A Study On Breach Of Contract By Health Insurance Companies In India

TABLE OF CONTENTS

LIST OF TABLES

ABBREVIATIONS

TABLE OF CASES

LIST OF LEGISLATIONS

CHAPTER-I INTRODUCTION
1.1 INTRODUCTION
1.2 STATEMENT OF THE PROBLEM
1.2 STATEMENT OF THE PROBLEM
1.3 RESEARCH GAP
1.4 RESEARCH QUESTION
1.5 OBJECTIVES OF THE STUDY
1.6 HYPOTHESES
1.7 SCOPE OF THE STUDY
1.8 LIMITATION OF THE STUDY
1.9 RESEARCH METHODOLOGY
1.10 CHAPTERISATION
1.11 CONCLUSION

CHAPTER 2 REVIEW OF LITERATURE

CHAPTER-3 CONCEPT OF INSURANCE AND HISTORICAL BACKGROUND OF INSURANCE
3.1 INTRODUCTION
3.2 ORIGIN OF INSURANCE
3.3 GENERAL PRINCIPLES OF INSURANCE
3.4 KINDS OF INSURANCE IN INDIA
3.5 HEALTH INSURANCE POLICIES AND SCHEMES
3.6 ROLE OF NGOS IN HEALTH INSURANCE
3.7 CONCLUSION

CHAPTER-4 LEGAL FRAMEWORK OF HEALTH INSURANCE:INTERNATIONAL DIMENSIONS AND INDIAN PERSPECTIVE
4.1 INTRODUCTION
4.2 INTERNATIONAL CONVENTIONS ON RIGHT TO HEALTH
4.3 INTERNATIONAL PERSPECTIVES
4.4 PROTECTION OF THE INSURED PERSON IN HEALTH INSURANCE
4.5 AMERICAN HEALTH INSURANCE REGULATION
4.6 GERMANY HEALTH INSURANCE REGULATION
4.7 HEALTH INSURANCE IN GREAT BRITAIN
4.8 AUSTRALIA'S HEALTH INSURANCE SYSTEM
4.9 SPAIN'S HEALTH INSURANCE
4.10 FRANCE'S HEALTH INSURANCE
4.11 INDIAN PERSPECTIVE ON BREACH OF CONTRACT IN HEALTH INSURANCE: INTRODUCTION
4.12 NATIONAL PERSPECTIVES ON BREACH OF CONTRACT IN HEALTH INSURANCE (INSURANCE LAWS AND REGULATIONS IN INDIA)
4.13 THE INSURANCE ACT, 1938 & THE SUBSEQUENT LEGISLATIONS
4.14 IRDA REGULATIONS CONCERNING HEALTH INSURANCE
4.15 IRDA (THIRD PARTY ADMINISTRATORS—HEALTH SERVICES) REGULATIONS, 2001
4.16 THE INSURANCE REPRESENTATIVES AND DEALERS ACT, 2000
4.17 IRDA REGULATIONS, 2000
4.18 IRDA REGULATIONS, 2001
4.19 THE PROTECTION OF POLICYHOLDERS' INTERESTS BY THE INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY (REGULATION), 2002
4.20 ALTERNATIVE INSURANCE DISPUTE RESOLUTION MECHANISM
4.21 THE IRDA (HEALTH INSURANCE) REGULATION, 2013
4.22 THE HEALTH INSURANCE AND SOCIAL SECURITY LAWS
4.23 THE GENERAL INSURANCE BUSINESS (NATIONALIZATION)ACT, 1972
4.24 THE PUBLIC LIABILITY INSURANCE ACT, 1991
4.25 THE HEALTH INSURANCE AND BANCASSURANCE
4.26 THE TARIFF ADVISORY COMMITTEE: THE INSURANCE (AMEND.) ACT, 1968
4.27 CONCLUSION

CHAPTER-5 CLAIMS PROCESSING AND SETTLEMENT
5.1 INTRODUCTIONv 5.2 HISTORICAL BACKGROUND OF HEALTH INSURANCE INDUSTRY IN INDIA
5.3 IMPORTANCE OF SETTLEMENT OF CLAIMS FOR POLICYHOLDERS
5.4 OVERVIEW OF CONTRACTUAL AGREEMENTS IN HEALTH INSURANCE
5.5 TYPES OF CONTRACT VIOLATIONS
5.6 CAUSES OF CONTRACT VIOLATIONS
5.7 LEGAL FRAMEWORK AND REGULATIONS
5.8 IMPACT ON POLICYHOLDERS
5.9 RESOLUTION MECHANISMS
5.10 CASE STUDIES AND ANALYSIS (JUDICIAL RESPONSE)
5.11 CONCLUSION

CHAPTER-6 DATA ANALYSIS AND INTERPRETATION

CHAPTER-7 CONCLUSION AND RECOMMENDATIONS
7.1 INTRODUCTION
7.2 DOCTRINAL FINDINGS
7.3 SUGGESTIONS
7.4 RECOMMENDATIONS
7.5 CONCLUSION

REFERENCES

ANNEXURES

ACKNOWLEDGEMENTS

I am profoundly grateful to the divine for guiding me through this journey, providing invaluable support, and countless blessings that have allowed me to successfully complete my research thesis.

I extend my heartfelt appreciation to the management, faculty members, and non-teaching staff of Saveetha School of Law, Saveetha Institute of Medical and Technical Sciences (SIMATS) for their unwavering support throughout my research work.

A special acknowledgment goes to my Research Supervisor, Professor Dr.B. Lavaraju, whose invaluable guidance, support, and encouragement have been instrumental in the completion of this research. I'd also like to express my sincere gratitude to my Co-Supervisor, Dr. Asha Sundaram, for her constant support from the very beginning.

I appreciate the encouragement and assistance from Professor Dr. Asha Sundaram, Principal of the School ofLaw, Saveetha Institute ofMedical and Technical Sciences.

I am deeply grateful to my parents, Mr. M.C. Mariyappan and Mrs. Periyakkal, and to Mr. Muthu and Mrs. Panjali for their constant encouragement and blessings, which sustained me throughout my work and gave me the confidence to focus. I also thank my wife, Mrs. M.S. Bravishma Panicker, and my mother-in-law, Mrs. Shoma L.C., for their support.

I am deeply grateful to everyone who supported and guided me throughout my research and thesis submission process. This accomplishment would not have been possible without the valuable contributions of many wonderful people.

C.M. Selvamuthu

LIST OF TABLES

6.1 Distribution of the Study Population by Gender

6.2 Distribution of study respondents by their age group

6.3 Occupation of study respondents

6.4 Distribution of the study respondents by their educational qualification

6.5 Marital status of the study population

6.6 Respondents by their annual income

6.7 The policy holder ofhealth insurance

6.8 Type of health insurance policy

6.9 The source of awareness about health insurance

6.10 Type of health insurance product

6.11 The coverage of health insurance

6.12 Disease coverage

6.13 The awareness on exclusions (diseases not covered)

6.14 The awareness level of study respondents regarding the hospital linked with health insurance schemes

6.15 Demonstrates non-payment voids

6.16 Indicates the cashless payment facility

6.17 Demonstrates the different promotional events

6.18 The awareness about claim settlement

6.19 Depicts the tax saving instrument

6.20 Family health needs

6.21 Availing good quality medical treatment

6.22 Attractive insurance policy

6.23 Risk coverage against old age illness

6.24 Risk unexpected illness in the future

6.25 Aspects regarding while choosing health insurance policy

6.26 Settlement of claims at the time of entering into the contract.

6.27 Ever availed (or) tried claim with the insurance company

6.28 The rating about claim process

6.29 Insurer provides clear guidelines for appealing denied claims.

6.30 Misinterpretation of the policy terms by the insurance company

6.31 Insurance company providing valid reason for the denial or partial payment of your claim.

6.32 The insurance company providing clear policy terms

6.33 The breach to a higher authority within the insurance company

6.34 The settlement timing

6.35 Issues related to health insurance policy while settlement

6.36 The nature ofbreach

6.37 The difficulties in claim settlement process

6.38 The main reasons for breach

6.39 The common challenges

6.40 The transparency of policy terms

6.41 Breaches of contact in health insurance

6.42 The impact ofinsurance policy holders from rejection claim

6.43 The impact of fraudulent claims on the settlement process

6.44 Seeking legal help

6.45 Awareness about legal rights

6.46 The complaint with the insurance regulatory and development authority ofIndia.

6.47 The effectiveness of regulatory bodies

6.58 The responses about the inadequate communication of policy terms & conditions

6.49 The ambiguous or misleading policy language

6.50 The ineffective complaint/ grievance resolution mechanisms

6.51 Ineffective regulatory oversight

6.52 Enforcing strict penalties for delayed settlements

6.53 Study respondents about the regular audits and oversight

6.54 Providing guidelines for best practices in claims management

6.55 Stricter penalties for health insurance companies found guilty ofbreaching contracts

6.56 Taking measures to prevent breaches of contract

6.57 The compensation or punitive damages in cases of proven breach of contract by health insurance companies

6.58 The handling disputes or disagreements with policyholders regarding claim settlements

6.59 The discrepancies or errors in claim submissions from healthcare providers or policyholders

6.60 The insurers manage both communicating claim settlement decisions to policyholders and handling appeals or disputes

6.61 Suggestions to enhance the efficiency of the health insurance claim settlement process

6.62 Role should insurance agents or intermediaries play in facilitating smoother claim settlements

6.63 Responsiveness to policyholder inquiries and grievances during claim settlement

6.64 The implementing electronic health record integration

6.65 Establishing direct billing agreements

6.66 Streamlining of provider credentialing processes

6.67 Conducting risk assessments and scenario planning

6.68 Collaboration with industry peers for insights and best practices

6.69 The adaptation of policies and procedures to mitigate risks

6.70 The recommendation for the insurers to prevent fraudulent activities during claim settlements

6.71 Suggestions for making the dispute resolution process more accessible

6.73 Hypothesis on the frequent denial of insurance claims by insurance companies contributes to increased levels of mental distress and psychological disorders among policy holders.

6.74 Hypothesis on the frequent denial of insurance claims by insurance companies contributes to increased levels of mental distress and psychological disorders among policy holders.

6.75 Hypothesis on the frequent denial of insurance claims by insurance companies contributes to increased levels of mental distress and psychological disorders among policy holders.

6.76 Hypothesis on the frequent denial of insurance claims by insurance companies contributes to increased levels of mental distress and psychological disorders among policy holders.

6.77 Null hypothesis: there is no significant mean difference between the occupation of the study respondents and satisfaction with the transparency of policy terms and conditions provided by health insurance companies

ABBREVIATIONS

Accident Claims Journal ACJ

Administrative Court Report ACR

Affordable Care Act ACA

All India Report AIR

Artificial Intelligence AI

Atal Bimit Vyakti Kalyan Yojana ABVKY

Australian Consumer And Competition Commission ACCC

Australian Prudential Regulation Authority APRA

Autoregressive Integrated Moving Average ARIMA

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana AB-PMJAY

Benefit Amount Settlement Ratio BASR

Brazil, Russia, India, China, And South Africa BRICS

California Department OfInsurance CDI

Cardio Vascular Disease CVD

Central Excise Law CLT

Central Government Health Insurance Scheme CGHS

Central Tax Cases CTC

China Health And Retirement Longitudinal Study CHARLS

Chronic Respiratory Disease CRD

Community-Based Health Insurance CBHI

Company Limited Co. Ltd

Compound Annual Growth Rates CAGR

Consumer Protection CP

Consumer Protection Judgments CPJ

Consumer Protection Reports CPR

Cumulative Bonus CB

Current Tamil Nadu Cases CTC

Data Envelopment Analysis DEA

Decision Tree DT

Delhi Revenue Journal DRJ

Digital Health Technology DHT

Electronic Funds Transfer EFT

Employees And Journalists Health Scheme EJHS

Employees' Organisational Citizenship Behaviour EOCB

Employees’ State Insurance Corporation ESIC

England And Wales Court Of Appeal EWCA

Extreme Gradient Boosting XG Boost

Federal Capital Territory FCT

Financial Activity Authority FAA

General Insurance GI

General Insurance Companies GIC

General Insurance Council GIC

Government Health Insurance GHI

Gross Domestic Product GDP

Health Insurance Companies HIC

Health Maintenance Organisations HMO

Information Commissioner's Office ICO

Inpatient Department IPD

Insurance Association Of Turkey IAT

Insurance Claims Settlements INCLM

National Insurance Company NIC

Insurance Regulatory And Development Authority IRDA

International Covenant On Economic, Social And Cultural Rights ICESCR

International Health Regulations IHR

K-Nearest Neighbour’s KNN

Life Insurance Corporation LIC

Linear Regression LR

Machine Learning ML

Madras Law Journal MLJ

Manu Patra MANU

Markov-Modulated Non-Homogeneous Poisson Process MMNPP

National Association OfInsurance Commissioners NAIC

National Commission NC

National Consumer Disputes Redressal Commission NCDRC

National Family Health Survey NFHS

National Health Accounts NHA

National Health Insurance Fund NHIF

National Health Policy NHP

National Sample Survey NSS

National Sample Survey Organization NSSO

Newspaper Of Citation NOC

Non-Governmental Organisation NGO

Non-Communicable Diseases NCD

Original Application OA

Out Patient Department OPD

Out-Of-Pocket Expenditure OOPE

Particle Swarm Optimization PSO

Pradhan Mantri Jan Arogya Yojana PM-JAY

Pre-Existing Diseases PED

Preferred Provider Organisations PPO

Propensity Scoring Matching PSM

Protected Health Information PHI

Prudential Regulation Authority PRA

Psychological Contract Fulfilment PCF

Queen's Bench QB

Rajiv Aarogyasri Community Health Insurance Scheme RACHI

Random Forest RF

Rashtriya Swasthya Bima Yojana RSBY

Rent Control Reporter RCR

Return On Assets ROA

Return On Equity ROE

Social Health Insurance SHI

State Consumer Disputes Redressal Commission SCDRC

Support Vector Machine SVM

Supreme Court SC

Supreme Court Cases SCC

Supreme Court Reports SCR

Supreme Court Weekly SWC

Tariff Advisory Committee TAC

Taxmann's Indian TMI

The Department OfIndustrial Policy And Promotion's DIPP

Third-Party Administrator TPA

United Kingdom UK

United Nations Convention On The Rights OfPersons With

Disabilities UNCRPD

United States Of America USA

Universal Declaration OfHuman Rights UDHR

Universal Health Coverage UHC

Universal Health Insurance Scheme UHIS

Voluntary Health Insurance VHI

World Health Organisation WHO

World Medical Association WMA

Writ Petition WP

LIST OF CASES

1 B. Shah v. Presiding Officer, Labour Court, Coimbatore, AIR 1978 SC 12.

2 Bhagwati Bai vs Life Insurance Corporation (LIC), [1984] AIR 346, 1984 SCR (3) 595 .

3 Biman Krishna Bose v. United India Insurance Co. Ltd., AIRONLINE 2001 SC 525.

4 BS Jaisimhav. Reliance General Insurance Company., (2018) 10 SCC 341.

5 Coxe v. Employers Liability Assurance Co. Ltd.,, 191 S.C. 233 (S.C.1938).

6 Dalby vs India and London Life Assurance Co., (1854) 15 CB 365; 139 ER 465.

7 Darshan Kaur v. M.D. India Healthcare Services ,2019 (4) CPJ 326.

8 Dhananjay Chaturvedi v. Oriental Insurance Co. Ltd., (2018) 2 SCC 75.

9 Director ofPension v. B. Sarada , (2017) 10 SCC 258.

10 Dr. Sudarshan Jindal v. United India Insurance Company Limited, 2017 (5) TMI 1136(NCDRC).

11 General Assurance Society Ltd. v. Chandumull Jain and another, 1996 (1) SCR 500.

12 Gillespie Brothers & Co. Ltd. v. Roy Bowles TransportLtd., 1973 (1) Q.B. 400.

13 H.P. Housing Board v. Janak Gupta , [2009] INSC 627.

14 Harpreet Singh Kand v. Max Super Specialty Hospital ,2019 CPJ 21 NC.

15 HDFC Ergo General Insurance Co. Ltd. v. Shyam Sundar Choudhary., 2018) 2 SCC 75.

16 In New Asiatic Insurance Co. Ltd. v. Srinivasan , (1911) 22 M.L.J. 71.

17 In Regina Fur Co. Ltd. v. Bossom, 1958] EWCA Civ J1114-3.

18 Jacob Punnen v. United India Insurance Co. Ltd., (2021) 2 SCC 50.

19 Jumbo Bags v. New India Insurance , (2016) 9 SCC 76.

20 K.Subramanian @ A.K.Subbu v. The State Rep, (2020) 2 MLJ (Criminal) 432 (SC).

21 Khatema Fibres Ltd. v. New India Assurance Company Ltd. and Ors, 2019 (8) SCC 500.

22 L.I.C. ofIndia & Anrv. ConsumerEducation & Research, AIR 1811, 1995 SCC (5) 482.

23 Lataben Maheshbhai Matiya v. Oriental Ins.Co.Ltd , Consumer CP No. 874/2022.

24 LIC ofIndia v. Dharam Vir Anand, AIRONLINE 1998 SC 154.

25 Life Insurance Corporation ofIndia and Ors. v. Sunita Life Insurance Corporation ofIndia and Ors., (2023) 5 SCC 723.

26 Life Insurance Corporation ofIndiav. Anuradha., (2004) 2 SCC 327.

27 Life Insurance Corporation ofIndia v. Dharam Vir Anand, AIRONLINE 1998 SC 154.

28 Life Insurance Corporation ofIndiav. Shakuntala., AIR 1992 SC 767.

29 Life Insurance Corporation ofIndiav. Smt. Bina Joshi, (1997) 7 SCC 567.

30 Life Insurance Corporation ofIndiav. Parvathavardhini Ammal, [1986] AIR 220, 1986 SCR(1)223.

31 M/s United India Insurance v. Jai Parkash Tayal, AIR 2020 (NOC) 88 (DEL.).

32 M/S. Care Well Hospital v. Anil Arora & Ors, (2004) ACC 533.

33 Manmohan Nanda v. United India Assurance Co. Ltd., Civil Appeal No. 8386/2015,

34 Mithoolal Nayak v. Life Insurance Corporation ofIndia, AIR 1962 SC 814.

35 Mondal v. United India Insurance Co. Ltd., (2004) ACC 533.

36 Mr. Purshotam Murarka v New India Assurance Co. Ltd., (1999 (1) CPR 157 (NC).

37 Ms Geo Chem Laboratories Pvt. Ltd v. United India Insurance Co., (2013) 6 SCC41.

38 Muthuraman v. The New India Assurance Co. Ltd., 2009 (4) CTC 189; MANU/TN/1108/2009.

39 N.K.Mathavaraj Ganesan v. Government ofTamil Nadu, WP No 19578 of 2016 &WPNo 14117of2019.

40 Narsingh Ispat Ltd. v. Oriental Insurance Company Ltd. and Ors., 2022 SCC Online SC 1451.

41 National Insurance Co. Ltd. v. Seema Malhotra & Ors., [2001 (3) CPR 22].

42 National Insurance Company (NIC) v. Himanshu, NIC 2019 (3) CPJ 172.

43 New India Assurance Co. Ltd. v. Hilli Multi Specialty Hospital, SCC 740 (AIR 2020 SUPREME COURT 1267).

44 New India Assurance Company Limited v. Asha Rani & ors, [2001 (6) SCC 724],

45 Oriental Insurance Co. Ltd. v. K. B. Reddy, 2010 (3) CPJ 198 (NC).

46 Oriental Insurance Co. Ltd. v. Premlata Shukla, 13 SCC 476 (2007 AIR SCW 3591).

47 Oriental Insurance Co. Ltd. v. T.H. Abdul Kader, (2009) 7 SCC 636.

48 Pankaj Kumar v. HDFC ERGO General Insurance Company Ltd., 2017 (6) TMI 535 (NCDRC).

49 Parveen Vij v. M/s Apollo Munich Health Insurance, 2014 (3) CPJ 72 (NC).

50 Peerless Hospital v. Gopal Chandra Mukherjee, 2014 CPJ 348 NC.

51 Poonam Sood v. New India Assurance Co. Ltd., 2017 SCC Online NCDRC 250.

52 Pradeep Kumar Garg v. National Insurance Co. Ltd, (2009) 1 SCC 693.

53 Purnima Prasad And Ors. v. The Oriental Insurance Company Limited , 1 (2007 ACJ 2213).

54 Rakesh Kumar v. Oriental Insurance Co. Ltd., (2011) 2 SCC 123.

55 Ratan Lal and anr. v. Metropolitan Insurance Co. Ltd., AIR 1959 PATNA 413,

56 Re Bradley vs Essex &Suffolk Accident Indemnity Society, [1911-13]All ER p.444.

57 Reliance General Insurance Co. Ltd. v. M/s. Pramod Kumar Gupta, 2018 (3) RCR (Civil) 353 (SC).

58 Reliance General Insurance Company v. Vijay Kumar & Another, OANo. 1234/2020.

59 Reliance Life Insurance Co. Ltd. & Anr. v. Rekhaben Nareshbhai Rathod, (2019)6SCC 175.

60 Sandeep Shukla V. Star Health and Allied Insurance Company Ltd., 2019 SCC Online NCDRC 233.

61 Satwant Kaur Sandhu v. New India Assurance Co. Ltd., (2009) 8 SCC 316.

62 Seema Sharma v. Oriental Insurance Co. Ltd., (2007) 9 SCC 285.

63 Septal Singhs Case, (2000 (1) SCC 237).

64 ShikhaNischal v. National Insurance Company Limited ., W.P.(C) 3190/2021.

65 Shiva Kant Jha v. Union of India, 2018(5) MLJ 317,

66 Shri Ashok Kumar v. Delhi Jal Board, OA No. 3760/2010.

67 Shri Mukut Lal Duggal v. United India Insurance Co. Ltd., (2005) 1 CPJ 48 (NC).

68 Smt. Leela Wadhwa v. New India Assurance Co. Ltd., (2009) 1 SCC 142.

69 Smt. Poonam Kumari v. New India Assurance Co. Ltd., (2016) 7 SCC 592.

70 Smt. Ranjana Roy v. National Insurance Co. Ltd., 2009 (1) CPJ 130 (NC).

71 Smt. Usha Kumari v. New India Assurance Co. Ltd, (2015) 6 SCC 326.

72 Sri Benson George v. Reliance General Insurance Co. Ltd., (SC)-2022-2-94.

73 Star and Allied Insurance Co. Ltd. v.R. S. Dhanraj, (2020) 8 SCC 458.

74 Star Health And Allied Insurance Co. Ltd. v. A. Chokkar, 2010 (2) CTC 627.

75 State ofHaryanav. Smt. Santra, AIR2000 SC 1888.

76 Sukhdeep Singh Bhinder v. Star Health and Allied Insurance, (2021) SCC Online NCDRC 85.

77 Surinder Kumar Aggarwal v. New India Assurance Company Ltd. & Anr., 2009 (4) CLT313.

78 Tarlok Chand Khanna v. United India Insurance Co. Ltd., (2011) 4 SCC 365.

79 Tata Employees Union v. Union OfIndia (UOI), (1993) ILLJ580KER

80 The Bombay Fire Insurance Association Ltd. v. The Ahmedabad Municipality , AIR 1921 Bom 101.

81 The National Commission in M/s. Apex Buildtech Ltd. Vs. Madhu Talreja, Revision Petition No. 739 of 2017,

82 The Oriental Insurance Company Ltd. v. Gopal And Ors., (2000 ACJ 255).

83 United India Insurance Co. Ltd. v. Dinesh Kumar Bansal, (2008) 5 SCC 194.

84 United India Insurance Co. Ltd. v. Harshad Bhai K. Dhaduk, AIR 2009 SUPREME COURT 446.

85 United India Insurance Co. Ltd. v. M/s. Sharma and Sons, 1 [2014 (5) CPR 156]

86 United India Insurance Company Limited v. Manubhai Dharmasinhbhai Gajera and Others , AIR 2009 SUPREME COURT 446.

87 United India Insurance Company Ltd. v. S.Marimuthu, (2020) 5 MLJ 624.

88 Vijay Kumarv. Oriental Insurance Co. Ltd ., (2016) 4 SCC 128.

89 Vikram Greentech (I) Ltd. v. New India Assurance Co. Ltd. (2009) 5 SCC 599.

90 Vishal Gupta v. ICICI Lombard General Insurance Co. Ltd., (2017) 3 SCC 109.

91 Wilson v. Jones, 123 F.3d 456 (9th Cir. 2001).

LIST OF LEGISLATIONS

1 The Arbitration and Conciliation Act, 1996,

2 The Constitution ofIndia, 1949.

3 The Consumer Protection Act, 2019.

4 The Employees State Insurance Act, 1948.

5 The First Documented Insurance Policy, 1347.

6 The General Insurance Business (Nationalisation) Act, 1972.

7 The Health Insurance Regulations, 2016.

8 The Indian Contract Act, 1872.

9 The Income Tax Act, 1961.

10 The Indian Life Assurance Companies Act, 1912.

11 The Indian Life Assurance Companies Act, 1912.

13 The Industrial Disputes Act, 1947.

14 The Information Technology Act, 2000.

15 The Insurance (Amend.) Act, 1968.

16 TheInsurance Act, 1938.

17 TheInsurance Act, 1973.

18 The Insurance (Amend.) Act, 1950.

19 The Insurance Ombudsman Rules, (Amend.) 2018.

20 The Insurance Ombudsman Rules, (Amend.) 2021.

21 The Insurance Ombudsman Rules, 2017.

22 The Insurance Regulatory & Development Authority Act, 1999 .

23 The Insurance Regulatory Authority (IRA), 1996.

24 The Insurance Representatives and Dealers Act, 2000.

25 The International Health Regulations (IHR), 2005.

26 The IRDA (Health Insurance) Regulation, 2013.

27 The IRDA (Licensing ofInsurance Agents) Regulations, 2000.

28 The IRDA (Protection ofPolicyholders’ Interests) Regulations, 2017.

29 The Life Insurance Corporation (Amendment) Bill, 2008.

30 The Life Insurance Corporation (LIC),1956.

31 The Marine Insurance Act, 1963.

32 The Motor Vehicles Act, 1988.

33 The National Health Bill (NHB), 2009.

34 The National Public Health Act, 2017.

35 The Personal Injuries (Compensation Insurance) Act, 1963.

36 The Public Liability Insurance Act, 1991.

37 The Redressal ofPublic Grievances Rules, 1998 (RPG Rules).

38 The Specific Relief Act, 1963 .

39 The Transfer OfProperty Act, 1882.

40 The Workers' State Insurance Act, 1948.

41 The Workmen's Compensation Act, 1923.

42 The Workmen's Compensation Act, 1923.

AUSTRALIA

43 The Private Health Insurance (Prudential Supervision) Act, 2015.

44 The Private Health Insurance Act, 2007.

FRANCE

45 TheFrench Constitution, 1958.

GERMAN

46 The Chancellor Otto von Bismarck's Health Insurance Act, 1883.

UNITED STATES OFAMERICA

47 The Affordable Care Act (ACA), 2010.

48 The Health Insurance Portability and Accountability Act, (HIPPA), 1996.

49 The National Association ofRegistered Agents and Brokers Reform Act, 2015.

UNITED KINGDOM

50 The British Insurance Act (BIC), 1870.

51 The Financial Services and Markets Ac, 2000.

INTERNATIONAL

52 The Universal Declaration ofHuman Rights (UDHR), 1948.

53 The International Covenant on Economic, Social and Cultural Rights (ICESCR), 1966 .

54 The International Health Regulations (IHR), 2005.

CHAPTER-I INTRODUCTION

1.1 Introduction

Insurance is a legal agreement where an insurance company promises to pay a specific amount of money (the sum assured) if something unexpected happens to the insured person or their property. In exchange, the insured person makes regular payments to the insurance company (the premium).¹ Insurance is broadly divided into two categories: Life Insurance and General Insurance. While the concept ofhealth insurance was introduced in 1694 by Hugh the Elder Chamberlen of the Peter Chamberlen family, disability insurance emerged as the first form of health coverage in the late 19th century, initially limited to emergency care for injuries. Good health is fundamental to human well-being, fostering a higher standard of living, sustainable economic growth, and global peace. Health is a crucial factor influencing other societal issues like unemployment, poverty, and living conditions. A nation's human resources significantly impact its cultural, social, and economic progress. The Indian government prioritizes improving public health, especially for vulnerable populations. Consequently, public health has become a major socio-economic concern, with the government striving to meet public expectations for quality healthcare. Factors such as education, housing, nutrition, and employment directly affect health outcomes.

The states and territories that make up India are in charge of the country's universal healthcare system. As per Article 47 of India's Constitution,² A primary responsibility of each state is to"improve public health and raise the standard of living and nutrition of its citizens.³ The Indian Parliament approved the National Health Policy in 1983, and it was revised in 2002. The main objectives of the National Health Policy in India are to provide universal access to high- quality, affordable healthcare for all age groups and genders. It mainly focuses on reducing premature mortality from major diseases, improving health outcomes through preventive measures, rehabilitative services, by promoting sustainable development. In India, the private medical sector runs parallel to and is even more well-liked than the governmental health system.⁴ “Insurance” plays a significant role in the life of the individuals such as

• Insurance offers protection and assurance against unforeseen and contingent losses brought on by particular events.⁵
• Insurance shields and lowers the risk of losses for both individuals and businesses against minor, recurring payments .⁶
• Insurance gives people and businesses peace of mind by relieving stress and anxiety related to future uncertainties, while providing financial security. Because insurance requires regular premium payments, it fosters and instils saving habits.⁷
• By collecting premiums, insurance creates enormous sums of money that are used for the nation's industrial and economic growth.⁸
• Through encouraging trade and commerce, insurance mobilises domestic savings, transforms capital into profitable investments, and speeds up economic growth and development.⁹
• In addition to providing security and welfare for workers, promoting international trade, and protecting social wealth, insurance also gives tax benefits. It is currently a necessity and is available in all spheres of society.¹⁰

1.1.1 Concept oflnsurance

Insurance allows many people who are exposed to the same risk to combine and spread their risks. Only up to the designated insured limit does it offer financial stability and protection against monetary losses incurred by an insured individual. In an insurance program, risks are transferred and shared based on a cost known as the premium. It is one of the most important forms of risk transfer. There are many definitions of insurance, some of them are as follow:- John Beveridge: "Insurance is the guarantee to one, on condition of contributing while he can work:, an income sufficient for his existence and that of his family when for any reason of sickness, accident, old age or unemployment he cannot work: but relationship between contribution & benefits remained sacrosanct”.

Justice Lawrence: “Insurance is a contract by which the one party, in consideration of a price paid to him adequate to the risk, becomes security to the other that he shall not suffer loss, damage, or prejudice by the happening of the perils specified to certain things which may be exposed to them.”

Dictionary of Business and Finance: “A form of contract or agreement under which one party agrees in return for a consideration to pay an agreed amount of money to another party to make good for a loss, damage, or injury to something of value in which the insured has a pecuniary interest as a result of some uncertain event.”

Dictionary of Commerce: “The payment of a sum of money by one person to another on the understanding that in specified circumstances the second person will make good any loss suffered by thefirst.”

Prof. John H. Magee: “Insurance is a plan by which large number of people associate themselves and transfer, to the shoulders of all, risks that attach to individuals.”

A.H. Willett: “Insurance is a social devicefor making accumulations to meet uncertain losses of capital which is carried out through the transfer of risks of many individuals to one person or to a group ofpersons.”

Rock Fell: “ Insurance is a source of distribution of loss offew persons among many persons.” Prof. Allan L. Mayerson: “Insurance is a devicefor the transfer to an insurer of certain risks of economic loss that would otherwise be borne by the insured”.

1.1.2 History ofinsurance

In India, insurance has a long and fascinating history. Manusmrithi, Dharmasastra, and Arthasastra, among other works by Manu, Yagnavalkya, and Kautilya, all make reference to it. In the event of unfavourable circumstances or disasters like fire, floods, starvation, etc., all of these texts discuss pooling resources that have been redistributed. It served as a solid foundation for insurance in the modern era. India's insurance industry has developed from other nations, primarily from England, where it began as marine insurance.

Types of insurance: -

Insurance contracts are mainly of two types: -

1. Life Insurance.
2. General Insurance.

General Insurance are of following types: -

a. Health Insurance
b. Fire Insurance
c. Marine Insurance
d. Personal Accident Insurance
g. Credit Insurance
h. Motor vehicle Insurance
i. Workmen’s compensation Insurance

1.1.3 Health Insurance in India

Concern over illness and accident-related losses dates back to ancient civilisations in India. Indeed, the ancient practice of paying the doctor when well and stopping payment when unwell may have served as the foundation for one of the first types ofhealth insurance. India and other South East Asian nations followed this tradition. India's current health insurance system was developed following the same model as Europe and America. In India, health insurance or medical insurance programs have emerged as a result of issues with employer-employee relations. Employees used to receive both core and non-core benefits from the Corporate Houses. Large corporate houses were given insurance policies solely as a matter of accommodation. The insurance policy pack that was often provided to employees covered hospitalisation and in-home dentistry and non-surgical eye care. There used to be relatively little benefit. There were no programs for families or individuals. One area of the Indian economy that is expanding is health insurance. In 2011, the health sector in India accounted for 3.9% of the country's GDP. This is one of the weakest economies among the BRICS (Brazil, Russia, India, China, and South Africa) countries, according to the World Health Organisation (WHO). There are policies that provide both family and individual coverage.¹¹ Since its inception in 1986, the health insurance sector has expanded dramatically, mostly as a result of economic liberalisation and increased public awareness.¹²

1.1.4 Concept ofHealth Insurance:-

The traditional way of paying for medical care is through health insurance. Health insurance is the distribution of an individual's or household's unpredictable risk by pooling the risk of many people. They make contributions to a common fund that, in the event of an accident, covers the loss incurred by any member. People who share a certain level of risk pay premiums to a health insurance fund as part of a insurance program. Health insurance uses collected premiums to cover the medical expenses of policyholders who become ill and require hospitalization. Effective health insurance relies on both risk pooling (combining premiums from many individuals) and prepayment (paying premiums in advance). While healthy individuals in stable financial situations pay these premiums, the accumulated funds are then available to cover their healthcare costs should they become ill, minimizing the financial burden during times of sickness..

It is true that mental and spiritual well-being depend on a healthy body. Therefore, it is crucial to stay healthy in order to keep the soul and intellect in good condition. However, because modern life is so fast-paced and complex, maintaining physical health over time becomes challenging. High pollution levels and shifting lifestyles have raised the danger of several deadly illnesses throughout time. One is concerned and well-informed about health advice, yet he still becomes sick. Health care is getting more and more expensive every day. One of life's fundamental needs is health. One can survive without luxuries and comfortable things, but one cannot function well or live comfortably without excellent health.

The World Health Organisation Statistics, 2017 “the essential premise of a health story we heard and learnt as children was that "a person's happiness is concerned with his health, not with his wealth." Without being in excellent health, a person cannot work, and without work, he cannot earn enough money to meet his necessities.¹³ Between the ages of 30 and 70, the risk of dying from any of the following conditions is quite high: 23% for cardiovascular disease (CVD), cancer, diabetes, and chronic respiratory disease (CRD)”. Health insurance will be quite helpful in this situation because it will offer financial security.

According to a 2016-2017 report by the Insurance Regulatory Development Authority of India (IRDAI), less than 34% of India's population (approximately 43.75 crore people) had any form ofhealth insurance, including private, community-based, mandatory, and voluntary plans, despite the liberalization and privatization of the insurance sector.¹⁴ Of India's estimated 133 crore people, 77% of those with health insurance are covered by government-sponsored programs, typically requiring only a nominal contribution from the insured individuals. However, the insured must stay in the hospital for at least twenty-four hours in order to be eligible to receive reimbursement for medical costs. Health insurance policies typically cover day-care procedures and associated costs only in exceptional cases. With declining government spending on public health and steadily increasing private healthcare costs, health insurance becomes a valuable asset. All members of the family can benefit from insurance under family floater policies. High out-of-pocket health expenses are caused by low public health spending and low health insurance coverage. Health and economic development are complementary to each other.

1.1.5 Features ofHealth Insurance

A health insurance policy is a contract between an insurer and an individual or organization. In exchange for regular payments (premiums), the insurer agrees to provide specific health coverage as detailed in the policy's terms and conditions. Health insurance is designed to cover medical expenses resulting from illness, accidents, hospitalization (including pre- and post­hospitalization costs), and other unforeseen health events. Coverage may include the sum insured for claims within a policy period, cumulative bonuses, health check-up costs, and other additional or standalone benefits.

a) Accommodation and board costs
b) Treatment of the patient (insured)
c) Surgeon, anaesthetist, doctor, consultant
d) Specialized medical expenses such as anaesthesia, oxygen, blood, operating room fees, surgical equipment, medications, diagnostic supplies (including X-rays), dialysis, chemotherapy, radiotherapy, pacemakers, artificial limbs, and organ costs.

Sum Insured: The total coverage amount offered by a health insurance policy can be structured as either a family floater (shared among family members) or an individual plan (covering a single person).

Cumulative Bonus (CB): Some health insurance policies offer a Cumulative Bonus. This feature increases the sum insured by a certain percentage upon renewal for each claim-free year, up to a maximum limit (typically 50%). If a claim is made, the Cumulative Bonus is reduced by 10% at the next renewal.

Cost of Health Check-up

A clause for repayment of the cost of a health examination may also be included in health policies. To find out what is permitted, one must carefully read his or her policy.

Minimum period of stay in Hospital

Policyholders must stay in the hospital for a minimum number of hours to be eligible to submit a claim. This is typically take 24 hours. Certain defined procedures and the treatment of unintentional injuries may be exempt from this time limit.

Pre and post hospitalization expenses

As long as they are related to the illness or disease, costs incurred during a predetermined number of days before hospitalisation and after hospitalisation for a predetermined amount of time after the date of discharge may be included in the claim.

Cashless Facility

Insurance providers maintain partnerships with a nationwide network of hospitals. If an insured person receives treatment at a network hospital, the insurance company, through its Third-Party Administrator (TPA), handles direct payment to the hospital, eliminating the need for upfront payment by the insured. However, the insured is responsible for any costs exceeding the policy's sub-limits or for services not covered by the policy. If the insured chooses to receive treatment at a non-network hospital, they must pay the hospital directly and then seek reimbursement from the insurance company. Cashless payment is not available in these cases.

Additional benefits and other stand-alone policies

Other advantages are provided by insurance firms as add-ons or riders. Additionally, there are stand-alone policies that are intended to provide benefits such as Surgical Expense Benefits, Hospital Cash, and Critical Illness Benefits. These policies can be used in conjunction with the hospitalisation policy or as a stand-alone measure. A few companies have released goods under Top-Up insurance to cover actual expenses beyond the basic health policy's limit.

1.1.6 Exclusions from Health Insurance

According to the IRDA, the following are typically not covered by health policies.

a) All pre-existing conditions (all nonlife and health insurance firms define the pre­existing condition exclusion in the same way).
b) While there is a 30-day waiting period for claims related to illnesses or diseases in the first year of the policy, this restriction does not apply to claims for unintentional injuries.
c) The following conditions and related treatments are not covered during the first year of coverage: cataracts, benign prostatic hypertrophy, fibromyoma or menorrhagia hysterectomy, hernias, hydroceles, congenital internal diseases, anal fistulas, piles (hemorrhoids), and sinusitis.
d) Circumcision, unless it is necessary to treat an illness
e) The price of glasses, contacts, and hearing aids
f) Dental care or surgery, unless hospitalisation is necessary
g) This policy does not cover AIDS, general debility, congenital external defects, venereal diseases (V.D.), self-inflicted injuries, conditions resulting from substance or alcohol abuse, convalescence, diagnostic costs, or hospitalizations not supported by diagnostic or lab results.
h) Pregnancy and delivery treatments, such as caesarean sections
i) Treatment with naturopathy.

The precise exclusions could differ between products and companies. It might be feasible to remove or waive exclusions in group insurance in exchange for an additional premium.

1.1.7 Establishment Insurance Regulatory and Development Authority

To regulate the insurance sector, the Indian Parliament enacted the Insurance Regulatory and Development Authority (IRDA) Act in 1999, opening the industry to private companies. The IRDA's mandate is to protect policyholder interests and oversee the growth and development of the insurance market. To ensure financial stability, the IRDA mandates a minimum paid-up equity capital of Rs. 100 crores for insurance companies and Rs. 200 crores for reinsurance companies. As India's primary regulatory body for insurance, the IRDA's guidelines benefit both insurance providers and policyholders.

1.1.8 Problems for Health Insurance in India

In many countries the health insurance is highly established and regulated, but in India, it is an unexplored and underutilised market. However, there are a few obstacles that are seriously hurting the health insurance industry. This segment will grow faster than any other if things are handled positively and with great strength. The following issues or obstacles are now plaguing the health insurance market:

1. The primary obstacle to the enrolment and expansion ofhealth insurance among Indians is their low degree of awareness about it. Pre-existing conditions, exclusions, inclusions, and claims procedures and settlements are complexity in nature.
2. The extension of health insurance is hampered the lack of reliable statistics on morbidity, death, and claims. Health insurance premiums are typically too high or too low without an accurate, up-to-date, and trustworthy database, and creating new health insurance products will be challenging.
3. India's health insurance sector is still developing, facing challenges due to inadequate medical services and infrastructure. This includes a critical shortage of primary health centers, community health centers, and sub-centers.
4. The main issue facing insurance firms is excessive claims, which are frequently the consequence of false claims. The increasing expense of fraud detection and prevention is another major problem faced by the insurance companies. In order to identify and prevent fraudulent activity, insurers have a responsibility to make significant investments in cutting­edge technology like artificial intelligence and data analytics as fake insurance claims get more complicated. These additional costs have the potential to reduce business margins and raise policyholder premiums.
5. The insurance companies generally undervalue their goods as part of a fiercely competitive strategy to obtain a competitive edge. For businesses, it results in a high ratio of claims incurred and losses in the health insurance market.
6. The claim process, claim format, application form, definitions of important terminology, etc. are not standardised.
7. The market for health insurance is more complex and expensive because of high-risk to enrol in a plan.
8. The industry's sustainability and growth are further threatened by policyholders' moral hazard, which encourages unnecessary medical care because of insurance coverage, and agents' coercive selling tactics, which frequently involve inflating the benefits of plans, whichjeopardise the long-term viability ofhealth insurance policies.
9. People who lived in rural and metropolitan place currently pay the equal health insurance premium, despite the fact that the cost of healthcare differs on depending the location. Therefore, the impoverished and those living in rural areas find the current health insurance policies and products less appealing. Because private health care is more expensive, impoverished people have difficulty accessing health care facilities when public spending on health care is lower.^[15]

1.1.9 Factors affecting health insurance claims

The health insurance is essential part of personal future planning as a safeguard against the excessive expenses of medical care. The premiums that policyholders pay, which represent the cost of keeping health insurance, can, however, differ greatly. Understanding the factors that affect premiums empowers individuals and families to make informed healthcare coverage decisions. This study examines the main variables influencing health insurance rates and provides information on how these variables affect the total cost of keeping a coverage. In order to calculate the risk and possible expense of offering coverage, insurance firms evaluate a number of factors that affect health insurance premiums. These elements include individual traits, the insurance policy's details, and more general economic and legal influences.

Age

Policyholder age is a key factor in determining health insurance rates; as people age and become more prone to health issues, premiums generally increase.

Gender

Women have paid higher health insurance rates because they use healthcare services especially during the childbearing years.

Location

The accessibility of medical providers, and state-specific laws, geographic location also affects the premiums because of differences in local healthcare prices. Premiums are generally higher in urban areas with more medical expenses and in locations with fewer healthcare providers. An individual's medical history, including chronic illnesses and pre-existing conditions, is evaluated by insurance companies. Because insurers expect more possible claims, people with a history of serious health problems may pay higher premiums.

Lifestyle and habits

Lifestyle decisions including drinking alcohol, smoking, and exercising are important considerations while deciding the validity of Health Insurance claims. For instance, smokers frequently pay much higher premiums because of the heightened risk ofhealth issues linked to tobacco use.

Policy type and coverage level

The premium is directly impacted by the details of the insurance policy, such as the coverage level, deductible, co-payment requirements, and plan type (HMO, PPO, etc.). he Premiums are usually higher for more comprehensive plans with lower deductibles and wider coverage options.

Family size

The rates for policies that cover more family members—like a spouse or kids—will often be higher than those for policies that only cover one person.

1.1.10 Economic and market influences

Besides individual characteristics, general market and economic conditions have a big impact on health insurance rates. Among these influences are:

Healthcare prices: Increasing insurance rates are a direct result of rising prescription medication and healthcare service costs. To make sure they can pay for the expected medical claims, insurers must take these expenses into consideration when determining rates.

Insurance Sector Competition: The degree of rivalry between company in a particular region may have an impact on rates. While premiums may be higher in regions with little competition, insurers may reduce rates in highly competitive sectors to draw clients.

Regulatory environment: The Government rules and directives have a big influence on premiums. The cost of premiums may change, for instance, if certain benefits must be covered or if applicants must be accepted regardless of their condition.

Economic factors: General economic factors, including unemployment and inflation, influence health insurance costs. Premiums may increase during economic downturns when insurers make adjustments to maintain their financial stability and pay for growing claims expenses.

1.1.11 Role oflnsurance Companies

The Companies that provide health insurance are essential to contemporary healthcare systems. They spread the cost of medical bills and offer financial security against unforeseen medical problems by pooling the risks of many people. Hospitalisation, operations, prescription drugs, and diagnostic tests arejust a few of the many benefits that insurers provide. Through wellness initiatives, they encourage preventive healthcare, create networks of healthcare professionals, and enable cashless hospital stays. The Insurers use a number of legal and regulatory frameworks, including as contract law, tort law, and regulatory compliance, to guarantee effective operations and safeguard policyholder interests. Health insurance firms support social justice, economic expansion, and public health by carrying out these duties.

1.1.12 Areas where the Breach of Contract arises

Many policyholders reported difficulties with health insurance claim processing. Common issues included claim rejection due to pre-existing condition classifications and partial claim approvals. A survey found that 43% ofhealth insurance policyholders who filed a claim in the past three years experienced processing challenges.¹⁶

The major problems faced by the policyholders include:

a) Contract ambiguity brought on by the use of technical language and complicated terms.
b) Rejected claims because of pre-existing conditions.
c) Eligibility for claims other than pre-existing conditions.
d) Lack of complete information regarding exclusions and eligibility for claims in their policies.

An insurance policy offers defence against potential losses. Once committed, the insurer is legally obligated to support, aid, and assist the insured as needed. If the insured is involved in an accident, the insurance provider must provide all services and coverage outlined in the contract. Once the insured begins making payments, both parties are legally bound to uphold the policy's terms. Failure to do so by either party constitutes a breach of contract.¹⁷ There are numerous ways for an insurer or insured to violate the terms of the insurance contract. For instance, it will be deemed a breach of contract if the insurance company denies the insured's rights. The insurance company has broken the agreement if it only covers a portion of a claim following a storm, hailstorm, tornado, or other weather-related incident.

Various ways in which the breach of contract takes place:

a) If the insurance provider rejects the claim in an unreasonable manner.
b) If the insurance provider does not offer support.
c) In the event that the insurance company fails to promptly pay a claim under an insurance policy.
d) If the contract is interpreted incorrectly by the insurance company.
e) If the benefits outlined in the contract are rejected by the insurance provider.
f) If the insurance provider rejects the claim without conducting a thorough inquiry.
g) The insurer may delay processing claims, refuse to negotiate in good faith, or place unreasonable conditions on the policyholder, among other poor faith actions.

