwise, the individuals may have to bear a certain percentage of the expense out of their pockets. Sometimes, insurance companies insist to inform them before getting admitted for elective surgeries in order to get full reimbursement of the medical expenses. Every individual should purchase a health insurance plan during their early years of life in order to reap best benefits as an average individual having a fit body at the time of applying for insurance will face lesser restrictions from the insurance provider for offering coverage benefits.

37

2.5 DISPUTE IN INSURANCE CLAIM

An argument or disagreement about a request to an insurance company to pay for costs related to damage, an accident, etc. When you make an insurance claim, you have usually suffered some type of a loss or your property has sustained damage that is caused by one of the named perils insured by your insurance policy. Your insurance policy provides coverage and compensation to you for covered losses or the damages you sustain as a result of the claims process. Having more insight about the insurance claim, how companies handle insurance claims and the methods by which you can file insurance claims can take the worry and guesswork out of the insurance claim process and empower you to get the money you deserve in a claim settlement. Resolving insurance claims disputes is a difficult process and could take long. The insurance claim however is the application and benefits which is brought to you by the company. This can be done by filing the insurance claim and the company depends whether they will approve the insurance claim or not. But that’s not that easy as you will face many steps before clearing all and you will do a lot of things in fixing these problems. Here are some simple tips in solving these problems easily.

1)

The best and the first thing to do is to prepare. When getting involved to the insurance policies you must consider all the things that could be

considered like what could it brought you in the future or is this insurance policy company is a right choice, and what problems should I face in the future. Knowing the problems, you might face in the future is a good way of avoiding this problem. At least for a reason that you already know what you would face in the future and so if it happened you will be found it easier to face it or at least you are ready on those problems and you might be prepared for that problem or may be getting important papers on the ready.

2)

Estimating how much your loss is. This is second must be in cooperation with the first top which is to be prepared on the possible

problems. You may not know how much exactly your loss is. However, you may try to compute it by just estimating. This could be a good way especially if you are close to your exact loss. If you are close or you think it is below the deductible, you are probably better off not filing the insurance claim. This will be based on your history of claims and you might end to the paying for your own pocket. Some of the companies are requiring timeframes. 38

3)

Call an insurer. If you are not sure what the insurance claim disputes is, you have to ask for the insurer or the

insurance agent so that you are not predicting on what insurance claim dispute is. Insurer may be off to a working to the insurance company, the insurer will somehow tend to help and give the best they could for their customers. An adjuster would tell you your estimated loss.

4)

Read the exclusions. You must read carefully about exclusions sections. These sections are sometimes hard to understand

or may be difficult to read. This will just for you to find out that there are exclusions on you so you may not pay some of it. If you read the exclusions, you may ask the insurer if the company has exclusion.

5)

Recall phone calls with the insurance company. The phone calls may be important for the future use. As this could be proof if there are problems that

may happen. If you did not recall the phone calls with the insurance company. This is important especially if you are dealing with the insurance policies. So far those who are beginners into the insurance matters, remember that a single conversation or communication with the insurance company is very important.

6)

Report the insurance company at once. If you think that the insurance company is harassing you at the time that they really forcing you to

pay, you may report it or you may file an appeal to your state's department of insurance. For the procedures, you go to your department of insurance, different states have different procedures so you better see it off yourself.

7)

If there is a problem, call the insurance company. If there is a problem regarding with your claims, you have to call the insurance company right away.

Especially that if you found out there is an error.

39

QUOTE OF THE DAY:

Insurance companies tend to investigate on some of the claims as many people are inflating the claims despite the fact that there are many claims paid. This may bring the people to cover their claims but they could be faced to many difficult problems due to this like increasing in premiums.

Defining Risk 

A variation in the possible outcome



The degree of uncertainty associated with a particular loss



Greater the accuracy with which the outcome can be predicted the lower is the risk



Risk is the possibility of an unfortunate occurrence.



Risk is the possibility of loss.



The combination of hazards.



Uncertainty of loss



The tendency that actual results may differ from predicted results.

40

2.6 THE INDEMNITY PRINCIPLE OF GENERAL INSURANCE

Insurance contracts can be defined or categorized in various manners. Two of these common contracts and valued contracts. These two contracts represent one of the various insurance dichotomies. On the one hand, indemnity is more on the compensation aspects, but it is important to note that not all of the existing insurance contracts are the same with the nature of indemnity contracts.

The principle of indemnity asserts that on the happening of a loss the insured shall be put back into the same financial position as he used to occupy immediately before the loss.

In other words, the insured shall get neither more nor less than the actual amount of loss sustained.

This, of course, is always subject to the limit of the sum insured and also subject to certain terms and conditions of the policy.

41

Therefore, to put it in a much better way, on the happening of a loss, the insurers will try to put back the insured into the same financial position as the insured used to occupy immediately before the happening of the loss, only if the insurance is properly arranged on full value insurance.

