Insurance Policies and Claims

Insured - The person who obtains or is otherwise covered by insurance on his or her health, life, or property is called "insured". In consideration of this, the insured provides premium to the insurer (The Insurance Company).

Yes, a complaint can be launched against a private insurer. There are 17 Insurance Ombudsmen in different locations and you can approach the one having jurisdiction over the location of the insurance company office that you have a complaint against. 

All the above statements are correct. According to Indian Stamp Act, "Policy of insurance" includes (a) any instrument by which one person, in consideration of a premium, engages to indemnify another against loss, damage or liability arising from an unknown or contingent event (b) a life policy and any policy insuring any person against accident or sickness, and any other personal insurance

Life insurance is a contract for payment of a sum of money to the person assured (or failing him/her, to the person entitled to receive the same) on the happening of the event insured against. Usually, the insurance contract provides for the payment of an amount on the date of maturity or at specified dates at periodic intervals or at unfortunate death if it occurs earlier. Obviously, there is a price to be paid for this benefit. Among other things, the contract also provides for the payment of premiums by the assured. First Premium Receipt marks the beginning of the contract. 

The calculated difference between net premium and gross premium equals the expected present value of expense loadings less the expected present value of future expenses. The typical loading to a net premium would have 3 parts: (a) a percentage of premiums, (b) a constant amount for each ‘1000 sum assured’ and (c) a constant amount per policy.

A third-party administrator (TPA) is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. Reimbursement of the hospitalization expenses can be claimed where cashless hospitalization facility is not availed or treatment is availed in a non-network hospital. In this case, one will have to settle the hospital bill, collect all original hospitalisation documents and submit the documents to TPA's office for their scrutinizing the same in terms of the policy and check the admissibility or otherwise of the claim/expenses. 

If the insured person loses the original life insurance policy document, the insurance company will issue a duplicate policy without making any changes to the contract.

A related doctrine is the insurance law doctrine of efficient proximate cause. Under this rule, in order to determine whether a loss resulted from a cause covered under an insurance policy, a court looks for the predominant cause which sets into motion the chain of events producing the loss, which may not necessarily be the last event that immediately preceded the loss. Many insurers have attempted to contract around efficient proximate cause through the use of "anti-concurrent causation" (ACC) clauses, under which if a covered cause and a non-covered cause join together to cause a loss, the loss is not covered.

Term insurance plan is pure risk cover which pays out the sum assured in case of death and does not have any maturity benefits. You do not get any maturity benefits in a pure term plan because it is a pure protection insurance plan.

Risk decreases as the number of exposures increases. This is the most important foundation of insurance. This is called the law of large numbers. This law is critical to understand the nature of risk and how it is managed. 

Insurers inspect the property before acceptance of a risk to assess the risk for rating purposes. Before acceptance of a risk, insurers arrange survey and inspection of the property to be insured, by qualified engineers and other experts. They not only assess the risk for rating purposes, but also suggest and recommend to the insured, various improvements in the risk, which will attract lower rates of premium. 

ROP plan offers premium refund at maturity if the policyholder survives the tenure.

In a non-medical case, risk can be assessed in the absence of medical report. No medical report is required in a non-medical case.

A prospectus should contain the facts that an investor needs to make an informed investment decision.

Alterations can be done by both of the methods. Alterations may not be permitted in the first year, but in the subsequent years, alterations can be done by placing a suitable endorsement on the policy or on a separate paper. Other alterations which require material change in the policy conditions may require cancellation of existing policy and issuance of new policy.

The most common underwriting decision is to accept at an ordinary rate.

Acceptance at ordinary rates (OR) is the most common decision. This rating indicates that the risk is accepted at the same rate of premium as would apply to an ordinary or standard life.