Insurance Underwriting, Claims & TPA Operations

• Core principles: Utmost Good Faith (Uberrimae Fidei), Insurable Interest, Indemnity, Subrogation
• Product categories: Retail & Group Health, Term Life, Motor (OD/TP), Fire, and Marine insurance
• IRDAI master guidelines, policyholder protection regulations, and standard exclusions

• Medical underwriting: Interpreting Medical Examination Reports (MER), ECG, lipid profiles, and diabetes HbA1c
• Financial underwriting: Income tax returns (ITR), CIBIL scores, and Sum Assured eligibility multipliers
• Loading premiums, issuing counter-offers, exclusion clauses, and reinsurance treaties

• TPA operations: Processing Cashless Initial Pre-Auth and Final Discharge approvals
• Itemized hospital bill scrutiny: Standard non-medical expense deductions and room-rent proportionate deductions
• Detecting Fraud, Waste & Abuse (FWA): Staged admissions, ghost surgeries, and medical audit verifications

Q1: Explain the principle of "Proportionate Deduction" in health insurance claims when a patient chooses a room higher than their eligible category.

If a policyholder selects a hospital room category with a tariff exceeding their policy's allowable room-rent limit (e.g., policy allows 1% of Sum Assured = ₹5,000/day, but the patient stays in an ₹8,000/day room), the insurer proportionately reduces not only the room charges but all associated medical fees (doctor visits, surgeon fees, operation theater charges) by the ratio of allowed limit to actual room tariff.

Q2: What is the "Free Look Period" and "Grace Period" under IRDAI guidelines?

The Free Look Period gives a policyholder 15 to 30 days from receiving the physical/electronic policy document to review its terms and cancel for a full refund (minus stamp duty/medical test costs) if unsatisfied. The Grace Period is an extra 30 days granted after premium due dates to renew the policy without losing accrued continuity benefits (like waiting period credits).