Under-insurance and restrictive terms of the policy may preclude the insured from getting the actual loss.

On the other hand, even if the sum insured is more than the actual value of the property or subject matter; this would not entitle the insured to get more than the actual loss.

This principle of indemnity will permit the insurer to pay a smaller amount compared to the money insured but never go beyond the sum insured. If the replacement for of an asset is smaller than the original amount, the insurer can be liable only in paying replacement fee – even if it is smaller than then the insured amount.

Moreover, in the contract of indemnity, any insured client cannot get insurance which is beyond his insurable interest. For example, of a person buys full insurance on a commercial building that same person co-owns only a total only a total of 50% share. If this client for instance destroys the building insured the co owners will not ne able to get a full compensation from the insurance company. The insurance company will only provide the 50% of the total lost amount because that is the limit of the client's insurable investment or interest in the property.

An indemnity contract is the total opposite of the valued contract. The valued contract is more focused on an insured benefit and not on the amount or value connected to a loss. This is due to the fact that the valued contracts, as life insurance basically include very vital assets such as life or body parts like limbs. Thus this kind of insurance is considered to be one of the most important among all existing insurances.

The following Acts and Regulations are to be considered:

a)

The Insurance Act, 1938

b)

The Companies Act, 1956

c)

The General Insurance Business (Nationalization) Act, 1972

d)

The Insurance Regulatory and Development Authority, 1999 42

e)

The Insurance Regulatory and Development Authority Regulations, 2002

Applicability of Accounting Standards:

While preparing receipts and payments accounts, profit and loss account, and the balance sheet of the Insurance Company the recommendations of Indian Accounting Standards (A3) framed by the ICAI should strictly be followed as far as practicable to the General Insurance Company with the exemption of 

AS 3 (Cash Flow Statement) to be prepared under Direct Method only.



AS 13 (Accounting for Investment) – not to be taken into consideration.



AS 17 (Segment Reporting) – to be applied in general without considering the class of Security.

43

2.7 FINANCIAL STATEMENTS OF GENERAL INSURANCE COMPANIES

The financial statements of general insurance companies must be in conformity with the regulations of IRDA, Schedule B.

It has three parts: viz: a)

Revenue Accounts

b)

Profit and Loss Accounts

c)

Balance sheet

Revenue Accounts (Form B-RA): The Revenue Account of general insurance companies must be prepared in conformity with the regulations of IRDA, Regulations 2002, as per requirement of schedule B. It has already been stated above the separate Revenue Account is to be prepared for each individual unit i .e. for Marine, Fire, and Accident. These individual revenue accounts will highlight the result of operation of each individual unit for a particular accounting period. It also reveals the incomes and expenditures of each individual unit. Like Revenue Account of a life insurance company, Revenue Account is prepared under Mercantile System of Accounting

Items appearing in Revenue Account: Premiums: It has already been started above that general insurance policies are issued for a short period, say, for a year. As a result, many of them may be unexpired at the end of the year. Therefore, the entire premium so received cannot be treated as an income for the current year only. A portion of that amount should be carried forward to the next year in order to cover the unexpired risks. This is what is known as Reserve for Unexpired Risks.

As per Schedule IIB of the IRDA the Reserve for Unexpired Risks should be provided for out of net premiums so received as: 

50% for Fire Insurance Business 44



50% for Miscellaneous Insurance Business



50% for Marine Insurance Business



100% for Marine Hull Business.

Profit and Loss Account (Form B – PL): An income statement or profit and loss account also referred to as a profit and loss statement (P&L), statement of profit or loss, revenue statement, statement of financial performance, earnings statement, operating statement, or statement of operations) is one of the financial statements of a company and shows the company’s revenues and expenses during a particular period.

Balance sheet (Form B – BS): A balance sheet is a financial statement that reports a company's assets, liabilities and shareholders' equity at a specific point in time, and provides a basis for computing rates of return and evaluating its capital structure. It is a financial statement that provides a snapshot of what a company owns and owes, as well as the amount invested by shareholders.

45

2.8 LIMITATIONS OF THE STUDY

Every research has its limitations and this study is also no exception. The present study has the following limitations: 1.

The responses for the study have been solicited from the state of Navi Mumbai only. The

perceptions and expectations of the customers in Maharashtra may vary from those of the rest of India. 2.

The customers of only Tata AIG Insurance companies were selected to study the service and

satisfaction of customers. As a result, the generalization of the findings of the present research should be considered carefully. 3.

Any study which is based on the primary data collected through the pre-designed

questionnaire suffers from the basic limitation of possibility of difference between what is recorded and what is truth, no matter how carefully the interview has been conducted. The same may be with the present study because the people may not deliberately report their true opinion due to some biasness. 4.

The information collected for the secondary data-based study carries all the limitations

inherent with the secondary data.