1.1.13 Impact ofbreach of contract on policyholders

The Policyholders may experience substantial social, cultural, and financial repercussions from a health insurance company's breach of contract.

Social Impact

Breakdown of Goodwill: The Policyholders and insurance companies' trust can be damaged by contract violations, which can result in a general mistrust of the insurance sector. Future interactions between people and insurers may be hampered as a result.

Greater Distress and Depression: The uncertainty and financial strain brought on by rejected claims or late payments may cause policyholders to feel more stressed and anxious. Decreased quality oflife and mental health problems may result from this.

Cultural Impact

Health and Well-Being: The Policyholders' health and well-being, especially those with chronic illnesses or disabilities, may suffer if medical care is delayed or withheld as a result of

a contract violation. Given that health and well-being are frequently entwined with cultural customs and traditions, this can have important cultural ramifications.

Displacement of Cultural Traditions: In certain cultures, customs and cultural practices are closely linked to health and wellbeing. A contract violation may interfere with these customs and have a detrimental effect on cultural identity.

Economic Impact

Financial Difficulty: A breach of contract could lead to serious financial hardship for policyholders because they might have to pay for medical expenditures out of pocket. This could lead to debt, bankruptcy, and other financial problems.

Limited Access to Medical Services: Postponed or rejected claims may restrict access to essential medical care, which over time may result in worse health outcomes and higher medical expenses.

Effect on Employment: A breach of contract may have a detrimental effect on a policyholder's employment and income if they are not able to work which result in illness or accident. Poverty, losing one's work, and other financial difficulties may result from this.

1.1.14 Legal Remedies for Breach ofHealth Insurance Contracts in India

According to Indian law, policyholders have a number of legal options in the event that a health insurance firm violates their agreement. In Indian Contract Act, 1872 and the Insurance Act ,1938 mostly regulate these remedies.

1. Specific Performance

A court may order an insurer to carry out its responsibilities, such as paying claims or offering coverage, under specific situations, such as breach of contract. In order to guarantee that policyholders receive the full extent of their legally mandated benefits, insurers are subject to potential fines or remedial measures in cases of non-compliance.

2. Injunction:

If the insurance company does anything that would be detrimental to the policyholder's interests, including refusing coverage or postponing claim payments, a court may grant an injunction.

3. Damages:

It is to be stated that Seeking monetary compensation for losses is the best remedy for the breach.

• This can include, Paying for direct monetary losses, like unpaid medical bills. These are known as actual damages.
• Paying for indirect costs, such as missed income or psychological suffering. . These are known as consequential damages.
• Vindictive Damages: To penalise the insurer and discourage such behaviour in the future, the court may grant punitive damages in circumstances of deliberate or malicious breach.

4. Rescission:

Contract Termination: In certain circumstances, the policyholder may be allowed to end the agreement and request a reimbursement of the premiums they have paid.

1.1.15 Laws and Regulations:

The Indian Contract Act of 1872 governs general contract principles, including remedies for breach of contract. The Insurance Act, 1938 regulates India's insurance market, including health insurance. The Insurance Regulatory and Development Authority of India (IRDAI) sets regulations governing insurance business practices and protecting policyholder interests.

Implementation of Health Insurance Laws in India^[18]

The Policyholders' Protection & Grievance Redressal Department was created by the IRDAI to handle the following portfolios: -

a) Education and Awareness: A large number of policyholders lack knowledge of their rights and the conditions of the health plans. To inform the public of their rights and obligations, IRDAI and insurance providers ought to launch awareness programs. In order to give prospective policyholders correct information, agents and brokers ought to receive proper training.
b) Lack of Policy Standardisation: Policyholders are confused by the absence of uniformity in terms and conditions. To help policyholders better understand their coverage, IRDAI has released recommendations to standardise policy terms and conditions.
c) IRDAI timely Claim Settlement : Policyholders frequently deal with delayed claim settlements. IRDAI timely Claim Settlement: Policyholders frequently deal with delayed claim settlements. Strict deadlines for claim settlement have been mandated by IRDAI. Insurance firms ought to make technological investments and simplify their claim handling processes.
d) Network of Healthcare Providers: Access to high-quality care may be restricted by an inadequate network ofhealthcare providers. More clinics and hospitals should be part ofinsurance companies' networks, particularly in rural areas.
e) Regulatory Oversight: To guarantee compliance, regulations must be effectively enforced. IRDAI ought to bolster its regulatory supervision and take decisive action against insurers who fail to comply.
f) Consumer Protection: It could be challenging for policyholders to settle disagreements with their insurers. In order to handle customer complaints, The IRDAI has instituted formal procedures for the redressal of grievances. In the event of disagreements, policyholders must to be invited to lodge complaints with IRDAI.

1.2 Statement of the Problem

The inaccurate language used in policies may cause misconceptions about the scope of coverage and limitations. Uncertainty around pre-existing condition clauses could lead to denials of claims. The Insurance companies may refuse claims on the basis of supplied documentation errors without providing adequate advice for correction. The Fairness issues are also raised by denials that are made only on the basis of the policy holders medical opinion, without requesting an independent evaluation or offering convincing explanations. The Policyholders may suffer great hardship as a result of significant settlement delays that exceed acceptable limits and a lack of clear information about the reasons behind the delays. It's possible that policyholders are unaware of all the terms and conditions, their rights, and the deadlines for contesting claims denials. The Policyholders are further harmed by insufficient details about appeal processes and restricted access to efficient resolution of conflicts processes. This ultimately contributes to increased levels of mental distress and psychological disorders among policyholders.

1.3 Research Gap

The review of literature revealed that some studies had been conducted on factors affecting health insurance purchase patterns and the various consequences of health insurance on individuals. In India, there are numerous variations in the causes and effects between nations and states. The issues and opportunities that the insurer faces when settling the claims in health insurance market are the main subject of this study. There hasn't been any prior research of this kind on breach of health insurance. Although they weren't thoroughly examined, the previous research concentrated only on the function of the health insurance market. The researcher's goal in this study is to investigate how policyholders perceive health insurance, the role that insurance firms play, and industry changes. These breaches manifest in various forms, including denial of claims, delays in claim processing, and unfair policy terminations, among others.

1.4 Research Question

The researchable questions of this present study are that:

1. Whether the existing legal framework is sufficient to protect the interest of health insurance policy holders?
2. What are the common grounds for denial of health insurance claim settlements by insurance companies?
3. Does the denial of insurance claims by insurance companies significantly impact the mental health and contribute to psychological disorders among policyholders?

1.5 Objectives of the Study

The objectives of the study are as follows:

• To examine of the legal framework governing the settlement of claims between parties involved in health insurance contracts.
• To analyze the grounds on breach of contract by the health insurance companies in India,
• To discuss the major issues around the violation of contract in settlement of claims, and
• To analyze the difficulties faced by insured in settlement of claims by the health insurance companies in India,

1.6 Hypotheses

The hypotheses of this study are ,

1. Null Hypothesis (H O ): There is no significant relationship between regulatory framework effectiveness and health insurance policyholder protection.

Alternative Hypothesis (H l ): There is a significant relationship between regulatory framework effectiveness and health insurance policyholder protection.

2. Null Hypothesis (H O ): The frequent denial of insurance claims by insurance companies does not contribute to increased levels of mental distress and psychological disorders among policyholders.

Alternative Hypothesis (H l ): The frequent denial of insurance claims by insurance companies contributes to increased levels of mental distress and psychological disorders among policyholders.

3. Null Hypothesis (H O ): There is no significant difference in knowledge about the policy terms and conditions on the socio-economic status of the policy holder.

Alternative Hypothesis (H l ): There is significant difference in knowledge about the policy terms and conditions on the socio-economic status of the policy holder.

1.7 Scope of the Study

The current research focuses on breach of contract by Health Insurance Companies against the policy holders which covers a range of legal, social, economic, and practical considerations. By taking a comprehensive and interdisciplinary approach, it makes possible to gain a deeper knowledge of this important and complex issue, and to develop effective strategies for addressing it. The study attempts to find the ways to improve the regulatory environment, guarantee better consumer protection, and accomplish more efficient enforcement of health insurance contracts throughout Tamil Nadu and may the larger Indian context, more research could examine these crucial areas.

1.8 Limitation of the Study

This study thoroughly examines the legal framework on breach of contract, it does not go into the detail about systemic issues that impact the execution of contractual obligations.

1.9 Research Methodology

This study used a mixed-methods approach, combining qualitative and quantitative research techniques and utilizing both primary and secondary data. Primary data was collected via structured questionnaires from 315 policyholders and members of the general public in Tamil Nadu, India, using convenient sampling The information collected such as gender, age, place of residence, occupation, education, marital status, income, Policyholder, type of Health Insurance Policy, the mode of payment, source of awareness, elements/aspects of health insurance product, the reasons for taking health insurance policy, information about the matters related to health insurance contract, availed or tried claim , clear guidelines for appealing denied claims, breach due to a misinterpretation, valid reason for the denial, clear policy terms, escalate the breach to a higher authority, experience with insurance claims, facing issued during claim settlement, nature of the breach, difficult in claim settlement process, reasons for breach of contract, challenges faced by the insured, transparency of policy terms and conditions, impact on breaches of contract, fraudulent claims on the settlement process, legal rights as a policyholder effectiveness of regulatory bodies, factors to breaches of contract, effectiveness of the regulatory bodies, stricter penalties for breach of contract, preventive measures for breaches of contract, receive compensation or punitive damages, disputes or disagreements, addressing the discrepancies or errors, handling appeals or disputes, improvements of the health insurance claim settlement process, agents or intermediaries play in facilitating smoother claim settlements, recommend for insurers, methods for insurers to improve their collaboration and coordination, recommend to insurers to prevent fraudulent activities, dispute resolution process.

The secondary source of data’s are collected from various cases filed against the insurance companies, government websites, IRDA websites, journals, magazines, government reports, books and other published materials.

1.10 Chapterisation

Chapter-I: Introduction.

This chapter explains about the historical background of this research work and statement of the problem. The research scholar identified the research gap and prepared relevant questions and tentative hypothesis of my research along with the scope and limitation of the present research work.

Chapter-II: Review of Literature

This chapter reviews around 180 review of literature that includes Indian authors and foreign authors works.

Chapter-III: Health Insurance in India: Concept and Historical Background

This chapter explores the concept ofhealth insurance and its historical development in India. It examines the nature, purpose, and meaning ofinsurance in general, tracing its evolution in India from prehistoric times through the British colonial period and into the post-independence era. The chapter covers fundamental insurance principles, including utmost good faith, insurable interest, indemnity, and subrogation, as well as core concepts like cooperation and probability. It also discusses the contractual elements of insurance, such as offer and acceptance, legal consideration, and free consent. Various types of insurance are addressed, including general, life, fire, marine, and health insurance, with a focus on the nature, concept, and different forms ofhealth insurance (social security, private, community, and government). Finally, the chapter highlights the role of NGOs in health insurance policies and programs, providing a comprehensive overview of health insurance concepts, types, and operations, with a particular emphasis on the Indian context.

Chapter- IV Legal Framework of Health Insurance: International Dimensions & Indian Perspective

This chapter focuses of the national and worldwide legal systems controlling health insurance is given in this document. This chapter focused with a review of international agreements such the UNCRPD 2000, ICESR I960, UDHR 1948, and WHO 1948 Next, it looks at the laws governing health insurance in the US, Germany, Great Britain, and other nations. Nationally, it examines how India's Preamble, Fundamental Rights, and Directive Principles relate to health insurance and other aspects of the constitution. This chapter examines key Indian legislation relevant to insurance, including the Insurance Act of 1938, the Life Insurance Corporation Act of 1956, the Consumer Protection Act of 1986, the Indian Contract Act of 1872, and the IRDA Act of 1999. It also outlines relevant social security laws, such as the Public Liability Insurance Act of 1991 and the Employees' State Insurance Act of 1948 (formerly the Workers' State Insurance Act). Furthermore, the chapter details specific IRDA regulations pertaining to health insurance (Regulations 2000, 2005, 2013, and 2017). Finally, it discusses the role ofinsurance ombudsmen in resolving disputes and the impact of the Insurance Amendment Act, including the establishment of the Tariff Advisory Committee.

Chapter-V Claims Processing and Settlement

This chapter focuses on the historical context and contemporary dynamics the Ihealth insurance market are described in this part, with an emphasis on the significance of claim settlements for policyholders. This chapter also explores the policyholder rights and duties, the contractual structure of health insurance agreements, and the functions of insurance firms in the claim processing process. This chapter covers a variety of contract violations, looking at the reasons from the viewpoints of policyholders and insurance firms. These violations include the denial of legitimate claims, delayed pay-outs, and misleading policy language. The Resolution options such as mediation and arbitration are examined with the effects of these difficulties on policyholders, including financial pressure and loss of faith, and the function of Ombudsmen. This chapter also focuses on case studies, court rulings, upcoming developments in claims handling, and suggestions for enhancing consumer protection and transparency. All of this culminates in a need for stricter laws and more transparent contracts to protect policyholder interests.

Chapter-VI: Analysis and Interpretation

The chapter titled "analysis and interpretation outlines the methodology for a research project investigating health insurance breach . It details about various stages of the research process, including the research design and data collection methods, data sources, the research instrument that will be used to collect data, the variables under investigation, the sampling design and method used to select participants, the target population, the sampling frame from which the sample will be drawn, the process of determining the sample size, the duration of the study, data analysis methods, and how the results will be interpreted. Finally, the chapter concludes by summarizing the key findings of the research.

Chapter-VII: Conclusion

This chapter summarizes the research by presenting the findings, recommendations, and the conclusions reached based on the data collected.. The researcher attempts to analyse the main ideas and data from each of the previous chapters in this chapter. Recommendations are made based on this thorough examination.

1.13 Conclusion

In conclusion, addressing breach of contract in the health insurance industry is not only a legal and regulatory imperative but also a moral responsibility to uphold policyholder trust, dignity, and rights. By embracing a holistic approach grounded in fairness, transparency, and collaboration, we can create a future where health insurance serves as a reliable and equitable means of protecting and promoting the health and financial security of all individuals in India. The researcher highlights the critical role of legal frameworks in governing unsettled insurance claims, ensuring that insurers fulfill their obligations to policyholders. In this study the researcher reveals that, how laws are protecting the policy holders from unjust claim denials and to ensure timely compensation to the insured person. The researcher b examining the relevant case law and regulations, the researcher emphasizes the importance of legal recourse in cases of fraudulent practices or breach of contract by insurance companies. These legal mechanisms not only safeguard consumer rights but also promote fairness and transparency within the insurance industry. The effective legal oversight helps maintain the trust and stability essential forthe sector’s long-term sustainability.

CHAPTER-II REVIEW OF LITERATURE

2.1 Introduction

The health insurance plays an essential role for reducing the financial strain brought on by unexpected circumstances and medical bills. But the health insurance market is complicated and multidimensional, impacted by several variables like governmental regulations, socioeconomic circumstances, and technology developments. Several studies examine the various facets of health insurance, such as its effects on patient safety, effectiveness, and accessibility, are examined in this study. The importance of medical malpractice insurance in resolving problems involving mistakes or carelessness in healthcare services is clarified by Adina Pandele (2023). The study emphasises how this type of insurance supports people affected by medical mistakes by offering them monetary reimbursement. In the meantime, Adzakpah and Dwomoh (2022) investigate how the health insurance error margins are affected by Digital Health Technology (DHT). This research demonstrates the potential of DHT to significantly reduce error rates in claims processing, leading to cost savings and increased efficiency. Ahuja (2004) contributed to the understanding of community-based health insurance (CBHI) as a potential healthcare solution for low-income Indians. This research also examines the effects of insurance sector reforms on healthcare access and quality for the underprivileged. Aiyar and Sunder (2024) furthered this understanding by analyzing the impact of RSBY on child mortality in India, using temporal and spatial analysis to evaluate its implementation. These studies collectively provide valuable insights into the complexities, challenges, and potential of health insurance to improve healthcare delivery and policyholder outcomes.

2.2 Review of Literature

A. V. Rao (2008) This study emphasizes the mutual responsibility of good faith in insurance contracts. Both the insurer and the insured are obligated to act honestly and disclose all relevant information regarding the covered risks. The study further aims to highlight these shared obligations throughout the contract's duration. Insurers design proposal forms to gather necessary information, while insured individuals must truthfully answer questions and not hide any relevant details. Similarly, insurers are responsible for providing accurate information about their products and claims settlement processes. Failure to disclose relevant information or providing incorrect information can lead to misrepresentations and fraud, which may result in contract avoidance.

Adina Pandele (2023) explores the significance of medical malpractice insurance in addressing issues related to errors or negligence in healthcare services. The study aims to understand how medical malpractice insurance provides a sense of safety and trust for patients by offering compensation for damages incurred due to medical negligence. It also acknowledges the challenges healthcare professionals face, including allegations of malpractice even when they adhere to professional standards. The research focused on the importance role of medical malpractice insurance in providing financial compensation for additional medical expenses, lost wages, and other damages faced by patients due to medical errors.

Ahuja, Rajeev (2004) This study examined the suitability of community-based health insurance (CBHI) for providing health coverage to low-income individuals in India. Analyzing various CBHI schemes, including the Prime Minister's universal health insurance scheme, the study also explored how insurance sector reforms impact access to and quality of health services for the poor. The research emphasized the need for government interventions to encourage CBHI and ensure effective service delivery by formal insurance providers to the low-income population. It concluded that a balanced approach is necessary to minimize healthcare cost escalation while expanding health insurance coverage for the poor in India.

Aiyar and Sunder (2024) This research reviewed the impact of India's national health insurance policy, the Rashtriya Swasthya Bima Yojana (RSBY), on child mortality. This study utilised temporal and spatial variations in RSBY implementation to assess its effects on infant and child under-five mortality rates. The findings revealed a 6% reduction in infant mortality and a 5% decrease in child under-five mortality, particularly in poor urban households. The study also highlights the increased usage of reproductive health services among mothers and a rise in complementary health services, such as child immunisation, indicating positive spill over effects ofRSBY on healthcare utilisation beyond its coverage.

Alan, Burak & Avci, Emin (2022) aimed to identify the factors influencing the reinsurance costs for Turkish non-life insurance companies. The study analysed how financial and technical ratios affect the expenses incurred by insurance firms for reinsurance, using panel data analysis. Data from the Insurance Association of Turkey (IAT) covering 26 non-life companies from 2009 to 2021 was utilized. Two models were developed based on financial and technical ratios, with analyses also considering periods like the COVID-19 outbreak and the 2018 currency crisis. Findings indicated that higher returns on assets, lower debt ratios, and lower retention ratios were associated with reduced reinsurance costs, suggesting that profitability, lower debt levels, and risk retention influence how much insurance companies spend on reinsurance.

Allwaim, Ali & Cherif, Mohamed, 2O23. The authors in their research aimed to explore how the money collected from premium and the money paid out for claims relate to the financial health of insurance companies in Saudi Arabia. It focused at financial data from five companies over ten years, using methods approved by the Saudi Central Bank. The study found that when companies collect more premiums and pay out claims, they are financially healthier and better at managing risks. It suggests that companies should focus on increasing their subscriptions to ensure they have enough money to cover their long-term commitments.

Anam et al. (2O23) aimed to develop a method for predicting health insurance claims using Support Vector Machine and the Bat Algorithm. The study addresses the importance of accurately predicting claims to ensure the profitability and sustainability of the health insurance industry. SVM is a robust Machine Learning method, but its performance relies on parameter selection, which can be time-consuming. BA, a swarm intelligence-based algorithm, was used to optimize SVM parameters due to its efficiency in finding global solutions. The study compared the proposed approach with conventional SVM and a hybrid of SVM and Particle Swarm Optimization (PSO) using metrics like accuracy, recall, precision, and computing time. Results showed that the SVM-BA method outperformed other models in predicting health insurance claims with faster computing time and avoiding over-fitting.

Ramadhani & Muazaroh (2O23) conducted quantitative research to examine the impact of financial performance on the soundness of general insurance companies. The study analyzed how liquidity and profitability ratios affect the overall health of these companies. Using statistical analysis and a purposive sample of 49 conventional general insurance companies registered with the financial services authority, the findings revealed a significant positive effect of the liquidity ratio and a partial positive effect of the profitability ratio on company soundness. This suggests that maintaining liquidity and profitability is crucial for ensuring financial health.

Bakshi (2O21) investigated the growth and pattern of premiums in voluntary health insurance companies in India, focusing on the increasing importance of health insurance due to limited public funding in developing economies like India. Analyzing data from 2002-03 to 2015-16, the study calculated Compound Annual Growth Rates (CAGRs) for both public and private health insurance companies, finding significant growth trends. This research highlights the increasing role of private health insurance in meeting the healthcare needs of India's middle class and the importance of market-based insurance policies in improving healthcare access. Arivalagan & Perumal (2015) aimed to educate insurance professionals and the public about the state ofhealth insurance in India. The study focused on health insurance within the broader context of non-life insurance, highlighting its significant contribution to the insurance industry. It discussed the development and performance of health insurance in India, comparing it to global scenarios. The study also evaluated the role of the insurance regulator IRDA in monitoring and regulating health insurance in India, along with the implemented regulations to safeguard policyholders' interests.

Army & Nahda (2023) analyzed the impact of BPJS Kesehatan regulations on insurance companies' efficiency and performance, focusing on the period from 2009 (pre-regulation) to 2019 (post-regulation). Using Data Envelopment Analysis (DEA), Return on Assets (ROA), and Return on Equity (ROE) to analyze 12 insurance companies, the findings indicated a significant positive change in company efficiency after the BPJS Kesehatan regulation. This study provides insights into the effects of regulatory changes.

Aswin, Suhendro, & Afrita, Indra. (2021) The authors in their research aimed to understand life insurance policy defaults through a legal lens. The study focused on three key questions: how defaults occur, how they are resolved, and the legal implications of these resolutions. It utilized normative legal research methods, likely involving an analysis of relevant laws and regulations. The findings suggest that policy defaults can occur due to unpaid premiums, leading to potential consequences such as policy cancellations, loss of coverage, and forfeiture of premiums.

Ayoni and Oyetunji (2021) This study examined the correlation between poor claims settlement and insurance policy demand in Nigeria. Using primary data from structured questionnaires and employing Chi-squared statistics and correlation analysis, the research focused on a select group of dominant, licensed Nigerian insurance firms to provide empirical evidence for insurance companies and policymakers to enhance future services and policies. Results indicate a significant impact of poor claims settlement on insurance policy demand, emphasising the need for redefining the insurance industry through regulatory measures, competition, and innovative services to meet consumer expectations and ensure satisfaction for all parties involved.

Ayoni, Momoh & Oyetunji, Oyefemi. (2021) This study investigated the impact of poor claims settlement on insurance policy demand in Nigeria, providing empirical evidence to guide insurance companies and policymakers. Targeting dominant licensed insurance firms, primary data were collected via structured questionnaires and analyzed using Chi-squared statistics and correlation analysis. Findings revealed a significant, long-term relationship between poor claims settlement and reduced demand. The study recommends legislative measures to redefine the industry, fostering competition and innovation to meet consumer expectations and ensure stakeholder satisfaction.

Ayuba, Bello & Agugua, George & Azuoonwu (2020) The authors in their research investigated the influence of claim settlement on general insurance businesses in Abuja, Nigeria. Their study focused on motor vehicle and fire insurance in the Federal Capital Territory (FCT). Using 408 questionnaires, they found that claim settlement significantly impacts insurance company performance. Ethical issues and fire insurance policies were particularly influential. Challenges like poor premium collection and standards were identified, the need for better customer service and strategies to enhance overall business success.

Ayuba, Bello & Agugua, George & Azuoonwu, 2020. The authors in their research explores how the settling claims affects the success of general insurance companies in Abuja, Nigeria. The findings revealed that settling claims promptly is crucial for the company’s success, especially for car and fire insurance. Problems like unethical practices, poor premium collection, and low cash flow were identified as reasons for delays in settling claims, which hurt the company’s performance. This study suggests that insurance companies should focus on providing good services, fair pricing, and quick responses to complaints to satisfy customers and perform better.

Babrah & Alex (2023) This study investigated how risk management practices affect the financial performance of insurance companies in Uganda, focusing on AAR Health Services Uganda Ltd. A case study and descriptive design were used to focus the research. A total of f07 staff members were surveyed using close-ended questionnaires and interview guides. The study found that risk management at AAR Health Services Uganda Ltd. was satisfactory, with an average mean score of 2.87. Similarly, financial performance was rated relatively satisfactory with the same mean score. The regression analysis showed a positive relationship (R value of .753) between financial performance and risk management components such as risk identification, assessment, monitoring, controlling, planning, maintenance, and transfer.

Baker (2006) aimed to address the issue of medical malpractice insurance reform, focusing on periods of legislative attention due to increases in insurance premiums. The study had three main goals: explaining the pricing cycle behind rising insurance premiums, evaluating potential policy goals for reform, and suggesting ways to achieve those goals. The author's primary interest was in promoting "enterprise insurance" as a reform model but also provided conceptual tools for assessing other reform options. The study highlighted the volatile nature of the medical liability insurance market due to cyclical insurance business patterns and the challenges in predicting future medical liability losses accurately.

Bakshi (2021) analyses the trend of voluntary insurance in India, focusing on public and private insurance companies. The study aims to understand how health insurance contributes to improving healthcare access in a country where public funding for health is limited. The research method involves examining the growth pattern of premiums in the voluntary health insurance sector from 2002-03 to 2015-16 and calculating Compound Annual Growth Rates (CAGRs) for public and private insurers. The findings indicate a significant and increasing trend in premiums underwritten by these companies, highlighting the growing role of insurance in addressing health care financing challenges in India.

Banmore, Adefulu, and Makinde (2023) This study investigated the relationship between claims management and firm performance of Nigerian insurance companies, focusing on the moderating effect of marketing factors. Data from 776 management, senior, and junior staff members in Lagos State were gathered via questionnaires and analyzed using hierarchical regression analysis (HRA). Findings revealed that marketing factors significantly moderate the effect of claims management on firm performance. The study recommends that insurance companies in Lagos State emphasize positive marketing strategies, such as employee training, promoting job satisfaction, and fostering a positive work environment, to enhance claims management and achieve sustainable performance.

Barannyk and Kachula (2023) aimed to explore the theoretical and practical aspects of implementing compulsory health insurance within the social security system, focusing on Ukraine. They used theoretical analysis and mathematical/statistical methods to address the challenges and potentials of mandatory health insurance. The study highlights the significance of health protection within social security and emphasizes mandatory health insurance as an effective model for financing healthcare needs. It argues that compulsory health insurance can significantly contribute to economic development and social security, urging Ukraine to consider its implementation as part of broader reforms to enhance the country's health care system and meet EU standards.

Basaula, Damodar. (2018) This study examined the significance of claim settlement in Nepal's life insurance industry, assessing customer awareness and satisfaction with the process. Using a descriptive design and stratified sampling to select 391 respondent agents, primary data were collected via a five-point Likert scale questionnaire and analyzed using SPSS and MS Excel The findings indicated that while most respondents had a neutral view on claim settlement satisfaction, they believed that faster claim settlement processes could enhance the life insurance business. The study suggests that the government should prioritise raising awareness about life insurance and consider making it mandatory for all citizens to improve the industry's overall performance.

Bawazir, Saleh et al. (2013) This study evaluated pharmaceutical policies implemented by private health insurance companies in Saudi Arabia and their impact on medication access and utilization. Using a descriptive design, face-to-face interviews were conducted with medical managers from 16 of 25 eligible companies between March and June 2011. The study found that all participating companies had a prior authorization policy, with varying reasons, and some had limitations on medication refills. The findings indicated a need for improving pharmaceutical policy standards and regulation in these companies to enhance medication quality, reduce over-prescription, and promote rational medication use. Further research in this area is recommended.

Berto Samudra (2021) The author his research examined insurance to handle uncertain risks by transferring responsibility through agreements. The aim was to clarify the legal basis for insurance claim rejections and the subsequent dispute resolution process. This study used a legal and conceptual approach to understand insurance agreements' rejection causes. It is observed that rejections ofhealth insurance claims often stem from conditional terms in the agreement, where the insurer covers losses only as agreed. If a claim is rejected, the insured can seek legal recourse by filing a lawsuit in accordance with Law no. 8 of 1999, typically through institutions like BMAI.

Bertrand Lefebvre (2024) explored health insurance coverage using NFHS-5 estimates, focusing on the impact of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB- PMJAY) scheme, particularly in northeastern India. The study aimed to analyze the increase in coverage to 41% of households and assess geographic variations. It highlighted the role of government-led programs like AB-PMJAY in achieving better coverage but noted challenges in states with private insurers and Third-Party Administrators (TPAs), such as Haryana, Maharashtra, and Punjab. The study suggests bridging the gap between national objectives and local health systems for AB-PMJAY's success, emphasizing the need to monitor scheme usage, impact on out-of-pocket expenses, and health outcomes for effective assessment.

Bhagyalakshmi (2023) analyzed the growth of India's health insurance sector, focusing on the relationship between earned premium and underwriting profit or loss. Using secondary data from a 14-year period, the study conducted regression analysis to understand this relationship. The findings revealed a significant relationship between premium collection and underwriting outcomes, with increased premiums leading to higher claims, commissions, management expenses, and underwriting losses. This study provides valuable insights into the dynamics of the health insurance sector's financial performance.

Boltaev, Sotivoldievich (2022) The author in his research explores voluntary health insurance, emphasizing its contractual nature based on parties' agreement and freedom in determining coverage and terms. The study aims to investigate the concept, features, and legal framework of voluntary medical insurance contracts. It examines the process of contract formation, the role of such contracts in insurance relations, and their application within legislation. The research highlights the importance of defining contract subjects and conditions, shedding light on the distinct characteristics and implications of voluntary health insurance agreements.

Cady, T. C., Andrews, A., Cuppett, D., & Glover, M. (1988) The authors in their research categorises insurance into first-party and third-party types, focusing on misconduct within first­party insurance. They aim to highlight how insurance companies can harm their policyholders by denying valid claims, delaying payments, undervaluing claims, or misleading the insured. This study emphasises that insurers should act in good faith to protect policyholders, and misconduct can lead to legal liabilities.

Choudhary, Dr-Pooja (2019) This study compares the claims settlement performance of public and private life insurance companies in India, a crucial aspect for insurers. Analyzing the status and efficiency of all 23 private life insurers alongside the public sector giant, Life Insurance Corporation of India, the research aims to understand their effectiveness in handling maturity, survival benefit, and death claims. The findings shed light on the success factors influencing claim settlement in the competitive Indian life insurance market.

Crocker, K. J., & Tennyson, S. (2002) The author in their research studied how the of the liability insurers handle claims suspected of fraud. Their research aims to understand the approach insurers take when fraud is a concern, considering claimants' potential misrepresentation of losses. Using a strategic model, the study suggests that insurers may underpay claims strategically to discourage exaggeration, factoring in litigation costs and bad faith accusations. These findings support this strategy, particularly in cases where it's easier to exaggerate losses, such as car insurance bodily injury claims. This indicates that insurers might adjust their settlement practices to influence claimant behaviour in fraud-prone situations.

Debnath, Pranesh (2024) explored customer satisfaction and buying decisions related to life and health insurance in the Dima Hasao district of Assam, Northeast India. The study aimed to identify factors influencing customer satisfaction, preferred insurance types, and purchase motivations, revealing insights into customer demographics, policy preferences, and purchase reasons. Key findings included a preference for saving plans, children's policies, and critical illness insurance. Customers prioritized health insurance and guaranteed protection, with premium rates and payment flexibility significantly impacting satisfaction. The study highlighted diverse factors influencing satisfaction based on demographic factors, providing valuable insights for consumers, policymakers, and insurance companies in Northeast India to enhance the overall consumer experience with insurance products.

Deeksha Chaurasia (2023) explored the impact of digitalization on India's health insurance market, focusing on the rapid growth of digital health insurance sales. The study aimed to identify strategies used by insurance providers to popularize digital health insurance. Data was collected via structured questionnaires from agents and service providers and analyzed using inferential statistics. The study indicated that digital sales have facilitated quick access to information, increased online sales and policy issuance, and expedited claim settlements. This research can assist companies in understanding effective strategies for promoting digital health insurance products.

Defulu, Adesoga & Banmore, Olawale (2023) assessed the impact of claims management practices on the profitability oflisted insurance companies in Nigeria. Using a survey research design targeting full-time top management employees oflisted insurance firms, with a sample size of776 determined through stratified sampling, the study recommends developing policies to integrate claims management across insurance companies in Nigeria to enhance sector profitability and long-term sustainability.

Dr. Satyanarayana & Dr. Swarupa (2020) discussed the importance and benefits of general (non-life) insurance in protecting individuals and their possessions from various risks and uncertainties. They highlighted general insurance's role in safeguarding against mishaps such as fire, natural disasters, theft, travel incidents, and legal actions, depending on the policy. The paper emphasized the rapid growth of general insurance in India post-liberalization, attributing this to factors like the entry of private companies, low premiums, third-party administrators, quick claim settlements, innovative policies, discounts, increased awareness, and expanded distribution channels. This study underscores the significance of general insurance in mitigating financial risks associated with unforeseen events.

Dutta, Madan (2020) The research analyzed the performance of the health insurance sector in India with the aim of understanding how it contributes to the growth of the broader general insurance industry. The study specifically focused on examining the relationship between earned premium, underwriting loss, and overall profitability, employing regression analysis as the primary analytical method. Despite a 27% compounded annual growth rate in earnings, the sector struggled to achieve underwriting profit, highlighting issues affecting its performance. The study's originality lies in its self-driven approach using secondary data from the insurance regulatory authority's website. Findings revealed a significant relationship between premium earnings and underwriting loss, indicating challenges in translating premium growth into profitability.

Elangovan, Jeevitha & Michael (2020) This research explored the challenges faced by Indian life insurance policyholders regarding the marketing mix (Product, Place, Price, Promotion, People, Process, and Physical Distribution). Discussing the financial risk coverage provided by life insurance, the study highlighted issues such as product variety, pricing discrepancies, and claim settlement doubts. Using a descriptive approach to analyze the 7 Ps of marketing in the life insurance sector, the authors recommended solutions to address these challenges and enhance life insurance penetration in India.

Fadun (2023) The author examined the impact of claims settlement in insurance on economic growth, focusing on Nigeria. This research study aims to analyze how the settlement of insurance claims affects a nation's economic growth using 28-year time series data from 1992 to 2019 and utilises an ex-post facto design with Gross Domestic Product (GDP) as the dependent variable and insurance companies' claims settlement in Nigeria as the independent variable. The findings reveal an insignificant negative effect of insurance claims settlement on economic growth, contrary to the expected positive impact. In this the author suggests a complex relationship influenced by various factors, including country-specific conditions and the performance of the insurance industry.

Fadun, Olajide Solomon (2023) aims to explore the impact ofinsurance claims settlement on economic growth, focusing on Nigeria as a case study. The study uses a 28-year time series data from 1992 to 2019 and employs an ex-post facto design. It examines the relationship between insurance claims settlements (INCLM) and Gross Domestic Product (GDP). The research findings reveal an insignificant negative effect of insurance claims settlement on economic growth, suggesting that a percentage increase in INCLM leads to a slight decrease in GDP. This implies that the connection between insurance claims settlement and economic growth is influenced by various factors, including country-specific conditions and the performance of the insurance industry.

Faith Neale, Kevin Eastman, Pamela Drake (2009) aimed to understand the alterations in the medical malpractice insurance market and the factors influencing these changes. They analysed premiums, losses, investment earnings, and loss variability to identify key drivers affecting the market. The study found a significant deterioration in the market between 1998 and 2001, primarily driven by insurers' losses during the period from 1998 to 2003. This research highlights on the dynamics of the medical malpractice insurance market during this time frame, highlighting the impact of insurers' losses on market conditions.

Freund et al. (2014) aimed to understand how health insurance reform in Massachusetts impacted insurance coverage and stability for underserved women. They analysed insurance claims data from 1,946 women with abnormal cancer screening before (2004-2005) and after (2007-2008) the reform. The study measured longitudinal insurance instability by tracking switches in coverage. Post-reform, there was a decrease in uninsured rates without a significant change in insurance switches, indicating increased stability in insurance coverage.

Garnick, Deborah & Swartz, Katherine & Skwara, Kathleen (1998) aimed to show how insurance agents are important in health insurance reforms using New Jersey's individual health insurance market. They found that policymakers had not considered agents' role in selling these policies until recently. The study used New Jersey's reforms to demonstrate how agents can influence the implementation of such reforms. This research looks into the role of insurance agents and their potential impact on health insurance reforms, highlighting the need for policymakers to consider their involvement in future reform initiatives.

Gestwick, E. D., & Barnas, B. D. (2023) This research explores the implied covenant of good faith and fair dealing in insurance contracts, explaining how this covenant requires parties to act fairly and avoid harming each other. Focusing on insurers' responsibilities to thoroughly investigate and pay valid claims, the study discusses a court case where a plaintiffs attempt to sue for both breach of contract and breach of good faith was dismissed due to the claims being based on the same facts.

Ghosh, Madhurima (2021) studied mental health insurance coverage in India. The aim was to understand India's current standing regarding mental health coverage. The author highlighted the historical neglect of mental health issues in India but noted recent changes due to WHO campaigns and increased awareness among the public. India's large population of mental health patients faces challenges due to minimal spending and out-of-pocket expenses. The study emphasized the importance of implementing effective mental health insurance policies to address these challenges. It also mentioned the steps taken by the Indian government and its regulatory bodies to promote mental health coverage but noted the need for further progress in this area, taking cues from developed countries.

Gunarto, Gunarto, Intanida, Intanida, & Mashdurohatun (Year 2023) The authors in their research aimed to analyse the shortcomings of the Life Insurance Agent Work Contract Regulation and propose a reconstruction of the regulation based on justice values outlined in relevant legal articles and Islamic law. This research uses a constructivism paradigm, combining direct interviews with informants and literature studies. Findings reveal weaknesses in transparency within life insurance agent contracts, leading to unilateral decisions during disputes. The reconstruction proposes aligning contract practices with legal articles to ensure fairness, with suggestions for dispute resolution mechanisms and financial regulations in line with global standards and local contexts.

Hall (2010) explores the factual basis behind constitutional challenges to the Affordable Care Act in the United States. The study aims to gather empirical data to evaluate legal challenges to the ACA accurately. It discusses four main constitutional arguments against the ACA, highlighting the importance of understanding how people and institutions behave in the health care and insurance markets. By analyzing empirical information, the study reveals that many constitutional claims lack factual support. For instance, it shows that regulating health insurance markets requires addressing medical underwriting and encouraging broad coverage to avoid additional costs for insured individuals. The study emphasizes the need for a clear understanding of health care dynamics to assess the validity of constitutional challenges to health insurance reform accurately.

Harneja (2009) The author investigates individual future health insurance policyholders regarding critical issues and challenges in India's health insurance sector. The aim is to understand policyholders' views on cashless policies, exclusivity for senior citizens, coverage improvements, premium reductions, and claim-free discounts. The Findings reveal the high demand for cashless policies but a lack of exclusive schemes for seniors. Policyholder’s desire enhanced coverage, lower premiums, and streamlined claim processes. Executives perceive their plans as innovative, while senior officers acknowledge challenges in claim settlement due to third-party administrators and slow progress in cashless services due to operational issues.

Hartanto (2020) The author reviewed the role of insurance in sea transportation, considering both economic factors and security/safety concerns. This study highlighted the benefits of using ships for transporting goods due to their capacity for large quantities and suitability for less perishable items. It discussed how insurance helps protect personal and corporate assets, prompting individuals and companies to seek coverage to mitigate potential losses. The study aimed to understand insurance practices in general and how insurance companies like PT. Asuransi Jasa Indonesia handle claim settlements.

He, Xinchi, Alqahtani, Sarra, & Gamble, Rose (2018) The authors in their research address patient privacy concerns in healthcare insurance claims by proposing a blockchain-based solution to replace centralized clearinghouses. Their aim is to create a decentralized, HIPAA- compliant system using smart contracts for automated claim processing while ensuring data privacy on a distributed ledger. They implemented and evaluated their framework using Hyperledger Fabric, demonstrating effective performance and potential for enhancing privacy and security in healthcare insurance claim processes.

Hermawan, Iwan & Achsani, Noer & Ashanty, Laily (2022) aimed to evaluate strategies for optimizing freakful treaty property insurance for Indonesian Sharia general insurance companies. The study focused on identifying priority and alternative strategies to minimize issues in underwriting and claim handling. The research used a descriptive and qualitative approach, including surveys on freakful strategies, internal and external factors, and business processes. Alternative strategies were derived from SWOT analysis, and the priority strategy was determined using the Quantitative Strategic Planning Matrix (QSPM). Findings indicated a progressive strategy aligned with the company's growth position, reflecting quadrant II in the IE matrix analysis.

Holmes, E. M. (1980) The author in his research investigates the policyholder's viewpoint regarding insurance as a safety net for unexpected events. This study underscores the importance of trust in insurers to fulfil their responsibilities. It discusses the challenges posed when insurers delay or deny legitimate claims, leading to financial and emotional strain for policyholders. The research suggests the necessity of legal safeguards to address these issues, advocating for a more inclusive approach in modern legal systems beyond traditional contract law's confines.

Huang et al. (2024) This study assessed health insurance knowledge and self-efficacy among adolescents and young adults with inflammatory bowel disease (AYA-IBD) in the United States. Fifty English-proficient AYA-IBD (aged 15 and older) receiving care at an academic pediatric practice participated in surveys, which were analyzed using descriptive statistics and ANOVA. The findings revealed suboptimal health insurance knowledge and slight to moderate self-efficacy in choosing and using health insurance. These results highlight the need for health insurance education to better prepare AYA-IBD for managing medical care costs.

Imani Kapungu, Emmanuel Evarest, Nyimvua Shaban, and Andongwisye Mwakisisile (2023) The authors in their research conducted a study to model and forecast claim payments for Tanzania's national health insurance fund (NHIF). They used claim payment data from 2001 to 2021 to build an ARIMA model. The aim was to address the increasing expenses in medical services globally, which strain government and insurance budgets. This study revealed that the Autoregressive Integrated Moving Average (0, 2, 2) model accurately forecasts claim payments from 2022 to 2031. Their numerical analysis predicts a 68% growth in NHIF claim payments by 2031, highlighting the challenges and opportunities for sustainable health insurance coverage in Tanzania.

Ingole, Saurabh et al. (2022) conducted a survey highlighting the necessity of dental insurance in India. The study aimed to advocate for the formulation and introduction of a comprehensive dental insurance plan in the country. The findings indicated a significant demand and necessity for a comprehensive dental insurance plan in India. The conclusion emphasizes that the government should include dental insurance in general healthcare insurance to promote oral hygiene, the dental field, and reduce the burden of oral diseases in the country.

Iskandar and Basuki (2023) This study investigated how foreign insurance affiliation, market share, own retention ratio, claims ratio, and expense ratio influence the performance of Indonesian general insurance companies, using return on equity (ROE) as the performance measure. Analyzing data from 177 companies' financial reports submitted to the Financial Services Authority (2018-2021) using multiple linear regression with SPSS, the study found that foreign affiliation and own retention ratio positively impact ROE. These findings offer insights for regulators on foreign ownership and self-retention regulations and guide insurance company shareholders and management on cooperation policies, reinsurance strategies, and risk management in Indonesia.

J. Davey (2020) examines the differences between UK and US legal systems regarding insurance companies' obligations to indemnify insured individuals. The study aims to highlight how recent efforts in the UK to align with the US system have not sufficiently protected insured individuals. The author suggests that the threat of "bad faith" lawsuits in the US discourages strict regulation in the UK, leading to a potential failure of regulation. They propose a more detailed analysis to explore the policy goals behind each jurisdiction's approach, aiming to identify effective regulatory strategies in the insurance market.

J. Kuckreja, P. Nigde, & P. Patil (2021) The authors in their research highlight the importance of health insurance in handling medical emergencies including address challenges like data breaches and fraud. The study proposes blockchain technology as a solution due to its transparency. They suggest a new insurance claim model without agents, using blockchain to ensure transparency among insurers, hospitals, and the company. The paper also explores using IPFS for securely storing patients' private data with its cryptographic address recorded on the blockchain, aiming to enhance security and efficiency in health insurance processes.

Jain, Ankit, Swetha, Selva, Johar, Zeena, & Raghavan, Ramesh (2014) assessed the acceptability of and willingness to pay for community health insurance among rural residents in India. Using a mixed-methods approach involving interviews with 33 participants from eight villages in southern India, the study found that most respondents sought healthcare only when symptoms were present, showing little interest in preventive services. Few considered health insurance necessary due to concerns about coverage and provider reliability. However, those who were interested expressed a willingness to pay an average annual premium of Rs. 1500 ($27). The study suggests that implementing community health insurance in rural India requires consumer education, careful premium setting, and a deeper understanding of social support networks related to health financing.

Jain, Kumar, and Agarwal (2022) addressed the issue of inadequate health insurance coverage in India, focusing on the "missing middle." Analyzing the current state of health insurance in India, the study considered the impact of government spending and the role of private insurance. By examining data from countries like the USA, China, and Canada, along with insights from hospitals and private insurers, the study explored ways to expand and make health insurance coverage more inclusive. The research highlighted the need for collaboration between the private and public sectors to achieve universal health coverage and reduce the insurance coverage gap.

Javaherkalam, Mohammad Hadi (2022) The author in their research examined the "duty of representation" in insurance obligations, focusing on how this duty helps balance information between insurers and insured individuals. This study aims to highlight the consequences of breaching this duty, whether through intentional misrepresentation or unintentional non­disclosure, and the impact on insurance contracts. The research method involves analysing Iranian insurance law and comparing it with English law to understand differences in rescission and avoidance remedies. Findings suggest that Iranian insurance law may have broader remedies for breaches, urging legislators and courts to consider more balanced approaches to address such issues effectively.

JuSeon Yoo (2022) The author addresses the outdated nature of traditional medical insurance claim methods in Korea due to the advancement of IT technology. The study aims to review proposed legislation aimed at modernizing insurance claim procedures to align with digital advancements. It highlights the importance of consumer-oriented digital processes in the insurance industry, particularly in simplifying medical insurance claims. The analytical approach taken considers real-world challenges and legislative proposals from the National Assembly. While emphasizing the potential efficiency gains and consumer convenience from simplified claims, the study also considers concerns from the medical community regarding patient information privacy and insurance subscription issues. Solutions to these challenges are proposed to implement efficient and cost-effective insurance claim processes for the future.

K. Sood, B. Kaur, & S. Grima (2022) This systematic review assessed the use of blockchain technology in the insurance industry. It highlights blockchain's potential for real-time information exchange among stakeholders and its role in reducing fraudulent claims and administrative costs. The research emphasizes the limited studies in this area and provides insights into blockchain applications in non-life insurance segments. The authors found that while some insurance companies are exploring blockchain for automated claims, fraud detection, and cash flow tracking, its adoption is still in early stages with unresolved issues.

Kadyan, Singh & Madhukar (2020) aims to understand the factors influencing the effectiveness of third-party administrators in health insurance claim settlement in Delhi and NCT, India. They explored how TPAs bridge the gap between insurers, policyholders, and healthcare providers, facilitating services like cashless hospitalization and smooth claim settlement. The study utilized qualitative methods to analyse policyholder perceptions, industry stakeholder support, and internal governance practices shaping TPA operations. The findings highlighted the importance of factors such as policyholder knowledge, communication, genuineness of disclosures, support from insurance agents and companies, network hospital collaboration, and internal practices in driving

Kaminskyi and Kaminska (2021) explored the role of assistance and insurance companies in providing travel, health, and transportation services. They investigated the theoretical principles ofinsurance assistance and analyzed the prerequisites for cooperation between these entities, aiming to establish the theoretical and organizational principles governing their collaboration. Their methodology focused on insurance assistance and assistance companies within the market for travel, medical, and motor transport services. The findings emphasize the essential role of assistance companies in the modern insurance market and highlight the growing cooperation between assistance and insurance companies to develop competitive insurance products, provide legal support, and manage financial aspects across various insurance sectors.

