SYLLABUS OF HEALTH INSURANCE

SYLLABUS
IC38 INSURANCE AGENTS (HEALTH INSURANCE)
SECTION I
CHAPTER 1: INTRODUCTION TO INSURANCE: Life insurance – History and
evolution – History of insurance – Insurance through the ages – Modern concepts of
insurance – History of insurance in India – Life insurance industry – How
insurance works – Risk management techniques – Risk avoidance – Risk retention –
Risk reduction and control – Risk financing – Insurance vs Assurance – Insurance
as a tool for managing risk – Considerations before opting for Insurance – Role of
insurance in society – Insurance and Social Security.
CHAPTER 2: CUSTOMER SERVICE: General concepts – Why Customer Service –
Quality of service – Customer service and insurance – Insurance agent’s role in
providing great customer service – The Point of Sale – Best advice – The proposal
stage – Acceptance stage – The claim stage – Grievance redressal – Integrated
Grievance Management System (IGMS) – The Consumer Protection Act, 1986 – The
Insurance Ombudsman – Communication process – Non-verbal communication –
Ethical behavior.
CHAPTER 3: GRIEVANCE REDRESSAL MECHANISM: Consumer courts,
Ombudsman – Integrated Grievance Management System (IGMS) – The Consumer
Protection Act, 1986 – The Insurance Ombudsman.
CHAPTER 4: REGULATORY ASPECTS OF INSURANCE AGENT: DefinitionsAppointment
of Insurance Agent by the Insurer- Appointment of Composite
Insurance Agent by the insurer- Insurance Agency Examination- Disqualification
to act as an Insurance Agent- Code of Conduct- Suspension of Appointment of an
Agent- Procedure for Cancellation of Agency- Effect of suspension/cancellation of
Agency appointment- Procedure to be followed in respect of resignation/surrender
of appointment by an insurance agent- General conditions for appointment of
Agents by the insurerCHAPTER
5: LEGAL PRINCIPLES OF AN INSURANCE CONTRACT: Insurance
contracts – Legal aspects and special features – Legal aspects of an insurance
contract – Elements of a valid contract – Insurance contracts – Special features –
Uberrima Fides or Utmost Good Faith – Measures implemented to reduce the risk –
Breach of Utmost Good Faith – Insurable interest – Gambling and insurance –
Proximate Cause – Contract of Adhesion – Indemnity – Subrogation.
SECTION 2
CHAPTER 6: INTRODUCTION TO HEALTH INSURANCE: What is health care –
Definition of Health Determinants of Health – Levels of Healthcare – Levels of
health care – Types of health care – Factors affecting the health systems in India –
Evaluation of health insurance in India – Employees State Insurance Scheme –
Central Government health scheme – Commercial health insurance – Health
Insurance Market – Infrastructure Public health sector – Private sector providers –
Pharmaceutical industry – Insurance Providers – Intermediaries – Insurance
selling activities – Insurance Servicing activities – financial product distribution –
Other important organizations which form part of the health insurance market.
CHAPTER 7: INSURANCE DOCUMENTATION: Proposal forms – Standard form of
Declaration – Nature of questions in a proposal form – Elements of Proposal –
Medical Questionnaire – Role of intermediary – Duty of an intermediary towards
prospect (client) – Acceptance of the Proposal –(Underwriting) – Note on
underwriting and processing of proposals – Premium receipts – Definition –
Payment of premium in advance – Method of payment of premium – Policy
Document – Conditions and warranties – Endorsements – Specimen Endorsements
– Interpretation of policies – Renewal Notice – Anti –Money laundering and know
your customer guidelines .
CHAPTER 8: HEALTH INSURANCE PRODUCTS: Classification of health
insurance product – Introduction – Definition – Features of health policies – Broad
classification of health insurance products – IRDA guidelines on standardization in
health insurance – Hospitalization indemnity product – Top up covers or high
deductible insurance plans – Senior citizen policy – fixed benefit covers – hospital
cash – critical illness – hospital daily cash policy – critical illness policy – long term
care insurance – combi-products – Package policies – Micro insurance and health
insurance for poor sections – Rashtriya Swasthya Bima Yojana – Pradhan Mantri
Suraksha Bima Yojana – Pradhan Mantri Jan-Dhan Yojana – Personal accident
and disability cover- overseas travel insurance – Group health cover – Special
products – Key terns in health policies.
CHAPTER 9: HEALTH INSURANCE UNDERWRITING: What is Underwriting –
Definition –need – Underwriting basic concepts – File and use guidelines – Other
health insurance regulations of IRDAI – Basic Principles of Insurance and tools for
underwriting -Underwriting process – Group health insurance – Underwriting of
overseas travel insurance – Underwriting of personal accident insurance
CHAPTER 10: HEALTH INSURANCE CLAIMS: Claims management in insurance
– stakeholders in claim process – Role of claims management in insurance
company – Management of health insurance claims – Challenges in health
insurance – claims process in health insurance – Documentation of health
insurance claims – Claims reserving – Role of third party administrators – Claims
management –personal accident – overseas travel insurance