46

CHAPTER NO. 3 LITERATURE REVIEW

47

LITERATURE REVIEW

A large body of literature on insurance provides the basis for this study. The literature reviewed mainly consists of journals published by the Insurance Institute of India, Federation of Insurance Institute, [RDA and insurance magazines. The researcher has also gone through the websites of various insurance companies and IRDA. An attempt has been made to briefly review previous studies in the area of privatization, liberalization, rural insurance, bancassurance, IRDA, customer satisfaction, insurance coverage, insurance marketing and insurance growth. Harold D. Skipper (2000) in his paper explains the terms liberalisation and deregulation. Liberalisation means the process by which the government take actions to move towards liberal markets. It denotes a reduction of government barriers to market access, especially as relates to foreign insurers. A liberal insurance market is one which determines: 1)

Who should be allowed to sell insurance?

2)

What products should be sold?

3)

How the products should be sold?

4)

At what price the products should be sold? Thirivadee Boonyasai, Grace and Skipper (1999) in their study examined the effects of

liberalisation and deregulation on the efficiency of life insurers in selected Asian life insurance markets. He also Presents a set of principles around which governments should craft their regulation Of insurance and suggests that for having a competitive and solvent insurance market, insurance regulation Should have the following traits namely, 

Adequacy



Impartiality



Minimal instructions



Transparency The lesson for the government is to craft laws and enforce regulations that promote more

transparent markets supported by fair competition. Competitive insurance market serves each county’s interest. The LIC’s range includes around 60 products and general insurance companies have a range of 150 products. They envisaged that the liberalisation scene would be marked by the following developments. 1)

The character of the industry will change in the wake of transition from a controlled to a

competition driven market. 48

2)

There will be new players. The foreign insurers will enter through the joint venture route.

3)

The range of products and services offered will widen.

4)

The industry will be closely regulated. Sen (2006) analysed the Indian life insurance industry alter the privatisation of the insurance

market. The entry of private firms will raise both price competition and service competition. The study concludes that there is a hint of movement towards a more competitive regime but there is a good level of competition among the private companies to capture market share. S. Krishnamurthy (2005) points out that the life insurance industry has shown extremely satisfactory results in terms of premium income and new policies sold but a huge potential still remains unexploited. Today there are alternate channels like bancassurance, brokers, corporate agents and direct marketing through internet. Prakash Rao B.K.S. and Bh.Venkateswara Rao (2005) have made an attempt to examine the opportunities for insurers in the rural market. They point out that the new companies entered into insurance business after liberalisation focused their attention mainly in urban areas. Table3.1 shows that majority of the rural population is uninsured. Table 3.1 Rural Population and Insurance Penetration Total Population

1.05

(as on July 2002)

billion

Rural Population

72.22%

Urban Population

27.78%

Insurance

26%

Penetration in rural markets They also listed the challenges in increasing the insurance coverage in rural areas. It was pointed out that the cost of building exclusive delivery systems for selling insurance in rural areas is very high. The second barrier is the paucity of channels to communicate the benefits of products to the entire rural population. They suggest that by establishing network with rural development agencies, banks, cooperative institutions and youth clubs, insurance policies can be sold in rural areas. In urban are as consumers belonging to the middle-income group prefer policies of public sector players and only high-income group preferred private sector players. The study also revealed that in urban areas the efficient customer service helped the market penetration by private players. The major reasons cited for the failure in the rural sector can be summarised as follows. 1)

Lack of popular appeal in marketing strategy. 49

2)

High variation between services provided and consumer’s expectations.

3)

High premiums.

4)

Product differentiation and innovation are not in conformity with the rural population.

50

CHAPTER NO. 4 PLANS OF HEALTH INSURANCE IN TATA AIG

51

1 TATA AIG MEDICARE HEALTH INSURANCE. 

Restore Benefits: It automatically restores your sum insured to 100% for you and your family members.



Bariatric Surgery: Covers expenses incurred for Bariatric Surgery for treatment of Obesity and weight control.



Global Cover: Covers Medical Expenses related to Inpatient & Day Care Hospitalization of the Insured Person incurred outside India, provided that the diagnosis was made in India.



Cumulative bonus: 50% increase in cumulative bonus for every claim free year, up to a maximum of 100%. In the case a claim is made during the policy year, the cumulative bonus would reduce by 50% in the following year.



In-Patient Treatment: Covers expenses for hospitalization due to disease/illness/Injury during the policy period that requires an Insured Person’s admission in a hospital as an inpatient. Medical expenses directly related to the hospitalization would be payable



Day Care Procedures: Covers expenses for 540+ Day Care Treatment due to disease/illness/Injury during the policy period taken at a hospital or a Day Care Centre.

52



Consumables Benefit: Covers expenses incurred, for consumables, which are consumed during the period of hospitalization directly related to the insured person’s medical or surgical treatment of illness/disease/injury.