Kelli Pedersen (2019) examined the effects of the Affordable Care Act (ACA) on property and casualty insurers in the United States, particularly concerning medical malpractice policies. The study investigated changes in the number and dollar amounts of medical malpractice reports and their impact on industry net income. Using statistical tests and regressions on data from 2003 to 2018, including healthcare expenditures and insurance coverage, the study found that while the number of malpractice reports increased after the ACA, the dollar amount of claims decreased. However, these changes had minimal impact on property and casualty insurer profitability. The study highlighted the stronger influence of healthcare consumption expenditures on medical malpractice statistics compared to ACA-driven changes in insurance coverage.

Kenechukwu et al. (2023) This study tackled fraudulent health insurance claims using a combination of decision tree algorithms and principal component analysis (PCA). The objective was to enhance fraud detection by extracting meaningful patterns from the data. The developed method combined decision tree modeling with PCA for dimensionality reduction. While the decision tree algorithm performed well, PCA further improved results by reducing complexity. These findings suggest that these algorithms can aid in informed decision-making, trend identification, and improved fraud detection in healthcare. The study recommends implementing advanced fraud detection systems incorporating these methods, along with continuous monitoring, collaboration, research, and compliance, to enhance fraud detection and protect against financial losses in insurance and healthcare.

Khabiri (2023) This study provided an overview ofhealth insurance in Iran, focusing on health system financing and progress toward universal health coverage (UHC). It highlighted the challenges and outcomes of health insurance reforms, particularly the 2014 "Health Transformation Plan." The research used data from household income-expenditure surveys and health insurance coverage statistics to analyses the impact of insurance policies on catastrophic expenditures and population coverage. Findings indicated that while coverage increased after reforms, there were limitations in service coverage, increased moral hazard, and instability of resources, leading to challenges in achieving UHC. The study recommended various demand and supply factors to improve health insurance, infrastructure, services, and management capacity for successful UHC implementation in Iran.

Khan, Pijush et al. (2021) This study investigated how community, district, and state-level factors contribute to variations in health insurance coverage across India. Using data from the 2015-2016 National Family Health Survey, the study analyzed these variations and their impact on coverage inequalities. Multilevel regression models assessed the relative influence of contextual versus household socioeconomic factors on insurance coverage. The findings revealed that contextual factors at different population levels significantly contribute to variations in health insurance coverage, highlighting the need to address place-based differences in coverage to reduce disparities across regions and population groups.

Khatooni, Elham & Ahmadnezhad, Elham & Olyaeemanesh, Alireza & Majdzadeh, Reza (2023) aimed to understand why certain groups in Iran were without health insurance despite its availability. The authors conducted a matched case-control study comparing 89 uninsured patients with 178 insured controls from a public hospital in Tehran. Results showed that unemployment, being single, low economic status, and negative attitudes towards insurance influenced the lack of coverage. The study highlights the need to focus on vulnerable groups and improve education to ensure universal health coverage effectively and inclusively.

Kiranmayi, Vootukuri, Kumar, K.S., & V, Sureah (2023) aimed to explore the link between non-communicable diseases (NCDs) and out-of-pocket (OOP) medical expenses in India. They utilized data from the National Sample Survey conducted in 2018 to analyses the prevalence of NCDs and their association with OOP health expenditures. The study found a significant connection between NCDs and higher OOP health spending, with most expenses being covered by individuals themselves rather than health insurance. The research also highlighted variations in NCD prevalence across different states in India, emphasizing the need for a comprehensive strategy to tackle NCDs. The study recommends policy measures such as increased public health spending, expanded insurance coverage, and targeted programs for NCD prevention and management to alleviate the financial burden on Indian households.

Kononenko, Ganna (2023) delves into the challenges faced by insurance companies during wartime situations, particularly in the context of the Russian military aggression against Ukraine. The aim is to understand how insurance functions and adapts amidst such large-scale destruction and economic losses. The study emphasizes that insurance remains a crucial tool for risk mitigation even during war, despite the complexities in structuring insurance contracts due to individualized risks. The research highlights the importance of upholding insurance contracts during natural disasters and military actions, stressing that martial law should not be a basis for denying insurance claims. The findings underscore the direct correlation between war-related events and the resulting losses, emphasizing the need for tailored insurance solutions during wartime.

Korir (2020) studied health insurance in Kenya, focusing on the government's 1967 launch of the National Health Insurance Fund (NHIF). The study aimed to understand the concept, benefits, and growth ofhealth insurance in Kenya. Findings highlighted the continuous growth of premiums, claims, and expenses in the sector during the study period, emphasizing the importance ofhealth insurance plans for the insured Kenyan population.

Korzh and Svyatoshnyuk (2021) The authors in their research investigated the legal consequences of breaching voluntary health insurance contracts in Ukrainian law. This study focuses on unilateral contract refusals, contract modifications, and penalty payments in the context of voluntary medical insurance. It explores jurisprudence’s legal positions regarding these issues, highlighting the complexities and restrictions of contract termination. This research aims to understand the legal framework governing voluntary health insurance breaches, emphasizing the importance of such studies due to the increasing prevalence of such contracts in insurance structures and modern healthcare policy directions. The findings reveal specific freedoms and restrictions for parties involved in contract termination, including cases related to intentional and unintentional actions that impact insurance compensation.

Kullberg, Linn & Blomqvist, Paula & Winblad, Ulrika (2019) investigated voluntary health insurance (VHI) in Sweden, which has grown in popularity since 2000. Using national survey data to identify VHI purchasers and analyzing plans from major insurance companies, they found that VHI is more prevalent among high-income earners, private sector employees, business owners, and white-collar workers. However, these plans typically exclude pre-existing conditions, emergency care, highly specialized treatments, and ongoing chronic care. This suggests that VHI in Sweden primarily benefits healthy and affluent individuals, highlighting work-related factors as key determinants for uptake and the limited coverage available to those with significant healthcare needs.

Kumar, Sonjai (2022) conducted a critical analysis of India's health insurance sector, focusing on the contributions of government schemes and private insurance companies. Analyzing data on population coverage, premium contributions, and the roles of different sectors in health insurance provision, the study found that while government schemes cover a significant portion of the population, their premium contribution is relatively low compared to standalone health insurance companies. Public sector general insurance companies primarily handle bulk health insurance, including group and government schemes, while individual health insurance is dominated by standalone companies.

Kumari, Lavanya (2023) delves into the changing landscape of the insurance industry due to e-insurance, focusing on enhanced claim management strategies. The study aims to introduce the "Benefit Amount Settlement Ratio" (BASR) as an efficiency measure, especially for private insurance companies. By analysing secondary data, the paper explores how BASR can provide insights into an insurer's performance beyond traditional metrics like claim settlement ratio. The research highlights the importance of advanced technologies in reducing claim-payment costs and improving customer service, emphasizing the need for innovative measures to assess insurance industry performance accurately.

Li and Mamon (2022) The author examined the increasing trend of data breaches, post-2021 despite regulatory efforts, focusing on private health data. The author in this study utilised data from the Privacy Rights Clearing House and the US Department of Health service and Human Services to develop a modelling framework. The authors in this research found that the Markov- modulated non-homogeneous Poisson process (MMNPP) effectively modelled breach incident counts, whereas the generalised Pareto distribution captured breach sizes. The results of this research include obtaining cyber insurance premiums per institution and assessing risk using value-at-risk (VaR) and average Clearing House VaR measures. Notably, longer-maturity cyber insurance policies were found to be more cost-effective, with implications for improving data breach modelling and cyber risk management for institutions.

Lopo Martinez & Carvalho (2021) This study investigated earnings management practices among Brazilian health insurance companies (HICs) from 2012 to 2018, focusing on the use of discretionary accruals or operational decisions to avoid reporting low sustainability indicators. Using the Jones, Modified Jones, and Roy Chowdhury models, the analysis of data from the ANS website revealed that HICs did employ earnings management strategies for this purpose. These findings are valuable for informing health insurance clients and may encourage regulators to increase scrutiny ofHIC-related economic and financial risks.

M. Ronghangpi & N. D. Roy (2020) The author in his research examined the importance of life insurance and the need for a regulatory authority to resolve the disputed claims between insurers and insured individuals. This study aims to know the procedures and effectiveness of authorities in settling these disputes. It addresses the common issue where insurers fail to fulfil their duties after the policyholder's death and explores how aggrieved individuals can resolve such issues. Additionally, the research investigates fraudulent activities related to life insurance and the necessity of regulatory oversight to monitor insurers and policyholders during claim settlements.

Madushani, D.D.L. & Ruwan Buddhika, H.J. (2022) The research aimed to investigate the factors influencing customer satisfaction within the health insurance sector. They focused on customer awareness, perceptions about providers, and the impact of lifestyle and policy types on satisfaction. Data was gathered using structured questionnaires from 152 health insurance policyholders through convenient sampling. Findings indicate lifestyle issues, customer awareness, and policy types significantly affect satisfaction, while claim settlement had a moderate relationship. The study makes the importance of customer satisfaction for insurance business growth, suggesting that companies focus on these factors to enhance market share and engagement.

Malhotra, Rashmi et al. (2017) sought to evaluate life and health insurance firms' financial standing during the 2007-2009 financial crisis, which had a major impact on financial institutions. Based on return on equity, investment yield, and loss ratio between the years 2009 and 2014, the study assessed ten insurance companies. A comparative examination of important financial parameters was the research methodology used. The results brought to light the difficulties that the health and life insurance sector experienced, which caused several companies to consolidate or leave the market as a result of persistent growth issues that persisted even years after the economic crisis.

Manurung, Qhairul (2023) conducted a normative juridical study to address legal protection concerns for customers affected by the conversion from conventional insurance to general Sharia Insurance. The aim was to assess the legal safeguards available to customers during this transition. The research highlighted the need for a clear format and solution from insurance companies, particularly PT Zurich Insurance Indonesia, to provide legal certainty and protection for clients who choose not to transfer their policies to Sharia General Insurance. This study underscores the importance of legal frameworks in ensuring consumer rights and transparency during insurance policy conversions.

Meenakshi, A. & Shree, S. (2019) This study examined customer satisfaction with health insurance in India, aiming to understand consumer perceptions and awareness and explore ways to improve coverage and reduce hospitalization costs. Analysing data on health insurance coverage and assessing consumer awareness and preferences, the study found low coverage (11% of the population) and emphasized the urgent need to expand coverage, increase awareness, and limit out-of-pocket expenses to improve healthcare accessibility and financial security.

Meitei, Moirangthem & Singh, Haobijam (2021 The research aimed to analyse health insurance coverage and identify associated factors within India's north-eastern region. Data from the National Family Health Survey (NFHS-4) were used to understand the factors related to health insurance coverage across the eight north-eastern states. Using logistic regression analysis, they found that Arunachal Pradesh and Tripura had the highest coverage rates, while Manipur, Nagaland, and Assam had the lowest. Socioeconomic factors like household banking and below poverty line (BPL) status significantly influenced insurance coverage. The study underscores the importance ofhealth insurance in preventing financial hardships due to medical expenses, especially in regions with low coverage like the north-eastern states ofIndia.

Michael Zaki, Robert LaSala, Donald Saltmarsh, Amos Gern, and Jean Eloy (2021) investigate the lack of exploration of professional liability during graduate medical education, leading to a limited understanding of medical malpractice liability coverage among new physicians. This study explores the intricacies of malpractice insurance for new otolaryngologists to address this gap. The research emphasizes the importance of malpractice insurance for new physicians due to potential high costs associated with defending malpractice claims. It provides insights into choosing insurance carriers, negotiating policy options, and understanding expectations during legal suits. The study offers a comprehensive review of coverages, limits, exclusions, and carrier considerations to assist new otolaryngologists in making informed decisions regarding their malpractice insurance.

Mohi and Kazim (2022) conducted a study to evaluate how financial health factors impact the success or failure of companies, focusing on the insurance sector. The aim was to help stakeholders understand the financial performance of these companies better. They used an analytical approach based on primary and secondary data, utilizing total financial ratios as tools to measure performance and predict potential failures. The study analysed strengths and weaknesses through ratio interpretation for a sample of insurance companies, comparing their ratios to industry averages. Financial ratios are valuable tools for evaluating performance over time and comparing it to industry benchmarks. The findings aimed to provide insights into strategic issues within the insurance sector related to financial health and success metrics.

Monahan, C. H. (2016) The author in his research examines the gaps in legal protections for individual health insurance within the Affordable Care Act (ACA). This study highlights instances of insurers not complying with ACA requirements despite the mandate for comprehensive coverage. It argues that existing state enforcement methods are insufficient and proposes a solution through the recognition of an "implied warranty of legality" by courts. This approach aims to ensure insurers and policies adhere to ACA standards, empowering consumers to take legal action against violations and fostering accountability in the insurance market. The findings suggest that implementing such a warranty could mitigate power imbalances, encourage compliance, and potentially be applied to other regulated markets facing similar challenges.

Mulhadi, D. H., & Harianto, D. (2022, July) The authors in their research explore s whether insurance companies frequently violate their contracts with policyholders. This study, based on 42 court decisions, reveals a high rate (80.95%) of breaches by insurers. These breaches often involve denying claims to policyholders, citing legal reasons, yet courts tend to rule in favour of the insured or their beneficiaries. The research aims to highlight potential unfair denials of coverage by insurers and suggests that policyholders who face such denials might seek legal recourse successfully.

Murzagaliyeva, Elnura & Askarova, Ainura & Omurzakova, Umut & Abdyrakhmanova, Gulchehra & Khalilov, Atakhan (2023) examine the state of personal insurance in the Kyrgyz Republic, focusing on its importance in stabilizing the population's welfare. The study delves into legislative definitions related to insurance activity and personal insurance contracts, alongside classifications of personal insurance types. It analyses the dynamics of insurance premiums and payments among leading insurance companies in Kyrgyzstan during the COVID-19 economic crisis. The findings reveal an overall increase in personal insurance volumes, particularly in premiums and payments, during the crisis period. The study reveals a slower development in life insurance segments. The research aims to highlight key areas for enhancing the progressive growth of personal insurance, especially in life insurance services, in the Kyrgyz Republic.

Muthu (2019) conducted a study focusing on health schemes offered by selected health companies in India. The aim was to understand how these schemes operate and provide coverage against medical expenses for individuals. The research likely involved analysing different health insurance policies, their benefits, premiums, and coverage areas. Based on the study, the author aimed to provide insights into the functioning and effectiveness of health insurance schemes in India, which are crucial for managing healthcare costs and ensuring financial protection for policyholders.

Nagendran, Nagalakshmi & Muthu, M. Vinoth. (2019) The authors in their research aimed to study the importance of claim settlement in life insurance services, focusing on prompt settlement as a crucial aspect for policyholders. The research delves into how claim settlement impacts insurance companies' revenue streams, especially considering that life insurance serves as both risk coverage and investment. This study specifically analysed the claim settlement ratios of leading life insurance providers like LIC, HDFC, SBI, and Aviva, It also noted an increase in claims alongside policy growth, underscoring the need for clear and efficient claim settlement processes to maintain trust and transparency in the insurance sector.

Najar, Parwaiz (2022) carried out a study examining the connection between health insurance, medical tourism, and the perception ofIndia as a travel destination. Analysing the consequence ofhealth insurance on the impression ofIndia as a destination for medical tourism was the goal. The study examined the body of research on health insurance and medical tourism in India using text analysis and a systematic mapping study. The report highlights how crucial creative health insurance models are to establishing India as a desirable medical tourism destination. Results indicate that the rise in health insurance has a beneficial impact on medical tourists' perceptions of India, presenting it as a cost-effective, sustainable travel destination with high- quality medical facilities.

Nasution, Regi & Rahma, Tri (2022) The authors in their research focused on Prudential Syariah as an insurance option tailored for Indonesia's Muslim population, providing Sharia- compliant financial help such as life insurance and asset management. This study aimed to explore the claim settlement process specifically at PT Prudential Syariah Prestasi Binjai. Qualitative methods like literature reviews and interviews were used to gather insights from company sources. The findings indicate that while Prudential Syariah offers long-term protection with investment benefits, successful claiming depends on adhering to policy procedures and completing specific claim forms.

Nayak, H. (2019) The author in their research examined the development of the insurance sector in India, highlighting its significant recent expansion yet noting low insurance penetration. This study particularly focused on the promising life insurance sector, anticipating widespread coverage and rapid growth. It identified regulatory changes and foreign investment as key drivers for future development. Challenges included potential hesitance from foreign insurers due to management control issues. The research emphasised the substantial opportunity for future expansion within the Indian insurance market.

Nicolae Sadovei (2023) The author in his research examined into the legal complexities of Moldova's compulsory health insurance law (Law No. 1585), focusing on the dynamics among insured individuals, insurers, and healthcare providers. Through qualitative legal research, the author examines legal interactions under this framework, analyzing legal documents and case studies. The findings emphasize the distinct yet interconnected legal relationships within Moldova's healthcare system, revealing challenges and dynamics impacting stakeholders. This sheds light on the implications and complexities arising from Law No. 1585, providing valuable insights into the healthcare landscape and legal framework in Moldova

Nil, Shachie & Nil, Sapna (2024) This study investigated the relationship between employment security, psychological contract fulfillment (PCF), and organizational citizenship behavior (OCB) in the Indian life insurance sector. Using empirical methods, it analyzed how job security (JS) influences employees' discretionary behavior toward the organization and colleagues. The goal was to understand how enhancing job security and fulfilling the psychological contract can improve OCB. The findings provide insights for life insurance managers on promoting positive employee behavior and productivity by focusing on these factors.

Nishida et al. (2023) investigated how multimorbidity patterns affect medical costs in Japan's working-age population. Using a cross-sectional study ofinsurance claims data from the Japan Health Insurance Association, they identified 30 latent classes of multimorbidity among patients with high medical costs. Kidney disease incurred the highest per capita costs, while metabolic syndrome (MetS), driven primarily by hypertension, dyslipidemia, and type 2 diabetes, accounted for a significant portion of total medical costs. MetS classes involving cardiovascular diseases or complex conditions, such as malignancies, were key factors influencing both medical costs and mortality rates, highlighting the substantial impact of these conditions on healthcare expenses and patient outcomes.

Niv and Tal (2024) focused on managing medical professional liability insurance to prevent medical accidents and defend against lawsuits. They aimed to outline a successful safety model for medical malpractice insurance, emphasizing four goals: engaging medical institutions in risk management, increasing therapist involvement, promoting systemic learning and cooperation, and efficiently handling claims. The study highlighted the need to improve treatment quality and safety, reduce complaints and claims, lower payment amounts and premiums, regulate double insurance, and shorten claims processing times. The research also discussed the introduction of self-insurance models in Israeli hospitals and emphasized the importance of transparency and information sharing in claim processes to prevent medical errors and improve healthcare quality.

Okamoto, Etsuji (2013) investigated the linkage rate between health check data and health insurance claims in Japan's National Database (NDB) to assess the reliability of linking these datasets for research. Using hash functions, the study compared observed medical charges among health check recipients with expected charges assuming complete record linkage. The findings revealed a low linkage rate of 14.9% in the NDB, with higher rates observed for women and elderly adults. This low linkage rate suggests that linking health check and insurance claims data may be unreliable due to discrepancies in data formats, such as names and birth dates, highlighting the need for improved data linkage processes.

Osterrieder (2023) explores strategic management challenges facing insurance companies, focusing on the future of mobility, digital applications, customer satisfaction, and collaborations with MGA-InsurTechs. The study aims to understand how these areas impact insurance operations and to develop strategies for addressing emerging risks and opportunities. Reviewing literature on mobility trends (autonomous, shared, and electric vehicles), demographic shifts, digitalization, sustainability, and urbanization, the study also investigates the opportunities and challenges presented by digital technologies like AI and cloud computing through academic and industry research. The findings contribute to strategic measures that enable insurance companies to navigate evolving risk exposures and meet changing customer demands in the digital age.

Otieno and Namyalo (2023) examined the challenges and opportunities within Uganda's health insurance system, focusing on the 2019 National Health Insurance Scheme Bill. Highlighting the lack of a legal framework and limited population coverage, the study explored the prevalence of community-based and private medical insurance. Their aim was to understand the complexities of Uganda's health sector and the potential impact of the proposed policy on health outcomes and universal coverage, pending presidential approval.

P. K. Pandey (2017) explored the effectiveness ofhealth insurance as a financial support tool for medical expenses through cashless treatments and reimbursements. The study aimed to clarify the impact of recent regulatory changes on the health insurance industry, focusing on the roles ofhealth insurance companies, policyholders, third-party administrators (TPAs), and network providers. It examined recent regulatory changes implemented by the IRDA to improve the smooth functioning and development ofhealth insurance in India.

Padmavathi et al. (2022) The author aimed to investigate the socioeconomic profile ofhealth insurance policyholders and analyse the correlation between their awareness levels and satisfaction with health insurance services. This study also assessed policyholders' perceptions of services provided by health insurance companies. Data from 100 samples were collected from two selected health insurance companies in Mysore City through primary sources. This research found that most policyholders agreed that purchasing a health insurance policy is easy and less time-consuming. However, there is a need to streamline procedures for policy surrender and reduce documentation during claim settlements. The study also revealed that most policyholders were male and from older generations, showing high awareness and satisfaction with the services provided by insurer in the Mysore City.

Pandeeswari (2023) The author examined the ethical concerns surrounding health insurance provision in Tamil Nadu, India. The author’s objective for this research was to recognize and address moral dilemmas in the planning, implementation, and oversight of health insurance programs, which are essential for ensuring healthcare access and financial stability for individuals and families. Through the examination of critical ethical issues such as fairness, openness, and equality, the author provides recommendations and solutions for policymakers, healthcare professionals, and insurance companies in Tamil Nadu. The author in this research gives emphasizes on the significance of ethical principles in health insurance practices, focusing on accessibility, affordability, privacy protection, and compliance with regulations. This research’s findings emphasise the need for reasonable premiums, coverage for pre-existing conditions, and comprehensive healthcare access to promote ethical health insurance practices. Pareek Ph.D., Manoj (2018) aimed to explore the growth potential and challenges in marketing health insurance in India. They analysed the rapid growth of the health insurance market in India, noting a 24% growth in fiscal year 2017 with significant premium amounts and market share. Despite this growth, only 25% of the population is covered by health insurance, indicating substantial room for expansion. The study delved into the opportunities and obstacles faced by insurance marketers in successfully promoting health insurance products in India, shedding light on the factors that impede the market's growth.

Park et al. (2019) sought to assess how well the top 41 private insurance providers in the US covered clinically significant pharmacogenetic testing. They looked for medical policies pertaining to 34 popular and clinically significant pharmacogenetic tests on the websites of these businesses. The study focused on gene-drug indication groups (GDIGs) and examined the coverage of these tests by company and gene-drug pair. The frequency with which each GDIG was mentioned in the policies was one of the outcome metrics. The results shed light on the disparities in pharmacogenetic test coverage among various insurance providers, offering a better understanding of the US private health insurer market.

Patricia Born and J. Karl (2016) This study explores the relationship between tort liability system reforms and changes in the medical malpractice insurance market, aiming to determine if such reforms improve deteriorating market conditions. Using data from the mid-2000s, the study found little evidence that tort reforms led to market improvements. While these reforms can reduce insurance losses and increase insurer profitability, they may not effectively address broader market deterioration. The research suggests that factors beyond tort reforms significantly influence the stability of the medical malpractice insurance market.

Patricia Danzon, Andrew Epstein, & Scott Johnson (1986) examine the medical malpractice insurance crisis experienced by many states since 1999. The study aims to know the factors contributing to the crisis and the effects on healthcare services. The authors discuss the significant premium increases for medical professionals and the withdrawal of major insurers from the market. The study highlights the reforms adopted by states, such as caps on noneconomic damages and establishment of joint underwriting associations, to address the crisis. The findings indicate mixed results regarding the effectiveness of these reforms in moderating premium increases, with states implementing tort reforms experiencing lower premium growth.

Pattnaik, Amarendra, Misra, Satya, Kumar, Propf, & Ghadai, Sanjaya (2019) aimed to compare customer satisfaction in government- health insurance schemes with private health insurance alternatives in India. This study, conducted in Bhubaneswar and Cuttack, Odisha, sampled 400 individuals to assess parameters like value for money, affordability, claim settlement process, and amount for both types of insurance. The findings revealed that overall satisfaction with government-sponsored schemes was higher due to their lower costs compared to private schemes. However, the study did not consider factors like age or education in determining satisfaction levels, indicating a preference for government schemes among lower- income groups due to the high premiums and processing complexities of private insurance.

Pattnaik, Misra, & Ghadai (2019) aimed to emphasize the critical nature of claim settlement in health insurance, highlighting its impact on patient anxiety and financial well-being. The study focused on how Health Insurance Companies (HICs) handle claim settlements, which represent the "Moment of Truth" for customers. The article discussed how failures in claim settlement led to high out-of-pocket expenses and financial hardships for patients, affecting customer satisfaction and overall Health Insurance penetration. It also addressed challenges such as procedural non-compliance and fine print conditions that can hinder smooth claim settlements, impacting the business model of HICs and the expansion of the Health Insurance Market (HIM).

Paul, Suchismita & Sarkar, Soumitra (2023) examined the current situation of the Indian health insurance market, emphasising developments, obstacles, and potential solutions. Because government healthcare funding is limited and medical costs are on the rise, the study sought to emphasise the value of privately purchased health insurance in addition to government-sponsored programs. Here are a few ways to rewrite the provided text, focusing on clarity, conciseness, and improved flow. Using past data, premium growth, underwriting profit, and other measures, the study evaluated industry performance. Results showed that underwriting was negatively impacted by ineffective risk pooling and unregulated private healthcare expenditures. The report recommended long-term business models, including managed care, to increase market share and suggested combining an indemnity model with risk-sharing for better cost management.

Polontoh (2024) Thanga, James, Lalremruati, Ashley, and Lalmuanpuia (2023) The authors analyzed the factors influencing the demand for life insurance to understand how the life insurance industry affects the Indian economy. In this the authors of the study hope to emphasise the sector's role in fostering economic growth and the necessity of strategic financial planning by building on earlier research that linked life insurance and economic variables, which was conducted by the same authors. The authors investigate the connection between the economy and the life insurance sector by applying established economic theories and data analysis techniques. In their conclusion, the study's authors stress the need of keeping an eye on and fostering the relationship between the economy and the life insurance sector because it benefits both parties.

Polontoh (2024) The author examined the insurance providers’ legal obligations with respect to unpaid claims. This study examines the legal protection provided to insurance participants, as well as the fallout when policyholders deny claims. Using normative legal research methods, data were gathered through a literature review and analysed qualitatively. The findings reveal that insurance companies facing unpaid claims can face civil and criminal legal consequences, with policyholders having recourse to bankruptcy through the court. The study highlights the regulatory framework, including laws on Consumer Protection and Insurance, providing legal protection for insurance policyholders as consumers.

Poonam Rani and Payal Chauhan (2022) This research focuses on the growth and development ofhealth insurance in India, exploring how premium-based insurance can expand access to quality healthcare. Highlighting the cost disparity between public and private healthcare, the study emphasizes the need for risk pooling to alleviate the financial burden on the poor. Using secondary data from sources such as WHO reports, IRDA data, and relevant research articles, the study underscores the untapped potential of the Indian health insurance market, particularly among the middle-income group.

Prawira, Khairul & Hindarto, Djarot & Indrajit, Eko (2023) discuss the importance of implementing enterprise architecture for companies, especially in the insurance sector. The aim is to highlight how business architecture supports insurance companies in providing optimal services to customers. The study emphasises the unique operational aspects of insurance companies compared to other financial service providers like banks or fintech companies. It focuses on structuring essential business processes such as sales, administration, claims, and financial processes to enhance operational efficiency and customer service. The research method involves analysing the operational forms and processes within insurance companies to identify areas for improvement and optimization, leading to better service delivery.

Probst, Ursula (2022) examined the challenges faced by migrant sex workers from eastern EU countries in accessing health insurance in European countries like Germany. The study aimed to understand how neoliberal reforms and privatization in European health care systems have created barriers to health insurance access, especially for marginalized groups. Through ethnographic research in Berlin, the study explored how racial, class, and sexual biases influence health insurance policies, portraying health insurance as a privilege rather than a right for certain individuals. Findings highlight the moral complexities and exclusions within health insurance systems, revealing a shift towards restrictive notions of citizenship and belonging that undermine universal health care aspirations in Europe.

Rajendran (2022) The author aimed to explore the natural disaster claim settlement in India, focusing on general and health insurance. This study aims to analyse factors affecting insurance policies like policy issuance, net incurred claims, profit, and claim settlements and it evaluates claim performance using metrics like claim settlement ratio, claim pending, and claim repudiation ratio. The researcher uses qualitative and quantitative interviews to assess the impact of the pandemic, noting a trend of economic recession with decreasing profits but increasing claims. The study focused on the need for insurers to adapt to remote work, enhance cybersecurity, and simplify claims processing amid the ongoing pandemic.

Rajendran, Saroja Devi (2022) aims to study natural disaster claim settlements in India, focusing on general and health insurance sectors. The research period spans from 2019 to 2021, analysing claim management procedures through statistical tools like percentage analysis to measure companies' claim settlement efficiency, particularly in terms of time taken. The research evaluates factors like policy issuance, net incurred claims, profits, and claim settlements. It uses metrics such as claim settlement ratio, pending claims, and claim repudiation ratio to assess claim performance. The study explores how natural disasters have increased policy issuance in various industries and examines the impact of aggressive marketing strategies by private insurers on consumer risk awareness.

Ramadhani, Anastasia & Muazaroh, Muazaroh (2023) conducted a study to explore how financial performance impacts the stability of general insurance companies. This quantitative research used statistical analysis to examine data from 49 conventional insurance companies registered with the Financial Services Authority in Indonesia. The study found that liquidity ratios positively influence the companies' stability, and profitability ratios also contribute significantly to their soundness. The implication drawn from these findings is that insurance companies can maintain their health by ensuring adequate levels ofliquidity and profitability. Ramya N (2023) conducted a study to understand why health insurance policyholders in Erode District prefer Standalone Health Insurance Companies (SHICs). Health insurance is crucial for managing risks and uncertainties in life. While it's well-established in many countries, the Indian market, particularly for SHICs, is still developing. The objective of this research is to explore the determinants of public policy choice within the context of SHICs. The study uses a qualitative approach, likely interviews or surveys, to gather insights into policyholders' attitudes and preferences regarding health insurance. The findings will shed light on the unique appeal of SHICs and their growing importance in the healthcare landscape.

Rares-Vasile Voroneanu-Popa, Richard Constantinescu, Veronica Ciocan, Mircea Lazar, & Beatrice Ioan (2022) conducted a study on malpractice insurance and professional liability in Romania. The aim was to analyse Romanian legal provisions regarding medical malpractice and insurance, focusing on how these are reflected in insurance contracts. The researchers analysed six professional liability insurance contracts from Romanian insurance companies. They observed that while malpractice insurance is mandatory, coverage is limited to certain damages, and contracts vary in clauses. This variation can pose challenges for doctors lacking adequate knowledge. The study emphasizes the need for a well-defined legal framework to address potential issues comprehensively in the medical field.

Renukadevi and Santhanakrishnan (2023) The author's study aimed to examine the role of health insurance in India, focusing on its function as pre-purchased coverage enabling individuals and groups to access quality healthcare through premium payments. The study discussed various national health indicators, including infant and maternal mortality rates, life expectancy, and birth and death rates, highlighting improvements in these areas over time. Consistent with findings in the Eleventh Plan, the study also noted the higher cost of healthcare in the private sector compared to the public sector. To address the healthcare burden on the poor, the study group recommended exploring risk-pooling systems.

Reshmi et al. (2021) This study aims to conduct a systematic review of interventions in India designed to promote health insurance awareness and uptake. The review will analyse the effectiveness of these interventions on both awareness and actual enrolment. Following Cochrane handbook, the review will include various types of studies focusing on adult populations (>18 years) in India and will consider interventions, policies, or programs related to health insurance awareness. The study will look at outcomes such as health insurance literacy, attitudes towards buying insurance, actual enrolment rates, and factors influencing awareness and uptake. The review will utilize databases like MEDLINE, Web of Science, and Scopus, along with government websites, to gather relevant data. The findings will be categorized and analyzed using quantitative, qualitative, and mixed-methods synthesis to provide insights into promoting health insurance awareness and uptake in India.

Roshani, Puja et al. (2022) aimed to understand consumer behaviour in the health insurance sector in India. They analysed factors influencing consumers' awareness and decision-making in choosing health insurance policies. The study utilized data on consumer awareness levels and the variables influencing policy selection. Findings indicated a growing awareness among Indians regarding the importance ofhealth insurance, leading to rapid expansion in the medical insurance market. Factors such as policy characteristics and benefits significantly influenced consumers' decisions in choosing and retaining insurance policies. The study highlights the impact of increasing income levels, demographic shifts, and the prevalence of lifestyle diseases on healthcare expenditure and insurance product choices in India.

Rothstein (2023) discusses the Metropolitan Life Insurance Company's health education programs based on historical perspectives. The aim of the study is to explore how insurance companies, particularly Metropolitan Life, contributed to public health through educational campaigns. The research method involves analysing historical documents and records to understand the company's initiatives and their impact on public health awareness. The findings highlight the significant role played by Metropolitan Life in promoting health education, offering free nursing care, and raising awareness about personal behaviours affecting health. This campaign positioned the company as a key player in public health efforts during the early 20th century, showcasing the potential of insurance companies in societal welfare beyond traditional insurance services.

S. Sawalka, A. Lahiri, & D. Saveetha (2022) The author in his research addresses the crucial role that health insurance plays in handling medical emergencies, the study will look at issues including fraud and data breaches. The aim of this research is to improve medical data access security, efficiency, and openness while placing a high priority on protecting patient privacy. The researchers suggest a blockchain-based claims model to accomplish this, which eliminates middlemen and enables direct communication between policyholders, hospitals, and insurance companies.

S.A., Senthilkumar & R., Ramamoorthy (2013) This study explored the Indian health insurance market and its implications for national development. Examining the evolution of health insurance products, growth trends, and future expansion potential through a qualitative approach, the study found that the Indian health insurance sector is growing, with significant opportunities for expansion, particularly by focusing on specialized policies and reaching rural populations for broader social development.

Sachan & Srivastava (2023) evaluated the financial performance of Indian general insurance companies (GICs) and standalone health insurance companies (SHICs) using Grey Relational Analysis (GRA) for the years 2019-2020 to 2021-2022. GRA is a practical method to analyses real-world data effectively. The study ranked 23 GICs and 4 SHICs based on their financial performance scores. Shriram Insurance ranked first among GICs, while Care Health Insurance topped the SHICs. The findings suggest that insurance firms should pay attention to profitability and operating ratios to enhance their financial standing. This research provides valuable insights for stakeholders in the insurance sector to make informed decisions regarding financial strategies and performance improvement.

Samhadaneh, Ahmad & Al-Rafai’e, Ameen (2023) aimed to understand the legitimacy of insurance contract termination conditions set by insurers. The study aimed to determine the legitimacy of this clause, concluding that it aligns with general legal principles and constitutes a valid voluntary termination provision. The study focused on defining and analysing these conditions, including their objectives, characteristics, and legal implications. Results showed that most insurance contracts include a clause allowing insurers to terminate the contract voluntarily before the legal timeframe without infringing on the insured's rights.

Schilling, Raphael & Pavlova, Milena & Karaman, Andrea (2023) attempted to ascertain the preferences of German health insurance clients about the medical services that insurance firms offer. The results showed that consumers place a high value on preventive health services that have immediate therapeutic advantages, such as health programs, care management, and initial exams. These preferences held true for different population segments, indicating that in order to successfully satisfy consumer expectations, health insurers should concentrate on these essential services.

Seelam (2023) This study examined the role ofhealth insurance in India's social and economic advancement. It analyzed the development of the health insurance industry, the available insurance options, and market growth. The study highlighted how the entry of private and independent insurers broadened product variety and underscored health insurance's importance in advancing social security. It also identified potential for growth, particularly through specialized policies targeting rural areas for social development. The research methodology involved a thorough market analysis to assess the industry's growth and potential avenues for expansion.

Seim, Asbjorn et al. (2007) aimed to identify the characteristics of companies that purchase private health insurance in Norway. A postal survey was administered to a sample of 2,500 companies, each employing at least two individuals, in the spring of 2005. The response rate achieved was 0.43. Using logistic regression, they analysed the likelihood of companies buying health insurance. The study found that around 1.8% of the Norwegian population, mainly through collective insurance contracts, had private health insurance by 2007. Companies with higher profitability, younger employees, higher education levels, and those in high-risk sectors like agriculture and forestry were more likely to purchase private health insurance. The study suggests that future demand for private health insurance in Norway is potentially influenced by factors such as tax incentives, waiting periods for treatment, and the profit margins of insurance providers.

Sengar, Vineet, & Mittal, Shivi (2019) aimed to explore the recent trendsand challenges in insurance sector in India. They observed that health sector has become the essential financial tool for individuals managing healthcare needs. The study noted a demand for health insurance due to increased education, awareness about health, and improved living standards, particularly among the middle-income group and youth. The Government initiatives and tax incentives have further fueled the development of the health insurance company, with substantial revenue and premium growth seen in recent years. However, challenges such as consumer-driven demands, technological advancements, claim settlement issues, and changing customer needs pose hurdles for industry players despite the growth opportunities.

Shoviana and Rohmah (2023) This study compared the financial health of government­managed Sharia and non-Sharia insurance companies within BUMN during the COVID-19 pandemic in Indonesia. Using purposive sampling, data were collected from ten insurance companies and analyzed using a paired difference test. The findings revealed that both Sharia and non-Sharia companies demonstrated healthy levels of liquidity, return on assets (ROA), return on equity (ROE), and risk-based capital (RBC) ratios, but not in solvency ratios. The study suggests that both types of companies exhibited comparable financial health. Limitations include incomplete data for certain companies and the reliance solely on financial ratios for assessment. Future research is recommended to incorporate operational and administrative factors using a mixed-methods approach (combining quantitative and qualitative methods) for a more comprehensive analysis.

Siddiqui (2022) examined the productivity and efficiency of independent health insurance providers in India between 2014-15 and 2018-19. The study sought to offer insights for practitioners and policymakers by using data envelopment analysis based on reports from the IRDA. It was discovered that during the study period, the average efficiency of independent health insurers was 64.78%, with a variance of 30.19%. The primary inefficiencies were caused by high commission and operating costs as well as problems with equity capital. The study also found that efficiency and technology advancements were responsible for a 19.11% yearly rise in total factor production. For those making decisions in the health insurance industry, these findings provide useful information.

Singh et al. (2021) This study examined how health insurance businesses are using Internet of Things (IoT) technology to transform their service models and enhance the client experience. The chapter explores how IoT is changing business processes and impacting both policyholders and enterprises. It also discusses the obstacles and difficulties that come with integrating IoT in the health insurance sector. The results draw attention to the possible advantages and difficulties of incorporating IoT into health insurance firms' operations.

Sonal, S. (2022) The author in his research examines the historical origins of insurance in India, referencing ancient texts such as Manusmriti, Dharmasastra, and Arthashastra. This study aims to assess how effective Indian legal provisions are in combating insurance fraud. Using a doctrinal qualitative legal research method, the investigation delves into various types of insurance fraud, including consumer and practical fraud, and compares insurance fraud prevention laws between India, New Jersey, and West Virginia. The findings aim to provide insights into potential enhancements or adjustments required in legal frameworks to better tackle insurance fraud across these regions.

Sonjai Kumar (2022) This research critically analyzes the health insurance business in India, examining its development and highlighting the disparity between government schemes, which cover 61% of the population but contribute only 11% of total premiums. Public sector general insurance companies dominate health insurance, handling group and government schemes, while standalone health insurance companies contribute significantly to individual health insurance premiums, accounting for 20% of the total premium with a 73% contribution.

Stern (2007) The author examined the emergence of the bad faith and subsequent breach of contract which is primarily against insurance companies and its potential extension to health maintenance organisations (HMOs). This study aims to discuss the basis for comparing insurers with HMOs, the grounds for initiating a bad faith breach lawsuit and the implications for both HMOs and consumers. This research analyses how this relatively new cause of action may impact industries beyond insurance, particularly those serving the public interest like HMOs. This research is primarily based on legal analysis and discussions surrounding present litigations and public awareness regarding bad faith breach cases against HMOs.

Stern, Joanne (2007) explores the potential extension of the tort of bad faith breach of contract to health maintenance organisations (HMOs). The aim is to analyse whether this legal concept, primarily applied to insurance companies, could also be relevant to HMOs due to their role in serving the public interest. The study discusses the basis for comparing insurers and HMOs, the legal grounds for initiating a bad faith breach suit, and the implications for both HMOs and consumers. It is suggested that as more bad faith breach cases are litigated against HMOs, this tort may be extended beyond the insurance industry to encompass other sectors like healthcare. Stream, Chris (1999) investigated the state-level health insurance market reforms the United States, particularly focusing on small group insurance reforms. The study aimed to understand why these reforms gained popularity and which factors influenced their adoption by states. Using a pooled cross-sectional time series model, the research analysed factors such as regulatory environment, state fiscal health, severity of the problem, and neighboring states' activities. Findings indicated that these factors significantly influenced the adoption of low group health insurance market r, highly ghting the role of states as leaders in healthcare reform in the absence of federal action.

Sugita, Yone (2013) explored Japan's health-insurance reforms during the Asia-Pacific War from 1937 to 1945. The study aimed to understand the nature of these reforms and their historical significance. It focused on three aspects: increasing the number of insured individuals, changing payment systems for physicians, and improving access to medical facilities. The article hypothesized that Japan's health insurance, originally designed to support workers' health and economic needs, evolved during wartime into quasi-public assistance programs reliant on state funding. This transformation laid the groundwork for increased health-insurance spending in the post-war period.

Surahio et al. (2019) aimed to assess health insurance satisfaction among insured individuals and the financial profitability of the companies offering these products. The study focused on whether health insurance meets client expectations and if it contributes significantly to the financial success of insurance providers. Primary data was gathered using a questionnaire from 70 respondents. The findings suggest that employees are moderately satisfied with employer­based health insurance, and there isn't a significant difference between premiums paid and benefits utilized. This indicates that health insurance products may not be highly profitable for insurance companies.

Suto et al. (2023) conducted a scoping review to understand how health insurance claims data are utilized in healthcare research in Japan. They searched databases for studies up to April 2021 and analysed 1,493 studies. The most common diseases studied were related to circulatory, endocrine, nutritional, and metabolic systems, along with neoplasms. Key research themes included medical treatment status, intervention effects, and clinical epidemiology. Different types of claims databases focused on varying diseases and themes. Some studies assessed the validity of claims data definitions and compared them with other data sources, mostly hospital based. The findings underscored the diverse use of claims data in healthcare research, highlighting its importance for informing healthcare policy and management in Japan. Suyoko, S., Sarwo, B., & Kuntjoro, T. (2019) The authors in their research conducted research at Telogorejo Hospital, Semarang, focusing on how hospitals handle patients' medical information for insurance purposes and the challenges they encounter, particularly with third parties like insurance companies. They used a juridical sociology approach with analytical description, gathering data through observations, interviews, and questionnaires, and analysing it qualitatively. A sociological understanding emphasizes the influence of people's social background on their health and healthcare quality. The findings revealed that while the hospital allows access to medical information for partnered insurance companies, patient permission is required otherwise, impacting reimbursement rights. This situation calls for improved patient information handling practices and government guidance to address legal responsibilities and external factors influencing hospital duties, such as insurance regulations and understanding. Svyatoshniuk (2023) The author conducted research on the pervasive but often inaccurate interchangeability of the terms "health insurance" and "medical insurance," which leads to confusion. The aim of this study is to distinguish between these concepts by focusing on their legal implications and implications for insurance and healthcare provision. An analysis of the legal frameworks and definitions reveals the difficulties in providing medical services based on insurance principles and concepts. The key findings emphasize the importance of accurately comprehending these terms to prevent misinterpretation and ensure proper legal and practical applications in the healthcare industry.

Tatjana Dimov (2018) The author in his research explored the concept of subrogation in property insurance, aiming to clarify its role and benefits. The study highlights how subrogation helps uphold insurance principles like indemnity and prevents double recovery. It distinguishes subrogation from recourse, explaining that subrogation transfers the policy holders rights to the insurance company, who can then claim compensation from the at-fault party. This research emphasises the importance of subrogation in ensuring insurers are not exploited for profit and can recover claim pay-outs from responsible parties, maintaining fairness and accountability in insurance agreements.

Tkachenko, Nataliia & Kyrylenko, Serhiy (2023) aimed to explore the role of insurance companies as institutional investors and their engagement in investment life insurance services. The study focused on understanding how insurance companies respond to dynamic market challenges by introducing innovative products like investment life insurance. The authors aimed to identify the attributes and differences of investment life insurance compared to traditional life insurance and outline prospects for its development in the domestic insurance market. This research used qualitative methods to analyze insurers' activities as institutional investors and their ability to offer investment financial services, especially investment life insurance. The findings highlighted the distinct features of insurance companies' functioning in the context of investment-oriented life insurance.

Tom Baker (2004) delves into the complexities of the liability insurance underwriting cycle, particularly in medical malpractice insurance. The aim is to understand why the cycle is so severe and its implications for risk distribution and loss prevention. The study utilizes a research-based approach to explain that recent spikes in malpractice insurance premiums are tied to the underwriting cycle rather than significant changes in claim payments. It explores the reasons behind the severity of the cycle in medical malpractice insurance, highlighting the time gap between premium payments and known losses and the uncertainty surrounding future malpractice losses. The study also discusses whether regulators should intervene to moderate the cycle, weighing potential impacts on patient safety against insurance stability. This emphasises the need for further research before making conclusive decisions regarding the underwriting cycle's management.

Tu, Jiong (2016) examined the evolution of China's health insurance system, noting its shift from state-run to privately financed care and back. The study aimed to understand how these changes impact healthcare access and act as regulatory mechanisms. Using analytical methods, the research explored how health insurance regimes create inequalities, evaluate patient qualifications, and expand state surveillance. The findings suggest that health insurance reforms in China have become tools for differentiation and discipline, leading to new discriminations and inequalities among patients within the healthcare system.

Vadakam and Gaddam (2021) evaluated the financial performance of selected private sector health insurance companies in India using the CARAMEL model. Analyzing secondary data from company annual reports with descriptive statistics (mean, standard deviation) and ANOVA, the study identified top performers across key financial ratios, including net premium to capital, expense ratio, return on equity, and investment income ratio. ANOVA results revealed significant inter-company differences in several of these ratios, providing insights into financial strengths and areas for improvement.

Van der Aa et al. (2019) examined the impact of recent Dutch national health insurance reforms on solidarity, focusing on health and long-term care insurance. Using a comparative analysis of the 2015 long-term care insurance reform and the 2006 health care insurance reform, they employed a multidimensional framework to assess solidarity effects. The reforms yielded mixed results, with both increases and decreases in solidarity observed. Health care insurance demonstrated greater resilience to reduced solidarity compared to long-term care insurance. The study recommended further quantitative research to understand the reforms' specific and long-term impacts on various groups, emphasizing the value of international comparative research for systematic insights into the solidarity effects of insurance reforms.