Vaccination Cover: Covers expenses related to Human Papilloma Virus (HPV) vaccine & Hepatitis B Vaccine after 2 years of continuous coverage and Antirabies vaccine & Typhoid vaccination without any waiting period.



Compassionate Travel: Covers expenses upto Rs. 20,000 related to a round trip economy class air ticket, or first-class railway ticket, to allow the Immediate Family Member to be at insured person's bedside during his stay in the hospital.



Accidental Death Benefits (optional cover): Covers 100% of sum insured in the event of death of insured person due to accident. This benefit is not applicable for dependent children covered in the policy.



Pre-Hospitalization Medical Expenses: Medical Expenses incurred in 60 days before the date of admission to the hospital.



Post-Hospitalization Medical Expenses: Medical Expenses incurred in 90 days after the date of discharge from the hospital.



Domiciliary Treatment: Covers for expenses related to Domiciliary Hospitalization of the insured person if the treatment exceeds beyond three days. The treatment must be for management of an illness and not for enteral feedings or end of life care.



Second Opinion: A second opinion from Network Provider or Medical Practitioner will be provided, if an Insured Person is diagnosed with the mentioned Illnesses during the Policy Period.

53



Ambulance cover: For utilizing ambulance service for transporting insured person to hospital in case of an emergency, coverage limit Rs.3000.



Hearing Aid: Covers reasonable charges for a hearing aid every third year. The maximum payable is 50% of actual cost or Rs. 10,000/- per policy, whichever is lower.



Daily cash for accompanying an insured child: A fixed amount per day will be paid, as mentioned in the schedule, if the Insured Person Hospitalized is a child Aged 12 years or less, for one accompanying adult for each complete period of 24 hours. Coverage limit 0.25% of base sum insured and max. Rs. 2000 per day.



In-patient Dental Treatment: Covers expenses incurred towards hospitalization for dental treatment under anesthesia necessitated due to an accident/injury/illness.



Organ Donor: Covers Medical and surgical Expenses of the organ donor for harvesting the organ where an Insured Person is the recipient.



AYUSH benefit: Medical Expenses incurred for In-patient treatment taken under Ayurveda, Unani, Sidha or Homeopathy.



Health Checkup: Expenses for a Preventive Health Check-up up to 1% of policy sum insured subject to a maximum of Rs. 10,000/- per policy.



Daily Cash for choosing Shared Accommodation: A fixed amount per day will be paid as mentioned in the policy schedule if the Insured Person is hospitalized in Shared Accommodation in a Network Hospital for each continuous and completed period of 24 hours. Coverage limit 0.25% of base sum insured and max. Rs. 2000 per day.

54

2 MEDICARE PREMIUM HEALTH INSURANCE 

Global Cover: Covers Medical Expenses related to Inpatient & Day Care Hospitalization of the Insured Person incurred outside India, provided that the diagnosis was made in India.



Consumables benefit: Covers expenses incurred, for consumables which are consumed during the period of hospitalization directly related to the insured person's medical or surgical treatment of illness/disease/injury.



Bariatric Surgery: Covers expenses incurred for Bariatric Surgery for treatment of Obesity and weight control.



Restore Benefits: It automatically restores your sum insured to 100% for you and your family members.



Emergency Air Ambulance: Covers expense for ambulance transportation by airplane or helicopter for emergency life threatening health conditions, which require immediate ambulance transportation to the hospital/medical centre for upto Rs. 5 lacs. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.



Day Care Procedures: Covers expenses for 540+ Day Care Treatment due to disease/illness/Injury during the policy period taken at a hospital or a Day Care Centre.



In-Patient Treatment: Covers expenses for hospitalization due to disease/illness/Injury during the policy period that requires an Insured Person’s admission in a hospital as an inpatient. Medical expenses directly related to the hospitalization would be payable.

 

High End Diagnostics: Covers the insured person for the listed diagnostic tests on OPD basis if required as part of a treatment subject to Rs. 25,000 per policy year.



Accidental Death Benefit: Covers 100% of sum insured in the event of death of insured person due to accident. This benefit is not applicable for dependent children covered in the policy. 55



Maternity Cover: Covers maternity expenses – up to a maximum of Rs. 50,000/- per policy subject to a waiting period of 4 years of continuous coverage under this policy subject to IRDAI portability guidelines. (in case of birth of girl child cover would be for Rs. 60,000) per policy. No limit on number of delivery events.



First year Vaccinations: Covers vaccination expenses for up to one year after the birth of the child subject to a limit of Rs.10,000/- (in case of girl child cover would be for Rs. 15,000) provided the child is covered with us.



Organ Donor: Covers Medical and surgical Expenses of the organ donor for harvesting the organ where an Insured Person is the recipient.



Vaccination Cover: Covers expenses related to Human Papilloma Virus (HPV) vaccine & Hepatitis B Vaccine after 2 years of continuous coverage and Anti-rabies vaccine & Typhoid vaccination without any waiting period. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.



Compassionate Travel: Covers expenses up to Rs. 20,000 related to a round trip economy class air ticket, or first-class railway ticket, to allow the Immediate Family Member to be at insured person's bedside during his stay in the hospital. In the event the Insured Person is Hospitalized for more than Five consecutive days in a place where no adult member of his immediate family is present. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.



OPD Dental Treatment: Once the Insured has completed two years of continuous coverage with Us, we will pay for expenses related to the following dental treatments only subject to a maximum of Rs.10,000 per policy year annually: o Root Canal Treatment (single or multiple sittings) o Tooth extraction(s) o Filling



This benefit has a separate limit (over and above base sum insured) and does not affect Cumulative Bonus



Pre-Hospitalization Medical Expenses: Medical Expenses incurred in 60 days before the date of admission to the hospital.



Post-Hospitalization Medical Expenses: Medical Expenses incurred in 90 days after the date of discharge from the hospital.



Daily Cash for choosing Shared Accommodation: A fixed amount per day will be paid as mentioned in the policy schedule if the Insured Person is hospitalized in Shared 56

Accommodation in a Network Hospital for each continuous and completed period of 24 hours. Coverage limit 0.25% of base sum insured and max. Rs. 2000 per day. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus. 

Daily cash for accompanying an insured child: A fixed amount per day will be paid, as mentioned in the schedule, if the Insured Person Hospitalized is a child Aged 12 years or less, for one accompanying adult for each complete period of 24 hours. Coverage limit 0.25% of base sum insured and max. Rs. 2000 per day. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.



OPD Treatment: Once the insured has completed two years of continuous coverage with us, we will pay for expenses related to consultations and pharmacy subject to Rs. 5000 per policy year annually subject to policy terms and conditions. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.



Second Opinion: A second opinion from Network Provider or Medical Practitioner will be provided, if an Insured Person is diagnosed with illnesses mentioned in policy wordings during the policy period.



Domiciliary Treatment: Covers for expenses related to Domiciliary Hospitalization of the insured person if the treatment exceeds beyond three days. The treatment must be for management of an illness and not for enteral feedings or end of life care.



New Born Baby Cover: Covers medical expenses incurred for the medically necessary treatment of the new born baby up to Rs.10, 000 for complications related to delivery. This benefit will trigger only in case where we have admitted the maternity claim.



Ambulance cover: For utilizing ambulance service for transporting insured person to hospital in case of an emergency, coverage limit Rs.5000.



Prolonged hospitalization Benefit: Pays a fixed amount of 1% of sum insured, in the event of insured hospitalized for a disease/illness/injury for a continuous period exceeding 10 days. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.



AYUSH benefit: Medical Expenses incurred for In-patient treatment taken under Ayurveda, Unani, Sidha or Homeopathy.



Health Checkup: Expenses for a Preventive Health Check-up up to 1% of policy sum insured subject to a maximum of Rs. 10,000/- per policy. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus. 57



In-patient Dental Treatment: Covers expenses incurred towards hospitalization for dental treatment under anesthesia necessitated due to an accident/injury/illness.



Hearing Aid: Covers reasonable charges for a hearing aid every third year. The maximum payable is 50% of actual cost or Rs. 10,000/- per policy, whichever is lower. This benefit has a separate limit (over and above base sum insured) and does not affect cumulative bonus.



Cumulative bonus: 50% increase in cumulative bonus for every claim free year. In the case a claim is made during the policy year, the cumulative bonus would reduce by 50% in the following year.

58

3 WELLSURANCE EXECUTIVE POLICY



Hospitalization: Specified hospitalization benefit shall be provided if the insured person is hospitalized for the treatment of injury/sickness.



Post Hospitalization Expenses: Pays lump sum amount after hospitalization under following circumstances only 1. Post-operative physiotherapy-eligibility: Minimum of 2 visits. 2. Chemotherapy and/or radiation-eligibility: Minimum of 3 visits. Payable once during the lifetime of the insured. 3. Kidney dialysis: Payable once during the lifetime of the insured. 

Value added service: Facilities like free health line, health portal, health query, discounted services for the health and wellness and e-news letter will be provided to the insured where he will get access to various health articles and will be able to raise queries and get them answered by experts.

59

4 CRITICAL ILLNESS



No money worries, no stress: We give the entire coverage amount in a lump-sum.



Our checklist for critical ailments: Heart attack, Cancer, Stroke, Open chest CABG, Kidney failure, Organ transplant, Bone marrow transplant, Blindness, Coma, Major burns, Multiple Sclerosis, and Paralysis are the critical illnesses covered.



Go for a second opinion: Assailed by doubts regarding your diagnosis? Go to another doctor/hospital for a second opinion. It’s all covered.



Enhance your sum assured: If you later decide to increase your coverage amount, our ‘Sum Insured Enhancement’ feature can kick-in during your policy renewal.