Vandali, Vijayaraddi (2018), Vandali and Vijayaraddi (2018) provided an overview ofhealth insurance in India, highlighting its importance and challenges as a financial protection mechanism against accidents and disabilities. Analyzing the current healthcare landscape and consumer insurance behaviors, the study found that low consumer awareness and inadequate healthcare infrastructure hinder wider health insurance adoption. Rising healthcare costs, however, are driving individuals, particularly older generations, to seek coverage for medical expenses. The study emphasizes the need for comprehensive insurance policies covering doctor visits, hospital stays, and diagnostic tests to mitigate financial risks associated with unexpected medical emergencies.

Vasilevskaya and Bailo (2019) aimed to assess and propose changes in healthcare funding through the reform of medical insurance systems in Ukraine. They analysed laws and regulations using comparison, analysis, synthesis, and deductive approaches. The study explored different forms ofhealthcare funding, focusing on voluntary, compulsory, and mixed insurance models. The research highlighted the challenges facing medical insurance in Ukraine, leading to proposed reforms based on a "taxes-budget-agency" model. The study emphasized the need for healthcare reforms and the development of insurance systems to ensure quality medical care for all social groups, especially the disadvantaged.

Verulava (2023) conducted a study on health insurance reforms in Georgia, focusing on the transition from a competitive to a monopolistic system in the health care sector. The research aimed to understand the reasons behind this transition. Qualitative methods were used in this research, involving interviews with experts. However, after the shift to a monopolistic system, the freedom to choose insurers or providers was restricted. The findings revealed that the competitive insurance model offered beneficiaries more choice of insurers, improved the quality of medical services, promoted effective management of health programs, controlled healthcare costs, ensured transparency of insurance products, and increased awareness among the insured.

Wijanto, Wihadi (2023) examined the need for regulatory improvements in insurance law in Indonesia to ensure legal certainty for both people and insurance companies. Using normative research with empirical support, the study aimed to address issues related to insurance policyholders' rights and protections, particularly concerning investments, and funds in non­state-owned insurance companies. Findings revealed gaps in existing regulations, such as the Commercial Law and Insurance Law, failing to specifically protect policyholders in cases of intentional mismanagement or criminal acts by insurance company directors. The study concluded that current regulations lack legal certainty in providing refunds to policyholders for their deposited funds, highlighting the need for reform to enhance protections for insurance consumers.

Worku et al. (2024) aimed to determine the elements that affect Ethiopian insurance companies' profitability. They looked examined data from 2011 to 2020 and chose nine insurance companies from the nation's total of 17. Their study employed a quantitative methodology, notably using classical linear regression analysis, and a descriptive and causal research design. According to the study, return on assets was positively impacted by characteristics such as firm age, asset tangibility, company size, management effectiveness, leverage ratio, premium growth, and GDP, while it was negatively impacted by factors such as inflation and loss ratio. These results provide information about the main factors influencing Ethiopian insurance companies' profitability.

Yadav, Rajesh & Mohania, Sarvesh (2015) This study examines the effectiveness and transparency of claim settlement procedures at LIC of India and ICICI Prudential Life Insurance Company. Its purpose is to analyze these companies' practices in the context of increasing policy numbers and market demand. Using secondary data from IRDA and various research papers, the study concludes that both companies have adequate claim settlement processes. However, it also highlights a key difference: while LIC of India's process is efficient, it lacks the transparency ofICICI Prudential's, which prioritizes customer preferences and sets a higher standard for the private life insurance sector.

Yani et al.(2023) analyzed the implementation of Indonesia's Health Insurance policy since its inception in 2014. Their qualitative research employed various data collection methods, including observations, interviews, focus group discussions, and reviews of relevant documents. The study involved citizens, hospital management, and national health insurance institutions. Results show that while the National Health Insurance system has benefits, it faces challenges like low participation, fee issues, fragmented health services due to benefit packages, and ineffective risk management. Budget deficits within the Social Security Agency ofHealth limit hospitals in providing services due to unpaid claims by BPJS Kesehatan.

Yasid et al. (2024) the author investigates the legal responsibilities of insurance providers about the scope of insurance contracts. When agreements are broken, the writers examine how insurance firms execute their obligations to policyholders. In closing, the author underlines that insurance companies must pay policyholders for unmet commitments by using a normative juridical procedure with qualitative descriptive analysis. In the event of an insurance company default, the policyholder retains the right to pursue legal recourse. The company, in turn, may be subject to regulatory sanctions, including warnings, fines, limitations on business operations, or revocation of its license. The legal framework governing insurance agreements and the rights of policyholders under these circumstances are subsequently elucidated.

Yassine et al. (2020) conducted a study to assess the medical costs associated with Morocco's Basic Health Insurance, focusing on healthcare utilization by the insured population. Using a cross-sectional analysis of economic data from the National Moroccan Health Insurance Agency, they examined spending patterns in both the public and private sectors. Their findings indicated a significant increase in medical spending between 2009 and 2014, with a more substantial rise observed in the public sector. Drug costs, particularly within public ambulatory care, constituted a significant portion of overall health insurance expenditures. The study concludes by emphasizing the need for regulatory and preventive measures to control healthcare spending and support health reforms, especially for chronic diseases.

Yastori (2022) aimed to investigating the ongoing cases and disputing claims in hospitals covered by Indonesia's National Health Insurance System were the goals of Yastori (2022). The study collected data by directly observing e-claim files from multiple hospitals using a descriptive method with a qualitative approach. Thirteen instances of pending claims and two instances of dispute claims were found among the fifteen e-claim files that were viewed between April and July of 2021. Non-adherence to clinical practice guidelines and coding standards led to pending claims. In order to prevent claim disputes and guarantee efficient processing the National Health Insurance System, this study emphasises the significance of precise coding, compliance with insurer regulations, and keeping abreast of code revisions.

Zallman, Leah & Nardin, Rachel & Sayah, Assaad & McCormick, Danny (2015) the study investigated the financial burden and perceived cost ofhealth insurance across different income levels in Massachusetts five years after health reform. Researchers compared individuals with low-cost-sharing plans (Medicaid and minimal cost-sharing exchange plans) to those with high- cost-sharing plans and those with commercial insurance, conducting in-person questionnaires with 976 patients from three hospital emergency departments. The findings revealed that despite higher incomes, individuals with greater cost-sharing responsibilities reported lower satisfaction with their insurance and greater difficulty affording it. Conversely, participants with low-cost-sharing plans reported higher satisfaction and less financial strain, suggesting that legislators should consider income-based cost-sharing to mitigate the financial burden of healthcare.

2.3 Research Gap

The review of literature revealed that some studies had been conducted on factors affecting health insurance purchase patterns and the various consequences of health insurance on individuals. In India, there are numerous variations in the causes and effects between nations and states. The issues and opportunities that the insurer faces when settling the claims in health insurance market are the main subject of this study. There hasn't been any prior research of this kind on breach of health insurance. Although they weren't thoroughly examined, the previous research concentrated only on the function of the health insurance market. The researcher's goal in this study is to investigate how policyholders perceive health insurance, the role that insurance firms play, and industry changes. These breaches manifest in various forms, including denial of claims, delays in claim processing, and unfair policy terminations, among others.

2.4 Conclusion

The present article summarises studies that provide light on the intricate web of health insurance and its varied effects on healthcare, with a focus on Chennai and Tamil Nadu. Research highlights how important medical malpractice insurance is for safeguarding policyholder rights and mitigating the financial effects of medical errors. Additionally, studies demonstrate how Digital Health Technology (DHT) can improve productivity and lower errors in the processing of claims. Studies on community-based health insurance (CBHI) highlight the difficulties low-income groups have obtaining coverage and the significance of government assistance. The potential of large-scale interventions is demonstrated by the effect of national programs like the Rashtriya Swasthya Bima Yojana (RSBY) on lowering child mortality. Additionally, emphasis is placed on the good faith principle in insurance contracts, which calls for truthful disclosure from both insurers and the insured. The findings in the above findings point to the necessity of approaching health insurance holistically, taking into account factors like affordability, accessibility, care quality, and long-term viability. Investigating novel approaches and laws to guarantee that everyone has efficient and reasonably priced insurance is crucial as healthcare systems change.

CHAPTER-III CONCEPT OF INSURANCE AND HISTORICAL BACKGROUND OF INSURANCE

3.1 Introduction

In everyday life, we face various risks, from accidents at work to natural disasters like floods or fires. These uncertainties can lead to financial losses, and while small losses can be manageable, larger ones may not be. To safeguard against such risks, insurance offers a solution. Insurance provides financial help to those who suffer losses, distributing the risk among many. The person seeking protection is called the "insured," while the one providing it to "insurer." In return for a premium, the insurer guarantees compensation if a specified event occurs, outlined in the "insurance policy”.¹⁹

3.1.1 Purpose ofInsurance

Insurance is a system designed to protect individuals from uncertain future losses, which are inevitable in life and business profession. There are certain risks such as illness, death, natural disasters, accidents, and property damage often lead to financial losses. While risk cannot be eliminated, insurance mitigates the impact up to certain extent by spreading the loss across many contributors. Individuals, known as policyholders, pay premiums to create a common fund. When a loss occurs, the affected person is compensated from this fund, with the financial burden shared by all contributors. The primary function of insurance is to transfer the risk of financial loss from one individual to a group of willing participants" changed to "The core function of insurance is to shift the burden of financial risk from an individual to a larger group.²⁰

3.1.2 Function ofInsurance

3.1.2.1 Primary Functions

(a) Provides Protection

Insurance provides financial protection against potential future losses arising from unforeseen events. While insurance cannot prevent these events, it offers compensation for resulting losses. By distributing the risk among others, insurance provides a financial safety net, protecting individuals from economic hardship caused by unforeseen events.

(b) Ensures Certainty

Insurance transforms uncertainty into certainty by guaranteeing payment in the event of an unpredictable loss. It shifts the burden of potential financial loss to insurers, relieving individuals of the need for complex risk management. The insurer assumes the responsibility for specific losses through collective premium contributions.

(c) Evaluates Risk

Insurance assesses the likelihood and extent of various risks, helping to predict potential financial losses. By evaluating multiple factors that contribute to risk, insurance determines the premium rates accordingly. This process provides individuals with a financial safeguard against unpredictable events, making future losses more manageable.

(d) Collective Risk-Sharing:

Insurance operates on the principle of distributing financial loss among a larger group. Contributors to the common fund share the burden of loss when one person is affected. Although risks cannot be avoided, the resulting losses are spread among many, reducing the financial impact on any one individual.

3.1.2.2 Secondary Functions

(a) Preventing Loss

Insurance encourages individuals and businesses to adopt preventive measures, such as installing alarm systems, to reduce risks and potential losses. By promoting safety and minimizing pay-outs, insurers can lower premiums. This, in turn, attracts more business and savings, while insurance companies also support organizations focused on risk prevention and awareness.

(b) Provides Capital

Insurance facilitates capital formation by collecting premiums from policyholders and investing them in organized sectors or industrial ventures, contributing to national growth and resource mobilization.

(c) Improves Efficiency

By ensuring assets and employees, businesses can focus on operations without fear of loss, improving productivity and stability, while individuals and society with saftey and peace.

(d) Ensures Welfare of Society:

Insurance supports societal welfare by reducing individuals’ financial worries, promoting economic stability, fostering commercial growth, and contributing to national development through resource mobilization and protection against risks.

3.1.2.3 Other Functions

(a) Savings and Investment Tool

Insurance restricts unnecessary expenses of a person and, therefore, considered as the best option of savings and investment. Also a person takes insurance as a good investment option to take the benefits of income-tax exemptions.

(b) Foreign exchange earning medium

Since international trade is possible, any nation can generate foreign exchange by issuing marine insurance policies.

(c) Risk Free Trade

Insurance offers compensation or indemnity in the uncertain event unforeseen loss. Insurance increases export insurance, making international trade risk-free with the aid of various marine insurance policy types.

3.1.3 Nature ofinsurance

(i) Sharing ofRisk and Its Transfer

Insurance protects individuals and families from financial loss caused by various risks like death, accidents, or property damage. It works by transferring the financial impact of these risks to the insurer. The insurer reimburses the insured for losses suffered due to unforeseen events, ensuring that risk is shared among many people facing similar risks.

(ii) Co-operative Mechanism

Insurance is a collective approach where individuals facing common risks come together and contribute to a shared fund. When one member faces a loss, they are compensated from this fund. By pooling resources, insurance reduces the burden of individual financial losses and distributes it among all contributors.

(iii) Valuation ofRisk

Before providing coverage, insurance companies assess the potential risks and calculate the likelihood of loss. This evaluation helps determine the premium that the insured must pay. If the loss is higher, a larger amount is required to cover the potential risk, ensuring fair contribution and protection.

(iv) Payment Made at Certain Contingency

Insurance guarantees payment if a covered event, or contingency, occurs. For example, in life insurance, payment is guaranteed because death will certainly happen. In other types of insurance like marine or fire, payment depends on whether the covered event occurs, meaning the pay-out is not always guaranteed.

(v) Amount of Payment

Upon the occurrence of a specified event, the insurer is obligated to pay the insured a predetermined sum. In life insurance, this payment is a fixed amount, regardless of the actual financial loss. Conversely, for other types of insurance, such as property insurance, the insured must provide proof ofloss, and the insurer's pay-out is based on the extent of the damage.

(vi) Large number of persons Insured

The principle of risk pooling, achieved by insuring a large number of people or properties, is fundamental to insurance affordability. A larger pool of insured individuals spreads the risk more effectively, reducing the overall cost of insurance and making it accessible to more people. With more participants, premium rates decrease, benefiting all policyholders.

(vii) Insurance is not charity or gambling

Insurance is a business, not charity or gambling. In gambling, people risk losing money, while insurance protects against risk involved in person or property. Insurance is also different from charity because it involves a contribution (premium) in exchange for financial protection. It provides security by turning uncertainty into certainty, helping individuals and businesses prepare for the unexpected.

(viii) Establishment of a Welfare State

Insurance contributes to national growth and prosperity by investing premiums into organized sectors and industries. It helps businesses focus on productivity by providing protection for assets and employees. By mobilizing resources and ensuring financial security, insurance fosters economic stability and supports the establishment of a welfare state, benefiting both individuals and society.

3.2 Origin of Insurance

Insurance has a long history, dating back to antiquity, and has evolved into a modern industry protecting against diverse hazards. The sector has long been lucrative and a significant part of both governmental and private long-term finance. In the ancient world, early forms of insurance emerged among Babylonian and Chinese traders. To mitigate losses, merchants divided their goods among different ships navigating dangerous waters. The Code of Hammurabi, dating back to around 1750 BC, documented one of the earliest loss limitation methods, where a merchant would pay a lender extra for a loan guarantee that would cancel the debt if goods were stolen. Additionally, gifts of significant value to monarchs were documented, allowing givers to prove their gifts' existence and receive assistance if needed In the 14th century, standalone insurance policies emerged in Genoa, marking the creation of the first documented insurance policy in 1347. By the following century, standalone maritime insurance developed, with premiums reflecting unique risks. This separation from contracts and loans represented a significant shift in the evolution of insurance.

The first book on insurance , the legal treatise on insurance and merchants bets by pedro de Santarem de Santarem , It was written by Pedro de Santarém and released in 1552. Insurance had developed into a more complex type of protection with a wide range of coverage possibilities by the end of the Renaissance. Up until the late 17th century, friendly societies predominated in numerous areas. However, the need for cargo insurance increased as London became a major commercial hub, which prompted the creation of underwriting businesses like Lloyds of London, which is still a well-known insurer today. The Great Fire of London, which occurred in 1666 and led to the destruction of more than 30,000 homes, is considered to be the origin of modern insurance. Nicholas Barbon, who had previously established a building insurance company, was the one who initiated the establishment of the city's first fire insurance company. The latter half of the 19th century saw the introduction of accident insurance, which is somewhat comparable to the current disability insurance that is available today. The insurance sector saw a significant shift as a result of this.²¹

In 1732, the first insurance enterprise in American history was established in South Carolina, focussing on fire prevention. To mitigate devastating fires, Benjamin Franklin initiated a similar initiative in the 1750s. Life insurance and more types of coverage were included into the insurance business as the 1800s progressed. The inception of social security in the 1930s made insurance essential, and in the 1940s, General Insurance (GI) was developed to support the families of fallen soldiers. The need for auto insurance had grown considerably by the 1980s, which led to attempts to make it required. Even though the insurance sector is well- established, it is always changing to meet the demands of its customers. Insurance's history demonstrates constant innovation and societal reactivity, guaranteeing its continued significance in markets to come.

3.2.1 Formation ofinsurance Industry in India

The idea of insurance has historical origins in India, tracing back to ancient Hindu practices, particularly in marine insurance among traders. The joint family structure functioned as a mechanism of social security. The insurance business has seen substantial evolution, shifting from nationalisation to recent reforms that permit private and foreign involvement. In India, insurance is governed by the Union List, which confers exclusive jurisdiction to the Central Legislature, leading to standardised insurance legislation nationwide. The industry's evolution has advanced through three main phases.

The roots of insurance legislation in India may be traced back to the United Kingdom, beginning with the establishment of the Oriental Life Insurance Company in Calcutta in 1818, followed by the Bombay Life Assurance Company in 1823 and the Madras Equitable Life Insurance Society in 1829. Before the formation of the Bombay Mutual Life Assurance Society in 1871, Indian policyholders faced an extra premium of up to 20% compared to their British counterparts. The first legal measure regulating life insurance in India was the Indian Life Assurance Companies Act of 1912, which concentrated on life insurance, while other insurance types were still nascent and lacked necessary regulations. General insurance started in the United Kingdom, with the first business, Triton Insurance business Ltd., founded in Calcutta in 1850. The Indian Mercantile Insurance firm Ltd. was established in 1907 as the first Indian general insurance firm. The proliferation of fire, accident, and marine insurance highlighted the need for regulation, leading to the enactment of the Insurance Act of 1938, which ultimately included both life and general insurance. This Act, together with its several revisions, constitutes the foundation of insurance legislation in India, delineating general insurance to encompass fire, marine, and miscellaneous insurance sectors.

3.2.2 History of Insurance

3.2.2.1 Ancient Historical Times

Insurance has ancient origins, dating back to early human society. Emerigon's Traite des Assurances, published in 1783, highlights that the Romans, Phoenicians, and Rhodians engaged in early forms of risk management. Historical texts by Livy and Suetonius indicate that transport contractors sought government protection against maritime losses, marking the inception ofinsurance. Additionally, friendly societies existed in ancient China and India to aid members through pooled contributions. Early Indian texts, such as Kautilya's Arthashastra, reference marine trade loans and contracts, demonstrating an understanding of risk and safeguarding measures.

3.2.2.2 British-India Period

In the British-India era, unregulated insurance commenced in the nineteenth century, predominantly controlled by British firms in urban locales. The inaugural life insurance firm, founded by Europeans in Calcutta, was succeeded by the Bombay mutual Life Assurance Society, in 1870, signifying the establishment of India's 1st indigenous life insurance company. The 1930s signified a crucial transformation in the economy, resulting in heightened industrialisation and diminished dependence on foreign currency. By the conclusion of the nineteenth century, the insurance sector was predominantly dominated by foreign corporations.

3.2.2.3 Post-Independence Era ofIndian Insurance

After independence, the Indian insurance sector grewrapidly, with Indian companies gaining a stronger foothold, although it remained primarily urban. During Mrs. Indira Gandhi's tenure (1966-1968), a divide emerged between protectionists and proponents of open trade. The Union Government supported economic liberalization, hoping to attract foreign aid. Deregulation ultimately benefited the poorest by creating jobs and fostering growth. However, fears about liberalization persisted among the lower middle class and state sector employees, making it crucial to introduce reforms during economic upswings to minimisejob-related risks^[22]

3.3 General Principles of Insurance

The insurance contract in India is governed by the Indian Contract Act of 1872, alongside many additional legislation, including the Insurance Act of 1938 and the Insurance Regulatory and Development Authority Act of 1999, among others. It encompasses both General Principles and Specific or Contractual Principles. The principles of insurance can be categorized into four approaches: Basic Principles, General Principles, Specific Principles or Contractual Principles, and Miscellaneous Principles. These frameworks ensure that insurance contracts are structured and enforced correctly.

3.3.1. Basic Principals

3.3.1.1 Principal of Cooperation

Insurance operates as a cooperative mechanism where the loss experienced by one individual is shared among a group. Members contribute premiums to a common pool managed by the insurer, enabling the payment of claims when insured risks materialize. By paying premiums in advance, individuals support fellow members who may incur losses.

3.3.1.2 Theory ofProbability

The calculation of premiums relies heavily on the Theory of Probability, which estimates the likelihood of risks and potential losses. Insurers analyse historical data to assess risk factors and determine appropriate premium amounts, ensuring that the collective contributions adequately cover expected losses.

3.3.2 General Principles

Insurance is essentially a contract in which one party agrees to pay another a certain amount upon the occurrence of a certain event, in exchange for a premium. The legal foundation for insurance contracts in India is primarily governed by Section 10 of the Indian Contract Act, 1872. The essential principles regulating these transactions include offer and acceptance, legal consideration, contractual capacity, voluntary consent, lawful purpose, and temporal constraints, among others.

3.3.2.1 Offer and Acceptance

In insurance contracts, the process begins with an offer and acceptance, akin to other contracts. The person seeking insurance makes a proposal, intending to purchase a policy, while the insurance company accepts the risk involved. Generally, the offer comes from the insured, but it can also originate from the insurer. It’s important to note that marketing materials serve as invitations to offer, not formal offers. Acceptance of the proposal solidifies the contract.

3.3.2.2 Legal Consideration

Legal consideration in an insurance contract occurs when the insured remits a premium in exchange for the insurer's commitment to produce a specific payment after the occurrence of a defined event. Consideration need not be purely monetary; it may also comprise privileges or incentives. The relevance lays not in the premium's value but in its position as consideration to determine the insurer's obligation. The insurance contract is void without premium payment.

3.3.2.3 Competency and Capacity to contract

For an insurance contract to be legitimate, both parties must have the legal power to enter into the arrangement . According to Section 11 of the Indian Contract Act of 1872, a competent person is defined as one who has attained legal age, has mental soundness, and is not subject to legal disqualification. Even if someone lacks the capacity to contract, they can still be a beneficiary under the insurance policy. Ensuring all parties are competent is crucial for contract enforceability.

3.3.2.4 Free consent

Voluntary consent is a crucial element of legitimate contracts. It signifies that both parties voluntarily agree to the terms and conditions without force, fraud, undue influence, deception, or significant errors. If assent is acquired using such methods, the contract may be rendered voidable at the judgement of the injured party. In instances of fraud, the contract is deemed worthless, underscoring the need for authentic consent in the agreement.

3.3.2.5 Legal object

The essential element of an insurance contract must be legal. Section 23 of the Indian Contract Act, 1872 stipulates that a purpose is considered illegal if it is prohibited by law, immoral, contrary to public policy, or contravenes any legal condition.²³ Ensuring that the contract's object is legal is vital for its validity and enforceability, preventing potential disputes and legal complications.

3.3.2.6 Limitation of time

Temporal constraints are pivotal in insurance agreements. Generally, lawsuits for breach of contract must be initiated within three years from the emergence of the cause of action. Any clause that seeks to abbreviate this duration, such as restricting it to one year, is deemed null and void. These constraints are crucial for safeguarding the interests of both parties and facilitating the prompt resolution of any potential conflicts.

3.3.3 Specific or Contractual Principles

Specific or contractual concepts are universally applicable to all forms of insurance. The principles include Uberrima fide (utmost good faith), insurable interest, the principle of causa proxima, the concept of indemnity, and the principle of subrogation. Every notion is crucial for the validity and regulation ofinsurance contracts.

3.3.3.1 Doctrine ofUberrima Fide (Utmost Good Faith)

Insurance Contract are based on reciprocal trust. The doctrine ofUberrima fide mandates that the insured must reveal all pertinent facts and refrain from misrepresentation. While underwriters can conduct surveys, certain facts may not be apparent. The insured's duty is greater, although they need not disclose publicly known facts or those found in documents.

3.3.3.2 Insurable Interests

Insurable interest is crucial for the legitimacy of insurance coverage. It relates to the policyholder's financial interest in the subject matter, ensuring the possibility of loss. The law acknowledges this interest, which may emerge in several circumstances, including life, fire, or marine insurance, since the insured may gain or incur financial loss.

3.3.3.2.1 Insurable Interest in Life Insurance

In life insurance, insurable interest exists in the life of the insured. Creditors can insure their debtor's life, making the policy valid even after the debt is repaid. Relationships like principal­agent or trustee-co-trustee also exemplify insurable interest, allowing partners to collectively insure one another's lives.

3.3.3.2.2 Insurable Interest in Fire or Accident Insurance

In fire insurance, a contractual agreement is established between the insurer and the insured, whereby the insurer indemnifies the insured for damages incurred as a result of fire. Full ownership is not necessary, as shown in Wilson v. Jones²⁴, policies taken by shareholders for company success are valid. This reflects the broader applicability ofinsurable interest.

3.3.3.2.3 Insurable Interest in Marine Insurance

Sections 7 to 17²⁵ of the Marine Insurance Act, 1963, outline insurable interest in marine contexts. Individuals involved in marine adventures have an insurable interest, as they may benefit from the safety or arrival of property incur losses from its loss. This provision underscores the concept's relevance across different insurance types.

3.3.3.2.4 Terms and conditions ofInsurance Policy

Insurance companies must clearly state their conditions and liabilities in both the proposal form and policy. Bradley v. Essex & Suffolk^[26] highlighted that failure to fulfil these conditions can render the policy voidable. Conditions arising post-issuance must also be explicitly communicated to ensure enforceability.

3.3.3.2.5 Interpreting Insurance Documents

Courts must attribute ordinary meanings to terms within insurance policies. The insured must demonstrate that the contingency aligns with the contract's terms. Courts interpret policy language based on the parties' agreement, ensuring that the original contract remains intact without imposing new interpretations.

3.3.3.2.6 Ambiguous Clauses

The contra proferentem principle stipulates that unclear clauses in insurance contracts must be construed in favour of the covered party. This principle applies only when the language is unclear; clear terms do not warrant such interpretation, as established in Alder v. Moore²⁷. Clarity in language is essential to avoid disputes.

3.3.3.3 Principles of causa Próxima

The principle of proximate cause in contracts law states that the immediate cause, not a remote one, determines liability for loss. This principle is vital in insurance, ensuring that if the cause of loss is covered compensation will be provided. Identifying the exact cause is critical for policy applicability.

(i) Accident

Accident policies pose challenges when determining whether an injury or death results from proximate or remote causes. Establishing the actual cause is crucial, especially since policies often provide double benefits. Conditions such as environmental factors complicate the distinction between accidental and non-accidental causes.

(ii) Suicide

Insurance policies typically restrict payment if the insured commits suicide within a of the policy initiation. If the insured intends to commit suicide, claims are limited to third-party interests, provided these interests were expressed a month before the act. This stipulation protects insurers from potential exploitation.

(iii) War-risk

Insurance policies often exclude coverage for deaths arising from war. In cases like Coxe v. Employers Liability Assurance Co. Ltd^[28], courts clarified that insurers waive liability for losses resulting from such conflicts. Understanding these exclusions is essential for both insurers and insured to prevent misunderstandings.

3.3.3.4 Principles oflndemnity

The concept of indemnification stipulates that an insurance contract pays for damage, loss, or injury only to the degree of the incurred loss. With the exception of life insurance, the majority of insurance contracts adhere to the concept of indemnification, which seeks to reimburse real losses sustained. In contrast to life insurance, which provides a predetermined sum, the indemnity principle guarantees that insured individuals get recompense commensurate with their loss, hence preventing any profit from the insurance pay-out.

3.3.3.5 Principles of Subrogation

The idea of subrogation in insurance permits the insurer to assume the policyholder's legal right to seek compensation for losses. Subrogation enables insurers to inherit the rights of the insured after settlement. Upon compensating the insured for a loss, the insurer may pursue claims against other parties accountable for the harm. This principle reinforces accountability and prevents unjust enrichment.

3.3.3.5.1 Burden ofProof

In Regina fur co. Ltd v. Bossom^[29], the court of Appel, England & Wales determined that the burden of proving the loss vested on the insured Insurers have the right to demand evidence of loss or damage, emphasizing the importance of thorough documentation when filing claims to support the insured's assertions effectively.

3.3.3.5.2 Time Limit

Insured individuals must file claims within specified time limits, usually in writing. In Asha Mondai v. United India Insurance Co. Ltd^[30], the Supreme Court ruled that claims submitted after the deadline, and not in writing, were invalid. Adhering to time limits is crucial for maintaining eligibility for compensation.

3.3.3.5.3 Essentials of the principal of Subrogation

The fundamentals of subrogation include that(i) insured parties may only seek restitution for genuine damages incurred. (ii) Following compensation, insurers acquire the insured's rights against third parties. Insurers are permitted to reclaim just the amount disbursed, with any surplus refunded to the insured. (iv) Complete restitution from wrongdoers extinguishes the insured's claim against the insurer. Subrogation is inapplicable to personal insurance, preventing insurers from seeking claims against third parties for personal damages.

3.3.4 Miscellaneous Principles

3.3.4.1 Principles of Contribution

Principles of Contribution applies when multiple insurers cover a single risk. If one insurer pays the full loss, they can seek contributions from co-insurers based on their respective policy amounts. This principle ensures fair distribution of liability among insurers and is supported by the principle ofindemnity.

3.3.4.2 Principle of Return of Premium

Generally, insurance premiums are non-refundable; however, exceptions exist. Refunds may be granted under specific circumstances, such as express agreements, over-insurance, or when an insurance company liquidates. Total refunds can occur if no fault exists, fraud is present, or if the subject of insurance poses no risk .

3.3.4.3 Legal Principles

Insurance contracts include the payment of a set amount in return for the insurer accepting a financial loss. A contract has been breached. Consequently, additional legislations, like the Indian Contract Act of 1872, are applicable to these circumstances. In addition to many other statutes, including the Specific Relief Act of 1963 and the Transfer of Property Act of 1882, control insurance contracts and their enforceability.

3.3.4.4 Auxiliary Principles

(i) Contract of Indemnity

Insurance contracts, except life insurance, are contracts of indemnity, signifying their purpose to recompense for real loss rather than to provide a profit.

(ii) Contract of Adhesion

In contracts of adhesion, insurance policy terms are pre-determined between the parties to the contract leaving the insured with no negotiating power. The insurer must accept the policy as it is.

(iii) Conditional Contract/Contingent Contract

Insurance policies are conditional contracts, where both parties must adhere to agreed terms. The insured must pay premiums, while the insurer must fulfill claims upon specific events occurring.

(iv) Aleatory Contract

Insurance is speculative in nature, with both parties agreeing to pay fixed sums based on uncertain future events. Life insurance specifically requires insurable interest at policy commencement.

(v) Unilateral Contract

Life insurance is a unilateral contract, whereby only the insurer is obligated to disburse payment upon the occurrence of a specified event, while the insured is required to reveal all relevant information to prevent fraud and maintain the policy's validity.

3.4 Kinds oflnsurance in India

3.4.1 General Insurance

3.4.1.1 Introduction and Early Development (1850-1957)

Since Triton Insurance Company Limited was founded in Calcutta in 1850, general insurance has existed in India since the 19th century. A variety of general insurance types were later pioneered when the Indian Mercantile Insurance Limited was established in 1907. Until 1957, the general insurance industry experienced steady expansion and diversification.

3.4.1.2 Nationalization and Regulatory Measures (1957-1999)

The Insurance Amendment Act of 1950 abolished Principal Agencies. Nonetheless, several insurance firms existed, and the competitive landscape was intense. Allegations of inequitable trading practices were also present. The Government ofIndia therefore resolved to nationalise the insurance sector. Nonetheless, several insurance firms existed, resulting in a high degree of competition. Allegations of inequitable trading practices were also present. The Government ofIndia therefore resolved to nationalise the insurance sector. Subsequently, an Ordinance was promulgated on 19th January 1956, nationalising the Life Insurance sector, which was succeeded by the Life Insurance Corporation (LIC) under the Life Insurance Corporation (LIC) Act, 1956. The LIC assimilated 154 Indian insurers, 16 non-Indian insurers, 75 provident societies, and a total of 245 Indian and international insurers. The LIC maintained a monopoly until the late 1990s, when the insurance industry was liberalised for private enterprises. The General Insurance Council (GIC) was founded in 1957 to ensure ethical business practices in India. In 1968, the Insurance Act was revised to establish the Tariff Advisory Committee (TAC), which governed investments and determined minimum solvency margins. In 1972, the General Insurance Business (Nationalisation) Act was enacted, signifying a pivotal moment that led to the nationalisation of the general insurance business in 1973. Four companies— Oriental Insurance Company Limited, National Insurance Company Limited, United India Insurance Company Limited, and New India Assurance Company Limited—were established as a result of the amalgamation of 107 insurers. The establishment of the General Insurance Corporation (GIC) ofIndia resulted in further centralisation of ownership and control.³¹

3.4.1.3 Liberalization of National Insurance Policy and establishment of IRDA & Sectorial Transformation

The Indian insurance sector saw a significant transformation with the liberalisation of the National Insurance Policy in the early 1990s. The Union Government established a committee chaired by R.N. Malhotra to liberalise the Indian insurance business by permitting private and international involvement, enhancing competition, and creating a robust regulatory framework. It aimed to modernise the sector, enhance insurance penetration, and safeguard policyholders' interests. The principal recommendations of the R.N. Malhotra Committee, 1993, were to liberalise the insurance market by permitting the entry of private and international enterprises, and to create an independent regulatory authority (IRDAI) to promote equitable competition and safeguard policyholders' interests.In 1995, the Mukherjee committee was established, leading to the creation of the interim Insurance Regulatory Authority (IRA) in 1996. The Mukherjee Committee of 1995 was constituted to examine the 1992 Indian stock market scandal and propose improvements for the capital market. The main aims were to augment openness, fortify regulatory control, and promote investor protection. The Mukherjee Committee's principal recommendations were enhancing SEBI's operations, reinforcing laws for stock exchanges, and instituting measures to mitigate insider trading and market manipulation. Nevertheless, the conclusions of the Mukherjee Committee were not disclosed to the public. In that year, the Indian Government granted more power to the General Insurance Corporation, Life Insurance Corporation, and its subsidiaries, with the objective of improving flexibility in insurance regulations to direct revenues towards infrastructure development.³² In 1998, the government resolved to permit 40% foreign ownership in private insurance firms. In 1999, the committee led by Mr. Murali Deora proposed capping equity in the private insurance market at 26%. The Insurance Regulatory Authority Bill was renamed the Insurance Regulatory and Development Authority Bill. In 2000, the President ofIndia granted assent to the Insurance Regulatory and Development Bill, signifying a pivotal moment in the history of India's insurance industry. The IRDA was established as a legislative body in 2000 to promote competition, enhance customer satisfaction, reduce rates, and ensure financial stability within the insurance sector. A significant step in the industry's evolution was the restructuring of operations under the General Insurance Company (GIC) and its transformation into a reinsurer in 2002.³³

In Khatema Fibres Ltd. v. New India Assurance Company Ltd. and Ors^[34]

The Court ultimately determined that a Consumer Forum, which mainly addresses claims of service failure, cannot submit the surveyor's report to a forensic analysis ofits structure. Upon determining that there is no deficiency in the quality, nature, and execution of the surveyor's duties and responsibilities, as outlined by the Regulations governing their code of conduct, and once it is established that the report is neither holistic nor tainted by arbitrariness, the jurisdiction of the Consumer Forum to proceed further would cease.

3.4.2 Life Insurance in India

Prominent ancient texts like Manusmrithi, Dharmasastra, and Arthasastra are where the history of insurance in India begins. They have talked about how important it is to gather money so that it can be given to people in difficult times, including during natural disasters like famines and floods. Insurance has changed dramatically in the contemporary era in response to these ideas and is founded on several international best practices.

• 1818 - 1870 - Initially referred to as the Oriental Life Insurance Company, this life insurance business was established in 1818 in Calcutta. Its activities were unsuccessful, leading to its closure in 1834. Additionally, Madras Equitable inaugurated the life insurance sector in 1829 inside the Madras Presidency.
• 1870 - 1912 - The British Insurance Act (BIC), enacted in 1870, facilitated the establishment of companies such as Bombay Mutual, Empire of India, and Oriental in the Bombay Presidency. A multitude of multinational insurance firms, such as Royal Insurance, Albert Life Insurance, and Liverpool, established their operations in India. Indian enterprises were striving to establish their presence in the life insurance sector despite intense competition.
• 1912- 1938 - Enacted in 1912, the Indian Life Assurance Companies Act sought to regulate the life insurance sector in India. The Government of India began the disclosure of the business and returns oflife insurance firms operating in India.

. In 1928, the Indian Insurance Companies Act was enacted by the Union Government to scrutinise the operations oflife and non-life insurance products offered by both domestic and foreign insurers, along with certain accountable insurance entities. It was a significant development in India's insurance history. The 1938 modification to the prior legislation established the Insurance Act 1938, which instituted the necessary laws to oversee and administer the activities of insurance businesses in India.

• 1938 - 1956 - A significant number of new insurance companies started operations in India. The increased rivalry ultimately resulted in the closure of some commercial operations. As a result, the Indian government decided to create the LIC (Life Insurance Corporation of India) to nationalise the insurance sector. There were 154 Indian insurance firms, 75 provident societies, and 16 non-Indian insurance businesses represented. Subsequently, in the 1990s, private entities formed.

In Life Insurance Corporation of India v. Parvathavardhini Ammal ^[35]

In this instance, Parvathavardhini Ammal (the policyholder) procured a life insurance policy on her husband's life from the Life Insurance Corporation of India (LIC). The insurance application included a declaration that the deceased spouse (insured) was in excellent health. Regrettably, the spouse died soon after the policy was enacted. The LIC declined to disburse the death benefit upon the receipt of a claim from Parvathavardhini Ammal. The court determined that there was insufficient evidence to prove that the dead husband's secret medical condition constituted a significant deception. The insurer (LIC) has the burden of evidence to establish that the non-disclosure of a medical condition substantially affected their choice to provide the policy or the premium assessed. The LIC was unable to definitively demonstrate that the hidden condition directly influenced the risk assessment. This case underscores the need of unequivocal proof for the insurer when rejecting a claim due to deception. The unreported medical condition must be clearly significant to the risk assessment for the insurer to evade culpability.

In Bhagwati Bai v. Life Insurance Corporation^[36]

The Plaintiff, as the beneficiary of the insurance, is the wife of the deceased Moolchand, who insured himself with the defendant on 28-03-1972 for the amount of Rs. 25,000/-. He submitted a proposal form and personal statement on the same day and passed away within a month on 16-04-1972. The division manager denied the appellant's claim on the grounds that he had disguised the existence of three policies from March 1965, which had expired in March 1970, prior to applying for the current policy. The court applied Sections 17³⁷ and 19³⁸ according to the Contract Act of 1872, it was determined that the Insurer cannot deny obligation only based on minor inaccuracies or falsehoods in the statement, nor can the insurance be voided for serious misrepresentation if it does not affect the risk. Consequently, a contract cannot be annulled only due to insignificant or immaterial misrepresentations or omissions of fact.

In Ratan Lal and anr. v. Metropolitan Insurance Co. Ltd.^[39]

Pyare Lal (the insured) died on 19-04-1946, and the plaintiffs in this case are his sons (successors and heirs). According to his policy, prior to the acceptance being finalised with a regular policy, the insured passed away on 19-04-1946. The amount paid by the deceased was initially placed in a suspense account and subsequently adjusted to the first annual premium on 28-03-1946. Thus, it can be asserted that on the date of the account adjustment, the policy constituted a binding contract between the parties. The court of trial determined that the company was liable to pay the sum to the insured; however, the defendants failed to remit any payment to the plaintiffs, leading to this appeal before the High Court. The principle of uberrima fides applies until the contract is concluded by the company, and any breach would render the contract voidable at the discretion of the party entitled to uberrima fides.

The Supreme court handled the problem ofinsurance claim settlement after an accident in the case of Jacob Punnen v. United India Assurance Co.Ltd⁴⁰ (2021). Jacob Punnen, whose injuries from a vehicular accident were indemnified by a United India Insurance policy. The insurance company denied the claim, asserting that the policy had lapsed due to non-payment of premiums. The investigation focused on two topics: the policy's validity at the time of the accident and the implications of premium non-payment on the insurance coverage. The insured sought to renew the policy and had a legitimate expectation of payment; hence, the court ruled that the insurer could not deny the claim solely on the grounds of non-payment as shown by previous communications with the insurer. . The ruling required insurers to behave fairly and openly, emphasizing the importance of "utmost good faith" in the insurance contracts. The Court decided in insured favour, directing United India Insurance to pay the claim. This strengthened the rights of consumers in insurance transactions and made it clear that insurers must keep their word unless there is unmistakable proof of fraud or a serious violation. This decision emphasizes thejudiciary's responsibility to shield policyholders from insurance firms' capricious denial of claims.

In Life Insurance Corporation of India and Ors. v. Sunita Life Insurance Corporation of India and Ors^[41]

The accident claim payout, according to the insurance policy provisions, was payable only if the policy was active on the day of the accident. The coverage had expired at the time of the accident, and the premium was attempted to be paid three days post-incident. The complaint said that the premium, together with late fee penalties, was paid, therefore reviving the insurance prior to the death of her spouse. In rejecting the claim of the complainant, the Supreme Court relied upon its own decision in Vikram Greentech (I) Ltd. v. New India Assurance Co. Ltd.^[42] The Court noted that an insurance contract requires uberrima fides, or utmost good faith, from the insured party. The four fundamental components of an insurance contract are (I) the specification of the risk, (ii) the term of the risk, (iii) the premium, and (iv) the coverage amount. Upon issuing of the insurance policy, the insurer commits to compensating the insured for losses incurred due to the risks covered by the policy. The Court determined that the provisions of the insurance policy must be interpreted rigorously, and it is impermissible to amend the contract during the interpretation of the Policy's terms.

In Life Insurance Corporation of India v. Shakuntala.^[43]

Jamanadas (Insured) succumbed to jaundice on November 4, 1986, having had an insurance policy with the appellants for one and a half years prior to his death. This policy was enacted based on his assertion that he had neither had any disease nor sought the counsel of a medical professional in the last five years, although he had previously endured dyspepsia for many days and had used chooranam from an Ayurvedic practitioner. The court deemed it very absurd to classify periodic headaches or a case of indigestion as a 'material fact' that an insured individual was required to divulge. No reasonable man would deem it material to tell an insurance company of all the casual headaches he had in his life, and if he knew that it was an ordinary casual headache, there would be no breach of his duty towards the insurance company in not disclosing it.

3.4.3 Health Insurance in India

3.4.3.1 Meaning

A health insurance policy is a contract between the insurance company and the individual policy holder. The individual pays a premium to the insurer and he offers financial protection against health care expenses to the individual in return. It offers coverage for expenses against medical and surgical treatments to the policyholder. Subject to the terms and conditions of insurance coverage either the insured pays the costs out of pocket and is subsequently reimbursed or the insurance company reimbursed the costs directly.

Health Insurance in India

India has only had health insurance for a few decades. Its history is profound, though, and references to it can be found in the works of Manu (Manusmithi), Yagnavalkya (Dharmashastra)and Kautilya (Arthasastra). India has made significant progress in the last 50 years with regard to health insurance. In India, the Insurance Act of 1938 and the IRDAI of 1999 are the only laws that regulate health insurance. The growth of the Indian health insurance market has been largely attributed to the increased accessibility of cutting-edge medical facilities, income growth that has kept pace with medical costs, and increased public awareness ofhealth issues.

Several Government initiatives were gradually implemented starting in 1948. Among them was the introduction of the Employer State Insurance Program (ESIP). ESIS was introduced as a secure protection measure, particularly for workers in organized sector. It permitted payment for medical emergencies and income loss compensation in addition to Inpatient Department (IPD) and Out Patient Department (OPD) costs. This long-standing program is still in place and is funded equally by employers and employees.

In the outpatient department (OPD), there is no requirement to admit a patient in a hospital, but in an inpatient department a patient is admitted to a clinic or hospital for at least 24 hours. If we look at cost-wise, there is a difference. Inpatient Department (IPD) is slightly costlier than OPD. The frequency of visits to a hospital or clinic may be more in OPD, whereas in IPD, a patient usually gets discharged when a patient is completely fit to go.⁴⁴

The Central Government Health Insurance Scheme (CGHS) was introduced in 1954 with an object to provide all-inclusive medical care. It was created specifically for the families and employees of the Centr al Government. The Central Gdovernment employees and their families are the primary targets of this ongoing contributory health scheme. To maintain this program, the Government and the employees each contribute in accordance with their pay grades. In 1986 when 'Mediclaim' was first launched by the Indian Government it offered minimum and maximum health coverage ofRs 15,000 and Rs 5 Lakh respectively. Today the minimum sum assured by the public sector insurance companies is Rs 50,000 and Rs 1 Lakh for the private sector companies while in 95% of the online health insurance policies, the minimum sum assured is Rs 3 Lakh.

India's first Mediclaim policy was introduced in 1986 by the General Insurance Corporation (GIC), with an object to bring uniformity in terms and conditions across the country. It was a voluntary health insurance program that paid hospital bills, but it excluded contagious disease like HIV/AIDS, pregnancy, childbirth, and pre-existing medical conditions. The costs were paid back directly through the third-party administrators' mechanism following the indemnity clause. Nonetheless, the insurance industry was privatized in 1991 following the Government of India's introduction of new economic policies and a liberalization process. Following the 1991 Economic Policy Review, the Government instituted the liberalization process, paving the way for the health insurance industry to be privatized. The Indian Parliament approved the Insurance Regulatory and Development Authority (IRDA) bill. It represents a turning point in the development ofhealth insurance. In the annals of the Indian health insurance industry, this is a momentous occasion.

The major objectives of the IRDAI include protecting the interest of policyholders, speedy and orderly growth of insurance industry, speedy settlement of genuine claims, effective grievance redressal mechanism, promoting fairness, transparency and orderly conduct in financial markets dealing with insurance, prudential regulation while ensuring the financial security of the Insurance market.⁴⁵

3.4.3.2 Features ofIRDA Act, 1999

1. Establishment of IRDA: The Insurance Regulatory and Development Authority (IRDA) Act, 1999, established the Insurance Regulatory and Development Authority (IRDA) as the primary regulatory body for the insurance sector. The IRDA is responsible for issuing licenses to insurance companies, regulating their activities, and promoting the development of the industry.
2. Licensing ofinsurance Companies: The Insurance Regulatory and Development Authority (IRDA) Act, 1999 provides for the licensing of insurance companies, both life and non-life, that meet the prescribed eligibility criteria. The licensing process includes scrutiny of the company’s financial stability, management expertise, and other parameters.
3. Control over insurance Premiums: The Insurance Regulatory and Development Authority (IRDA) Act, 1999 empowers the IRDA to regulate insurance premiums, including the rates, terms, and conditions. The IRDA can intervene if it finds the premiums charged by the insurance companies to be excessive or unreasonable.
4. Protection of Policyholders’ interests: The Insurance Regulatory and Development Authority (IRDA) Act, 1999 provides for the protection of policyholders’ interests by mandating insurance companies to disclose all the relevant information related to the policy, including the benefits, terms, and conditions. The Act also provides for the establishment of the Insurance Ombudsman, an independent body to resolve disputes between the policyholders and the insurance companies.
5. Development of the insurance sector. The IRDA Act of 1999 created the IRDA to foster the growth of the insurance business by competition, innovation, and regulatory adherence. Between 1990 and 2000, there was a focus on public-private partnerships and public health expenditure, which transitioned to regulatory methods from 2000 to 2005. Engagement of stakeholders, including local agencies and NGOs, was seen as essential for sector development. By the late 2000s, affluent demographics were increasingly inclined to get health insurance, with private enterprises thriving despite governmental interference. Following COVID-19, mental health coverage was mandated, and the introduction of third-party administrators in 2001 enabled cashless treatments, resulting in a tripling ofhealth insurance plans since 2003­2004.