60

5 Wellsurance Family



Intensive care unit benefit: We will pay a daily benefit for each day you are an inpatient admitted in the intensive care unit in a hospital due to injury/sickness subject to any applicable deductible shown in the policy schedule and commences under the circumstances described in a hazard and while this policy is in effect, subject to the maximum shown in the policy schedule.



Ease of hospitalization: When a family member is admitted to the hospital for a illness or injury, we will provide them with a daily cash allowance for up to 90 days.



Ambulance Charges: Pays up to the specified amount towards the medical transportation fees and services incurred for bringing the insured to the hospital following an accident and returning to the normal place of residence after being discharged from the hospital.



Value added service: Facilities like free health line, health portal, health query, discounted services for the health and wellness and e-news letter will be provided to the insured where he will get access to various health articles and will be able to raise queries and get them answered by experts .

61

6 MediRaksha



More coverage, greater security: This policy extends coverage to seven family members. That means besides yourself, you can secure your spouse, parents, and three children too.



No hassle of medical tests: You don’t have to undergo medical tests until the age of 55.



In-patient treatment: The policy covers the costs of hospitalisation due to illness or an accident. The covered expenses include room rent, boarding, ICU, and nursing. You also receive coverage for medicines, drugs and other consumables.



Organ donor: The policy also covers the costs of an organ transplant – both for the organ receiver and the donor in the harvesting stage.



Day-care procedures: In case you need any Day care procedures, your policy is bound to take care of the expenses. Just look at the 144 day care procedures we cover.

62

7 Wellsurance Woman



Ambulance Charges: Pays up to the specified amount towards the medical transportation fees and services incurred for bringing the insured to the hospital following an accident and returning to the normal place of residence after being discharged from the hospital.



ICU charges for 15 days are included in our hospitalization benefit. So, don’t stress about daily expenses when you’re admitted to the Intensive care unit.



Cosmetic Reconstruction Surgery: Pays the specified amount if the surgery is conducted as a reconstructive procedure on structures of the body for the purpose of the restoring/improving bodily function or correcting significant deformity resulting from accidental injury as covered under the hazard, subject to the maximum shown in the policy schedule.



Value added service: Facilities like free health line, health portal, health query, discounted services for the health and wellness and e-news letter will be provided to the insured where he will get access to various health articles and will be able to raise queries and get them answered by experts

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CHAPTER NO. 5 DATA ANALYSIS, INTERPRETATION AND PRESENTATION

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5.1 PROFITABILITY

Performance is the process of carrying into effect policies, programmes and plans in order to, achieve defined and measurable results. Performance in an organisation can be measured in such term; as Net Profit, Return on equity, and Earnings per share etc. In changing economic scenario marked liberalisation of policies and increased competition for sheer survival, 4 company has to make profits. Profits are the ultimate yard stick of management's ability to coordinate, plan and act in the interest of the consumer. Profits, in the accounting sense, defined as the excess of revenue receipts over the cost incurred in producing this revenue. The nature of Insurance business is long-term and its profitability is a key issue, which depends upon many factors and is measured differently. The overall performance of the four public sector and Private sector general insurance companies were assessed using certain key indicators like the retention ratio: the incurred claims ratio, operating profits or losses in different business segments as also the costs of procuring business which is represented by commission pay-outs. To analyse the drivers of profitability, it is useful to decompose Return on Equity (ROE) into its main components. Profits are determined first by underwriting performance (losses and expenses, which are affected by product pricing, risk selection, claims management, and marketing and administrative expenses); and second, by investment performance, which is a function of asset allocation and asset management as well as asset leverage.

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PROFITABLIT OF HEALTH INSURANCE

ORIENTAL INSURANCE

NATIONAL INSURANCE GROSS INSURED CLAIM GROSS WRITTEN PREMIUM

TATA AIG

NEW INDIA

0

5000

10000

15000

20000

25000

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5.2 PROFITABILITY ANALYSIS OF THE TATA AIG

Calm Ratio The processing and settlement claims constitute one of the most important functions in any organisation. Indeed, the payment of claims may be regarded as the primary service of insurance to the public. The prompt and fair settlement of claims is the hallmark of good services to the insuring public. The claim settlement ratio, which is an index of customer service. Claims incurred ratio may be defined as total net incurred claims divided by net written premium (NWP). It indicates the extent to which the ‘net premium’ is to be applied to meet this obligation and is a measure of the risk retained by the insurer. This enables an assessment of profitability of underwriting operations and reinsurance arrangements.

What is incurred calm ratio (ICR)? Incurred Claims Ratio is nothing but the total value of all claims paid by the health insurance c0 I11pan): divided by the total amount of premium they collected in the same period. Incurred Claims Ratio indicates the company’s ability to pay the claims. AS an example, a 70 percent incurred claims ratio means that for every Rs 1000 of premium earned in a given accounting period, Rs 700 is paid back in the form of benefits (claims). Incurred Claim ratio is the ratio of the claims settled to the premium received. So, how to analyse the ICR data? Whether a Non-life Insurance company which has say ICR of 120% is better than a company which has incurred claims ratio of say 75%?? Let us now understand this point. If ICR is greater than 100%, it means that the company has given more money away as claims than what it has collected as premium. This is not good for the company. If ICR is less than 100% say in the range of 60% to 90%, it means that the health insurance company has given as claims than what it has collected. It means that they are making profits. If ICR is very low say 30%, it means that either the company is charging higher premium rates than its peers and making huge profits (or) it has a good pool of low-risk (may be youngsters) profile individuals as clients (or even both). Hence it is better to be with an insurance company which has neither high nor low incurred claim ratio. I believe that the ideal ratio (percentage) range can be anywhere between 60% to 90%.

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The main difference between Incurred Claims Ratio and Claim Settlement ratio is Incurred Claim ratio is the ratio 0f the claims settled to the premium received. Claim Settlement Ratio (CSR) is the ratio of claims approved to total claims made (received). The higher the CSR the better. Same is not me case with ICR. Non-Life Insurance Companies provide products under various segments like Motor, Health, Home, Personal Accident, Travel, Manne and other types 0f Insurances. In this post, we are analysing the ICR details of Health Insurance vertical only

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Health Insurance and Latest IRDA Incurred Claims Ratio 2016-17

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I marked with red for those companies whose ICR is below 50% and above 100%. I marked with blue for those companies whose ICR ranges from less than 100% to 80%. I marked with green for those companies whose ICR ranges from above 50% to less than 80%.

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5.3 INDIAN INSURANCE: SECTOR REFORM

The formation of the Malhotra Committee in 1993 initiated reforms in the Indian insurance sector. The aim of the Malhotra Committee was to assess the functionality of the Indian insurance sector. This committee was also in charge of recommending the future path of insurance in India. The Malhotra Committee attempted to improve various aspects of the insurance sector, making them more appropriate and effective for the Indian market. There commendations of the committee put stress on offering operational autonomy to the insurance service providers and also suggested forming an independent regulatory body.

PROTECTION OF THE INTEREST OF POLICY HOLDER.

IRDA has the responsibility of protecting the interest of insurance policyholder Towards achieving this objective, the Authority has taken the following steps: 

IRDA has notified Protection of Policyholders Interest Regulations 2001 to provide for: policy

proposal documents in easily understandable language; claims procedure in both life and non-life; setting up of grievance redressal machinery; speedy settlement of claims; and policyholders' servicing. The Regulation also provides for payment of interest by insurers for the delay in settlement of claim. 

The insurers are required to maintain solvency margins so that they are in a position to meet their

obligations towards policyholders with regard to payment of claims. 

It is obligatory on the part of the insurance companies to disclose clearly the benefits, terms and

conditions under the policy. The advertisements issued by the insurers should not mislead the insuring public. 

All insurers are required to set up proper grievance redress machinery in their head office and at their

other offices.



The authority takes up with the insurers any complaint received from the policy holders in

connection with services provided by them under the insurance.

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5.4 MILESTONES OF THE INSURANCE REGULATIONS IN THE 20TH

CENTURY.

Insurance industry in India: A Historical Perspective The history of insurance in India can be traced with the establishment of a British company called the Oriental Life Insurance Company in 1818, followed by the Bombay Assurance Company in 1823, and the Madras Equitable Life Insurance Society in 1829. All these companies operated in India but did not insure the lives of Indians. They were insuring only the lives of Europeans living in India. The first general 74

insurance company known as Triton Insurance Company Ltd., was established in 1850. It was owned and operated by the British. The first indigenous general insurance company was the Indian Mercantile Insurance Company Limited set up in Bombay in 1907 (Sinha, 2005; Shanna and Agarwal, 2005). The wholly Indian-owned insurance company, namely, The New India Assurance Company Limited was incorporated on July 23, 1919 which commenced its operations in October the same year (Narayanan, 2006). There was no exclusive legislation to govern the activities of insurance companies during the 19thcentury. To control the operations of life insurance in India, the Indian Life Insurance Companies Act, 1912 was enacted. However, the first comprehensive legislation was introduced with the passing of Indian Insurance Act, 1938. In spite of the commendable growth and performance of the LIC and GIC on both economic and social fronts, a vast potential still exists as majority of insurable population is still untapped. Macro indicators such as population coverage, per capita premium, contribution to employment and GDP are still very low as compared to developed countries, although they compare reasonably well with other developing countries..

Reform Process of Insurance Sector in India. The Government of India constituted the Malhotra Committee to examine and recommend the measures for the introduction on of the reforms process in the insurance sector. R.N. Malhotra, retired Governor of the Reserve Bank of India, was named its Chairperson. The committee examined the structure of the insurance industry and recommended changes to make it more efficient and competitive, keeping in view the structural changes in other parts of the financial system of the economy (Sharma and Agarwal, 2005). The Government accepted the report of the Committee, which was submitted to the Government in January 1994.