In Biman Kishna Bose v. United India Insurance co. ltd .^[46]

The appellant and his spouse, Smt. Alka Bose (the insured), procured a Mediclaim insurance policy from the respondent (insurance firm) on December 14, 1990. Subsequently, the appellant's wife became unwell and was hospitalised on August 14, 1991. He remitted Rs. 8243 for her medical expenses, and the appellant submitted a claim to the respondent. Despite many payment demands, they were not fulfilled, prompting her to file a complaint with the District Forum, which was subsequently dismissed. On appeal, the State Commission annulled the trial court's ruling and mandated the Company to compensate the appellant's claim. Moreover, the National Consumer Redressal Commission annulled the request for monetary compensation from the Insurance Company while the dispute remained ongoing. Meanwhile, the appellant's insurance lapsed owing to non-renewal; thus, he sent a letter together with checks amounting to Rs. 1796 for the renewal of his existing Mediclaim policy on 24-01-1996, which the business rejected based on his prior behaviour. The Insurance Company declined to renew the appellant's policy on the grounds that the appellant initiated legal action against the company, which operates as a monopoly in the general insurance sector in the country and thus possesses the characteristics of a State entity under Article 12 of the Constitution ofIndia. .⁴⁷ In Monmohan Nanda v. United India Co. Ltd. and Ors,^[48]

The Supreme Court, in permitting an insurance claim under a Mediclaim policy, delineated the rules to be adhered to when submitting an insurance proposal: (a) the language of the inquiry must be interpreted fairly and reasonably, and the response will be similarly interpreted; (b) negligence is not a valid justification unless the mistake is so apparent that no one could be deemed misled. (c) An response that is factually true, to the extent it covers, is inadequate if it is deceptive due to omissions. (d) If the space for an answer is left blank, it may reasonably be inferred that there is no response to provide; (e) If an answer is deemed unsatisfactory due to apparent incompleteness or inconsistency, insurers may be considered to have a duty to enquire further; thus, if they issue a policy without additional investigation, they are presumed to have waived the need for further information; (f) A proposer may find it expedient to group multiple questions together and provide a collective response; (g) Any answer provided, regardless of its accuracy and honesty at the time of documentation, must be amended if any event or circumstance arises before the acceptance of the proposal that renders it inaccurate or misleading.

3.4.3.3 Health Insurance nature

A number of plans and choices created by governmental or voluntary organisations with the intention of advancing particular health-care goals is known as health policy. Policies may be aimed at patients, doctors, drug manufacturers, or healthcare systems. Health insurance is a kind of insurance that covers an insured individual's medical and surgical expenses. It compensates the healthcare provider of the insured individual directly or reimburses the expenses spent due to sickness or damage.

3.4.3.4 Types of Health Insurance

• Individual Health Insurance

You can purchase an individual health insurance policy to provide coverage for your parents, spouse, children, and yourself. Generally, these policies cover a broad spectrum of medical expenses, including hospital admissions, nursery consultations, hospital accommodation fees, and additional costs. Every participant in an individual health insurance plan possesses a distinct sum insured.

• Family Floater Health Insurance

A family floater plan allows you to cover all family members under a single policy, with the entire insured amount shared among them. Due to the pooled insured amount, these plans are often more cost-effective than individual policies.

• Senior Citizens Health Insurance

The medical demands and requirements of senior folks have been especially taken into consideration throughout the construction of these health plans. The majority of senior citizen policies provide extra coverage, including some mental benefits and even domiciliary hospitalisation.

• Critical Illness Insurance

Many illnesses linked to lifestyle choices are becoming more common. Chronic health conditions like cancer, stroke, renal failure, and heart disease can be extremely costly to treat and manage. Critical illness insurance coverage was developed for just this reason. They may be purchased separately as a stand-alone plan or as a rider or addendum to your existing health insurance policy.

• Group Health Insurance

Group managers have the capability to acquire group health insurance plans for a substantial number of individuals, in contrast to individual and family floater policies. For example, a building administrator may purchase a plan for every resident, or a business may get group insurance for all its employees.

3.4.4 Social Security Insurance (Required)

3.4.4.1 Social Security Insurances

Social health insurance (SHI) is a mechanism for financing healthcare. It is classified as 'prospective' finance, as money are aggregated in advance, mostly via regular payments from insurance fund members, employers, and the Government (Whitaker 2004). It is required for specific group to prevent negative and risky choices. It is a social agreement between the government and those who are enrolled. Social health insurance often refers to a health insurance programmed with distinct features. The premium is often income-based, meaning that lower-ranking employees pay a lesser premium than higher-ranking employees. It deals with disparities in health finance by having the healthy cover the expenses of the sick and individuals who can afford medical medical treatment supporting those who cannot.

3.4.4.2 Eligibility Social Security Insurance

Low-wage employees in the formal sector, especially within certain sectors. Employees whose monthly salary do not surpass Rs.21,000 (Rs.25,000 for those with disabilities) are eligible for coverage under the ESI system. The market and competition prioritise the effective allocation of resources above equity. Substantial market failures are present in the insurance and healthcare sectors. The government's regulations have failed to effectively resolve market issues. Social insurance is a crucial mechanism for improving equity and addressing market inefficiencies. Governmental failures are substantial. Politics influenced by self-serving motives.

The Government functions like a monopoly. The Government operates under a top-down system where the interests of higher-ranked officials take precedence over those of the common people. The Government is governed by bureaucratic regulations that hinder innovation and lead to inefficiency. To be eligible for benefits, the enrollee must have paid the premium for a certain minimum duration. Therefore, Social Security is not a universal right for all citizens and is not a charity programmed. Financially independent and responsible for maintaining its own financial stability

3.4.4.3 Advantages of Social Security Insurance

• Diversify risks extensively
• Enhances fairness
• Gathers financial funds for healthcare from formal sector employees
• Minimal administrative expenses
• Can manage healthcare cost increases if programmed is well-designed

Social insurance programmed necessitate robust institutional capabilities, particularly for gathering revenue In low- and middle-income countries, where a considerable segment of the population is employed in the informal sector and there are large rural communities, restricted administrative capabilities and little governmental monitoring render Social Health Insurance (SHI) often impractical.

Efficiency and the cost of reaching poor people

a. Administrative expenses for providing coverage to extensive numbers of informal workers can be substantial in low-income nations.
b. Collection expenses for Social Health Insurance (SHI) systems are significant as compared to normal tax collection, which is necessary for other purposes as well.
c. Schemes targeting the informal sector rely mostly on general tax receipts or levies designed to fund the programmed.

3.4.4.3 Disadvantage of Social security Insurance

• Demands advanced expertise and organization for successful execution
• Changes economic dynamics
• Shifts financial influence, which may be abused
• Universal coverage is unattainable without government subsidies for farmers and informal sector workers

3.4.5 Insurance For Private Health (PHI)

Private health insurance encompasses interrelated stakeholders: customers, employers, insurers, and governments, each with obligations that include premium payments, regulation, and service delivery. Consumers get coverage via employer-sponsored (group) or direct (nongroup/individual) policies, which may be fully insured or self-insured and accessible on or off marketplaces. These plans function in accordance with federal and state rules, mandating participants to remit designated sums for the covering of specified healthcare services. Insurance functions as a risk transfer mechanism, safeguarding customers against unforeseen healthcare expenses by reallocating a segment of the financial responsibility to insurers. Nonetheless, both customers and insurers maintain a degree of financial risk.

3.4.6 The Community Based Health Insurance (CBHI)

Community-Based Health Insurance (CBHI), a micro-health insurance framework for low- income populations, depends on strong community involvement in its creation and administration. These voluntary, small-scale initiatives aggregate health risks and financial resources within a community defined by common attributes like as geographic area or profession, often using uniform premiums irrespective of individual risk factors. Benefits are often associated with donations, membership is optional, and schemes function on a non-profit basis. Although CBHI provides some financial security and access to healthcare, its effectiveness is minimal, since restricted enrolment often excludes the most impoverished individuals. Therefore, CBHI alone is insufficient for attaining Universal Health Coverage (UHC) and functions optimally as an ancillary element of a comprehensive national health finance plan, particularly in light of the absence of subsidies for at-risk groups.

3.4.7 Health Insurance Started by the Government (GHI)

A government health insurance program is a medical coverage established by the relevant government to safeguard people and their families from the financial strain ofhealthcare costs. It is essential for all individuals to retain an active health insurance coverage owing to the unexpected nature of medical situations.

- Important factors influencing Health Insurance

i. Age

Age is a significant factor in determining the amount of premium paid by the insurer. The younger insurer are, the lower the premium insurer will need to pay. Youth often have fewer health issues than older individuals and are less inclined to need medical care and insurance. It is recommended to get health insurance policies with extensive coverage from a younger age. Our 20s and 30s are often referred to be the golden years of our lives for a specific reason. It is to be related that taking health insurance in 20s and 30s might result in lower costs due to the decreased likelihood of filing a claim. Most insurers increase the premium charges for those aged 45 and above. Most insurers do not provide policies to individuals over a particular age and instead provide specialised plans for seniors at increased premium rates.

ii. Pre-Existing Diseases

Pre-existing diseases (PED) are medical conditions that an individual has had a diagnosis, treatment, or consultation for within 48 months prior to obtaining a health insurance coverage. If you have high blood pressure or thyroid issues, these will be classified as pre-existing conditions. The whole insurance industry operates based on risk evaluation and probability. Individuals with the pre-existing health conditions are more prone to have subsequent health issuers. Therefore, the likelihood of filing claims rises for such individuals. In such instances, no insurer would voluntarily assume a risk. Most insurers do not offer coverage for pre-existing conditions. They will raise the rates for individuals with pre-existing conditions in order to enhance financial security. It is likely that your insurance company will need you to buy additional coverage for pre-existing conditions. Historical medical records are crucial in determining the premium amount. Individuals having a medical history of illnesses or pre­existing conditions may incur elevated insurance rates. If you have not had any ailments and maintain a generally healthy lifestyle, your premium will be reduced.

iii. Occupation

The type of insurer job and the level of risk insurer face at work impact the cost of insurance premiums. If insurer work in school, insurance premium will be lower. However, if insurer work in a high-risk setting like a construction site or factory, the premium will be higher. Factory or manufacturing unit employees may need to pay a greater premium than normal office workers. The insurance may raise their rate due to the elevated risk of injury or illness. Typically, insurance companies do not provide coverage for occupational dangers. The profession significantly influences both your health state and the amount of health insurance premium insurer must pay. Individuals in high-stress occupations or those working in dangerous settings are at a greater risk of experiencing severe health problems, which may result in increased insurance premiums. It is crucial to stay well-informed on the health status of oneself and one's family. Understanding your health issues will help you select appropriate insurance plans and additional coverage options. Ensure that the premiums insurer pay are accurately calculated, avoiding overcharging or undercharging.

iv .Body Mass Index (BMI)

Customers having a high BMI are subjected to higher premiums. Individuals with an elevated Body Mass Index (BMI) are prone to serious problems like cardiovascular diseases, type 2 diabetes, respiratory disorders, hypertension, and cancer. Body Mass Index (BMI) is a commonly used metric for assessing an individual's physical fitness. A high BMI indicates an increased likelihood of experiencing health problems like heart disease, respiratory troubles, and joint discomfort. Customers with a high BMI are considered high-risk insurance buyers who are more likely to acquire health concerns in the future. Many health insurance companies provide discounts and prizes for customers who lead an active lifestyle, manage obesity, and participate in wellness programmes to promote good health. Individuals with an elevated BMI typically face increased insurance premiums compared to those with a healthy BMI.

v .Smoking Habits and Alcohol

India accounts for around 11.2% of the global smoking population, as reported in Lancet, a medical magazine. Smoking raises health risks, leading insurance firms to categorise smokers as high-risk clients and charge them more premiums. Smokers are charged more premiums than non-smokers. Regular smokers must pay a higher premium for medical insurance because of the substantially elevated health risks associated with smoking. Insurers globally demand greater premiums to offset the increased risks of insuring a smoker Regular smokers have an elevated chance of getting ailments such as lung cancer, stroke, heart disease, asthma, respiratory disorders, chronic obstructive pulmonary disease (COPD), and hypertension.⁴⁹

vi.Geographical Location

The insurer's location influences the premium cost of the covered policy. In some geographic areas, elevated premium rates are attributed to the scarcity of nutritious food alternatives, climatic conditions, and health-related concerns. The location of the insured house may influence the premium rate that the insurer must pay. Some zip codes need a higher premium cost, while others do not.

3.4.8 The nature and unique features of health insurance

i. Waiting Period Concerning Pre-existing Illnesses

Once insurer buy a health insurance plan, certain illnesses do not automatically become a part of this insurance coverage. This is especially true for certain existing illnesses. Example Diabetes: If a person has diabetes before acquiring a health insurance plan, the insurer might not immediately pay for diabetes-related medical expenses. Before coverage for diabetic care becomes accessible, there may be a waiting period, which typically lasts between two and four years. They become eligible to be covered only after a certain waiting period. This waiting period, however, can be different for different health insurance plans. Thus, do check on the waiting period as it can range from a few months to even years depending upon the policy. A shorter waiting period will provide you with the right coverage immediately.

ii. Sum Insured or Policy Coverage

This is the maximum amount of expense insurer can incur which will be either reimbursed by the insurer or paid for directly to the hospital. In case, the total medical expenses go beyond the sum insured, the insurer will be forced to pay from your pocket. Ensuring the insurer take the right sum insured thus, becomes important. Choosing the amount which will ensure enough coverage without insurer having to dip into the savings, thus becomes important. Do look for this while deciding on the health insurance plans.

iii. Sub-Limits

Another area that can be quite expensive when undergoing medical treatment is the room rent. The room rent is mostly tied to the sum insured. It is generally 1-2% of the sum insured. In case of the ICU, the room rent allowed is a little higher. It is, however, important that you examine your policy closely to ensure this amount is enough for your needs.

iv. Network ofHospitals Available for Treatment

The cashless feature of a health insurance plan relies on the insurance company's network of affiliated hospitals. A larger network facilitates easier cashless payments for treatment. Conversely, a smaller network may necessitate upfront payment before seeking reimbursement from the insurer. A large network of hospitals thus makes it easier to get treatment without any hassles. The insurance company in this case settles the bill directly.

v. No Claim Bonus

Like vehicle insurance, if health insurance is not utilized in a particular year, the firm rewards the insurer with a no-claim bonus by providing a bigger sum covered without altering the cost. Therefore, the insurer receives increased coverage while maintaining the same premium as before. Examine the insurer's no-claim bonus policy while choosing a health insurance plan.

vi. Co-payment Options

Due in major part to new IRDAI regulations and rising loss ratios, several insurers in India are modifying the most recent premium rates for health insurance plans with co-payment alternatives. For example, starting in November 2024, New India Assurance would raise rates for a few health plans, including Senior Citizen Mediclaim, Jan Arogya Bima, and Arogya Sanjeevani, by almost 10%. Similar increases of 10-15% for various plans are also being considered by other insurers. Co-payment plans, in which policyholders split a portion of the medical bills, typically have cheaper premiums but transfer some costs to the insured the event of a claim. By plan type and insurer, the precise co-pay percentages and their effect on premiums vary greatly; they usually range from 10to20 percent.⁵⁰

vii.Exclusion in the Policy

Certain health insurance policies have terms about exclusions. This pertains to certain illnesses or disorders that are excluded from coverage under the health insurance policy.

viii.Pre Hospitalization and Post Hospitalization Expenses

These are the costs incurred before to and after the hospitalisation. It is essential to assess the duration for which the insurer would pay pre-and post-hospitalization charges. Typically, costs incurred 30 days before to hospitalisation and 60 days after hospitalisation are reimbursed.

3.4.9 Fire Insurance

3.4.9.1 Fire Insurance in India:

Fire insurance is a kind of property insurance that provides coverage for losses or damages resulting from fire. It may offer financial protection for a broad variety of assets, including buildings, equipment, inventories, and personal property. In the case of a fire, the insurance company pays the insured for their losses, according to the limits of the policy. According to section 2(6A) of the Insurance Act 1938, fire insurance business is defined as the activity of entering into insurance contracts that cover loss due to fire or other events typically encompassed within fire insurance policies, excluding any independent association with other classes ofbusiness.

3.4.9.2 Pre Independence Period

The inception of fire insurance dates to 1601 A.D. with the enactment of the Poor Relief Act in England. Under this Act, letters referred to as "briefs" were read from the pulpit soliciting public donations to assist those who had losses due to fire. A significant conflagration occurred in London, a historical catastrophe during which 80% of the city was obliterated over three days, from September 2 to September 5, 1666, leading to the inception of fire insurance.The first fire office in India was founded by builder Nicholas Barbon in 1680. The British East India Company's entry in the 17th century signified the adoption of Western insurance principles. Fire insurance was originally provided by individual entrepreneurs or partnerships rather than established corporations. In 1708, Charles Povey established the Traders Exchange to insure movable goods, merchandise and stocks against loss or damage, marking the first instance of insuring both the building and its contents. The first fire insurance firm in India, the Oriental Fire and General Insurance firm, was founded in Calcutta (now Kolkata) in 1818. This signified the start of structured fire insurance activities in the nation. Subsequently, several other fire insurance firms were founded in prominent towns across India, including Bombay (now Mumbai), Madras (now Chennai), and Lahore (presently in Pakistan).

3.4.9.3 Post-Independence Period

Substantial transformations occurred in the insurance sector following India's independence in 1947, notably the nationalisation of insurance firms. The Life Insurance Corporation ofIndia (LIC) was established in 1956 as a state-owned entity to provide life insurance services, while the General Insurance Corporation of India (GIC) was formed to oversee non-life insurance, including fire insurance. The fire insurance market was centralised under governmental oversight due to the nationalisation of insurance companies, with GIC and its subsidiaries dominating the majority of the market. The General Insurance Business Nationalisation Act of 1972 instituted a significant shift, establishing the General Insurance Corporation of India (GIC) and its four subsidiaries, thereby granting them a monopoly over general insurance products, including fire insurance.

3.4.9.4 Liberalization, Globalization and Privatisation (LGP)

The history and roots of the Indian life insurance industry are unique. It has surmounted various hurdles and failures since its foundation in order to attain its present position. The two primary variables affecting the growth of any insurance sector are the capacity of each individual citizen of a nation to create an income and the general public's desire and awareness. Therefore, a solid educational system and more mass job possibilities should be made accessible. Moreover, while these measures facilitate the growth of the insurance industry, it is imperative to educate the public on the importance and benefits of life insurance. In the Indian context, the populace's propensity for insurance was comparatively rare during the decade of independence and progressively escalated in the subsequent decades. Shortly after the acceptance and adaptation of liberalisation, privatisation, and globalisation (LPG) in 1991, the Indian insurance business saw significant enhancement. The Indian life insurance industry has evolved in all aspects since 1991, while also facing intense competition from several local and international private insurance firms. LIC had substantial challenges due to the decrease in the savings rate, intensified competition in the main market, and particularly the proactive mobilisation of mutual funds.⁵¹

Since 2000, private enterprises have been permitted to participate in the fire insurance business, providing a broader array of products and promoting innovation. In the early 2000s, the Indian Government initiated a series of economic reforms to liberalise many industries, including insurance. This resulted in the incremental liberalisation of the insurance industry to private entities. The Insurance Regulatory and Development Authority of India (IRDAI) was founded in 1999 as an independent regulatory entity to supervise and govern the insurance industry, including fire insurance. The liberalisation of the insurance sector has led to heightened competition, innovation, and the proliferation of fire insurance products and services provided by both public and private insurance firms in India.

In New Asiatic Insurance Co. Ltd. v. Srinivasan[5]-[2]

This case involved a fire insurance policy issued by New Asiatic Insurance Co. Ltd. to policyholder Srinivasan for his furniture. The policy required the claimant to disclose any additional insurance obtained for the same property. Srinivasan failed to reveal that he had acquired another fire insurance policy from a different company for the same item. The court ruled in favour of New Asiatic Insurance Co. Ltd., determining that the claimant's non­disclosure of the additional policy constituted concealment of a material fact, thereby breaching the principle of utmost good faith (uberrimae fidei) fundamental to insurance contracts. This failure to disclose permitted the insurance company to void the contract and absolve itself of any liability for the fire loss.

The Bombay Fire Insurance Association Ltd. v. The Ahmedabad Municipality^{[52] [53]} the suit against the Ahmedabad Municipality (local governing body). Several insured properties in Ahmedabad suffered fire damage. The fire insurance companies claimed that the fires were a direct consequence of the municipality's negligence in maintaining the city's water supply system. Due to the lack of proper water pressure, firefighters were unable to effectively extinguish the blazes, leading to extensive property damage. whether the Ahmedabad Municipality was able to levy the insurance premiums that the Association received. The court had to decide whether the fire insurance industry was covered by the applicable municipal statutes' definitions of taxable entities. The tax's legitimacy was questioned, particularly in relation to whether it infringed upon the Association's fundamental rights. The court ruled infavour of insured While acknowledging the fire damage and the fire insurance companies' losses, the court determined that the lack of water supply wasn't the proximate cause of the fires.

In Narasingh Ispat ltd v. oriental Insurance Company.^[54]

The Supreme Court determined that the insurer did not meet the need to confine the case within the parameters of the exclusion. When the policy explicitly delineates acts of terrorism under the exclusion clause, the stipulations of the policy, as a finalised contract, will dictate the rights and obligations of the parties involved. Consequently, the parties cannot depend on the definitions of 'terrorist' included in different criminal legislation, since the exclusion clause provides a comprehensive description of acts of terrorism. The insurance specifically covers responsibility for damage to the insured's property resulting from riots or violent methods; so, there was no justification for invoking the Exclusion Clause. The Insurer's decision to reject the insurance was deemed untenable.

3.4.10 Marine Insurance

A different kind ofinsurance that covers losses or damages sustained by ships, cargo, terminals, or other property transported by water is known as marine insurance. As it shields ships and their cargo from maritime risks involved itisa vital part of the maritime sector

3.4.10.1 Marine Insurance in India during Pre-independence

British insurance companies dominated the maritime insurance market in India during the colonial era. The Indian traders and shipowners could get insurance from these businesses, but the coverage was restricted and the premiums were expensive. In order to safeguard their investments, a large number of Indian shipowners and traders turned to unofficial insurance arrangements such as mutual insurance societies.

3.4.10.2 Marine Insurance in India after Post-independence

Subsequent to India's 1947 declaration of independence, the government sought to promote the growth of the nation's insurance industry, including the marine insurance sector. The General Insurance Corporation ofIndia (GIC) was established in 1972 to regulate the non-life insurance business, including marine insurance, while the Life Insurance Corporation ofIndia (LIC) was created in 1956 to govern the life insurance market. The Indian shipping industry has seen substantial growth since independence, necessitating the establishment of regulations tailored to Indian circumstances to ensure the continued development of Indian marine insurance. Prior to legislation, matters concerning this legal domain were adjudicated based on English rulings that implemented common law contract concepts with the overarching law of contracts. The

Indian legislation largely adheres to the structure of the English version, diverging just somewhat at critical junctures. It is a significant reproduction of the English version. The preamble to the Insurance Act of 1938 states it is "an Act to codify the law relating to marine insurance." A codifying Act must be read according to its explicit wording, with the former status of the law considered only in cases of confusion or ambiguity.

3.4.9 Social Insurance

Social insurance is a governmental initiative aimed at delivering financial assistance and social security to people at significant life events, including retirement, disability, unemployment, and sickness. In contrast to private insurance, social insurance is often financed by payroll taxes or contributions from both employers and workers. This approach seeks to enhance social welfare by reallocating resources to those in need, therefore guaranteeing a safety net for residents. Social insurance plays a crucial role in establishing stability and alleviating poverty by providing guaranteed income or benefits during difficult times.

3.5 Health Insurance Policies and Schemes

Health policy, as defined by the WHO, encompasses choices and activities aimed at attaining societal healthcare objectives. Following independence, India implemented insurance legislation to enhance economic stability and social welfare, prioritising marginalised communities and increased access to healthcare. The first National Health Policy (1983) sought to provide universal healthcare access, ensure the supply of critical medications, and improve infrastructure, with an emphasis on preventative treatment and the alleviation of illness load. The nationalisation of life insurance (LIC Act, 1956) and general insurance (1972) expanded coverage. Recent programs such as PMJDY (2014), PMJJBY (2015), andPM-JAY (2018) have enhanced financial inclusion and health security by providing inexpensive life and health insurance, especially to low-income populations. These policies provide a safeguard against life occurrences, enhancing healthcare accessibility, alleviating poverty, and ensuring economic stability. The NHP (1983) underscores the need of comprehensive healthcare services, prioritising preventative, promotive, curative, and rehabilitative treatment, particularly for at-risk populations.

1) Ayushman Bharat Scheme, 2018

The Ayushman Bharat Yojana, launched by the Ministry of Health and Family Welfare, guarantees extensive and complimentary health insurance services to all individuals. This aims to assist persons in the lowest tier of the socio-economic ladder. The insurance offers coverage of Rs 5 lakh, including pharmaceuticals, diagnostic fees, medical treatment charges, and pre­hospitalization costs. Pradhan Mantri Suraksha Bima Yojana, 2015,the Pradhan Mantri Suraksha Bima Yojana aims to provide insurance coverage to Indian citizens aged 18 to 70 with an active bank account, in the event of disability or death resulting from accidents. The insurance offers yearly coverage of Rs 2 lakh for disability or death due to accidents and Rs 1 lakh for partial disability. The premium is immediately withdrawn from the insurance holder's bank account.

2) Aam Aadmi Bima Yojana (AABY), 2007

The Aam Aadmi Bima Yojana was formed in 2007 to tackle the issues encountered by individuals living in rural regions or developing urban centres in India. The program incorporates provisions for granting scholarships to disadvantaged children in India to enhance educational opportunities. This coverage is accessible to those aged 18 to 59, namely renters living in urban or rural areas who do not own land. The policyholder, often the family's main income earner, pays an annual premium of INR 200. In the event of natural death, the family receives Rs 30,000, however in instances of death resulting from lifelong impairments, the family is awarded Rs 75,000.

3) Janshree Bima Yojana, 2000

Initiated collaboratively by the Government of India and the Life Insurance Corporation, the Janshree Bima Yojana provides insurance to those living below the poverty line in both urban and rural regions. The strategy targets the working class of India, classified into several vocations. The coverage is now available to 45 diverse job categories. The policy's primary advantages include cash remuneration to the legal successor upon the policyholder's death, whether resulting from natural causes or accidents. It also include financial remuneration for entire or partial disability. The package notably incorporates perks specifically designed for women. This include maternity benefits and treatment costs for female severe illnesses.

4) Mukhyamantri Amrutam Scheme, 2012

Initiated by the Gujarat government in 2012, the Mukhyamantri Amrutam Yojana primarily served families and people living below the poverty line. Nevertheless, after many deliberations and modifications, the advantages of the legislation were also conferred to those from the lower income bracket. The primary advantage of this program is its comprehensive coverage of all medical expenses, ranging from diagnostic assessments to post-hospitalization care. The most advantageous aspect of this program is that it requires no enrolling fee or insurance premium payment. It encompasses a broad spectrum of medical conditions whose treatments will be entirely financed by the government. All policyholders are supplied with an amount insured of

INR 3 lakh; however, in instances of specialised procedures such as kidney, liver, or pancreatic transplants, the sum insured is elevated to INR 5 lakh. It is essential to remember that a maximum of five individuals per household may join in this initiative.

5) Mahatma Jyotirao Phule Jan Arogya Yojana, 2012

Mahatma Jyotiba Phule The Jan Arogya Yojana was established by the government of Maharashtra for the residents of the state. The major objective is to provide cashless medical services and high-quality healthcare to those from lower-income demographics. The coverage includes a comprehensive list of 971 medical treatments together with an extra 120 post-therapy packages. This include orthopaedic surgery, gynaecological and obstetric treatments, heart surgeries, radiation procedures, and plastic surgeries, among others. The annual sum insured per family is about Rs. 1.50 lakhs, which is insufficient, although the policy offers a variety of advantages. The state bears the insurance premium. Medical benefits include consulting fees in addition to diagnostic care costs. In addition to government institutions, several private hospitals adhere to the program and provide treatments to beneficiaries.

6) Bhamashah Health Insurance Scheme, 2015

The Bhamashah Swasthya Bima Yojana was established by the government of Rajasthan to benefit its inhabitants. This technique mostly advantages low-income families who are permanent residents of Rajasthan. The insurance provides coverage of Rs 5 lakh for medical treatments and emergencies. Female policyholders may use their Bhamashah Swasthya Bima Yojana insurance cards to get rations from certain PDS outlets, affording them exclusive advantages. The Rajasthan government implemented a unique initiative to improve healthcare knowledge among women.

7) National Health Insurance Scheme, 2008

The Bhamashah Swasthya Bima Yojana was established by the Rajasthan government to benefit the state's citizens. This technique mostly advantages low-income families who are permanent residents of Rajasthan. The insurance provides coverage of Rs 5 lakh for medical treatments and emergencies. Female policyholders may use their Bhamashah Swasthya Bima Yojana insurance cards to get rations from sanctioned PDS outlets, affording them distinct advantages. The Rajasthan government implemented a unique initiative to improve healthcare knowledge among women.

8) Central Government Health Scheme (CGHS), 1954

The Central Government Health Scheme was established in 1954 and mainly serves officials employed by the central government, including Supreme Court justices and central railway personnel. The policy further covers pensioners. The policy seeks to provide hospitalisation and home care, including both allopathic and homoeopathic medications. This program also offers complimentary X-ray and laboratory testing services to central government personnel. The Central Government Health Scheme now serves 3.5 million people in71 cities.

9) Universal Health Insurance Scheme (UHIS), 2003

The Universal Health Insurance Scheme, another major initiative of the central government, is designed to serve a broad spectrum of those living below and slightly over the poverty line. The insurance covers hospitalisation and maternity coverage. The insurance primarily covers medical treatment expenses and accident coverage for the family's principal income earner. In instances of accidental death, the family will be entitled to the insurance payout.

10) West Bengal Health Scheme, 2008

West Bengal has garnered several plaudits for its emphasis on enhancing public health services. Participation in the West Bengal health system may be essential for preserving lives. This perk is only available to those in the All-India Services or retirees. This programming covers the costs for at least 1014 medical problems, including outpatient care. The policy's primary features include cashless claims, reimbursements for treatments at non-network hospitals, coverage for outpatient operations, and compensation for expenses incurred outside of hospitalisation. Registration and enrolling for the insurance may be conducted online via the official West Bengal Health Scheme website.

11) Yeshasvini Health Insurance Program, 2002

The Yeshasvini Health Insurance Scheme is funded by the state government and development cooperatives to support farmers and others with low to medium incomes in Karnataka. This approach seeks to provide superior and economical healthcare services in Karnataka. Policyholders are insured for Rs 5 lakh and may avail themselves of cashless claims at affiliated hospitals. The program offers advantages for 1,650 conditions and delivers discounts on certain diagnostic or treatment costs.

12) Karunya Health Scheme, 2008

The Karunya Health Scheme seeks to provide healthcare services to those in Kerala afflicted with serious ailments. Individuals from lower income groups may use this program to get medical treatments for chronic diseases, including cancer, cardiovascular issues, and palliative care, among others. The coverage limit for the Karunya Health Scheme is INR 5 lakh per family. The coverage covers costs for diagnostic tests, medical consultations, pre- and post­hospitalization charges, and intensive care treatments.

13) AWAZ Health Insurance Program, 2015

The AWAZ health insurance scheme, established by the Government of Kerala, is to provide insurance protection for migrant workers. This insurance is accessible to migrant workers living in Kerala aged 18to 60. Each insured is eligible to get gratis medical care for up to Rs. 15,000 at government-operated hospitals. The strategy further addresses health repercussions stemming from accidents affecting migrant labour.

14) Health Scheme for Telangana State Government Employees and Journalists, 2015 The Telangana state government has established a unique insurance coverage called the Employees and Journalists Health Scheme (EJHS). The approach seeks to improve healthcare and well-being for its workforce, especiallyjournalists and their families. The scheme permits cashless hospitalisation coverage at network hospitals throughout the state. The benefits include inpatient and outpatient therapy, hospitalisation, and post-treatment care. The insurance provides limitless coverage.

15) Employees’ State Insurance Act, 1948

The Employment State Insurance Scheme is one of India's oldest health insurance programs established by the government to provide coverage for working citizens. A company is generally required to enrol in the ESI program if it employs more than 10 individuals. This plan encompasses several health-related scenarios and offers pension options for the family in the case of death or incapacity due to occupational hazards. The insurance offers coverage for sickness, maternity, disability, unemployment, funeral expenses, and geriatric medical care, among other advantages.

16) Dr. YSR Aarogyasri Health Care Trust, established in 2007

The Dr YSR Aarogyasri Health Care Trust, founded by the Andhra Pradesh government, offers health insurance to citizens in the state from lower economic backgrounds. This health insurance plan provides several characteristics, including maternity coverage, rehabilitative therapies, cashless claims, and uninterrupted care from diagnosis to post-treatment. The strategy emphasises preventive healthcare initiatives, including the provision of free health examinations and screenings for certain diseases. The insurance covers coverage for many treatments of chronic diseases, including chemotherapy, radiation therapy, and dialysis.

17) Comprehensive Insurance Scheme of the ChiefMinister, 2019

The Chief Minister's Comprehensive Insurance Scheme in Tamil Nadu has over 65% of the state's population enrolled, demonstrating significant achievement. Low-income families may now choose this program to get a diverse array of medical services and benefits. Each household is insured for Rs. 5 lakhs per year. The insurance provides access to several network hospitals. Designated hospitals often provide free health check-up events, and policyholders may use a dedicated 24/7 hotline for support.

18) Rajiv Aarogyasri Community Health Insurance Scheme (RACHI), 2007

The Andhra Pradesh government established the Rajiv Aarogyasri Community Health Insurance Scheme (RACHI), a prominent government health insurance initiative, using an innovative social strategy. The plan functions via a public-private partnership to ensure that economically disadvantaged persons may receive high-quality healthcare services without obstacles. Individuals living within the poverty threshold and possessing a ration card are automatically enrolled in this program. The list of network hospitals includes both private and public institutions. The premium price is rather affordable. This policy covers about 900 medical procedures.

In Gaurav v. Oriental Insurance Company Limited,^[55]

The primary issue in Gaurav v. Oriental Insurance Co. Ltd. was determining who was at fault in a car accident involving a pedestrian who died and an Oriental Insurance-insured vehicle. The facts showed that the pedestrian dies as a result of the collision, which was caused by the drivers negligence. The claimant, who were the deceased's legal heirs, sued the insurance company, claiming that the policy's provisions held the insurer accountable for the damages. The court decided on the claimant's favour, highlighting the insurer's obligation to make up for the victim's losses. The idea that victims of carelessness should be fairly compensated was reinforced when it was decided that the insurer could not avoid accountability simply because the insured had not complied the insured had not complied with the terms of the policy. The ruling set standards for similar claims and emphasised the significance of accountability in auto insurance situations.

Indian health NGOs function in rural and urban regions, emphasising curative, preventative, and rehabilitative care via institutions and community health camps, often supporting government initiatives. Beneficiaries generally do not incur costs for these services, which are mostly financed by grants and contributions, however Tamil Nadu depends increasingly on user fees. HIV/AIDS and health system management get the predominant allocation of single­purpose funds, followed by RMNCH projects. Most NGOs emphasise preventative care via outreach, with little provision of hospital or outpatient services; curative care is the second- largest expenditure in most states. Healthcare services supplied by NGOs, particularly EPI and FP packages, are often economical and efficient.

1.1.1 kinds ofHealth Insurance policy in India

Indemnity-based: In this model, the insurance provider directly compensates the hospital for the medical expenditures incurred by the covered individual. This occurs when the insured need financial support to address hospitalisation and associated expenses.

Fixed-benefit model: In this scenario, the insured individual first settles the hospital expenses and then submits the receipts to the insurance provider. The corporation then compensates the insured for the expenditures. These plans, often referred to as Mediclaim, need the insured to remit a periodic payment in return for financial coverage against hospitalisation and accident- related medical expenses. They provide financial stability and assist in alleviating healthcare costs. These insurance often possess a restricted coverage duration and need frequent renewal (monthly or yearly). Standard Mediclaim insurance often have a coverage cap of Rs 5 lakh. The premiums paid for these plans are eligible for tax deductions under Section 80D of the Income TaxAct, 1961.

1.1.2 Types of Mediclaim Policies

Mediclaim policies are designed to meet diverse needs and circumstances. Here are some common types:

• Individual Mediclaim insurance: This insurance offers coverage that is exclusive to the individual policyholder, and it covers expenditures that are spent both before and after hospitalisation, as well as diagnostic testing. In most cases, these plans are effective for a period of one year. In order to cater to particular requirements, such as coverage for critical sickness or pregnancy, there are a variety of specialised individual plans available.
• A Family Floater Policy: This kind of insurance policy provides coverage for the policyholder as well as their family members, which may include their spouse, children, and parents, under a single amount insured.
• Senior Citizen Mediclaim coverage: This kind of coverage is particularly intended to cover the medical expenditures of senior citizens, who are often defined as those who are above the age of sixty. Coverage for critical ailments such as cancer and renal failure is provided by the Critical Illness Mediclaim Policy. This policy was developed in recognition of the significant expenses that are involved with the treatment of severe illnesses.
• Mediclaim insurance with low premiums: These policies are intended to be affordable for individuals and families with reduced incomes. It is common for small and medium-sized firms to acquire these in order to offer their workers with health coverage.

1.1.3 Ingredients of Mediclaim policy covers the following

a) X-rays, diagnostic tests, operating room (OT) fees, and other associated costs are all included in the category ofhospitalisation costs.
b) Medical costs incurred up to 30 days before to hospitalisation and up to 60 days following release may be covered by certain insurance. It's crucial to find out from your insurer if this benefit is covered by your particular insurance.
c) Daycare Costs: This includes medical costs for cutting-edge procedures that don't necessitate hospital stays longer than 24 hours.
d) Fees for physicians, nurses, and other medical personnel are included in this category.
e) Hospital Room Services: The insurance company usually pays for hospital ward and intensive care unit (ICU) expenses.

1.1.4 Health insurance has a wider ambit than the Mediclaim policy

Regular examinations (depending on the insurer), hospitalisation, pre- and post-hospitalization fees, ambulance costs, and compensation for lost wages due to accidents are just a few of the many benefits that health insurance gives. Additional choices include critical illness, accidental disability, and maternity coverage. Policies provide flexibility by permitting changes to the duration and premium after a predetermined amount of time. Up to Rs 6 crores can be covered. Depending on the insurer and plan, claims for critical sickness and accidental disability may be paid in full or in instalments until the entire amount insured is used up.

The IRDAI launched the Corona Kavach plan (Rs 50,000-5 lakh coverage, 3.5-9.5 month term) and the Aarogya Sanjeevani Policy (Rs 1-5 lakh coverage) during the COVID-19 pandemic, and it also extended the renewal premium payment period. Hospitalisation for COVID-19 was required to be covered by the existing policies. Processing of COVID-related death claims was accelerated thanks to the Life Insurance Council. In contrast to pre-pandemic rules, which protected individuals making over Rs 21,000 under the Employee State Insurance Act, the government now requires all employees, regardless of income, to have health insurance supplied by their employers.

3.6 Role ofNGOs in Health Insurance

Non-governmental organisations (NGOs) in India play a significant part in tackling problems such as malnutrition, sanitation, and infectious illnesses via awareness campaigns and direct assistance. This helps to ensure that disadvantaged communities are able to enjoy better health and well-being. Additionally, they place an emphasis on preventative measures such as immunisation and health education, which gives people the ability to make educated choices about their health and reduces the strain placed on the healthcare system. In light of the significance of community involvement, non-governmental organisations (NGOs) work in conjunction with local communities to educate health professionals on how to become agents of change. In addition to this, they encourage the formation of partnerships between healthcare professionals, community organisations, and government agencies in order to establish comprehensive solutions. In addition, non-governmental organisations (NGOs) work to address particular health issues, such as HIV/AIDS and mental health, by delivering specialised services and pushing for public policy reform. The last thing they do is provide access to healthcare for underserved areas and populations, such as refugees, underprivileged communities, and tribal people, often using methods that are sensitive to cultural norms.

3.7 Conclusion

The increase in illnesses among younger adults can be attributed to lifestyle changes. Factors such as increasing pollution levels, fast-paced lifestyles, stress, and habits might lead to unforeseen medical disorders. The necessity for medical insurance is particularly pressing currently. Consider the significant changes in an ordinary person's daily routine from a few years ago. We are more exposed to health dangers because of our lifestyle, even if we may not be aware of it. Although preventative steps are important, it is crucial to acknowledge the significance of health insurance in your life. When seeking an appropriate health insurance plan, priorities the requirements of your family above everything else. Health insurance is particularly crucial for those who have family members who rely on them financially. Relying on a one revenue source to cover healthcare costs for several individuals is overwhelming. It is crucial to thoroughly evaluate your circumstances and invest in a strategy that provides you with the best possible advantages. Ageing parents are health insurance at a young age to plan and ensure sufficient financial protection. The expense of receiving high-quality medical care has increased significantly in recent years. Additionally, there is a substantial number of individuals afflicted by diseases and catastrophic illnesses. We are all susceptible to this terrible truth. Health insurance plays a significant role in managing medical inflation. When seeing a doctor, several fees are often incurred for consultation, medical tests, prescription medication, hotel accommodation, and other services. Understanding the importance ofhealth insurance at the appropriate moment allows for successful management. An abrupt sickness is the reason for intense mental and physical strain. If you are not financially prepared to cover the costs, it will significantly increase your load. No one desires to be denied dependable healthcare because of insufficient cash. Health insurance is crucial for safeguarding your funds and supporting your recuperation. Health insurance is crucial for safeguarding your finances.

CHAPTER: IV LEGAL FRAMEWORK OF HEALTH INSURANCE: INTERNATIONAL DIMENSIONS AND INDIAN PERSPECTIVE

4.1 Introduction

The contract breach occurs whenever one party fails to fulfil their obligations arisen under such contract. The essential rule is that the party who violates the contractual obligations must pay damages to the aggrieved party. A breach settlement may take a while and need thorough documentation and proof of the violation. The breach of contract in health insurance is a multifaceted topic requiring a comprehensive awareness of international rules and practices. It transpires when either party neglects to fulfil their responsibilities as specified in the insurance agreement. These violations may occur in many ways, including refusal to reimburse certain medical costs, erroneous claim denials, or failure to provide guaranteed benefits. The interpretation of these breaches can vary depending on thejurisdiction and insurer's operations. Breach of Contract in Health Insurance Contracts delves into the complex dynamics of contractual violations in a worldwide setting, emphasizing the protection of insured parties' rights. International health insurance policies often involve coverage across borders, adding complexity to coordination of care, billing procedures, and legal recourse. Addressing these issues requires an extensive knowledge of the policy provisions and the legal framework across many countries. In a world where contracts are made across borders and (are) becoming more intertwined, it is critical to comprehend the ramifications of breach of contracts. Legal experts in international law should give particular regard to commercial contracts due to their complexity. The object of this chapter is to provide light on the procedures that guarantee the protection of insured parties in foreign contractual relationships by setting the stage for a thorough analysis of the legal, practical, andjurisdictional issues at play.⁵⁶

4.2 International Conventions on Right to Health

The World Health Medical Association (WMA) is dedicated to inclusively defending and advancing the right to health. This covers fundamental elements including access to reasonably priced, high-quality healthcare, a secure workplace, suitable housing, and wholesome food. "The enjoyment of the highest attainable standard of health is one of thefundamental rights of

every human being, according to the World Health Organization’s (WHO) 1946 Constitution, which first stated the right to health”. Recent years have seen substantial changes in international law on the normative interpretation of the right to health, which includes both healthcare and health conditions. These criteria provide a framework that shifts the emphasis of research from care quality concerns to social justice problems, including treatment disparities. International law grants the right to health care and encompasses the broader idea ofhealth. The 1948 Universal Declaration of Human Rights includes the first reference to a right to health under international law. Health was identified as an element of the right to an adequate standard of life in Article 25 of the 1948 Universal Declaration of Human Rights (UDHR).⁵⁷

Article 12 of the ICESCR (1966) acknowledges the right to health as essential, mandating governments to provide each individual's entitlement to the best possible level of bodily and mental well-being. This encompasses measures to: (a) safeguard child health and diminish mortality rates; (b) enhance industrial and environmental sanitation; (c) avert and manage illnesses; and (d) enable access to healthcare services. The right includes fundamental health factors such as access to adequate water, sanitation, conducive working circumstances, and health education, including sexual and reproductive health. This right is generally applicable, since all nations have signed treaties acknowledging it.

Regulations for International Health Regulations (IHR) (2005)

The IHR, as defined by the WHO, is a worldwide legal framework for managing public health risks that may cross national borders. This legally binding piece of international law went into force on June 15, 2007. It emphasises disease surveillance, preparedness, and reaction to public health emergencies, like the Corona Pandemic 2019, in order to guarantee global health security.

4.3 International Perspectives

4.3.1 Definition ofBreach of Contract

Breach of Contract in health insurance transpires when the insurer neglects to meet its duties specified in the insurance policy. This may encompass the rejection of legitimate claims, postponement of payments, or the provision of insufficient coverage.

4.3.2 Legal Implications in Health Insurance

The legal effects of contract violation in health insurance may result in disputes, litigation, and financial detriment for both the insurer and the insured. Insurers may face penalties or fines for violating contractual agreements, while insured individuals may suffer from denied coverage or delayed

4.3.3 Significance for Insured Individuals

For insured individuals, a breach of contract in health insurance can have significant consequences, including financial hardship, inability to access necessary medical care, and loss of trust in the insurance provider. It shows the need of comprehending the terms and circumstances of the insurance policy and pursuing legal redress where warranted.

4.4 Protection of the Insured Person Health Insurance

4.4.1 Legal Frameworks for Protecting Insured Persons

Various legal frameworks exist to protect insured persons in health insurance, including consumer protection laws, insurance regulations, and contractual provisions. These frameworks aim to ensure fair treatment, transparency, and accountability in the insurance industry.

4.4.2 Rights and Remedies Available to Insured Individuals

Insured individuals have rights and remedies available to them in case of breach of contract, including the right to appeal denied claims, seek mediation or arbitration, or file lawsuits against the insurer for damages. Additionally, insurance regulators may intervene to enforce compliance with contractual obligations.

4.4.3 Comparative analysis of protections in different jurisdictions:

Protections for insured persons vary across jurisdictions, depending on the regulatory environment, legal system, and cultural norms. For example, some countries may have stricter regulations and stronger consumer protections in place, while others may rely more on market forces to regulate the insurance industry. Comparative analysis allows for identifying best practices and areas for improvement in protecting insured persons worldwide.

4.5 American Health Insurance Regulation

In the United States, insurance regulation is a collaborative effort between federal and state governments, with the McCarran-Ferguson Act of 1945 granting primary responsibility to the states. States often require coverage for certain types of medical services or healthcare providers and oversee the provisions ofhealth insurance plans. The pre-emption provision of the Employee Retirement Income Security Act (ERISA) of 1974 typically prohibits state legislation from governing health plans of major companies. The pre-emption rule of ERISA explicitly forbids states and municipalities from compelling businesses to adopt or modify an employee benefit plan or from passing laws or regulations governing the administration of an employee benefit plan created under ERISA.⁵⁸

The California Department of Insurance (CDI ) regulates health insurance inside the state. Our objectives are to protect clients, foster a robust and stable insurance market, and enforce health insurance laws and regulations impartially and equitably. In order to safeguard consumers, CDI ensures that insurers abide by the law. In addition to other duties, CDI examines each coverage offered for sale in California to ensure compliance with legal requirements, evaluations and remarks on the pricing adjustments of insurer has suggested; provides customer assistance who wish to lodge a grievance, or wish to challenge an insurer's decision. It also examines the financial records of insurance businesses to ensure that they have the financial stability to cover policyholders' claims; and license brokers and agents that offer insurance in California.

National Association Insurance Commissioner (NAIC)

The National Association of Insurance Commissioners is the U.S. organisation tasked with establishing standards and provide regulatory assistance. Five US territories as well as the District of Columbia. The State insurance authorities coordinate their regulatory control, carry out peer review, and set standards and best practices through the NAIC. The staff of the NAIC backs these initiatives and speaks for state regulators both locally and globally. The State insurance regulatory frameworks are open to the public, answerable to them, and considerate of the social and economic circumstances in their communities. State regulation has demonstrated its ability to successfully safeguard customers and guarantee that promises insurers' claims are retained. The main tenets of insurance regulation include consumer services, market conduct, product regulation, producer licensing, insurer licensing, and financial regulation.

The Interstate Insurance Product Regulation Commission (IIPRC)

The Interstate Insurance Product Regulation Commission (IIPRC) is a multi-state governmental entity created under the Compact, functioning as an instrumentality of the Member States. Annuities, life insurance, and many insurance products may be centrally electronically submitted at the IIPRC. The establishment of standardised product criteria for long-term care insurance and disability income, offering purchasers of asset protection insurance products substantial safeguards.

The Affordable Care Act, 2010 significantly changed the US health insurance market by giving uninsured people more options for coverage. Therefore, if one is not employed, they can obtain full medical coverage from private plans via the ACA- established health insurance marketplace, where qualified individuals can get premium subsidies.

TheNationalAssociation ofRegisteredAgents andBrokers ReformAct, 2015 expedited the approval process for insurance sellers who are not residents to conduct cross-state business. By facilitating the comparison of policies that match their profiles, the 1986 Liability Risk Retention Act increased market choice for insurance consumers and reduced costs by enabling individuals and organizations with similar risk profiles to create groups.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the establishment of national standards to protect against the unauthorised disclosure of private patient health information without the patient's informed permission or awareness.

4.6 German Health Insurance Regulation

Chancellor Otto von Bismarck’s Health Insurance Act of 1883 established the first social health insurance program in Germany. At first, only blue-collar workers had access to health insurance. In 1885, 10% of the population was insured, meaning they were entitled to monetary payments in the event of births, illness (up to 50% of salary for a maximum of thirteen weeks), or death. Coverage gradually expanded despite initial restrictions. The final step towards universal health coverage was taken in 2007 when all citizens and permanent residents were obliged to carry health insurance, whether it be statutory or private. The existing system covers the entire population and provides a full range of benefits. There are subsystems supply Health Insurance are prevailed in Germany: Statutory Health Insurance (SHI), which consists of Private Health Insurance accompanies In Germany, statutory long- term care insurance is required and covers long-term care services individually (LTCI).

Germany Governmental’s Role

The German health care system is unique in that decision-making authority is shared by the federal, state, and self-governing payer and provider organizations. The Federal Financial Supervisory Authority and the Ministry of Health oversee private health insurance to make sure that policyholders don't experience significant premium hikes as they get older or are overcharged if their income drops.The federal government establishes provider costs for additional, complementary, and substitutive private insurance via a fee schedule. These expenses often exceed SHI expenses. Private insurance is not supported by government subsidies.

Statutory Health Insurers are mandated to provide health insurance and ensure that patients get necessary care. This is achieved by agreements with many organisations and organisations, including associations of doctors, hospitals, pharmacies, and statutory insurance physicians and dentists. The federal organisation representing all statutory insurers is known as the National Association of Statutory Health Insurance Funds, or "GKV-Spitzenverband". It embodies the interests of many insurers and is governed by legal regulations in its activities. Members of private health insurance plans may choose from comprehensive, partial, or supplementary coverage options. The Association of Private Insurers (PKV-Verband) serves as their spokesman.

4.7 Health Insurance in Great Britain

In the UK, insurers are dual-regulated businesses. The Financial Activity Authority ("FAA") regulates their activity, while the Prudential Regulation Authority ("PRA") authorizes and oversees them in terms of rules and policies. The Financial Service Market Act,2000 ("FSMA") established the legal framework under which insurance regulation functions.

In the UK, Insurance regulation includes Personal regulation of specific individuals under the Senior Managers and Certification Regime ("SM&CR") in addition to the regulation of an insurer itself. According to this regime, some people who work in high management positions need permission from the PRA and/or the FCA and risk facing personal consequences if they don't complete their assigned tasks. Additionally, companies need to attest to the suitability and competency of workers who represent a risk of injury to the insurance company or its clients both initially and continuously. The PRA and FCA's conduct guidelines apply to all certification staff and other employees who do not perform auxiliary activities; violations of these rules may result in disciplinary action.

Office of the Information Commissioner (ICO) :The Information Commissioner's Office (ICO) is the autonomous body in the United Kingdom, created to protect information rights in the public interest, advocate for openness among public organisations, and uphold individual data privacy. Its function involves gathering public issues and addressing them to improve information rights standards. It is tasked with supervising the UK's execution of the General Data Protection Regulation (GDPR), which came into force in May 2018 .

4.8 Australia’s Health Insurance System

The Private Health Insurance Act of 2007 is the primary law that delineates the standards for health insurers and private health insurance in Australia. The 2015 Private Health Insurance (Prudential Supervision) Act emphasises the capacity of private health insurers to maintain financial stability. The Australian Prudential Regulation Authority (APRA) oversees the prudential aspects of private health insurance to ensure insurers maintain solvency and fulfil their commitments.

Regulations Government Private Health Insurance: In accordance with the Private health Insurance Act, these regulations provide supplementary information regarding several facets of private health insurance. Regulations for Private health Insurance firms and providers: the Department of Health and Aged Care issues laws governing insurers' communication with policyholders and healthcare providers. Concerning the processing of claims, communication, and additional domains.

- Licensing : In Australia, health insurers are required to hold an operating license.
- Policy Content and Disclosure : Insurance companies are required to provide a comprehensive delineation of coverage and exclusions within their policies, along with information on pricing and waiting periods.
- Consumer protections: Rules, such as those governing premium increases, complaint procedures, and policyholder rights to amend or cancel, guarantee that policyholders receive fair treatment.
- Marketing and Sales Practices : To maintain openness and prevent false information, insurers' marketing and sales ofhealth insurance are also subject to regulations.

When private health insurers have obligations regarding complying health insurance products and health insurance business that do not fall under the purview of the Australian Prudential Regulation Authority's prudential regulatory role, the Department regulates those obligations. Through the declaration of private hospitals and regulations guaranteeing insurer benefits for services rendered through private hospitals, the Department also supports patients' access to private healthcare services.

The Private Health Insurance Act of 2007 , later The Private Health Insurance (Prudential Supervision) Act of 2015, together with its corresponding rules and regulations, is the primary regulatory framework for private health insurance. The Australian Prudential Regulation Authority (APRA) supervises the Department of Health, which manages private health insurance. The Private Health Insurance Ombudsman, functioning under the Office of the Commonwealth Ombudsman, resolves consumer complaints and publishes an annual State of the Health Funds report. The Australian Consumer and Competition Commission (ACCC), which also submits yearly reports on the industry to the Senate, handles broader consumer and competition issues.

4.9 Spain's Health Insurance

Spain's healthcare system, the Sistema National de Salud (SNS), is a universal framework that offers extensive coverage to all legal citizens, irrespective of their income or job status. The system provides primary care, expert consultations, hospital treatments, medications, and preventative care services. The system operates in a decentralised manner, with regional health administrations supervising the management and provision of services. Private health insurance provides further advantages, including access to private hospitals and coverage for treatments excluded from the public system. Spain's healthcare system provides benefits relative to other nations, including universal coverage, regional autonomy, and cost-effectiveness. The system offers extensive services, including basic care, expert consultations, hospital treatments, medications, and preventative care initiatives. The decentralised government of Spain fosters adaptability, responsiveness to regional need, and innovation.

Legal Framework in Spain

Spain has many laws and regulations aimed at protecting the rights and interests of those insured by health insurance. The Insurance Contract Law governs the contractual relationship between insurers and insured parties, fostering transparency and clarity in policy terms and conditions. The Consumer Protection Law, established to safeguard consumer rights, requires insurers to provide clear and precise information on rights, coverage alternatives, and claims processes. The Data Protection Law ensures the privacy and security of personal data acquired and processed by insurers, affording insured persons the right to manage their information. Health insurance laws and regulations ensure adequate coverage for medical treatments and services, establishing standards for scope, reimbursement rates, network provider requirements, and patient rights.

Breach Of Contract in Spain

The Spanish healthcare system is esteemed for its universality; nonetheless, private health insurance significantly contributes to broader coverage and expedited access to specialists. Unfortunately, disputes can arise when insurance companies fail to uphold their contractual obligations. This essay explores the challenges of navigating a breach of contract in Spanish health insurance and proposes strategies to protect your healthcare rights. The first step involves a thorough understanding of the insurance policy. This intricate document outlines the agreed- upon terms between you and the insurer. Crucially, focus on clauses related to coverage details, exclusions claim procedures, and dispute resolution mechanisms. Once a breach is identified, several courses of action can be pursued. Attempting to resolve the dispute directly with the insurer is often recommended. Filing a formal complaint, outlining the specific breach and referencing relevant policy clauses, can initiate this process. Many companies have internal procedures for handling disputes, and a fair resolution might be achieved. However, if the insurer remains unresponsive or unwilling to address the breach, seeking external support becomes crucial. Spain boasts a robust consumer protection system. Organizations like OCU (Organization Consummators Usurious) provide invaluable guidance and can mediate disputes between policyholders and insurance companies. Their expertise and experience can significantly improve the chances of a favourable outcome.

In situations where attempts at direct resolution and mediation fail, legal action may become necessary. Consulting with a lawyer specializing in insurance law is crucial at this stage. The lawyer can asceses the strength of the insured case and advise on the most effective course of action. This might involve filing a lawsuit against the insurer to enforce the terms of the contract and compel them to fulfil their obligations. The prospect of navigating a breach of contract can be daunting. However, by understanding insured rights, taking a proactive approach, and utilizing available resources, individuals in Spain can effectively protect their healthcare rights. A multi-pronged strategy involving communication with the insurer, seeking assistance from consumer protection organizations, and potentially resorting to legal action can ensure access to the healthcare services you deserve.

4.10 France's Health Insurance

The healthcare system in France comprise a combination of public and private alternatives, providing a strong safety net through universal public health insurance, Security Social. This system extends coverage to citizens, legal residents with work permits, and EU citizens registered for social security. The system offers reimbursement rates of 70% to 100%, covering a broad spectrum of medical services. However, it has limitations, such as long wait times for specialist appointments and limited coverage for certain services like dental or vision parimutuels plans, not mandatory but widely popular, bridge these gaps by covering the remaining portion of medical bills not reimbursed by Security Social. These plans can expedite access to specialists, offer a faster route to needed care, and often cover dental and vision care, services with limited public coverage. For those who prefer more comfort during hospitalization, multiple plans can cover the cost of a private room. Some plans even extend coverage to non-traditional services like alternative therapies or gym memberships. France's healthcare system offers a balance between affordability, accessibility, and quality. The public system provides a strong foundation, while the private market allows for customization. This cultivates a system that is both extensive and flexible, enabling residents to navigate healthcare with confidence and access to high-quality care at a reasonable cost.

Legal Framework Relating to Health Insurance:-

The Constitutional (Amend.) Act, 1958 protects the right to social security , encompassing access to healthcare. Social security is regulated by multiple statutes, including the Public Health Code and the Social Security Code. The Ministry of Solidarity and Health manages the general administration of social security while national health insurance funds manage specific populations. Private Health Insurance has no specific law, but general insurance legislation applies. Regulatory bodies oversee multiple plans, including the French Prudential Supervisory Authority (ACPR), Insurance Code, and Consumer Code. The ACPR ensures the financial stability of the insurance companies, while the Insurance act sets standards for fair practices, consumer protection, and transparency in contracts. The French Consumer Code provides a framework for fair treatment by multiple insurers.

Breach of Contract in France

There are some challenges of navigating a breach of contract in French health insurance, focusing on the importance of understanding policy documents and identifying specific breaches. The French legal system offers a framework to protect the insured in cases of breach of contract, with potential courses of action including direct communication, consumer protection, and legal action. To resolve a breach of contract, individuals should first attempt to resolve the directly with the insurer, filing a formal complaint outlining the specific breach and referencing relevant clauses in the policy. Consumer protection organizations like UFC-Que Choisir can offer guidance, mediation services, and help navigate the legalities of your situation. The French Ombudsman, the Defensor des Droits, can investigate your case and potentially mediate disputes with the insurer. If direct resolution and mediation fail, consulting a lawyer specializing in insurance law is recommended. The burden of proof typically falls on the policyholder in France, and consulting a lawyer ensures that you don't miss the window for legal action. In conclusion, facing a breach of contract with your health insurer can be stressful, but by understanding your rights, taking a proactive approach, and utilizing resources like consumer protection organizations and legal counsel, individuals can effectively address breaches and ensure access to healthcare services they deserve.

4.11 Indian Perspective on Breach of Contract in Health Insurance Introduction

4.11.1 Right to Health: A Human Right Codified in International Human Right Law

The World Medical Association (WMA) is dedicated to robustly promoting the right to health. This includes vital elements like as access to inexpensive, high-quality healthcare, secure working and living environments, enough housing, and healthy food. The 1946 World Health Organisation (WHO) Constitution asserts that the attainment of the highest possible quality of health is a basic right of every individual, being the first text to explicitly acknowledge the right to health. Article 25⁵⁹ In the 1948 Universal Declaration of Human Rights (UDHR), "health" was identified as a component of the right to an adequate standard oflife.

Article 12 reaffirmed the right to health as a human right⁶⁰ (ICESCR) 1966, The International Covenant on Economic, Social, and Cultural Rights. The States Parties to the present Covenant recognise that every individual has the right to the highest attainable standard ofbodily and mental health, as stated in paragraph 1. Paragraph 2 delineates the obligations of the States Parties to the current Covenant to fully actualise this right, which encompass: (a) Implementing measures to reduce infant mortality and stillbirth rates, alongside promoting the healthy development of children; (b) Enhancing all aspects of industrial and environmental hygiene; (c) Preventing, treating, and managing endemic, occupational, and other diseases, (d) The creation of conditions that provide access to comprehensive medical care and treatment in the event of disease, According to paragraph 11, the right to health encompasses the fundamental determinants of health, including access to safe drinking water, adequate sanitation, healthy working and environmental conditions, and access to health-related education and information, particularly regarding sexual and reproductive health, As every State has ratified at least one international human rights treaty acknowledging the right to health, this right is significant for all States,

International Health Regulations (IHR) (2005)

The International Health Regulations (IHR), established by the World Health Organisation (WHO), provide a worldwide legal framework for managing public health threats that may cross national borders, This legally binding instrument of international law becomes effective on June 15, 2007, To guarantee global health security, it emphasises disease monitoring, preparedness, and response to public health crises, including pandemics,

4.11.2 Constitutional provisions for Insurance

Constitutional provisions for insurance

Insurance functions as a mechanism to protect individuals and organisations from the perils of financial loss by distributing risks among a large group of participants who choose to bear the financial burdens in return for premium payments, In India, insurance encompasses both public and private sector enterprises, It may alone be implemented by the federal government since it is specified in Entry 47 of the Union List in the Seventh Schedule of the Indian Constitution, However, the concurrent list includes provisions that empower both the union and state governments to legislate in the insurance industry concurrently,

Constitutional Perspectives:

First of all, it should be noted that there isn't a specific article that directly addresses insurance; instead, the fundamentals of insurance as a social tool are covered by a number of Constitutional articles that are ancillary to the many insurance-related laws, The terms "economicjustice," "social justice," and "fraternity," which ensure human dignity, are included in the Preamble of the Indian Constitution, Furthermore, insurance-related subjects are included under PART IV of the Indian Constitution, which pertains to the Directive Principles of State Policy under Articles 3 8⁶¹, 3 9⁶², and 42⁶³,.

Schedule VII [Article 246]:

According to the majority judgement in several rulings, the Supreme Court noted that Parliament's legislative authority in specific areas—which is crucial under the Constitution— is undeniable. The boundaries of those regions as established by the courts are up for debate. In general, parliamentary paramountcy is outlined in Articles 246⁶⁴ and 254⁶⁵ of the Constitution of India. Article 246 of the Indian Constitution allocates legislative authority between Parliament and State Legislatures via three lists in the Seventh Schedule: the Union List (List I), State List (List II), and Concurrent List (List III). Clause (1) confers to Parliament sole authority over matters included in List I. Clause (2) grants both Parliament and State Legislatures authority over issues included in List III. Clause (3) confers to State Legislatures sole authority over matters included in List II, although subject to the stipulations of Clauses (1) and (2). This affirms Parliamentary supremacy; items in List I take precedence in instances of overlap. Concerning insurance, List I (items 24, 25, 29, 30, and 47) confers legislative power to the central government, but List III (entry 23 and 34) pertains to social security and insurance, including worker welfare.

4.11.3 Is Insurance is a fundamental right?

The insurers in country must accept that each citizen has a right to insurance under the Constitution ofIndia, as per the economic needs of the population. This brings to fore the need for the need to weed out the many bad practices on the underwriting side such as cancellation of policies, non-renewal of policies and refusal to give much needed policies to members of the public without serious reasons/breaches of insurance contractual requirements.

The Supreme court in LIC of India & Anr v. Consumer Education & Research,^[66] had to examine the selection of risks and the actuarial approaches of LIC in those days. In para 58 the SC stated: “ We have given our anxious and careful consideration to the respective contentions, since our answers to the questions involved are bound to have far reaching effect on the business of life insurance, we have minutely examined all the questions bearing in mind the larger public interest. Life insurance policies based on actuarial Tables and the Policy Holders' needs suited to their requirements... ”

The court looked at the constitutional provisions for further guidance. It stated: “ The Preamble, the arch of the Constitution, assures socio- economicjustice to all the Indian citizens in matters of equality of status and of opportunity with assurance to dignity of the individual.. Article 38 in the Chapter of Directive Principles enjoins the State to promote the welfare of the people by securing andprotecting effective social order in which socio-economicjustice shall inform all the institutions of the national life. It enjoins to eliminate inequality in status, to provide facilities and opportunities among the individuals and groups of the people living in any part of the country and engaged in any avocation. Article 39 assures to secure the right to livelihood, health and strength of workers, men and women and the children of tender age. The material resources of the community are required to be so distributed as best to subserve the common good. Social security has been assured under Article 41 and Article 47 imposes a positive duty on the State to raise the standard of living and to improve public health. ”

“In Murlidhar Dayandeo Kesekar v. Vishwanath Pandu Barde,^[67] this Court held that right to economic empowerment to the poor, disadvantaged tribes and depressed and oppressed Dalits, is a fundamental right to make their right to life and dignity of person meaningful and worth living.”

The SC concluded: “We have, therefore, no hesitation to hold that in issuing a general life insurance policy of any type, public element is inherent in prescription of terms and conditions therein. The appellants or any person or authority in the field of insurance owe a public duty to evolve their policies subject to such reasonable, just and fair terms and conditions accessible to all the segments of the society for insuring the lives of eligible persons. The eligibility conditions must be conformable to the Preamble, fundamental rights and the directive principles of the Constitution. The term policy under Table 58 is declared to be accessible and beneficial to the large segments of the Indian society. The rates of premium must also be reasonable and accessible It may be made clear that with a view to make the policy viable and easily available to the general public, it may be open to the appellants to revise the premium in the light of the law declared in this judgment but it must not be arbitrary, unjust, excessive and oppressive." This case was mentioned as recently as2018 by the Delhi High Court in M/s United India Insurance... v. Jai Parkash Tayal . ,⁶⁸ in the context of genetic disorder exclusion. Everyone is aware that insurance is an economic necessity for the modern man and the institutions that are set up to facilitate the progress of the economy. Naturally the contract of insurance has to be a useful tool of protection. The SC also pointed this out by stating: “An unfair and untenable or irrational clause in a contract is also unjust, amenable tojudicial review. In common law a party was relieved from such contract. In Gillespie Brothers & Co. Ltd. v. Roy Bowles Transport Ltd^[69] , Lord Denning for the first time construing the indemnity clause in a contract stated that the court to permit party to enforce his unreasonable clause, even when it is so unreasonable, or applied so unreasonably, would be unconscionable”

4.12 National Perspectives on Breach of Contract in Health Insurance (Insurance Laws and Regulations in India)

4.12.1 the Department of Foreign Direct Investment and the Insurance Sector in India.

The Foreign Direct Investment (FDI) framework established by the Department of Industrial Policy and Promotion (DIPP) permits the Indian insurance industry to solicit private investment from foreign entities. India now has 52 insurance companies, including 24 in life insurance and 28 in non-life insurance.

4.12.2 The National Health Bill, 2009

The National Health Bill, 2009 A Beacon for Universal Healthcare in India

The National Health Bill (NHB) of 2009 stands as a significant milestone in India's ongoing journey towards ensuring healthcare as a fundamental right for all its citizens. Introduced with an ambitious vision, the bill aimed to transform the healthcare landscape by guaranteeing access to essential, preventive and curative services for every citizen.

The Right to Health: A Cornerstone of the Bill

At its core, the NHB enshrined healthcare as a legal entitlement. This marked a paradigm shift, empowering individuals to seek medical attention without the burden of exorbitant costs. The bill envisioned a three-tiered system of healthcare delivery, with primary health centers at the village level forming the foundation. These centers would provide basic diagnostic services, preventive care, and essential medications. Secondary and tertiary care facilities would then offer more specialized treatment options.

A Three-Pronged Approach for Holistic Care

The NHB's approach to healthcare was comprehensive. It not only addressed curative measures but also emphasized preventive care. The bill proposed free check-ups and screenings for a range of diseases, enabling early detection and intervention. This proactive approach aimed to prevent illnesses and reduce the overall burden of the health insurance system.. Recognizing the critical role of medications in treatment, the NHB envisioned a system where essential drugs would be available free of charge at government facilities.

Strengthening Public Healthcare: The Backbone of the System

The bill acknowledged the vital role of a robust public healthcare system in achieving its goals. It outlined plans to strengthen existing infrastructure by upgrading village clinics and equipping them with better diagnostics and essential supplies. Additionally, the NHB proposed the creation of district healthcare teams with qualified medical professionals to ensure efficient service delivery and effective management of public health facilities.

Financing the Vision: Challenges and Proposed Solutions

The NHB recognized that achieving universal healthcare would necessitate a significant financial investment. The bill proposed a multi-pronged approach to raise additional funds. Increased government allocation to healthcare, contributions from social health insurance schemes, and a possible health cess were all envisioned as potential sources of revenue.

A Catalyst for Change: The Legacy of the NHB

While the NHB, in its original form, was not enacted, it sparked a crucial dialogue about healthcare reform in India. The ethical imperative of ensuring healthcare for all gained significant momentum, propelling various states to introduce their own versions of the bill. These efforts, along with the central government's initiatives, have resulted in a gradual expansion of healthcare access and services across the country. The National Health Bill of 2009 serves as a beacon, illuminating the path towards a future where quality healthcare is not a privilege for the few but a right enjoyed by every Indian citizen. It continues to inspire policymakers and healthcare advocates in their pursuit of this collective vision.

4.12.3 The National Public Health Act of2017

The proposed National Public Health Act has been in preparation since 2017 and, if passage, would replace the 125-year-old Epidemic Diseases Act of 1897. In 2017, the draft of the Public Health (Prevention, Control and Management of Epidemics, Bioterrorism, and Disasters) Act was released. In September 2020, the Government announced the development of a national public health legislation (National Public Health Bill). Quadrant Health Administration Framework: The draft Bill stipulates the establishment of "multisectoral" public health authority endowed with "well-defined" powers and tasks to address "public health emergencies." The Union Health Ministry is recommended to take the lead, with state health ministers acting as chairs. Block Medical Officers or Medical Superintendents will supervise block units, whilst District Collectors would manage the subsequent tier. These authorities will possess the capacity to adopt actions to avert both newly developing infectious illnesses and non-communicable diseases.

How is the healthcare system in India doing?

The government has increased health expenditure, as seen by the recently released National Health Accounts (NHA) report for 2017-18. Consequently, out-of-pocket costs (OOPE) dropped from 64.2% in 2013-14 to 48.8% in 2017-18. It indicates that the total public expenditure as a proportion of GDP has reached a historic high of 1.35 percent, beyond the 1%-1.2 percent range. Proportion of Primary Health Care: Primary healthcare has increased its share of government health expenditure from 51.1% in 2013-14 to 54.7% in 2017-18. More than 80% of the government's existing health expenditure is allocated to basic and secondary care. The segment of social security expenditure allocated to health, which includes government-funded health insurance programs, the social health insurance scheme, and medical reimbursements for government employees, has increased.⁷⁰

Problems with Healthcare Insurance:

According to a new analysis from NITI Aayog, 40 crore people, or at least 30% of the population, lack any kind of financial security for their health. This group is known as the "missing middle." People are also deterred from choosing health insurance by the high 18% GST on insurance rates. Lack of Private Sector Participation: The primary healthcare sector emphasises the delivery of essential healthcare rather than profit maximisation. Consequently, governments bear a substantial portion of the global primary health care obligation, mostly inside the public sector rather than the private sector. Lack of Original Molecular Innovation: India's strong pharmaceutical production positions it as the global pharmacy. However, there is little to no unique molecular development, which is necessary as inputs in medicine manufacture, because of a lack of funding. Government support is needed in this sector so that India's industry can be upgraded to include frontier medications as well, rather thanjust generic ones.

4.12.4 The Indian Contract Act, 1872

a. Health insurance is type of contract

Health insurance coverage offers financial support in the event of a medical emergency. Health insurance is a legally binding agreement between the insurer and the insured, outlining the exchange of value (premium payments for financial protection) and the specific obligations of each party. It is a contract between the policyholder and the insurer that covers medical expenses arising from illness, injury, or accident. Policyholders remit periodic payments, and in exchange, the insurance plan encompasses a range of medical treatments, including hospitalisation, operations, prescriptions, and preventative care. Health insurance seeks to mitigate the financial strain of medical treatments, facilitating access to essential healthcare services and enhancing general well-being.⁷¹

b. Components of an Insurance Contract:

• Proposal and Acceptance

The insurer offers a health insurance plan with specific terms and conditions (coverage details, exclusions, premium amount). The insured reviews and agrees to these terms by purchasing the plan.

• Parties’ Competency

Both parties must be capable of entering a contract. In most cases, this means being of adult age and sound mind.

• Free Consent

In health insurance agreements, free consent guarantees that both the insurer and the insured concur with the conditions without coercion, deception, or undue influence, so rendering the policy legally valid.

• Legal Consideration

The payment remitted by the insured and the insurer's commitment to provide financial coverage constitute mutual consideration, establishing the foundation of the health insurance contract.

• Legal Object

The subject of a health insurance contract must be legitimate, specifically offering financial protection against medical costs, which fulfils a valid and legal objective under the law.

d. Fundamental Principles oflnsurance

• Insurable interest

An insurable interest to financial investment in the individual or property being insured. This guarantees that the insured does not only benefit from another's misfortune. You may insure your own vehicle, but not that of your neighbour.

• Utmost Good Faith

This idea requires the highest level of good faith from both sides. The insured is obligated to reveal all pertinent facts at the time of application and during the policy term. The insurer is obligated to engage in fair dealings and refrain from any deceptive information or practices.

• Compensation for Losses

The majority of insurance agreements are indemnity contracts. The insurer's object to restore the insured to their prior financial status before the loss, rather than to confer an unexpected benefit. Exceptions may exist, such as certain life insurance policies that provide a predetermined payout sum irrespective of real financial loss.

• Subrogation:

Following the settlement of a claim, the insurer may assume the insured's rights to seek restitution from a third party liable for the loss. This enables the insurer to recover a portion of the financial expenditure.

• Contribution

When an insured possesses multiple insurance policies for the same loss, the insurance companies may apportion the payout liability in accordance with the coverage limitations of each policy.

• Proximate Cause

In insurance contracts, causa proxima, or proximate cause, is a crucial element that ascertains the insurer's liability to settle a claim.

Health insurance as a Risk Mitigation Instrument

Health insurance serves as a mechanism for risk management. The insured pays a modest, consistent premium to secure financial protection against the potentially substantial expenses of unexpected medical emergencies. The insurer distributes the risk among a substantial pool of covered individuals, enabling them to mitigate the financial impact of claims.

Implementation of the Contract:

Violation of Contractual Agreement: A failure by either party to meet their responsibilities constitutes a breach of contract.

Conflict Resolution: In the event of conflicts, the parties may seek resolution through negotiation or mediation. If not resolved, legal action may be taken in accordance with the contract conditions and any insurance legislation.

4.12.5 The Life Insurance Corporation Act, 1956

Establishment of the Life Insurance Corporation (LIC) Act, 1956

The Union Parliament passed the Life Insurance Corporation Act on June 19, 1956, resulting in the formation of the Life Insurance Corporation of India on September 1, 1956. In this Act, Chapter II, Sections 3⁷², 4⁷³ and 5⁷⁴ provide for the establishment, Constitution and Capital of the Corporation respectively. Section 6⁷⁵ of the Life Insurance Corporation Act of 1956 addresses the authority and functions of the Life Insurance Corporation Act

Definition of Life Insurance

According to Maggee "Life Insurance contract embodies an agreement in which broadly stated, the insurer undertakes to pay a stipulated sum upon the death of insurer to a designated beneficiary.”^[76]

In Dalby v. India and London Life Assurance Co[77] it was said that "Life Insurance is a contract to pay a certain sum of money on the death of a person in consideration of the due payment of a certain annuityfor his life calculated according to the probable duration of life", The primary goals ofLIC concerning health insurance plans are as follows:

• To provide comprehensive security and enable efficient service at competitive premium prices to policyholders.
• To do business with optimal competitiveness, fully recognising that the money belong to the policyholders.
• Toact as trustees, both individually and collectively, for the insured population.
• To include all workers in the firm to maximise their talents in advancing the interests of the insured public via polite and effective service delivery.

The primary aims of LIC concerning health insurance plans are to provide extensive financial protection against medical costs, facilitate cheap healthcare access for people and families, and increase knowledge about the significance ofhealth insurance. LIC seeks to assist policyholders by offering diverse coverage alternatives such as hospitalisation, critical illness, and surgical benefits, while promoting a savings culture for future healthcare need, thereby enhancing overall financial security and well-being.

The Life Insurance Corporation (Amendment) Bill, 2008

The Life Insurance company Act of 1956 nationalised the life insurance sector in India by transferring all life insurance activities to a company established for that purpose, the Life Insurance Corporation ofIndia (LIC). The LIC's insurance operations were also governed and regulated by this Act. Nevertheless, the Insurance Act of 1938 remained the principal legislation regulating and overseeing all entities involved in the insurance sector in India. Since the enactment of the Insurance Regulatory and Development Authority Act in 1999, twenty private sector companies have commenced life insurance operations in our country, alongside LIC. The Insurance Regulatory and Development Authority (IRDA) proposed amendments to the Insurance Act of 1938, the Insurance Regulatory and Development Authority Act of 1999, the General Insurance Business (Nationalisation) Act of 1972, and the Life Insurance Corporation Act of 1956 to ensure alignment with the 1938 Insurance Act. The Government completed modifications to the LIC Act after consultations with the LIC.

4.12.6 The Consumer Protection Act, 2019

According to Section 2 (1) (d) of the Consumer Protection Act, 1986, the word "consumer" concerning 'Health Insurance' refers to any anyone who obtains or utilises health insurance services for personal or family healthcare requirements. The Act of 1986 comprehensively defines customers to include policyholders, beneficiaries, and other persons who actively interact with health insurance goods or services. The Consumer Protection Act, 2019, augments consumer rights, particularly regarding insurance. The Act of 2019 does not specifically mention insurance; yet, it creates a comprehensive framework that applies to all products and services, including insurance services. Section 2 (7) of the Act, 2019 defines a "consumer" as any individual who purchases products or obtains services for compensation. This encompasses persons who acquire insurance policies, rendering them entitled to pursue remedies under the Act for any inadequacies in insurance services. The Act of 2019 establishes a thorough framework for the protection of consumers, including those using insurance services. It enables customers to pursue remedies for any inadequacies, unjust trade practices, or deceptive information presented by insurance firms. The Act is essential in protecting consumer rights in the insurance industry by ensuring that insurance services are equitable, transparent, and accountable.[78] Beneficiaries Included: The Act also includes within its definition of "consumer" the beneficiaries ofinsurance policies, allowing them to file complaints in case of disputes or deficiencies in service.

Who constitutes a ‘consumer’ (insured)?

1. Policyholders: Individuals who purchase health insurance policies directly from insurance companies are considered consumers. They enter into a contractual relationship with the insurer, paying premiums in exchange of the medical expenses as per the terms of the policy.
2. Beneficiaries: In many cases, health insurance policies cover not only the policyholder but also their family members or dependents. These family members, often referred to as beneficiaries, are also considered consumers under the Act. They have rights to access healthcare services covered by the policy.
3. Third-Party Users: The Act also extends protection to individuals who may not be the direct purchasers of health insurance but are beneficiaries of such policies through their employers or other group schemes. These third-party users, though not the primary policyholders, still benefit from the health insurance coverage and are therefore considered consumers.
4. Healthcare Service Recipients: Beyond those directly involved in purchasing or benefiting from health insurance policies, the Act also considers individuals who receive healthcare services covered by health insurance as consumers. This includes patients who undergo medical treatments or procedures covered by their insurance plans.

Definition of 'Service' as per Section 2(42) of the Consumer Protection Act, 2019

In the realm of banking, financing, insurance, transportation, processing, energy supply, telecommunications, accommodation, housing construction, entertainment, or information dissemination, "service" denotes any type of service offered to prospective users. Nevertheless, it omits the delivery of any service without charge or under a personal service agreement.

Service Contract and Contract for Services

A Contract of Service is an agreement between an employer and an employee. It is essential for both parties as it provides security and safety to each participant engaged. A Contract for Service establishes a client-contractor relationship rather than an employer-employee connection. The Act of 2019 classifies health insurance plans as service contracts and seeks to safeguard customers' rights within this context. The Act of 2019 acknowledges health insurance plans as service contracts and seeks to safeguard customers' rights within this context.

Concept of Contracts for Services under the Act, 2019

1. Right to obtain healthcare services: The Act categorises health insurance plans as contractual agreements for services between the insurance provider and the policyholder or beneficiary. It guarantees that customers possess the right to acquire healthcare services in accordance with the policy stipulations and are treated equitably by insurance providers.
2. Maintenance of Service Standards: Insurance firms are required to uphold certain service standards, including timely claims processing, transparent communication with policyholders, and compliance with the policy's terms and conditions. These requirements guarantee that customers get the benefits to which they are entitled under their health insurance policies.
3. The Act highlights the consumer rights in health insurance contracts, including the entitlement to precise information on coverage, equitable treatment in claims processing, and avenues for redress in cases of service delivery inadequacies.

4.13 The Insurance Act, 1938 & the Subsequent Legislations

4.13.1 The Insurance Regulatory and Development Authority Act, 1999

The creation of the Insurance Regulatory and Development Authority of India (IRDAI) was a pivotal advancement in fostering transparency, growth, and consumer safety in the Indian insurance sector. The Insurance regulating and Development Authority of India (IRDA) serves as the principal regulating body for insurance in India. According to the IRDA Act of 1999, the IRDAI is responsible with both marketing and regulating the insurance business. Making ensuring insurance businesses run responsibly and profitably while protecting policyholders' interests is one of its main responsibilities. The IRDAI promotes a fair and competitive market by laying forth precise rules and regulations, which stimulates industry innovation and expansion.

Promoting insurance awareness and uptake throughout India, especially in underserved and rural regions, is another important responsibility of the IRDAI. The authority encourages the use of contemporary insurance products while making sure that everyone in society can afford them. Along with aggressively preventing unfair trading practices, the IRDAI keeps an eye on insurance businesses to make sure they follow moral guidelines. It offers a grievance redressal process to shield customers against deception, fraud, and hold-ups in claim resolution. In addition to safeguarding policyholders, the IRDAI encourages the insurance sector's healthy growth by permitting foreign investments, enhancing industry infrastructure, and encouraging technological innovation. The Insurance Regulatory and Development Authority of India (IRDAI) is an independent agency formed by legislation, responsible for overseeing and enhancing the insurance sector in India. Its primary responsibilities are fostering market competition, protecting policyholders' interests, and maintaining the industry's orderly growth. The IRDAI is crucial to the insurance sector as it establishes standards, issues licenses, monitors business practices, and enforces compliance.

The Insurance Regulatory and Development Authority ofIndia (IRDAI) was founded in 1999 to supervise and regulate the insurance sector in India. It was established to safeguard the interests of policyholders, guarantee equitable treatment, and promote industry expansion.

To make sure they abide by the law and moral principles, IRDAI regulates insurance businesses, brokers, agents, and other stakeholders. Keeping insurance firms financially sound is one of its most important duties. In order to protect policyholders from any dangers, IRDAI makes sure that insurers have enough reserves to cover claims and other liabilities. This is known as solvency margin. Additionally, it keeps an eye on businesses' compliance with financial rules and procedures, guaranteeing openness and responsibility. By doing this, IRDAI contributes to a stable insurance market that upholds public interests, builds trust, and encourages industry expansion, all of which support economic growth and stability.

Professionalism and accountability in the insurance sector are guaranteed by licensing brokers, intermediaries, and insurance agents. By establishing precise guidelines and processes for resolving disputes, it aids in addressing policyholder complaints. While appropriate regulation supports market growth and improves consumer trust and access to high-quality services, competition encourages innovation and efficiency.

The Insurance Regulatory and Development Authority (IRDA) Act of f999 establishes a comprehensive regulatory framework for the Indian insurance industry, building upon the Insurance Act of 1938. The 1938 Act set fundamental standards for the insurance sector, whereas the IRDA Act revised and expanded laws to address evolving market requirements. The Insurance Regulatory and Development Authority (IRDA) was founded as an autonomous entity responsible for overseeing the growth, regulation, and promotion of the insurance sector. This Act establishes the framework for licensing, safeguarding policyholders, approving products, regulating investments, and resolving grievances. It protects the rights of policyholders while promoting openness, competition, and the expansion of insurance firms. In order to promote a competitive and stable insurance industry, boost customer confidence, and support economic expansion, the IRDA Act is essential.

The Insurance Act of 1938 initially designated the Controller of Insurance as the regulatory body for the insurance sector, tasked with overseeing and maintaining compliance within the business. Subsequent to the implementation of the Insurance Regulatory and Development Authority Act (IRDA Act) in 1999, these authorities were delegated to the newly formed Insurance Regulatory and Development Authority of India (IRDAI). The IRDAI was established to systematically enhance and regulate the insurance sector, safeguard policyholder interests, foster competition, and facilitate industry expansion. This transition signified a substantial change in the regulation of the insurance industry in India. The Insurance Act of 1938 primarily governs the insurance industry in India, concentrating on the formation, functioning, and regulation of insurance firms. It specifies rules for licensure, investment criteria, solvency norms, and policyholder safeguards. The Insurance Regulatory and Development Authority Act of 1999 created the Insurance Regulatory and Development Authority of India (IRDAI) to regulate and advance the insurance industry. The responsibilities of IRDAI include regulating, fostering competition, safeguarding consumer interests, and promoting industrial development. The 1938 Act governs practical aspects, whereas the 1999 Act prioritises dynamic regulation, modernisation, and market progression.

4.13.2 Important facets of the IRDA Act

The IRDAI Act were significantly transformed the health insurance sector in India since its implementation. It has resulted in an enhanced availability of numerous health insurance packages tailored to distinct healthcare requirements. Increased customer understanding and confidence in health insurance resulting from regulatory supervision and transparency initiatives. Enhanced affordability and equity in premium pricing, facilitating access to quality healthcare coverage for a broader demographic. Enhanced processes for dispute resolution and grievance redressal, fostering confidence between insurers and policyholders.

4.13.3 Role ofIRDAI in Health Insurance

A crucial component of the IRDAI's function is the regulation ofhealth insurance policies. The IRDAI guarantees that health insurance products provided by insurers adhere to regulatory criteria, give sufficient coverage, and maintain transparency in their terms and conditions. This oversight is essential for protecting the interests ofhealth insurance policyholders.

4.13.4 The IRDAI Act Regarding Health Insurance:

The IRDAI assesses and authorizes health insurance products to guarantee they fulfill consumer requirements and offer extensive coverage for medical costs, encompassing hospitalization, therapies, and pre-existing diseases. The Act authorizes the IRDAI to oversee health insurance premiums to avert inequitable pricing practices and guarantee affordability for policyholders across various demographic groups. The IRDAI Act emphasizes consumer protection by requiring explicit disclosure of policy terms, coverage limits, exclusions, and claims procedures. It also sets methods for addressing grievances and resolving disputes over health insurance claims. The IRDAI may establish standardized terms and conditions for health insurance plans to enhance uniformity, transparency, and comparability among insurance products provided by various providers.

4.13.5 Impact ofIRDA on health insurance

The impact on the health insurance landscape in India. It has led to:

• Increased availability of diverse health insurance products catering to various healthcare needs.
• Enhanced consumer awareness and confidence in health insurance due to regulatory oversight and transparency measures.
• Improved affordability and fairness in premium pricing, ensuring access to quality healthcare coverage for a wider population.
• Strengthened mechanisms for resolving disputes and addressing grievances, enhancing trust between insurers and policyholders.

4.13.6 Functions ofIRDA and Impact on Health Insurance

The functions of IRDA encompass the standardization of health insurance plans, terms, and conditions, as well as the promotion of transparency, comparability, and customer confidence in health insurance products. The actions of IRDA in consumer education, grievance resolution, and the enforcement of equitable practices have enhanced customer understanding, confidence, and satisfaction about health insurance goods and services. Through the promotion of innovation, the encouragement of competition, and the support of market development, IRDA has stimulated the expansion of the health insurance sector resulting in a broader array of products, enhanced affordability, and greater coverage. The IRDA's regulatory system guarantees adherence to health insurance regulations, preserves financial stability, and mitigates risks, therefore bolstering the sustainability and resilience of the health insurance industry. The functions ofIRDA include adopting technology innovations in health insurance, such as digital platforms, telemedicine services, and data analytics, to improve efficiency, accessibility, and customer experience.

4.13.7 Finance and Accounts ofIRDA

Insurance companies must maintain enough capital reserves in compliance with IRDA standards to meet obligations and ensure financial stability. The IRDA Act specifies investment restrictions and regulations for insurance, necessitating prudent investment strategies to safeguard policyholders' funds while maximising profits. Insurance companies are required to provide accurate and timely financial statements, including balance sheets, income statements, and cash flow statements, in compliance with IRDA-mandated accounting standards. The Act 136 mandates insurers to implement comprehensive risk management frameworks, including asset­liability management, to mitigate financial risks and ensure long-term sustainability.

4.13.8 Accounts management in the insurance sector involves

Insurers preserve distinct policyholder accounts, meticulously documenting received premiums, disbursed claims, and policy-related transactions. Effective account administration is essential for the timely processing of claims, the maintenance of audit trails, and the assurance of compliance with regulatory mandates. Insurance businesses are subject to periodic audits to evaluate their financial stability, compliance with IRDA laws, and conformity to accounting standards.

4.13.9 Power of the Central Government

The Insurance Regulatory and Development Authority Act of 1999 confers substantial authority onto the Central Government to regulate the insurance industry and guarantee its effective operation. This Act empowers the Central Government to designate the Chairperson and members of the Insurance Regulatory and Development Authority (IRDA). The nomination process is essential as it determines the leadership and direction of IRDA, influencing policy development and regulatory choices. The Central Government has a pivotal role in developing policies and regulations concerning health insurance under the IRDA Act. It has the jurisdiction to promulgate rules, directives, and notifications to govern many facets of health insurance, including premium rates, coverage criteria, claims processing protocols, and complaint resolution systems. These rules aim to guarantee equity, openness, and consumer safeguarding in the health insurance industry. Furthermore, the Central Government has the authority to act in extraordinary situations to safeguard the interests of policyholders and ensure market stability. This may include issuing directives, guidance, or implementing remedial actions to mitigate systemic risks, ensure financial stability, or resolve compliance concerns within the insurance industry. The Central Government's authority under the Insurance Regulatory and Development Authority Act, 1999, is crucial for establishing the regulatory framework for health insurance and protecting the interests of players in the insurance industry.

4.13.10 Challenges and Future Directions

Despite the substantial progress facilitated by the IRDA Act, difficulties like affordability, coverage deficiencies, fraud mitigation, regulatory responsiveness, and healthcare inflation remain prevalent. Future initiatives may concentrate on mitigating these problems via technological adoption, data analytics, risk-based pricing, targeted treatments for at-risk populations, and stakeholder collaboration.

4.13.11 Recommendations

To enhance the regulatory framework, it is advisable to implement ongoing monitoring, engage stakeholders, integrate technology, and increase capacity. Cooperation among regulators, insurers, healthcare providers, and consumer organizations is crucial to tackle growing difficulties and improve the efficacy ofhealth insurance regulation under the IRDA Act. Since the enactment of the act, the health insurance sector regulated by IRDA has undergone significant transformation. It provides policyholders with reassurance and access to superior healthcare services by financially covering medical expenses arising from illness or accident.

4.14 IRDA Regulation Concerning Health Insurance

4.14.1 The 2000 Regulation on the Obligation oflnsurance to Rural and Social Sector

The Insurance Regulatory and Development Authority (IRDA) is essential in overseeing health insurance in India, governed by the Insurance Regulatory and Development Authority Act of 1999. This legislation authorises the IRDA to regulate multiple facets of health insurance, guaranteeing adherence, safeguarding consumers, and maintaining market stability. This talk examines the principal regulations established by IRDA on health insurance and its consequences.

Mandates and Responsibilities ofIRDA:

IRDA regulates the licensing and registration of insurance agents, brokers, and other entities involved in health insurance. This ensures that only qualified and authorized entities operate in the market, maintaining standards of professionalism and competence. IRDA sets guidelines for health insurance products, including coverage, exclusions, pricing, and terms. Insurers must obtain IRDA approval for their products, ensuring they meet regulatory standards and offer adequate coverage to policyholders. IRDA mandates fair treatment of policyholders, transparency in policy terms, and grievance redressal mechanisms. Insurers are required to provide clear information about benefits, limitations, and claim procedures, empowering consumers to make informed decisions.

IRDA imposes solvency requirements on insurers to maintain financial stability and protect policyholder interests. Insurers must maintain adequate reserves and capital adequacy ratios to ensure their ability to fulfill claims obligations. IRDA implements measures to prevent fraud, such as fraudulent claims and misrepresentation. Insurers are expected to have robust risk management systems in place to assess and mitigate risks related to health insurance operations.