Recommendations of the Malhotra Committee. The Malhotra Committee had made certain recommendations to the Government to change the face of the industry and to give it a more meaningful direction. Regarding the liberalization of the insurance industry, the Committee made the following important recommendations:

a)

Private sector should be allowed to enter the insurance business: The committee had delivered on the subject and the following issues weighed in favour of opening the

industry to competition: 

Competition would lead to better customer service.



It would improve the quality and price of insurance products. 75



The entry of new players would lead to better penetration of the market.



When other wings of the financial sector like banking, mutual funds, merchant banking, and

nonbanking financial sectors were exposed to competition, there was no reason to keep insurance insulated. 

Public view was converging towards competition in the insurance sector.



As public sector insurance institutions had created a good pool of professional talent and marketing

network, there was no fear of they being incapable of facing competition.

b)

No composite Insurance Companies: The Committee recommended that no single company should be allowed to transact both life and

general insurance business. The Committee had so recommended as life and general insurance are two different lines of business, and prudence demands that there should not be any mixing UP of funds.

Number of new entrants to be controlled: The Committee felt that this step was necessary to control the cropping up of small private sector companies and their wilting away during a financial crisis.

c)

Minimum paid-up capital: With a view to ensure that only companies with a good track record in their line of business apply for

licenses to act as insurance companies, the Committee recommended a paid-up capital 0f Rs.100 crore for the new entrants. At the same time, the Committee felt that this requirement could be lowered in cases where the promoters are state level co-operative institutions. d)

Obligation to do business in rural areas and for weaker sections of the

community: This. stipulations were introduced to ensure a level-playing ground for all insurance companies. New entrants may tend to concentrate on more lucrative business to the neglect of the common people and the rural areas. To avoid this, the Committee had recommended that both life and non-life companies should procure a prescribed percentage of business from these segments.

e)

Selective entry to foreign companies: The Committee felt that permitting foreign insurance companies would be in the interest of the

Indian economy, particularly in the context of globalization. It recommended that entry to foreign companies should be on a selective basis. Foreign companies entering India should be required to float an Indian company, preferably as a joint venture.

f)

Technology upgradation: 76

The insurance has become an information-driven industry all over the world. This, in effect, means heavy dependence on IT and development of computer support systems. The industry has to develop software to improve effective customer service and claim management.

g)

Pension Sector: To popularize the contribution to individual pension funds by self-employed professionals, traders

and workers in the unorganized sectors, the Committee recommended income tax concessions up to a prescribed limit for contribution to individual pension schemes floated and managed by insurance companies. The Committee cited the nature of tax concessions available on individual contributions to the pension funds and concessions available to pension funds in the UK; it suggested that substantial concessions should also be available for contributions to pension funds in India, and this should cover schemes managed by all the insurance companies as well.

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QUESTIONAIR

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CHAPETER NO.7 CONCLUSION AND SUGGESTIONS

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7.1 CONCLUSION.

1)

We must be very practical and smart these days. In order to really live well and make the most out of

our lives, we must invest with health insurance. This way we will be always safe from all forms of challenges and calamities in view of our live and the lives of our loved ones.

2)

Nowadays, Tata AIG is progressing faster because promotes quality, not quantity; it encourages

talent. Public Sector is full of reservations like reservations for minority section, females, a person with a disability and much more, here nobody sees talent, it is completely ignored and because of this, competent youths remain unemployed.

3)

Tata AIG enterprises give so many facilities to their employees, which makes them satisfied that

their job is secured, due to which, all the people are running after it like it is a marathon. However, your job is never secured, even if you give years to it, you can be fired anytime just because of a single mistake.

4)

Again, in the Tata AIG, where performance is king, the workload is much, but it keeps you active,

this is missing in the other Insurance company due to which the work sometimes becomes monotonous which creates boredom. One thing is really good in Tata AIG i.e. it is corruption free. In Public Sector, you have to pay lots of money to the government officers even for a simple work, for no reason. It is an unending debate, both are good at their places, if the drawbacks are removed, they will surely prove good for the economy.

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7.2 SUGGESTIONS.

 Health insurance is most helpful to the customer every customer can buy this policy for better future.  In health insurance premium are small that's why customer can afford the policy.  In health insurance private sector provides better services so that customers can prefer to go private sector health insurance companies.

 In health insurance Tata AIG provides a better refund to the customer

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CHAPTER NO. 8 BIBLIOGRAPHY

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BIBLIOGRAPHY

https://www.policybazaar.com https://www.tataaig.com https://www.tataaiginsurance.in https://www.insurancedirect247.com https://www.coverfox.com https://www.cleartax.in https://www.theincrementallife.com https://www.2012books.lardbuvkets.org>books

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