4.14.2 Regulations in Health Insurance by IRDA

IRDA mandates standardization ofhealth insurance policies to facilitate comparison and clarity for consumers. Standardized policies define common terms, coverage limits, and exclusions, reducing confusion and disputes. IRDA regulates coverage for pre-existing conditions, ensuring that insurers provide coverage for such conditions after a waiting period. This regulation prevents discrimination against individuals with pre-existing health conditions. IRDA monitors and regulates premium rates charged by insurers to ensure affordability and fairness. Insurers must justify their premium pricing based on actuarial principles, risk assessment, and market competitiveness. IRDA sets guidelines for prompt and fair claims settlement by insurers. Insurers are required to process claims efficiently, communicate with policyholders transparently, and resolve disputes through internal mechanisms or IRDA's grievance redressal system. IRDA regulates the network of hospitals and healthcare providers empaneled by insurers. Insurers must maintain standards of quality care, timely access to services, and fair reimbursement practices for healthcare providers.

4.14.3 Comprehension Section 172: Mandate for Insurance in Rural and Social Sectors Regulation, 2000

Section 172 of the IRDA Act, known as the "Obligation of Insurance to Rural and Social Sectors Regulation, 2000," mandates that insurance firms in India provide a portion of their activities to the rural and social sectors. This allocation encompasses insurance policies and investment activities that promote the development and well-being of certain industries.

4.14.4 Regulations of the Insurance Regulation and Development Authority (2001Third Party Administrators- Health Services

The Insurance Regulatory and Development Authority (IRDA) Act of 1999 created the basis for comprehensive regulation and development of the insurance sector in India. This Act introduced a significant regulatory provision known as the Insurance Regulatory and Development Authority (Third Party Administrators—Health Services) Regulations, 2001. This assignment analyses the key components of this law and their impact on the health insurance sector in India.

4.14.5 Comprehending Third Party Administrators (TPAs):

Third Party Administrators (TPAs) are essential to the health insurance system. They act as intermediaries between insurers and policyholders, managing claims processing, network management, and customer support. The IRDA Act recognised the need to regulate TPAs to provide efficiency, transparency, and consumer protection.

4.15 IRDA (Third Party Administrators—Health Services) Regulations, 2001:

The Insurance Regulatory and Development Authority (Third Party Administrators—Health Services) Regulations, 2001. Third Party Administrators (TPAs) are required to get a license from the Insurance Regulatory and Development Authority (IRDA), evidencing adherence to eligibility criteria, financial stability, and operational standards. The laws delineate a code of conduct for TPAs, including ethical principles, confidentiality, equitable treatment of policyholders, and adherence to regulatory mandates. Third-Party Administrators are required to uphold service standards in claims processing, grievance resolution, network administration, and contact with policyholders. The regulations specify financial responsibilities of TPAs, including maintaining solvency margins, proper accounting practices, and reporting requirements to IRDA. IRDA conducts regular monitoring, inspections, and audits to ensure TPAs comply with regulations, maintain quality standards, and safeguard policyholder interests. Mechanisms for dispute resolution between insurers, TPAs, and policyholders are established, promoting fair resolution of conflicts and grievances.

4.16 The Insurance Representatives and Dealers Act of 2000

The Insurance Regulatory and Development Authority (IRDA) Act of 1999 created the regulatory framework for the insurance sector in India, including the registration and supervision of insurance agents. The IRDA (Licensing of Insurance Agents) Regulations of 2000 established standards and protocols for the licensing of insurance agents, significantly impacting the distribution and availability ofhealth insurance products throughout the country. This article analyses the fundamental components of this law and their impact on the health insurance industry in India.

Regulatory Framework Governing Insurance Agents

The IRDA Act empowered the IRDA to regulate insurance agents, who act as intermediaries between insurance companies and policyholders. The IRDA (Licensing of Insurance Agents) Regulations, 2000, delineated the licensing process, qualifications, responsibilities, and behaviour of insurance agents within the Indian insurance industry.

Licensing Process and Qualifications:

Under the regulations, individuals seeking to become insurance agents must fulfill certain criteria, including educational qualifications, training, and passing a licensing examination conducted by the IRDA. This process ensures that agents possess the necessary knowledge, skills, and ethics to effectively serve the interest of the policy holders, particularly in the realm ofhealth insurance where informed decision-making is critical.

Responsibilities oflnsurance Agents:

The regulations outline the responsibilities ofinsurance agents, which include:

Client Education: Agents must educate clients about insurance products, coverage options, terms, and benefits, especially regarding health insurance policies that require a thorough understanding ofhealthcare costs, treatments, and exclusions.

Disclosure: Agents must provide clear and accurate information to clients regarding premiums, policy features, limitations, and claim procedures, enabling them to make informed choices.

Ethical Conduct: Agents must uphold ethical standards, refrain from deception or coercion, prioritise clients' best interests, and adhere to regulatory norms and codes of conduct.

Professional Development: Agents should engage in continuous learning, stay updated on industry trends, regulations, and technological advancements, enhancing their ability to serve clients effectively.

IRDA Licensing Requirements:

Under the IRDA Act, licensing of insurance agents is regulated to ensure competence, integrity, and ethical conduct within the industry. The key requirements for obtaining an IRDA license as an insurance agent include:

Education and Training: Prospective agents must undergo prescribed education and training programs to acquire knowledge about insurance products, industry regulations, sales techniques, ethics, and customer service.

Examination: Agents are required to pass a qualifying examination conducted by IRDA or an accredited institution to demonstrate their understanding of insurance concepts and regulatory norms.

Background Check: IRDA conducts background checks to verify the applicant's integrity, financial soundness, and absence of criminal records or regulatory violations.

Continuing Education: Licensed agents must engage in ongoing professional development and training to stay updated with industry trends, product innovations, and regulatory changes.

Code of Conduct: Agents are bound by a code of conduct stipulated by IRDA, emphasizing honesty, transparency, fair dealing, confidentiality, and compliance with regulatory guidelines.

4.17 IRDA Regulations 2000

The term "regulations 2000" refers to particular rules or specifications created to control health insurance plans and guarantee that people have enough protection. Because it offers access to essential healthcare services and financial stability, health insurance is essential to these requirements. Regulation 2000 frequently highlights the necessity of requiring health insurance coverage to shield people from excessive medical costs, particularly in the event of a major illness or injury. Financial instability could result from consumers being exposed to ruinous healthcare bills in the absence of such controls. Access to and affordability of necessary services, including hospital care, preventive care, and specialist consultations, are guaranteed by health insurance. Usually, these rules mandate that insurers provide equitable, non- discriminatory policies that treat pre-existing conditions and guarantee equal access to medical care. By promoting preventative treatment and lessening the demand on emergency services, health insurance plays a crucial role in these policies by lowering healthcare access inequities and improving public health outcomes. Therefore, health insurance under these rules protects public health as well as individual well-being.

4.18 IRDA Regulations 2001

The Regulations 2001 generally refers to a set of guidelines that control health insurance markets with the goal of giving customers greater access to necessary healthcare services and protection. According to these rules, health insurance is crucial because it protects people from excessive medical expenses and offers a safety net during medical emergencies. Insurers are frequently required by Regulation 2001 to offer basic health coverage, which covers essential medical requirements such emergency services, hospitalization, and preventative treatment. This lessens gaps in healthcare access by guaranteeing that everyone has access to critical treatments, regardless of income or pre-existing conditions. Standards for equitable pricing and openness in the health insurance industry are regularly established by the rules. Health insurance under Regulation 2001 contributes to equity and fairness by prohibiting discriminatory practices like denying coverage due to pre-existing conditions. In general, these rules seek to promote a more sustainable and inclusive healthcare system that benefits people as well as the larger public health infrastructure.

4.19 The Insurance Regulatory and Development Authority’s protection of policyholders interest (Regulation,2002)

To protect policyholders' interests, IRDAI has established several regulations that insurers and intermediaries must follow. These include standardized health insurance guidelines and the 2016 health insurance regulations, guidelines for advertisements, procedures for partial loss claims under auto insurance, provisions for health insurance portability and renewability, and regulations concerning the insurance repository system, the free look period, warnings and fines, e-insurance policies, and claim rejections.

4.20 Alternative Insurance Dispute Resolution Mechanism

The Alternate Dispute Resolution (ADR) system provides a vital alternative to conventional litigation for settling conflicts between policyholders and insurance firms. In the insurance industry, where disputes over policy terms, claim resolutions, and coverage often arise, alternative dispute resolution (ADR) offers a prompt and economical method of redress, enhancing confidence among stakeholders. ADR provides numerous advantages: it accelerates dispute resolution relative to protracted court processes, conserving time and resources for all involved; it encourages flexibility and informality, enabling parties to select methods such as mediation or arbitration that suit their requirements; it guarantees confidentiality, encouraging candid communication without concern for reputational harm; it improves access tojustice by offering a venue for even minor claims; and it enables specialised expertise through mediators and arbitrators possessing insurance industry acumen, fostering equitable outcomes aligned with legal standards.

4.21 The IRDA (Health Insurance) Regulation,2013

There is financial protection against medical expenditures that might be incurred as a result of disease, accident, or hospitalisation via the purchase of health insurance. This protection includes coverage for expenses such as hospitalisation, tests, procedures, medicines, and outpatient treatment. Depending on the plan and the cost, different policies provide different levels of coverage for inpatient and outpatient care. Private insurers, government programs, and employer-sponsored plans are all examples of places where coverage may be obtained. Policyholders are responsible for paying premiums in exchange for reimbursement or direct payment of expenditures that are covered. Individual policies, family floater policies, group policies, and specialised policies are categories of plans. Health insurance helps to alleviate the financial constraints that are associated with medical crises, encourages well-being and prompt treatment, and protects against the possibility of experiencing financial difficulty. The IRDA (Health Insurance) Regulation, 2013, which was passed in 2013, is the regulatory framework that controls the industry. Its purpose is to promote transparency, fairness, and consumer protection by regulating policy issuance, coverage, premiums, and claims. The ultimate goal is to make health insurance more accessible and affordable.

4.22 The Health Insurance and Social Security Laws

4.22.1 The Employees State Insurance Act, 1948

The Employees' State Insurance Corporation (ESIC), which falls under the Ministry of Labour and Employment, is responsible for administering the Employees' State Insurance Act of 1948 (ESI Act), which guarantees health insurance for a major section of India's workers. This program, which is self-funded, offers financial protection against a variety ofhealth and work- related problems, serving as an essential safety net for Indian workers. In order to safeguard workers from the financial difficulty that might be caused by sickness, incapacity, or death as a result of accidents that occur on the job, the Employees' State Insurance Act (ESI Act) provides monetary compensation as a substitute for income. During India's early stages of industrialisation, in 1952, the Employment Security Insurance (ESI) system was developed to meet the need for comprehensive social security for industrial workers. Its operation was comparable to that of mandated health and disability insurance, and it established a precedent for subsequent pieces of legislation that would protect workers. In order to provide comprehensive coverage within the industrial sector, the ESI Act extends its protections to non-seasonal enterprises that have ten or more workers as well as non-seasonal businesses that do not use electricity and have twenty or more employees. Key benefits closely aligned with health insurance concepts include: medical benefits covering medical expenses for workers and their families through ESI hospitals and dispensaries, encompassing hospitalisation, outpatient care, and specialist consultations, comparable to comprehensive private health insurance; illness benefits providing cash compensation for lost income during approved sick leave, akin to short-term disability insurance; maternity benefits offering paid leave and medical care during pregnancy and childbirth, mirroring private maternity coverage; and disability benefits providing payments for temporary or permanent disability resulting from workplace accidents.

4.22.2 The Workmen’s Compensation Act, 1923

A safety net that is separate from normal health insurance but similarly focused at relieving financial burdens from work-related hazards is provided by the Workmen's Compensation Act of 1923 in India. This act offers cash compensation to workers who have been wounded or murdered on the job. The purpose of this legislation is to guarantee that workers are not left penniless as a result of work-related deaths, disfigurements, impairments, or injuries. It was enacted to rectify deficiencies associated with prior compensation laws. A wide range of industries are included in the scope of the Act, such as those working in aircraft crews, foreign workers (Schedule II), those working in factories, ports, mines, and construction (which is particularly relevant in Chennai's industrial environment), vehicle operators, and non­administrative railway personnel. Employer compensation is required under the Act, which applies to businesses in Chennai and Tamil Nadu that have more than ten workers. This includes compensation for accidents that occur in the workplace, the aggravation of pre-existing ailments caused by work-related occurrences, and death or disability that occurs while the employee is on duty.

4.23 The General Insurance Business 9Nationalization), 1972

The nationalisation and subsequent liberalisation of India's general insurance business significantly impacted the country's health insurance market. The General Insurance Corporation (GIC) and its four subsidiaries—National Insurance Company Limited, The New India Assurance Company Limited, The Oriental Insurance Company Limited, and United India Insurance Company Limited—were established by the General Insurance Business (Nationalisation) Act, 1972 (GIBNA), which mandated government control over all general insurance operations. This nationalisation facilitated the establishment ofhealth insurance as a distinct product category, despite its initial focus on other forms of general insurance, including fire, marine, and automobile insurance.

Prior to GIBNA, the Indian Health Insurance business was still in its infancy, had little market share, and was mostly provided by a small number of private companies. The following significant changes brought about by nationalisation affected the development of health insurance:

• Standardisation and Reach: A certain level of standardisation in insurance products, including health insurance, was brought about by the establishment of GIC and its subsidiaries. Through the vast branch networks of the public sector enterprises, this helped set fundamental coverage parameters and increased insurance accessibility for a larger population. Because of their official support, these businesses were more trusted by the general public, which was essential for encouraging the use of insurance.
• Emphasis on Social Goals: Beyond maximising profits, nationalisation sought to accomplish more general social goals. This includes offering social protection and increasing the uptake ofinsurance among marginalised populations. By highlighting the significance ofhealthcare access and financial protection against health risks, this focus indirectly benefited health insurance.
• Limited Product Innovation: Nevertheless, there were drawbacks to the nationalised setting as well. In the early decades, there was less emphasis on product innovation and diversity due to a focus on social goals and less pressure from competitors. Offerings for health insurance were comparatively simple, with an emphasis on hospitalisation costs and few options for coverage.

The liberalization of India's insurance sector, culminating in the 2002 General Insurance Business (Nationalisation) Amendment Act, significantly impacted health insurance. Key effects included: increased private sector entry (domestic and foreign) leading to product innovation (top-up plans, family floaters, etc.); improved service and claims processing due to competition; enhanced pricing and underwriting practices; and greater public awareness and insurance penetration, though still low compared to developed nations. This liberalization aligned with broader goals of increased private participation, improved social protection and insurance access, better protection of policyholder interests, and accelerated economic growth.

4.24 The Public Liability Insurance Act, 1991

Although not directly related to health insurance, the Public Liability Insurance Act of 1991 has significant links to it, especially when it comes to industrial accidents using dangerous materials in places like Chennai, Tamil Nadu. The Act requires owners who handle hazardous products to be insured in order to promptly compensate accident victims. This compensation can cover a range of damages such as death, property damage and injuries.

The Public Liability Insurance Act of 1991 adds an essential layer of protection, particularly for accidents involving hazardous materials, to health insurance in Chennai, Tamil Nadu. The Public Liability Act addresses damages resulting from such incidents, including lost earnings and long-term health consequences that may not be covered by regular health policies, even while health insurance covers general medical bills. By guaranteeing prompt financial support for victims of industrial accidents or environmental contamination, irrespective of their personal insurance constraints, this Act closes gaps in health insurance coverage. Its emphasis on instant alleviation is in line with health insurance's objective of facilitating prompt access to medical care. In contrast to individual health insurance, the Act guarantees remedies even for people who are not directly employed by the guilty enterprise, protecting the larger society, especially those who reside close to Chennai's hazardous industries. The Act's requirement of liability insurance reduces the potential catastrophic costs for individuals by moving the financial burden of such catastrophes to corporations, which in turn affects healthcare prices indirectly. Last but not least, it simplifies victim compensation by offering a legal framework for direct recovery from culpable parties, minimising the need for drawn-out litigation, particularly in situations when health insurance is insufficient.

The Public Liability Insurance Act is essential for safeguarding employees and the local community from the possible repercussions of incidents involving hazardous materials in Chennai's varied industrial landscape. By offering a particular compensation mechanism in these exceptional situations, it supplements health insurance by guaranteeing victims prompt treatment and holding companies responsible for the safe management of dangerous materials. The Act is a crucial part of the larger social safety net pertaining to health and well-being because of its emphasis on providing immediate aid, protecting the community, and filling up health insurance gaps.

4.25 Health Insurance and Bancassurance

Health Insurance

Health insurance is a kind of coverage that reimburses medical expenses. A health insurance policy is a contract between an insurer and an individual or organisation in which the insurer commits to provide designated health insurance coverage in exchange for a specified premium. Bancassurance

Bancassurance is a contractual arrangement between an insurance firm and a financial institution that allows the insurance firm to market its products to the bank's clientele. This collaboration may benefit both enterprises. Banks may augment their earnings by marketing insurance products, whilst insurance firms can broaden their clientele without employing more sales personnel.

Regulations of the Corporate Agency

Banks are only permitted to serve as corporate agents for a single life insurance firm under the IRDA regulatory framework in exchange for a commission. Except for their commission, banks are not eligible for any other payments. Banks must adhere to a code of behaviour that is set forth for both the principal, who is the insurer, and the consumer. It would be impossible for banks to act as brokers. Banks are not allowed to advertise independent insurance broking firms by the RBI. Insurance Ombudsmen The Government of India established the Insurance Ombudsman program to provide individual policyholders with an impartial, cost-effective, and 147 expedient means of resolving their grievances outside of the legal system. Any person with a complaint against an insurer, either personally or via legal heirs, nominees, or assignees, must submit a written grievance to the Insurance Ombudsman whose jurisdiction encompasses the complainant's residential address or the insurer's branch or office. Seventeen Insurance Ombudsmen are now situated in diverse locales.

Complaint-filing procedure and award

To lodge a complaint with the Insurance Ombudsman in Chennai, Tamil Nadu, India, several criteria must be satisfied. The grievance must be documented in writing and presented to the Ombudsman whose authority encompasses the insurance company's office location. The complainant or their legal successors must first present the grievance to the insurer. The insurer must have either dismissed the complaint, failed to react within 30 days after its receipt, or issued an inadequate answer. A complaint to the Ombudsman must be submitted within one year following the insurer's denial or inadequate response. The complaint must pertain to a personally owned policy, and the aggregate claim amount, inclusive of all costs, must not surpass INR 30 lakhs. Moreover, the same complaint must not be under consideration by any court, arbitration body, or consumer forum.

4.26 Advisory Committee: The Insurance (Amend.) Act, 1968

Section 64 U of the Insurance Act of 1938 mandates the establishment of a Tariff Advisory Committee (TAC), a corporate entity with perpetual succession and a common seal, tasked with supervising and regulating the rates, benefits, and terms and circumstances applicable to general insurance operations.

Advantages:

The Tariff Advisory Committee for health insurance provides numerous benefits:

• Standardisation: It facilitates the uniformity of premiums and coverage throughout the industry, ensuring equity and transparency for consumers.
• Consumer Protection: Regulating tariffs safeguards consumers from capricious price hikes and guarantees sufficient coverage for their premiums.
• Risk Management: It aids insurers in properly managing risks by offering recommendations on pricing techniques, potentially resulting in a more stable insurance market.
• Market Stability: Its oversight fosters stability in the health insurance market by averting price wars and unsustainable pricing strategies among insurers.
• Regulatory Compliance: It guarantees that insurers adhere to regulatory mandates, preserving the integrity of the insurance industry and protecting customer interests.

Disadvantages

• Reduced Competition: Strict tariff regulations may limit competition among insurers, potentially leading to fewer options for consumers and less innovation in coverage and pricing.
• Limited Flexibility: Insurers may find it challenging to adjust premiums dynamically based on changing market conditions or emerging health trends due to regulatory constraints.
• Risk Pooling Issues: In some cases, uniform tariffs set by the committee may not adequately reflect the diverse risk profiles of insured individuals, leading to cross­subsidization or adverse selection issues.
• Bureaucratic Processes: The involvement of a regulatory committee can introduce bureaucratic delays and complexities in the approval of tariff changes, hindering insurers' ability to respond promptly to market dynamics.
• Potential for Under-pricing: If tariffs are set too low relative to actual claim costs, insurers may struggle to cover their expenses, potentially leading to financial instability within the industry.
• Balancing regulation with market dynamics is crucial to address these potential disadvantages while still reaping the benefits of a Tariff Advisory Committee in the health insurance sector.

The insurance advisory commitees function s

• Advising the Authority on issues pertaining to the creation of regulations under section 26 is the main goal of the Insurance Advisory Committee. The Insurance Advisory Committee may advise the Authority on other topics as may be stipulated, subject to the terms of sub-section.
• A Tariff Advisory Committee exists in regard to the insurance firm. Its operations are also regulated by the IRDAI.

4.27 Conclusion

The insurance sector in India has seen a substantial upheaval, transitioning from an uncontrolled market to complete nationalisation and then embracing partial deregulation. This alteration has profoundly influenced the availability and accessibility of various insurance products, including health insurance, driven by landmark legislation such as the Insurance Act of 1938, the Life Insurance Corporation Act of 1956, and the General Insurance Business (Nationalisation) Act of 1972. Significant public sector enterprises such as LIC and GIC were founded during the nationalisation era, which centralised the insurance industry under governmental authority. While the objective of this period was to expand insurance accessibility and promote social objectives, it simultaneously impeded competition and product innovation. The ensuing deregulation, marked by the establishment of the IRDA in 1999, fostered a more competitive market by introducing private enterprises. This transformation has led to increased product variety, enhanced service quality, and more customer alternatives, particularly in the health insurance sector. The current insurance ecosystem in India is shaped by the interplay between market liberalisation and government intervention. This growth has directly influenced the manner in which individuals and corporations in Chennai, Tamil Nadu, and throughout the nation acquire and use insurance as an essential tool for risk management, financial safeguarding, and overall economic stability.

CHAPTER -V CLAIMS PROCESSING AND SETTLEMENT

5.1 Introduction

In this past, people were answerable for all clinical costs, which regularly brought about monetary hardships, especially in case of difficult sickness or injury. The implementation of health insurance established a safety net by distributing financial risk over a broad population. In return for consistent payments, or premiums, policyholders had access to coverage for a defined array of medical services. Europe originated the early iterations ofhealth insurance in the late 19th century. Most of the time, these were mutual aid societies where members pooled their resources to help each other out when they needed medical help. Business health care coverage organisations started offering greater plans with differing levels of inclusion and costs in the twentieth hundred years. The widespread use ofhealth insurance had a significant impact on healthcare access. As people's financial burden decreased, they were more likely to seek medical treatment and preventative care. Populaces' general well-being results worked on thus. Likewise, health care coverage gave a level of monetary security, permitting people to focus on recuperation as opposed to the nervousness of mounting hospital expenses. Notwithstanding, there were challenges with the presentation of health care coverage. The shifting landscape of healthcare, which includes new technologies and rising costs, continues to impede accessibility and affordability. Talks about envelope issues like cost climbs, consideration limitations, and the occupation of government relationships in clinical consideration structures. All in all, the presentation ofhealth care coverage is a critical stage toward making medical services more open to all. By lowering financial risk, it gives people the freedom to put their health and well-being first. In any case, keeping a health care coverage framework that is both maintainable and impartial remains part of a cycle that is progressing and requires consistent development and variation.⁷⁷, ⁷⁸

Health insurance is a financial agreement in which people or groups remit premiums to an insurance provider in return for coverage of medical costs. It functions as a safety net, alleviating the financial strain of healthcare expenses by offering payment for some or all covered medical services, treatments, and procedures. The details of coverage differ based on the insurance plan, but generally encompass services including medical consultations, hospital admissions, prescription drugs, and preventive healthcare. Health insurance seeks to guarantee that individuals can obtain essential medical treatment without incurring excessive out-of­pocket costs.⁷⁹

5.1.1 Importance ofHealth Insurance

Health insurance is essential for several reasons. Firstly, it offers an essential financial safeguard by addressing unforeseen medical costs, so shielding people and families from substantial financial distress. Secondly, health insurance guarantees access to vital medical services, encompassing preventative care, regular examinations, treatments, and pharmaceuticals, so enhancing general wellness and facilitating the early identification of health concerns. Thirdly, it provides access to a network of reputable healthcare professionals and facilities, ensuring prompt availability of excellent medical treatment when required. Fourthly, many health insurance plans cover preventive services such as vaccinations, screenings, and wellness programs, which aid in maintaining good health and preventing chronic conditions. Ultimately, possessing health insurance offers reassurance by ensuring financial stability in cases of sickness, accident, or other medical crises. In several nations, health insurance is mandated by law, and people may incur fines for lacking coverage.

5.1.2 Benefits of having a Health insurance Policy

Health insurance provides several advantages, such as cashless treatment at affiliated hospitals, coverage for pre- and post-hospitalization charges for up to 60 days, reimbursement for transportation costs, and the possibility of a No Claim Bonus (NCB) for years without claims. Moreover, many plans include provisions for health assessments, with certain insurers giving complimentary health evaluations contingent upon accrued No Claim Bonuses (NCBs). The insurance coverage may cover room rent expenses, depending upon the premium paid. Section 80D⁸⁰ of the Income Tax Act 1961, allows for the tax deduction ofhealth insurance premiums.

5.1.3 Factors influence the right insurance policy

Selecting the optimal insurance coverage can be difficult as many insurance companies offer similar plans. Before purchasing any insurance plan, it is essential to carefully evaluate several key factors. These include the guaranteed amount of coverage, the minimum entry age and the policy's renewability clause. Additionally, it is important to consider the room rent capping, the policy's inclusions and exclusions, any bonuses offered for claim-free periods, and any other additional benefits provided by the insurance plan

5.1.4 Types ofHealth Insurance

In India, health insurance plans come in various roles:

5.1.4.1 Based on Coverage, health insurance is of the following types

• Individual Health Insurance: This Covers a single person, ideal for Insuring adults or those without dependents.
• Family Floater Health Insurance: This Covers a family (spouse and dependent children) under a single sum insured, which can be used by any member.
• Senior Citizen Health Insurance: It is Designed specifically for the medical needs of senior citizens, often providing coverage for pre-existing conditions.

5.1.4.2 Based on Benefit Structure, health insurance is of the following types

• Indemnity Plans: It Reimburse Insurer for actual medical expenses incurred during hospitalisation, up to the sum insured. Insurer submit bills for cashless reimbursement or claim reimbursement later.
• Managed Care Plans: It Offer coverage through a network of hospitals and doctors at pre-negotiated rates. Insurer typically pay a lower premium but may have limitations on choosing providers outside the network.

5.1.4.3 Based on Specific Needs:

• Critical Illness Insurance: It Provides a lump sum pay-out if diagnosed with a critical illness like cancer or heart attack, helping manage financial burden during such times.
• Top-up Health Insurance: It Acts as an additional layer of coverage on top of Insured existing health insurance plan. It kicks in after Insurer exhaust the sum insured in Insurance primary plan.
• Hospital Daily Cash: It Provides a fixed daily benefit amount for each day of hospitalisation, irrespective of the actual medical expenses. This can be helpful for managing incidental costs during hospitalisation.

5.1.4.3 Other Considerations:

• Group Health Insurance: It is Offered by employers or associations, often at lower premiums due to group bargaining.
• Disease-Specific Plans: It Cover specific illnesses like cancer or heart disease.

5.1.4.5 Government-sponsored schemes

Government-funded health insurance programs in India are financed by the Indian government and provide financial support to low-income families and at-risk groups for medical care. Prominent instances are the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB- PMJAY), a nationally financed program providing up to Rs 5 lakh per household yearly for secondary and tertiary care hospitalisation. The Rashtriya Swasthya Bima Yojana (RSBY) offers cashless coverage for hospitalisation expenses up to Rs 50,000 yearly for families classified as Below Poverty Line (BPL). The Central Government Health Scheme (CGHS) provides extensive medical coverage to central government employees and their dependents, while the Employees' State Insurance Scheme (ESIS) offers comprehensive medical treatment to employees earning up to Rs 21,000 per month and their families.

5.2 Historical Overview of the Health Insurance Sector in India

Health insurance in India has been in existence forjust a few decades. References to this form of covering are found in the writings of Yagnavalkya (in the Yagnavalkya), Smriti (in the Manusmriti), and Kautilya (in the Arthashastra), among others. Health insurance has been present since the nation's independence, with its beginnings rooted in the modern era. Commencing in 1948, several governmental initiatives were undertaken. The health insurance business in India has undergone a significant transformation marked by certain developmental phases and legislative milestones that have shaped its current structure. The health insurance industry is crucial for providing financial protection and enabling access to healthcare services for individuals and families. The Indian health insurance sector is an expanding business providing financial security against healthcare costs. Since the entry of private entities in 2000, it has seen significant growth, resulting in more alternatives and competition. Nonetheless, obstacles such as claim settlement difficulties and restricted accessibility in rural regions persist. As the business progresses, prioritising openness, extensive coverage, and streamlined claims procedures will be essential for its success. Health insurance providers in India have launched unique products and services to address varied client requirements and preferences. These include specialist health insurance policies for critical diseases, maternity benefits, outpatient treatment, and wellness programs. The health insurance sector in India is using digitalisation to augment client experience, optimise operations, and promote operational efficiency. Numerous insurers provide online portals for acquiring insurance, managing claims, and receiving healthcare services. The health insurance sector has a dual nature of advantages and disadvantages. Although it provides a safety net for persons encountering medical crises, apprehensions about claim settlements and accessibility persist. As the sector progresses, achieving equilibrium between profitability and social responsibility will be essential. The health insurance sector in India has seen substantial expansion and evolution, propelled by escalating healthcare prices, heightened knowledge of health hazards, and an increased desire for financial safeguards against medical expenditures. .

Early Steps: Seeds of Social Security (1940s-1980s)

• Employee’s State Insurance Scheme (ESIS) (Late 1940s): This government program provided health coverage for organised sector workers. While not a court case, the establishment of ESIS under the Employees State Insurance Act, 1948, laid the foundation for social health insurance in India.

Standardisation and Choice (1980s-1990s):

• Mediclaim Policy (1986): The General Insurance Corporation (GIC) introduced the first standardised health insurance policy, Mediclaim. This case doesn't have a specific legal case associated with it, but it marked the beginning of private health insurance offerings in India.
• Liberalisation and Private Players (1990s): Economic reforms paved the way for private participation in the insurance sector. This decision was challenged in “ Bodh Raj v. Hindustan General Insurance Co. Ltd.^[81] , but the Supreme Court upheld the government's right to liberalise the insurance sector. This case established the legal framework for private companies to enter the health insurance market.”

Innovation and Growth (2000s-Present):

• Product Diversification: Private insurers introduced innovative products. Legal disputes can arise regarding claim rejections or policy exclusions. “In Oriental Health Insurance Ltd. v. Kiran Aggarwal ,^[82] t he Supreme Court ruled in favour of the policyholder, highlighting the insurer's obligation to clearly communicate exclusions at the time of policy issuance. This case set a precedent for fair claim settlements.”
• Regulatory Framework (1999): “The Insurance Regulatory and Development Authority (IRDAI) was established. The IRDAI's role in regulating the sector was challenged in New India Assurance Co. Ltd. v. IRDAI^[83] , and the court upheld IRDAI's authority, emphasising its role in protecting consumer interests. This case solidified IRDAI's role in ensuring fair practices within the health insurance industry.”

Challenges and Opportunities:

• Low Penetration: A large portion of the population remains uninsured. The focus is on increasing awareness and offering affordable products.
• Technological Advancements: Integrating technology can improve claim processing and healthcare access. Legal frameworks around data privacy and telemedicine consultations are evolving. The Information Technology Act, 2000, serves as a foundation for data protection in the digital health insurance landscape.

5.3 Importance of Settlement of Claims for Policyholders

Role ofHealth Insurance Companies

Customers purchase insurance to be compensated in the event of an unanticipated occurrence. It serves as a safeguard against unavoidable events. In most insurance policies, a loss is only covered if a particular event occurs. In the event that the protected experiences no misfortune no case is paid to him. The premium is charged on yearly premise and no collection happens. Anyway the situation is different in the event of extra security. Assuming that the protected bites the dust during the strategy time frame he gets the aggregate guaranteed alongside the reward accumulated under the arrangement if any. The insured receives the maturity amount accrued under the policy if the insured survives the policy period.

The policyholder has waited for the ultimate goal of life insurance—the settlement of their claim—for quite some time—sometimes literally for their entire life. Because the policyholder has already fulfilled his obligation to pay the premium on a regular basis in accordance with the terms outlined in the schedule of the policy document, it is the insurer's final obligation under the terms of the insurance contract. The strategy report likewise makes reference to in the timetable the occasion or occasions on the event of which the safety net provider will be paying a foreordained measure of cash.

Settlement of claims for policyholders is a crucial aspect of the insurance process, ensuring that individuals and businesses receive the financial support they need in times of unexpected events or emergencies.

1. Financial Protection: Settlement of claims provides policyholders with the financial resources necessary to recover from covered losses, such as accidents, illnesses, or property damage. It helps alleviate the financial burden associated with unexpected expenses and enables individuals to rebuild and move forward without significant financial strain.
2. Peace of Mind: Knowing that their insurance coverage will come through when needed gives policyholders peace of mind. It allows them to focus on their health, recovery, or rebuilding efforts without worrying about the financial implications of the situation.
3. Trust and Reliability: Timely and fair settlement of claims reinforces trust and confidence in the insurance company. When insurers honour their commitments immediately and fairly, it strengthens the relationship between the insurer and the policyholder, leading to greater satisfaction and loyalty.
4. Legal Obligation: Insurers have a legal obligation to settle valid claims according to the terms and conditions outlined in the insurance policy. Failure to do so could result in legal action and damage the reputation of the insurance company.
5. Customer Satisfaction: Efficient and transparent claims settlement processes contribute to overall customer satisfaction. Policyholders who have positive experiences with their insurance claims are more likely to renew their policies and recommend the insurer to others, thereby contributing to the company's success.

The settlement of claims is vital for policyholders as it provides financial protection, peace of mind, and reinforces trust in the insurance company. It is a fundamental aspect of the insurance contract and plays a significant role in maintaining the integrity and sustainability of the insurance industry.

General Claim Settlement Process:

1. Claim Intimation: Upon a covered event (hospitalisation, death, etc.), the policyholder or beneficiary needs to intimate the insurance company as soon as possible. This can usually be done by calling a helpline, submitting a claim form online, or visiting a branch office.
2. Document Submission: The policyholder will need to submit all the necessary documents to support their claim. These documents typically include the policy document, medical records (for health claims), death certificate (for life claims), and any other documents requested by the insurer.
3. Claim Review and Verification: The insurance company will review the claim and the submitted documents to determine if it's covered under the policy terms and conditions. They may also require further investigation or clarification.
4. Claim Settlement: If the claim is approved, the insurance company will pay out the claim amount to the policyholder or beneficiary. This can be done electronically or through a cheque.

5.3.1 Role ofHealth Insurance Companies

Health insurance companies play several crucial roles within the healthcare ecosystem:

1. Risk Management: Health insurance companies assess and manage the financial risks associated with healthcare expenses. By pooling premiums from a large number of policyholders, insurers spread the risk of high medical costs among the population they cover, thus protecting individuals from facing catastrophic expenses due to illness or injury.
2. Coverage Provision: One of the primary functions of health insurance companies is to provide coverage for medical services and treatments. They offer various types of insurance plans, including individual, family, and group plans for employers. These plans typically cover a range of healthcare services, such as doctor visits, hospital stays, prescription medications, and preventive care.
3. Provider Network Management: Insurers establish networks of healthcare providers, including hospitals, physicians, specialists, and other healthcare professionals. These networks help ensure that policyholders have access to a broad range of medical services at negotiated rates. Health insurance companies often negotiate contracts with providers to determine reimbursement rates and other terms of service.
4. Claims Processing: Health insurance companies are responsible for processing claims submitted by policyholders and healthcare providers. This involves verifying the policyholder's coverage, determining the eligibility of services, and adjudicating claims based on the terms of the insurance policy. Insurers also handle payments to healthcare providers for services rendered to policyholders.
5. Customer Service and Support: Health insurance companies provide customer service and support to policyholders, assisting them with inquiries, concerns, and issues related to their coverage and benefits. This includes helping policyholders understand their insurance plans, resolving billing disputes, and guiding them through the claims process.
6. Risk Assessment and Underwriting: Insurers assess the risk profiles of individuals and groups seeking coverage to determine appropriate premium rates and coverage options. This process, known as underwriting, involves evaluating factors such as age, health status, pre-existing conditions, and lifestyle habits. Health insurance companies use actuarial principles and statistical analysis to estimate the likelihood of future medical expenses and set premiums accordingly.
7. Compliance and Regulatory Oversight: Health insurance companies operate within a regulatory framework governed by laws and regulations designed to protect consumers and ensure the solvency and stability of insurers. Insurers must comply with regulatory requirements related to financial reporting, consumer protection, privacy, and other areas ofhealthcare insurance.

5.3.2 Health Insurance Claim Process

A medical coverage strategy prepares Insurer to seek the best medical care therapy without stressing over the enormous costs payable at the hour of release. Subsequently realising about the case interaction is a fundamental snippet of data that the safeguarded individual ought to know about consistently. The two fundamental kinds of medical coverage guarantee which an individual can browse while making a case are:

• Reimbursement Claim Process
• Cashless Claim Process

The insured person begins receiving treatment when they provide the hospital with information about their health insurance. The hospital will send the medical bills to the designated health insurance company after the patient is discharged. After that, the expenses will be audited by the company, and the hospital will receive the remaining payment. Because the hospital and the insurance company split the cost, this procedure is easy for the insured. The insured patient who has been admitted to a particular hospital is responsible for paying for all of their treatment up until their discharge during the reimbursement claim process.

When the back-up plan has paid for the treatment and hospitalisation costs caused, he/she need to make a repayment guarantee to the specific insurance agency. In order to receive reimbursement, the insured individual must submit the hospital's original bills to their health insurance. After conducting an audit, the insurance company will decide whether to approve or deny the claim. The policyholder will receive payment for the claim once it is approved by the insurance company. If the claim is denied, the insurance company will let the insured person know.

5.3.2.1 Claims Processing Procedures

In India, health insurance claims processing procedures are governed by various laws, regulations, and case laws to ensure fairness, transparency, and efficiency in the reimbursement process.

1. Verification of Coverage: Health insurance claims processing begins with verifying the policyholder's coverage and eligibility for the claimed medical expenses. Insurance companies check the policy terms, coverage limits, and exclusions to determine the extent of coverage applicable to the claim.
2. Claims Submission: Healthcare providers submit claims to the insurance company or third-party administrator (TPA), providing details of the medical services rendered, diagnosis, treatment, and charges incurred. Claims may be submitted electronically or through paper forms.
3. Adjudication and Review: Insurance companies adjudicate claims by reviewing them against the terms of the insurance policy, medical records, and supporting documents. Claims processors assess the eligibility of expenses, medical necessity, and compliance with policy provisions.
4. Coding and Documentation Review: Claims processors review the medical codes and documentation submitted with the claim to ensure accuracy and compliance with coding guidelines. They verify that the diagnoses, procedures, and services listed on the claim are appropriately documented and coded. While there may not be specific case laws in India related to coding and documentation review in health insurance claims processing, regulatory guidelines issued by the Insurance Regulatory and Development Authority of India (IRDAI) emphasise the importance of accurate coding and documentation in claims processing.
5. Payment Processing: Once the claim is adjudicated and approved, the insurance company initiates payment to the healthcare provider or policyholder. Payments are made based on the eligible expenses, policy coverage, and any applicable deductibles or co-payments.

Other related role ofhealth insurance claims processing procedures is multifaceted and crucial to the functioning of the healthcare system includes,

• Provider Network Management: Claims processing procedures involve verifying whether the healthcare provider is part of the insurer's network. In-network providers typically have negotiated rates with the insurer, which may affect the reimbursement amount. Claims processors also ensure that services provided by out-of­network providers are eligible for reimbursement according to the terms of the police.
• Cost Containment: Claims processing procedures play a role in containing healthcare costs by scrutinising claims for unnecessary or excessive services. Claims processors may conduct utilisation reviews to assess the medical necessity and appropriateness of treatments and procedures. They may also implement cost-sharing mechanisms such as deductibles, co-payments, and coinsurance to encourage responsible utilization ofhealthcare services.
• Communication and Transparency: Throughout the claims processing procedure, insurers maintain open communication with policyholders and healthcare providers. They provide clear explanations of benefits (EOBs) to policyholders, detailing the adjudication outcome, reimbursement amount, and any patient responsibility. Transparent communication helps foster trust and accountability in the claims processing process.
• Compliance and Regulatory Adherence: Claims processing procedures must adhere to applicable laws, regulations, and industry standards governing health insurance. Insurers ensure compliance with regulations such as the Health Insurance Portability and Accountability Act (HIPAA) and the Affordable Care Act (ACA) to protect the privacy and rights of policyholders.

The process of reimbursement ofhealthcare services are includes:

1. Patient Registration: The process begins when a patient seeks medical care from a healthcare provider. During registration, the patient provides their health insurance information, including the policy number, group number (if applicable), and other relevant details.
2. Treatment and Service: The healthcare provider delivers the necessary medical services or treatments to the patient based on their healthcare needs. This may include consultations, diagnostic tests, medical procedures, medications, and other services.
3. Claims Submission: After providing medical services, the healthcare provider generates a claim for reimbursement from the health insurance company. The claim includes details such as the patient's demographics, diagnosis, treatment codes (CPT/HCPCS codes), and charges for services rendered.
4. Claim Transmission: The healthcare provider submits the claim electronically or via paper to the health insurance company or a third-party administrator (TPA). Electronic submission is the most common method and allows for faster processing.
5. Claim Adjudication: Upon receiving the claim, the health insurance company begins the adjudication process. This involves reviewing the claim for accuracy, verifying the patient's coverage, and determining the amount payable based on the terms of the insurance policy and the provider's contracted rates.
6. Verification of Eligibility: The insurer verifies the patient's eligibility for coverage at the time of service. This includes checking the policyholder's enrolment status, coverage effective dates, and any applicable deductibles, co-payments, or coinsurance requirements.
7. Coding and Billing Review: The insurer reviews the medical codes submitted on the claim to ensure they comply with coding guidelines and are appropriate for the services rendered. This helps prevent errors, fraud, and abuse in billing practices.
8. Adjudication Outcome: After reviewing the claim, the insurer determines whether to approve, deny, or pending the claim for additional information. If approved, the insurer calculates the reimbursement amount based on the contracted rates and the patient's cost-sharing responsibilities.
9. Payment Processing: Once the claim is approved, the insurer initiates payment to the healthcare provider for the covered services. Payments are typically made electronically via electronic funds transfer (EFT) or by issuing a paper check.
10. Explanation of Benefits (EOB): The insurer sends an Explanation of Benefits (EOB) to the policyholder, detailing the adjudication outcome, the services covered, the amount paid, any patient responsibility, and any reasons for denial or adjustment.
11. Appeals Process: If a claim is denied or adjusted, the healthcare provider or policyholder may have the right to appeal the decision through the insurer's appeals process. This involves providing additional documentation or evidence to support the claim's reconsideration.

5.3.2.2 Internal Policies and Guidelines

Health insurance companies in India establish internal policies and guidelines to govern their operations, ensure compliance with regulatory requirements, and uphold ethical standards. These internal policies and guidelines cover various aspects of the insurer's functions and responsibilities.

1. Coverage Policies: Health insurance companies develop coverage policies that outline the types of medical services, treatments, and procedures eligible for coverage under their insurance plans. These policies ensure clarity and consistency in benefit determinations.
2. Provider Network Policies: Insurers establish policies and guidelines for building and managing their provider networks. These policies include criteria for selecting and credentialing healthcare providers, establishing reimbursement rates, and maintaining quality standards. The regulatory guidelines issued by the Insurance Regulatory and Development Authority of India (IRDAI) emphasise the importance of ensuring adequate network coverage and quality of services.
3. Claims Processing Guidelines: Health insurance companies develop detailed guidelines and procedures for processing and adjudicating claims submitted by policyholders and healthcare providers. These guidelines cover various aspects of claims processing, including claim submission requirements, coding and billing standards, reimbursement methodologies, and appeals processes.
4. Fraud and Abuse Prevention: Insurers implement policies and protocols to detect and prevent fraud, waste, and abuse within their insurance programs. These policies include measures such as fraud detection algorithms, claims audits, and employee training on recognizing fraudulent activities.
5. Compliance and Regulatory Policies: Health insurance companies develop internal policies and procedures to ensure compliance with applicable laws, regulations, and industry standards. These policies cover areas such as privacy and data security, consumer protection, and anti-money laundering regulations.
6. Utilisation Management Policies: Insurers implement utilisation management policies to monitor and manage the appropriate use of healthcare services. These policies may include preauthorization requirements for certain procedures, utilisation review protocols to assess the medical necessity of treatments, and care coordination initiatives to optimize healthcare outcomes while controlling costs.
7. Customer Service Standards: Health insurance companies set standards for customer service excellence to ensure positive interactions with policyholders and healthcare providers. This includes policies on call centre operations, responsiveness to inquiries and complaints, accessibility of information, and the resolution of disputes in a timely and fair manner.
8. Quality Improvement Initiatives: Insurers may implement quality improvement initiatives to enhance the quality and efficiency of healthcare services delivered to policyholders. This may involve collaborating with healthcare providers on quality improvement projects, collecting and analysing data on healthcare outcomes and patient satisfaction, and implementing best practices to drive continuous improvement.

5.3.2.3 Training and Compliance Programs

Health insurance companies play a vital role in implementing training and compliance programs to ensure adherence to regulatory requirements, ethical standards, and best practices in the healthcare industry. These programs are essential for mitigating risks, preventing fraud, and maintaining the integrity of insurance operations.

1. Training Programs: Health insurance companies develop comprehensive training programs to educate employees on various aspects of their roles and responsibilities. These programs cover topics such as insurance products, claims processing procedures, customer service standards, and compliance requirements.
2. Compliance Programs: Health insurance companies establish compliance programs to ensure adherence to laws, regulations, and industry standards. These programs include policies, procedures, and controls designed to prevent fraud, promote ethical behaviour, and maintain regulatory compliance.
3. HIPAA Compliance: Health insurance companies must comply with the Health Insurance Portability and Accountability Act (HIPAA), which protects the privacy and security of individuals' health information. Compliance programs include training on HIPAA requirements, safeguarding protected health information (PHI), and breach notification procedures.
4. Anti-Fraud Training: Health insurance companies conduct anti-fraud training to educate employees on detecting, preventing, and reporting fraudulent activities. These programs cover common fraud schemes, red flags indicating potential fraud, and procedures for investigating suspicious claims.

5.3.2 Policyholder Rights and Responsibilities

A policyholder is a person or entity that possesses an insurance policy. A policyholder in health insurance is an individual who acquires a health insurance policy from an insurance provider or is included in a group health insurance plan offered by an employer or organisation. The policyholder is obligated to remit premiums to the insurance company in return for coverage of certain healthcare services and expenses defined in the insurance policy. The policyholder may also be designated as the insured or the beneficiary of the insurance policy, contingent upon the terminology employed by the insurance provider.

Rights of Policyholders

In the context of health insurance, policyholders have specific rights outlined by laws, regulations, and contractual agreements. These rights ensure fair treatment, access to coverage, and protection against unfair practices. While there may not always be specific case laws for each right, legal precedents and regulatory actions often reinforce and protect policyholders' rights. Right to Coverage: Policyholders have the right to receive the coverage specified in their insurance policy. This includes coverage for eligible medical expenses, treatments, and services as outlined in the policy documents.

1. Right to Timely Claims Processing: Policyholders have the right to have their insurance claims processed immediately and efficiently. Insurance companies are required to adhere to regulatory guidelines and internal policies for claims processing.
2. Right to Information: Policyholders possess the right to obtain transparent and precise information regarding their insurance coverage, encompassing policy benefits, limitations, exclusions, premiums, and terms and conditions. The Insurance Regulatory and Development Authority of India (IRDAI) has underscored the necessity for insurance providers to furnish clear and comprehensible information to policyholders.
3. Right to Appeal: Policyholders has the right to contest the decision if a claim is denied or inadequately covered by the insurance company. Insurance firms must have an appeals mechanism that enables policyholders to contest claim denials.
4. Right to Non-Discrimination: Policyholders possess the right to equitable treatment devoid of discrimination based on age, gender, colour, ethnicity, or health status.
5. Right to Privacy: Policyholders has the right to confidentiality regarding their personal and medical information. Insurance businesses are required to adhere to privacy laws and regulations to protect policyholders' confidential information.

Responsibilities of a Policy Holder

Policyholders under health insurance have certain responsibilities to ensure the smooth operation of their insurance coverage and to fulfil contractual obligations. While there may not always be specific case laws for each responsibility, legal principles and regulatory requirements establish the framework for policyholder responsibilities.

1. Premium Payment: Policyholders must remit premiums to the insurance provider in return for coverage. Prompt payment of premiums is crucial to sustain the insurance policy and preserve coverage.
2. Obligation of Precise Information Disclosure: Policyholders are required to furnish correct and comprehensive information while seeking insurance coverage or filing claims. This entails accurately giving pertinent personal and medical information to the insurer.
3. Adherence to Policy Provisions: Policyholders must adhere to the stipulations and conditions specified in the insurance policy, encompassing coverage limitations, exclusions, and claim submission protocols. Noncompliance with policy terms may lead to claim denials or other negative repercussions.
4. Timely Notification of Claims: Policyholders must promptly inform the insurance company of any claims or incidents that could potentially result in a claim under the policy. Prolonged notification may impede the claims processing procedure and may lead to the denial ofbenefits.
5. Cooperation with the Insurer: Policyholders are expected to cooperate with the insurance company during the claims processing process. This may include providing requested documentation, attending medical examinations, or cooperating with investigations.
6. Prevention of Fraud and Misuse: Policyholders are responsible for preventing fraud and misuse of their insurance coverage. This includes safeguarding insurance documents, preventing unauthorised use of the policy, and reporting any suspicious activities to the insurer.

5.3.2.1 Understanding Policy Terms and Exclusions

Policyholders have both rights and responsibilities when it comes to understanding their insurance policy terms, including coverage provisions and exclusions. While there may not be specific case laws addressing each aspect in detail, legal principles and regulatory requirements underscore the importance of policyholders being informed and knowledgeable about their insurance coverage.

1. Policyholder Rights:

• Right to Clear Information: Policyholders have the right to receive clear and understandable information about their insurance policy, including coverage provisions, limitations, exclusions, and other relevant terms.
• Right to Full Disclosure: Policyholders have the right to receive complete and accurate information from the insurance company regarding policy terms and conditions. Insurers are obligated to provide policy documents that accurately reflect the coverage provided and any exclusions that may apply.
• Right to Ask Questions: Policyholders have the right to ask questions and seek clarification from the insurance company or agent regarding any aspect of their policy. Insurers are required to provide prompt and accurate responses to policyholder inquiries.
• Right to Review Policy Documents: Policyholders have the right to review their insurance policy documents in detail before purchasing coverage. This allows them to understand the coverage provided, exclusions, limitations, and other important terms.

2. Policyholder Responsibilities:

• Duty to Read and Understand: Policyholders have a responsibility to read and understand their insurance policy documents thoroughly. This includes reviewing coverage provisions, exclusions, limitations, and any other terms that may affect their coverage.
• Duty to Seek Clarification: If policyholders have questions or concerns about their policy terms or exclusions, they have a responsibility to seek clarification from the insurance company or agent. It is essential to address any uncertainties before purchasing coverage or submitting claims.
• Duty to Disclose Relevant Information: Policyholders have a duty to disclose all relevant information to the insurance company when purchasing coverage or submitting claims. This includes providing accurate and complete information about pre-existing conditions, medical history, and other factors that may impact coverage eligibility.
• Duty to Comply with Policy Terms: Policyholders are responsible for complying with the terms and conditions outlined in their insurance policy. This includes adhering to coverage provisions, exclusions, and any other requirements specified in the policy documents.

5.3.2.2 Filing Complaints and Appeals

Policyholders have rights and responsibilities when it comes to filing complaints and appeals regarding their insurance coverage. These rights and responsibilities ensure that policyholders have avenues for recourse if they believe their rights have been violated or if they disagree with a decision made by the insurance company. While there may not be specific case laws for each aspect in detail, legal principles and regulatory requirements establish the framework for policyholder complaints and appeals.

1. PolicyholderRights:

• Right to Lodge Complaints: Policyholders have the right to lodge complaints with the insurance company or relevant regulatory authorities if they believe their rights have been violated or if they are dissatisfied with the handling of their insurance claims or inquiries.
• Right to Timely Response: Policyholders have the right to receive a timely response to their complaints from the insurance company or regulatory authorities. Insurance companies are required to acknowledge receipt of complaints immediately and provide updates on the status ofinvestigations or resolutions.
• Right to Appeal Decisions: If a claim is denied or not fully covered by the insurance company, policyholders have the right to appeal the decision. Insurance companies are required to have an appeals process in place, allowing policyholders to challenge claim denials and provide additional information or documentation to support their case.
• Right to Fair Treatment: Policyholders have the right to fair and respectful treatment from the insurance company and its representatives throughout the complaints and appeals process. This includes being provided with accurate information, having their concerns addressed immediately, and receiving courteous and respectful service.

2. Policyholder Responsibilities:

• Duty to Understand Complaint Procedures: Policyholders have a responsibility to understand the procedures for filing complaints and appeals outlined by the insurance company or regulatory authorities. This includes familiarising themselves with the timelines, documentation requirements, and contact information for lodging complaints.
• Duty to Provide Relevant Information: When filing complaints or appeals, policyholders have a responsibility to provide relevant information, documentation, and evidence to support their case. This may include copies of insurance policies, claim documents, correspondence with the insurer, and any other relevant materials.
• Duty to Cooperate with Investigations: Policyholders are expected to cooperate with the insurance company or regulatory authorities during the investigation of their complaints or appeals. This may include providing additional information, attending interviews or hearings, and cooperating with any requested assessments or examinations.
• Duty to Respect Process and Decisions: While policyholders have the right to appeal adverse decisions, they also have a responsibility to respect the complaints and appeals process and abide by the final decisions made by the insurance company or regulatory authorities.

5.3.2.3 Seeking Legal Recourse

Policyholders have both rights and responsibilities when it comes to seeking legal resources related to their insurance coverage. These rights and responsibilities ensure that policyholders have access to legal remedies if they believe their rights have been violated or if they encounter disputes with the insurance company. Here's a detailed overview of policyholder rights and responsibilities in seeking legal resources, along with relevant considerations:

1. Policyholder Rights:

• Right to Legal Counsel: Policyholders have the right to seek legal advice and representation from qualified attorneys if they have concerns or disputes related to their insurance coverage. Legal counsel can provide guidance on rights, options, and potential courses of action.
• Right to File Lawsuits: Policyholders have the right to file lawsuits against insurance companies if they believe their rights have been infringed upon or if they encounter disputes that cannot be resolved through other means. Legal action may be pursued to enforce policy provisions, challenge claim denials, or seek damages for breaches of contract or bad faith.
• Right to Due Process: Policyholders have the right to due process in legal proceedings, including the opportunity to present evidence, cross-examine witnesses, and receive a fair and impartial hearing. Courts are required to adjudicate insurance disputes based on applicable laws, regulations, and contractual agreements.
• Right to Appeal Court Decisions: If policyholders disagree with court decisions related to their insurance claims or disputes, they have the right to appeal to higher courts for review. Appellate courts may review lower court decisions for errors oflaw or procedure and may overturn or modify rulings as appropriate.

2. Policyholder responsibilities:

• Duty to Understand Legal Rights: Policyholders have a responsibility to understand their legal rights and options when seeking legal resources related to their insurance coverage. This includes familiarising themselves with relevant laws, regulations, and contractual provisions that may impact their case.
• Duty to Engage in Good Faith: Policyholders have a responsibility to engage in legal proceedings in good faith and with honesty and integrity. This includes providing accurate information, cooperating with legal counsel, and adhering to court procedures and orders.
• Duty to Mitigate Damages: If policyholders suffer financial losses or damages as a result of insurance disputes, they have a duty to take reasonable steps to mitigate their losses. This may include seeking alternative coverage, pursuing settlement negotiations, or exploring other avenues for resolution.
• Duty to Respect Legal Process: While policyholders have the right to pursue legal remedies, they also have a responsibility to respect the legal process and comply with court orders and directives. This includes attending court hearings, responding to legal notices, and complying with discovery requests.

3. Considerations for Legal Resource: When seeking legal resources, policyholders should consider factors such as the complexity of their case, the availability of evidence, the potential costs and benefits of legal action, and the likelihood of success. Legal counsel can provide guidance on these matters and help policyholders make informed decisions about their legal options. Policyholders should also be aware of any statutes of limitations or deadlines for filing legal actions related to their insurance claims or disputes. Failure to comply with these deadlines may result in the loss oflegal rights and remedies.

5.4 Overview of Contractual Agreements in Health Insurance

Contractual agreements in health insurance are fundamental to understanding the relationship and obligations between various parties involved, such as the insured individuals, insurance companies, healthcare providers, and possibly employers (in the case of employer-sponsored plans). These agreements outline the rights and responsibilities of each party and provide a legal framework for how health insurance benefits are administered.

A contractual adjustment refers to the segment of a patient's invoice that a physician or medical facility is required to forgo (not charge) as a result of billing agreements with the insurance provider. Adjustments, or write-offs, refer to funds that are subtracted from a patient's account for various reasons. Contractual adjustments represent the most common form of alteration. Providers impose higher charges for services than the insurance company consents to reimburse, with the insurer's payment designated as the permissible amount. A contractual adjustment is a reduction that surpasses the sum the insurance company has consented to disburse. Participating providers believe that enhanced access for members justifies the contractual service prices. Moreover, this enables clinicians to guarantee that they recover a substantial portion of their expenses, which uninsured clients may be unable to afford.

Contractual adjustments are exclusively applicable to services encompassed by the insurance provider. A patient requiring medical treatment not covered by the insurance provider must bear the entire expense invoiced by the healthcare provider, without any contractual provisions to limit the cost. Contractual adjustments are necessary as healthcare providers must negotiate pricing with insurance companies and government programs to ensure appropriate compensation for their services. Negotiating these costs can be challenging, and providers may need to acquiesce to reduced charges to maintain their relationships with these payers.

A health insurance contractual agreements includes following components:

a. Policy Terms and Conditions: The contractual agreement starts with the health insurance policy, which is a legal document outlining the terms and conditions of coverage. It specifies what services and treatments are covered, as well as any limitations or exclusions.
b. Premiums and Payments: The agreement specifies the amount of premiums to be paid by the insured and the frequency of payments (e.g., monthly, quarterly, annually). It also outlines the consequences of non-payment, such as policy cancellation.
c. Covered Services and Benefits: The agreement details which medical services, treatments, and procedures are covered by the insurance plan. This includes inpatient and outpatient care, prescription drugs, preventive services, mental health services, and more.
d. Cost-sharing Arrangements: Health insurance agreements describe the cost-sharing mechanisms, such as deductibles, co-payments, and coinsurance. These are the expenses the insured individual must pay out of pocket when receiving healthcare services.
e. Provider Networks: Many health insurance agreements establish provider networks— lists of doctors, hospitals, clinics, and other healthcare providers that have agreed to provide services to plan members at negotiated rates. Going out of the network may result in higher costs for the insured.
f Authorization and Referral Requirements: Some health insurance plans require pre­authorization for certain services or referrals from a primary care physician to see specialists. The agreement will detail these requirements.
g. Claims Procedures: The process for filing claims and receiving reimbursements or direct payments from the insurer is outlined in the contractual agreement. This includes timelines for submitting claims and how disputes are handled.
h. Exclusions and Limitations: Health insurance agreements specify what is not covered under the plan. This typically includes cosmetic procedures, experimental treatments, certain pre-existing conditions, and other specific exclusions.
i. Renewal and Termination: The agreement describes the conditions under which the policy can be renewed or terminated by either party. It may also include provisions for continuation of coverage under certain circumstances (e.g., COBRA in the U.S.).
j. Legal Rights and Obligations: The agreement outlines the legal rights and obligations of both the insurer and the insured. This includes the process for resolving disputes, the responsibilities of each party, and any regulatory requirements.

5.5 Types of Contract Violations

5.5.1 Denial ofValid Claims

The denial of valid claims by health insurance companies can be frustrating and confusing for policyholders. Despite having legitimate medical needs and coverage under their policy, individuals may encounter situations where their claims are denied by the insurer. Understanding why valid claims get denied and how to address such situations is crucial.

5.5.1.1 Reasons for Denial ofValid Claims

a. Administrative Errors: Sometimes, claims are denied due to administrative errors such as missing information, incorrect coding, or incomplete documentation. This can lead to automatic denials even for valid claims.
b. Coverage Limitations: Although a claim may seem valid, certain policy limitations or exclusions may apply. If a particular treatment or service is not covered under the policy, the claim will be denied.
c. Pre-Authorization Requirements: Some health plans require pre-authorization for specific treatments or procedures. If this step is skipped or not completed correctly, the claim may be denied.
d. Out-of-Network Providers: If a policyholder seeks care from a provider who is not in the insurer's network (unless it's an emergency), the claim may be denied or processed at a lower rate.
e. Billing Errors: Providers may bill for services incorrectly, leading to claim denials. This could include using incorrect procedure codes or charging for services that are not covered under the policy.
f Policy Lapses or Non-Payment: If premiums are not paid or if the policy has lapsed for any reason, claims submitted during this period may be denied.
g. Medical Necessity: Insurers may determine that a treatment or procedure is not medically necessary based on their guidelines, leading to claim denial.
h. Duplicate Claims: Submitting duplicate claims for the same service can result in denials. Insurers usually process only one valid claim per service.
i. Time Limit Exceeded: Some policies have time limits for submitting claims after receiving care. Claims submitted beyond this timeframe may be denied.

5.5.1.2 Remedy When the Denial ofValid Claim Arises

a. Review the Denial Letter: Insurers are required to provide a reason for denying a claim. Review the denial letter carefully to understand why Insured claim was denied.
b. Contact the Insurer: It suggests to contact the insurer's customer service or claims department for clarification. The insured can ask for details on the denial reason and the steps taken by the insurer to appeal the decision.
c. Gather Supporting Documentation: If the claim was denied due to missing information or administrative errors, gather any necessary documentation to support the validity of Insured claim.
d. File an Appeal: Most insurers have an appeals process for denied claims. Follow the instructions provided by Insured insurer to file an appeal. Include any additional information or documentation that supports the validity ofInsured claim.
e. Seek Assistance if Needed: If Insurer having trouble navigating the appeals process or feel overwhelmed, consider seeking assistance from a healthcare advocate, patient advocacy organization, or legal professional specializing in health insurance.
f Escalate if Necessary: If Insured appeal is denied at the insurer level, Insurer may have the option to escalate Insured case to a higher authority within the company or seek external review through a state insurance department or regulatory agency.

5.5.2 Delayed Claim Settlements

Delayed claim settlements refer to situations where insurance claims are not processed or paid within a reasonable timeframe, causing frustration and financial strain for policyholders. Several factors can contribute to delays in claim settlements, including:

1. Complexity of Claim: Claims that are complex or involve large sums of money may require more time for investigation and assessment. For example, claims involving multiple parties, extensive damage, or disputed liability can take longer to resolve.
2. Insufficient Documentation: If the required documentation is incomplete or missing, insurers may delay processing until all necessary information is provided. This could include proof ofloss, medical records, police reports, or repair estimates.
3. Investigations: Insurers often conduct investigations to verify the validity of claims. This can involve gathering evidence, interviewing witnesses, or consulting experts, which may extend the processing time.
4. Legal or Regulatory Issues: Certain claims may involve legal complexities or regulatory requirements that necessitate legal review or compliance checks, causing delays in settlement.
5. High Claim Volume: During peak periods such as after natural disasters, insurers may face a surge in claims volume, leading to processing delays due to resource constraints.
6. Disputes with Policyholders: Disagreements over coverage, liability, or the extent of damages can prolong the settlement process if negotiations are required between the insurer and the policyholder.
7. Understaffing or Inefficiencies: Inadequate staffing or inefficient claim processing systems within insurance companies can result in delays as claims may sit in queues awaiting attention.

The impact of delayed claim settlements can be significant for policyholders, leading to financial hardship, stress, and dissatisfaction. To address delays, policyholders can take proactive steps such as:

A. Regular Follow-Up: Stay in communication with the insurer to track the progress of the claim and provide any requested documentation immediately.
B. Understand Policy Coverage: Be aware of what Insured insurance policy covers and what information is needed for claims, ensuring Insurer submit complete and accurate documentation.
C. Escalate if Necessary: If delays persist despite regular follow-up, escalate the issue within the insurance company by speaking to supervisors or claims managers.

Seek Legal Advice: In cases of extended delays or disputes, seeking legal advice or assistance from consumer protection agencies may be necessary to resolve the issue.

5.5.3 Unfair Policy Terminations

Unfair policy terminations occur when insurance policies are cancelled by insurers in a manner that is deemed unjust or unreasonable. This can leave policyholders vulnerable and without coverage when they need it most.

1. Unjustified Cancellation: Insurers must have valid reasons for cancelling a policy. Terminations without proper cause or based on incorrect information can be considered unfair. Valid reasons for cancellation typically include non-payment of premiums, misrepresentation or fraud on the application, or significant changes in risk.
2. Non-Disclosure or Misrepresentation: Insurers may terminate policies if the policyholder fails to disclose important information or provides false information during the application process. However, terminations must be based on material misrepresentation that influences the insurer's decision to issue the policy.
3. Improper Notice: Insurance regulations often require insurers to provide adequate notice before cancelling a policy. Terminations without sufficient advance notice can be deemed unfair as they limit the policyholder's ability to find alternative coverage.
4. Discriminatory Practices: Cancelling policies based on discriminatory factors such as race, ethnicity, gender, or disability status is illegal and considered unfair.
5. Retaliation: Terminating policies in retaliation for a policyholder exercising their rights, such as filing a claim or complaint against the insurer, is considered unfair and may violate consumer protection laws.
6. Failure to follow Procedures: Insurers must adhere to specific procedures outlined in insurance contracts and regulations when cancelling policies. Failure to follow these procedures can result in unfair terminations.

To address unfair policy terminations, policyholders can take the following steps:

A. Review Policy and Correspondence: Understand the terms of the insurance policy and review any communications from the insurer regarding the termination.
B. Seek Clarification: If unsure about the reasons for the termination, contact the insurer directly to seek clarification and review the relevant policy provisions.
C. File a Complaint: Lodge a formal complaint with the insurer's customer service department or regulatory agency if the termination appears unjust or violates insurance regulations.
D. Consult Legal Advice: Consider seeking legal advice or assistance from consumer protection organizations or attorneys specializing in insurance law to explore options for challenging the termination.

Insurers, on the other hand, should ensure that policy terminations are conducted fairly and in accordance with applicable laws and regulations. This includes providing clear explanations for terminations, following proper procedures, and avoiding discriminatory or retaliatory practices. Insurers should also prioritize transparency and effective communication with policyholders to mitigate the risk of unfair policy terminations and maintain trust within the insurance marketplace

5.5.4 Misleading Policy Language

Misleading policy language in insurance refers to terms, clauses, or wording within insurance policies that could confuse or mislead policyholders about the coverage, exclusions, or conditions of their insurance contracts. This can lead to misunderstandings, disputes, and dissatisfaction among policyholders.

1. Ambiguous or Vague Terms: Insurance policies that contain ambiguous or vague language may be subject to different interpretations. This can create confusion about the extent of coverage or the applicability of certain exclusions.
2. Complex Legal Jargon: Insurance policies often use legal terminology that may not be easily understood by the average policyholder. This can make it challenging for individuals to grasp the precise meaning and implications of the policy terms.
3. Hidden Exclusions or Limitations: Some policies may bury important exclusions or limitations in fine print or use misleading language to downplay their significance. This can result in policyholders being unaware of key restrictions until they file a claim.
4. Inconsistent or Contradictory Statements: Policies that contain contradictory statements or provisions can lead to uncertainty about the actual coverage provided. This can arise when different sections of the policy appear to conflict with each other.
5. False Promises or Guarantees: Misleading policy language may include promises or guarantees of coverage that are not supported by the actual terms of the policy. This can give policyholders a false sense of security.
6. Unrealistic Expectations: Some policies may use language that creates unrealistic expectations about what is covered or the level of compensation provided in the event of a claim. This can lead to disappointment and frustration when claims are denied or underpaid.

To address misleading policy language and protect consumers, several measures can be taken: A. Consumer Education: Encourage insurers to use plain language and provide clear explanations of policy terms to help policyholders understand their coverage.

B. Regulatory Oversight: Regulators should monitor insurance policies to ensure they comply with consumer protection laws and do not contain misleading or deceptive language.
C. Transparency and Disclosure: Insurers should be transparent about policy terms, exclusions, and limitations upfront, making them easily accessible to policyholders.
D. Standardization of Term: Establish standardized terminology and formats for insurance policies to enhance clarity and consistency across the industry.
E. Legal Remedies: Provide avenues for policyholders to challenge misleading policy language through legal channels if necessary, such as consumer protection laws or insurance ombudsman services.

By addressing the misleading policy language is essential for promoting transparency, fairness, and trust in the insurance industry. Insurers have a responsibility to communicate policy terms clearly and accurately to ensure that policyholders have a clear understanding of their coverage and obligations.

5.6 Causes Of Contract Violations

Contract violations in health insurance often occur due to various reasons. Non-disclosure of material facts, such as pre-existing conditions, and delayed premium payments can lead to contract breaches. Misrepresentation of claims, whether intentional or accidental, is another major cause. Policy exclusions, such as filing claims for uncovered treatments, and seeking care from out-of-network providers can also result in violations. Failure to follow the correct claim process or obtain necessary authorizations for certain treatments may lead to claim denials. Insufficient coverage for necessary medical procedures and breaches by insurers, like unreasonable claim denials or delays, further exacerbate the issue. Additionally, non­compliance with changing regulations can impact both insurers and policyholders, causing contract disputes and potential violations.

5.6.1 By Policy Holders

Policyholders can violate their health insurance contracts in several ways, often unintentionally, but sometimes deliberately. Understanding these causes is important, as they can lead to the rejection of claims or even the cancellation of the insurance policy.

One of the most common causes is. failing to disclose important information when applying for the policy. This could include hiding pre-existing medical conditions or not mentioning certain lifestyle habits, like smoking. Insurance companies rely on this information to decide the terms of the policy and the premium amount. If a policyholder hides such details, it can be seen as a breach of trust and a violation of the contract.

Another major reason for contract violations is delayed or missed premium payments . Health insurance contracts require regular premium payments, and if these are not made on time, the policy can lapse. Once the policy lapses, the insurance company is no longer obligated to cover medical costs, leaving the policyholder without protection.

Providing false or misleading information when making a claim is another serious violation. For example, some policyholders might exaggerate medical expenses or try to claim for treatments they didn’t actually receive. This is considered fraud and can result in the denial of the claim and even legal consequences.

In many health insurance plans, policyholders are required to use specific doctors or hospitals, known as in-network providers . If a policyholder seeks treatment from an out-of-network provider without proper approval, it can result in a violation. Insurance companies may refuse to cover the costs of such treatments or only provide partial coverage.

There are also certain procedures and treatments that need prior approvalfrom the insurance company before they can be carried out. Failing to get this authorization can lead to claim rejections, as the insurer may argue that the treatment was unnecessary or not covered by the policy.

Policyholders sometimes claimfor treatments that are specifically excluded from their policy, such as cosmetic surgeries or alternative therapies. Filing such claims goes against the contract terms and can result in the denial of coverage for those treatments.

Another violation occurs when policyholders allow others to use their insurance card . For example, giving a family member or friend the card to get treatment is a form of fraud. Health insurance policies are individual contracts, meaning only the named policyholder is entitled to the coverage.

Lastly, some policies require the policyholder to provide updates on their health status if there are significant changes, like being diagnosed with a new illness. If the policyholder fails to inform the insurer about these changes, it could lead to a breach of the contract, especially if the new condition affects the insurance coverage or premium.

5.6.2 By Insurance Companies

5.6.2.1 Ambiguous Policy Terms and Conditions

Contract violations in health insurance due to ambiguous policy terms and conditions can create significant challenges for policyholders and insurers alike.

1. Ambiguous Policy Terms: Ambiguity in health insurance policies refers to language or provisions that are unclear, leading to different interpretations by insurers and policyholders. Ambiguity can arise due to vague wording, conflicting clauses, or undefined terms. Ambiguous terms can lead to disputes over what these obligations entail.

2. Contractual Obligations: Health insurance policies are contracts between the insurer and the policyholder. Both parties have obligations outlined in the contract.

Unclear or ambiguous language in policy documents can result in misunderstandings between the insurer and the insured. The Satwant Kaur Sandhu v. New India Assurance Co. Ltd.[84] demonstrates the significance of clear and unambiguous policy terms. It also demonstrates the different types of ambiguity.

• Coverage Scope: Ambiguities may arise regarding what services, treatments, or conditions are covered under the policy.
• Limits and Exclusions: Lack of clarity on coverage limits, exclusions, or exceptions can result in disputes over claim denials.
• Definitions: Undefined terms like "medically necessary" or "experimental treatment" can be sources of ambiguity.
• Claims Process: Unclear guidelines on claims submission, approval criteria, or reimbursement timelines can create confusion.

3. Contractviolations:

• Denial of Valid Claims: Ambiguous terms can lead to insurers denying claims that should be covered under the policy, resulting in contract violations.
• Breach of Good Faith: Insurers may be accused of acting in bad faith if they use ambiguity to unfairly deny claims or delay payments.
• Consumer Protection Laws: In some jurisdictions, ambiguity can be construed against the drafter of the contract (typically the insurer), leading to legal repercussions.

4. Impact on Policyholders :

• Financial Burden: Policyholders may face unexpected costs for medical treatments they believed were covered.
• Legal Disputes: Ambiguities can lead to costly legal battles between policyholders and insurers to resolve coverage disputes.
• Loss of Trust: Ambiguous policies erode trust between insurers and policyholders, damaging the insurer's reputation.

5. ResolutionandPrevention:

• Clear Communication: Insurers should strive for clear and transparent policy language, minimizing ambiguity.
• Regulatory Oversight: Government regulators can enforce standards for insurance policy clarity and intervene in cases of unfair claim denials.
• Consumer Education: Policyholders should be educated about policy terms and encouraged to seek clarification when unsure.

6. Legal Recourse:

• Litigation: Policyholders can seek legal recourse through litigation if they believe the insurer violated the contract due to ambiguous terms.
• Alternative Dispute Resolution: Mediation or arbitration can provide faster and less costly ways to resolve disputes compared to court proceedings.

5.6.2.2 Lack ofTransparency in Communication

Contract violations in health insurance due to a lack of transparency in communication can significantly impact policyholders and lead to disputes between insurers and insured individuals.

Transparent communication in health insurance is crucial for ensuring that policyholders fully understand their coverage, benefits, and obligations under the policy. It involves clear, honest, and accessible information provided by insurers to their customers.

1. Types of Communication Issues:

• Unclear Policy Terms: Policies may contain complex language orjargon that is difficult for policyholders to understand, leading to confusion about coverage details.
• Inadequate Disclosure: Insurers may not fully disclose important information about coverage limitations, exclusions, or changes to policy terms.
• Poor Customer Services: Lack of responsiveness, incomplete information from customer service representatives, or delays in addressing inquiries can hinder understanding.

2. Contract Violations:

• Misrepresentation: If insurers fail to disclose key terms accurately or clearly, policyholders may unknowingly purchase inadequate coverage.
• Claim Denials: Insufficient communication about coverage details can result in unjustified claim denials or delays, violating the terms of the insurance contract.
• Ineffective Dispute Resolution: Insufficient communication during the claims process or disputes can exacerbate conflicts and lead to breaches of contractual obligations.

3. Impact on Policyholders:

• Financial Loss: Policyholders may face unexpected out-of-pocket expenses due to denied claims or inadequate coverage, leading to financial hardship.
• Stress and Frustration: Lack of transparency can cause stress and frustration when dealing with insurance-related issues, especially during critical health situations.
• Loss of Trust: Poor communication erodes trust between insurers and policyholders, impacting the insurer's reputation and customer retention.
• Failure to act in good faith during the claims settlement process can lead to contract violations . Oriental Insurance Co. Ltd. v. Meena Variyal[85] the Supreme Court of India dealt with a motor accident claim where the deceased was driving the vehicle and an employee of the owner. The Court held that the insurance company was not liable to pay compensation as the insurance policy did not cover the employee driving the vehicle. This case clarified aspects of liability in motor accident claims involving employer-employee relationships and insurance coverage.

4. Prevention and Resolution:

• Clear Policy Documentation: Insurers should use plain language and provide concise, clear policy documents that outline coverage details, limitations, and exclusions.
• Education and Outreach: Proactive communication strategies, such as educational materials and seminars, can help policyholders better understand their coverage.
• Improved Customer Service: Insurers should invest in training staff to provide accurate, timely, and complete information to policyholders.
• Transparency in Claims Process: Insurers should communicate openly about claim procedures, timelines, and reasons for claim decisions.

5. Regulatory Measures:

• Consumer Protection Laws: Regulatory bodies may enforce transparency requirements on insurers to ensure fair and clear communication with policyholders.
• Compliance Monitoring: Regulators can monitor insurers' practices to ensure compliance with transparency standards and take enforcement actions against violators.

6. Legal Recourse:

• Contractual Disputes: Policyholders can pursue legal action against insurers for breach of contract if lack of transparency results in financial harm or unjust claim denials.

In United India Insurance Co. Ltd. v. R. Balakrishnan [86], the Supreme Court of India addressed the issue of liability in motor accident claims when the driver of the offending vehicle did not possess a valid driving license. The Court clarified that the insurance company is liable to pay compensation to the third-party victims even if the driver lacked a valid license. This liability is subject to the insurance company's right to recover the compensation amount from the vehicle owner if there was a breach of policy conditions. The ruling emphasizes the protection of third-party rights in motor accident cases.

5.6.2.3 Insufficient Consumer Awareness

Contract violations in health insurance often stem from insufficient consumer awareness about policy terms, coverage details, and rights as policyholders. This lack of awareness can lead to misunderstandings, disputes, and ultimately, breaches of the insurance contract

1. Understanding Insurance Policies:

• Complexity of Policies: Health insurance policies can be complex, with technical language and detailed provisions that may be challenging for consumers to fully comprehend.
• Coverage Details: Many consumers may not fully understand what is covered (or not covered) under their health insurance policy, including deductibles, co­payments, limitations, and exclusions.

2. Types of Consumer Awareness Issues:

• Policy Terms and Conditions: Consumers may not thoroughly read or understand the terms and conditions of their health insurance policy, leading to misconceptions about coverage.
• Coverage Limitations: Lack of awareness about coverage limitations and exclusions can result in unexpected out-of-pocket expenses when seeking medical services.
• Claims Process: Insufficient knowledge about the claims process, including required documentation, timelines, and procedures, can lead to delays or denials of legitimate claims.

3. Contract Violations:

• Unmet Expectations: When consumers have inaccurate expectations about coverage based on insufficient understanding, they may perceive legitimate claim denials as contract violations.
• Non-Disclosure of Information: Insurers may fail to adequately inform consumers about important policy details, which can lead to disputes over coverage and claims.
• Misrepresentation: Consumers may unintentionally misrepresent information on their applications due to misunderstanding policy requirements, leading to potential contract violations.

4. Impact on Policyholders:

• Financial Consequences: Insufficient awareness can result in unexpected medical expenses and financial strain when consumers realize they are responsible for costs not covered by their insurance.
• Frustration and Confusion: Consumers may feel frustrated and confused when dealing with claim denials or disputes due to misunderstandings about their coverage.
• Limited Options: Lack of awareness about alternative coverage options or rights as policyholders can limit consumers' ability to make informed decisions about their insurance needs.

5. Prevention and Education:

• Consumer Education Initiatives: Insurers, government agencies, and advocacy groups should prioritise consumer education programs to enhance awareness about health insurance policies, coverage details, and rights.
• Clear and Transparent Communication: Insurers should use plain language and provide easily accessible information about policy terms, coverage limitations, and claims processes.
• Empowering Consumers: Consumers should be encouraged to ask questions, seek clarification from insurers, and review policy documents thoroughly before purchasing or using health insurance.

6. Regulatory Measures:

• Regulatory Oversight: Government regulators can establish and enforce standards for transparent communication and consumer education in the insurance industry.
• Enforcement of Consumer Protection Laws: Regulators should actively enforce laws that protect consumers from unfair or deceptive practices related to health insurance.

7. Legal Recourse:

• Dispute Resolution: Consumers can seek legal assistance or mediation to resolve disputes with insurers over denied claims or alleged contract violations resulting from insufficient consumer awareness.

5.6.2.4 Ethical and Compliance Issues

Contract violations in health insurance with ethical and compliance issues can have significant implications for both insurers and insured individuals. Below is a detailed brief on this topic: 1. Contract Violations in Health Insurance:

Provider Network Issues:

• Out-of-Network Charges: Insurers may inadvertently or intentionally fail to cover services rendered by out-of-network providers, leading to unexpected costs for patients.
• Inadequate Network: Insurers may promise a certain network of providers but fail to maintain it adequately, leaving patients without access to necessary care.

2. Coverage Denials:

• Pre-existing Conditions: Denying coverage for pre-existing conditions without legaljustification.
• In Satwant Kaur Sandhu v. New India Assurance Co. Ltd.[87] , the Supreme Court ofIndia addressed the critical principle of uberrimaefidei (utmost good faith) in insurance contracts, holding that the non-disclosure of pre-existing conditions, such as chronic diabetes and renal failure in this case, constitutes material misrepresentation. This concealment allows the insurance company to rightfully repudiate the claim, as such information would have significantly influenced a prudent insurer's assessment and decision regarding the acceptance of the risk, thereby upholding the requirement of full and honest disclosure from the insured party.
• Experimental Treatments: Denial of coverage for treatments that are considered experimental or investigational, despite being medically necessary.
• Medically Necessary Services: Denial of services that are deemed medically necessary by healthcare providers.

3. Policy Misrepresentations:

• Ambiguous Policy Language: Insurers may use vague language in policies that mislead consumers about what is covered.
• False Advertising: Misleading marketing tactics that promise coverage which is not actually provided in the policy.
• Claim Processing Issues:

Unreasonable Delays: Deliberate delays in claims processing to avoid or limit insurers. Underpayment of Claims: Paying less than the owed amount for covered services.

4. Ethical and Compliance Issues:

• Informed Consent: Insurers must ensure that policyholders fully understand the terms of their coverage, including limitations and exclusions.
• Fairness and Non-Discrimination: Treating all policyholders fairly and equally, regardless ofhealth status, age, or other factors.
• Transparency: Providing clear and accurate information about coverage, costs, and network limitations.
• Conflicts of Interest: Avoiding situations where financial incentives conflict with the best interests of policyholders.
• Data Privacy and Security: Protecting sensitive personal and health information in accordance with legal requirements.

5. Consequences ofViolations:

• Legal Ramifications: Violations may lead to lawsuits, regulatory fines, or penalties.
• Reputational Damage: Loss of trust from policyholders and the public.
• Financial Impact: Increased costs due to litigation, fines, or corrective actions.

6. Mitigation Strategies:

• Enhance Transparency: Clearly communicate policy terms and coverage limitations.
• Improve Compliance Monitoring: Regularly review claims processes to ensure fairness and accuracy.
• Ethics Training: Educate staff on ethical practices and compliance requirements.
• Strengthen Oversight: Implement robust governance structures to prevent and address violations.

Contract violations in health insurance with ethical and compliance issues pose significant risks to insurers and can harm consumers. Implementing transparent practices, ensuring compliance with regulations, and upholding ethical standards are essential to maintaining trust and integrity in the health insurance industry. Insurers must prioritize fair treatment of policyholders and uphold their contractual obligations to avoid legal and reputational consequences.

5.7 Legal Framework and Regulations

5.7.1 Indian Contract Act and its Applicability

Health insurance contracts, which are legally binding agreements between insurers and policyholders, are governed by the Indian Contract Act, 1872. Section 73, which addresses damages or losses resulting from breach, and Section 10, which outlines the necessary components of a legally binding contract, are pertinent provisions. In order to ensure justice and openness, Sections 17 and 18 deal with fraud and misrepresentation. In order to ensure that health insurance operations are in line with legal principles, the Act's provisions are essential for resolving disputes, establishing liability, and defending consumer rights in the event that claims are denied or contracts are broken.

1. Section 10: Which Agreements Constitute Contracts

Section 10 delineates the prerequisites for a legitimate contract, asserting that an agreement must possess free consent, lawful consideration, and a lawful object to be enforced. In health insurance, the insurer and the insured must reach a mutual agreement on the terms and conditions, including premium, coverage, and exclusions. The absence of any of these essentials may render the health insurance contract unenforceable.

2. Section 13: Consent

Section 13 specifies Consent between the parties must be free and not obtained through misrepresentation, fraud, or coercion. In health insurance, any lack of free consent (e.g., when the policyholder is misled about the terms of the policy) may render the contract invalid.

3. Section 14: Free Consent

Section 14 pertains Consent is deemed "free" when it is not affected by coercion, undue influence, fraud, deception, or error. In the realm of health insurance, both the insurer and the insured must engage in the contract willingly and with a comprehensive comprehension of the terms.

4. Section 17: Fraud

Section 17 defines Fraud involves intentional deception to induce a party into entering a contract. In health insurance, policyholders may commit fraud by not disclosing pre-existing conditions or fabricating claims. Conversely, insurers may mislead customers by hiding exclusions or important clauses. Fraud by either party can lead to the voiding of the contract.

5. Section 18: Misrepresentation

Section 18 defines Misrepresentation occurs when a party provides false information without intent to deceive but still influences the other party’s decision. In health insurance, misrepresentations regarding medical history or policy terms can affect claim validity. For example, if the policyholder unintentionally provides incorrect information about their health, the insurer may deny the claim based on misrepresentation.

6. Section 19: Nullification of Agreements Lacking Free Consent

Section 19 stipulates that if assent is acquired through pressure, fraud, or misrepresentation, the contract is voidable at the discretion of the misled party. If an insurer issues a policy based on deceptive representations, the policyholder may choose to annul the contract.

7. Section 23: Lawful Consideration and Object

Section 23 defines The consideration (premium) and object (health coverage) of the health insurance contract must be lawful. Any insurance policy that violates the law or is created for illegal purposes, such as covering activities prohibited by law, would be considered void.

8. Section 25: An agreement lacking consideration is void unless it is documented in writing and registered, or is a promise to recompense for an action performed, or involves a promise to settle debt that is extinguished by the statute of limitations.

Section 25 stipulates that agreements lacking compensation, such as premium payments, are unlawful unless they satisfy specific exceptions. In health insurance, the insured is required to pay the premium to obtain coverage. A policy lacking consideration (premium) would be rendered void under the Indian Contract Act, 1872.

9. Section 56: Agreement to perform an impossible act

If an insurance provider agrees to cover an event that cannot occur (such as offering coverage after a person has been diagnosed with a terminal illness without prior notification), the contract may be rendered void under Section 56 of the Indian Contract Act, 1872. This section in health insurance pertains to instances where coverage is sought for excluded or unfeasible conditions .

10. Section 62: Implications of Novation, Rescission, and Modification of Contract Health insurance agreements may be amended with the mutual permission of both parties. Section 62 of the Indian Contract Act, 1872 addresses the impact of novation (substituting an existing contract with a new one), rescission (annulling the contract), or modification (modifying the conditions) on the enforceability of the contract.

11. Section 73: Remuneration for Loss or Damage Resulting from Breach of Contract If the insurer violates the contract by failing to provide coverage according to the policy conditions, the policyholder may pursue reimbursement under Section 73 of the Indian Contract Act, 1872. If a claim is unjustly denied or postponed, the insurer may be obligated to compensate the policyholder for the financial losses sustained.

12. Section 74: Compensation for Breach of Contract

Numerous insurance policies impose penalties or fees for tardy payments or cancellations. Section 74 of the Indian Contract Act, 1872, permits the insurance to recover fines in the event of a violation. Nonetheless, the penalty must be equitable and commensurate with the harm inflicted.

Health insurance contracts are regulated by the Indian Contract Act of 1872. Important clauses like Sections 73 and 10 deal with losses, damages, and the fundamentals of contracts. To maintain equity and openness, Sections 17 and 18 concentrate on fraud and deception. These clauses are essential for settling conflicts, determining culpability, and defending the rights of consumers in health insurance.

5.7.2 Consumer Protection Laws and Health Insurance

Health insurance is a crucial service, and like any other service, it is subject to consumer protection laws in India. These laws ensure that policyholders, as consumers, are treated fairly by insurance companies and have access to legal remedies in case of grievances. The Consumer Protection Act, 2019 is the main legislation governing consumer rights and their protection in India. It provides safeguards against unfair trade practices, defective services, and unethical practices by service providers, including health insurance companies.

1. Section 2(7): Definition of "Consumer"

According to this section, a "consumer" is any person who buys goods or avails of services for consideration. Health insurance policyholders clearly fall under this definition, as they pay premiums in exchange for health coverage services. Thus, policyholders are entitled to protections under this Act.

2. Section 2(42): Definition of "Service"

Health insurance is considered a "service" under this Act, meaning that insurance companies must provide services that are free from defects and ensure the fulfilment of promises made in the policy. This includes timely claim processing and transparent communication regarding the terms and conditions of the policy.

3. Section 2(47): Unfair Trade Practices

If a health insurance company engages in misleading advertising, provides incomplete or inaccurate information about the policy, or makes false promises regarding coverage, this can be classified as an unfair trade practice. Policyholders can file complaints if they feel they were misled when purchasing a policy or filing a claim.

4. Section 17: Jurisdiction of State Consumer Disputes Redressal Commission

For health insurance disputes where the claim amount is between ?20 lakhs and ?1 crore, the State Consumer Disputes Redressal Commission has jurisdiction. This is relevant for larger claims, such as those arising from costly medical procedures, where the policyholder can approach the state-level commission for resolution.

5. Section 21: Jurisdiction of the National Consumer Disputes Redressal Commission (NCDRC)

The NCDRC handles claims exceeding ?1 crore. This is important in cases involving high- value health insurance disputes, such as those involving extensive hospital stays, critical illnesses, or denial of coverage for expensive treatments.

6. Section 35: Filing of Complaint

A consumer, including a health insurance policyholder, can file a complaint against an insurance company for defects in services, unfair practices, or refusal to settle claims. The policyholder can also file a complaint if the insurer fails to provide proper redress for grievances related to denied or delayed claims.

7. Section 39: Reliefs that Can be Granted

This section outlines the types of reliefs a consumer court can provide to the aggrieved party. In health insurance cases, this may include directing the insurer to pay the claim amount, refund excess premiums, or pay compensation for harassment, delayed claims, or financial losses caused by the insurer’s actions.

8. Section 47: Penalties for Non-compliance of Orders

If the insurance company fails to comply with the orders issued by the consumer court, this section allows the court to impose penalties, including fines and imprisonment. This ensures that the insurer respects the court’s orders and provides proper relief to the policyholder.

Consumer protection regulations apply to health insurance in India. The 2019 Consumer Protection Act protects policyholders from deceptive business practices and subpar services. If a policyholder's dispute exceeds a certain amount, they can submit a complaint with the State orNational Consumer DisputesRedressal Commission.

5.7.3 The Insurance Act, 1938

The Insurance Act of 1938 is among the oldest comprehensive legislations regulating insurance in India. Although it encompasses all categories of insurance (life, general, and health insurance), several rules are directly related to health insurance.

1. Section 2D: Health Insurance Sector

Section 2(d) delineates the "Health Insurance Business" as the establishment of contracts that offer sickness benefits or cover medical, surgical, or hospital charges. It designates health insurance as an acknowledged sector of the insurance industry.

2. Section 40: Prohibition ofRebates

In health insurance, offering or accepting rebates is prohibited under section 40 . It ensures that all policyholders receive fair treatment without the insurer or agent offering a discount on premiums to attract customers illegally. This is important for maintaining ethical standards in the health insurance sector.

3. Section 45: Policy Not Subject to Challenge After Two Years

Section 45 safeguards policyholders' rights by stipulating that a health insurance policy cannot be contested on any grounds after two years from the issuance date. Nevertheless, the insurer has the right to contest claims upon the discovery of fraud or misrepresentation. This segment is essential in health insurance conflicts over postponed claims or undisclosed medical issues.

4. Section 64VB:No Risk Shall Be Incurred Unless Premium is Received Prior Section 64VB applies to health insurance as it mandates that the insurance company cannot take on any risk (coverage) until the policyholder has paid the premium in advance. This is an essential principle ensuring that health insurance coverage only begins after payment is made.

5. Section 42: Licensing of Insurance Agents

Licensing of agents selling health insurance policies falls under this section. Only certified agents are allowed to sell health insurance, ensuring that policyholders are dealing with authorized individuals who have a certain level ofknowledge about the product.

One important piece oflegislation controlling health insurance in India is the Insurance Act of 1938. It contains clauses that define the health insurance industry, forbid rebates, safeguard policyholders' rights, guarantee timely premium payments, and control the actions of agents. In the health insurance industry, these clauses are essential for upholding moral principles and safeguarding the interests of customers.

5.7.4 The Insurance (Amend) Act, 1973

The Insurance Act, 1973 primarily amends the earlier Insurance Act, 1938 and includes provisions specific to the control and regulation ofinsurance companies, especially in terms of transparency and policyholder protection. Some sections that impact health insurance are:

1. Section 27D: Prohibition ofLoans and Advances to Directors

Section 27D prohibits insurance companies, including those involved in health insurance, from giving loans or advances to their directors. This ensures that the funds of health insurance companies are not misused, which could affect their financial stability and ability to honour claims.

2. Section 40A: Limitation on Expenses ofManagement

Health insurance companies must limit their expenses on management, including commissions and other operational costs, to ensure that policyholders' premiums are being used efficiently. This helps in controlling the cost of health insurance premiums and protecting the financial interests of the insured.

3. Section 43: Power to Investigate

Section 43 allows regulatory authorities to investigate any health insurance company suspected of irregularities. This is crucial for safeguarding policyholders' interests if there are complaints about unfair practices, denial of claims, or financial instability within the company.

Section 64UC: Traffic Advisory Committee

The Tariff Advisory Committee regulates the rates of premiums for general insurance policies, including health insurance. This helps to standardize health insurance rates and prevents overcharging by insurance companies. Insurance firms, especially those that provide health insurance, are mostly governed by the Insurance Act of 1973. It guarantees financial stability, guards against financial mismanagement, restricts management costs, permits inquiries, and controls premium rates. These clauses protect the rights of policyholders and advance openness in the health insurance industry.

5.7.5 The Insurance Regulatory and Development Authority Act, 1999

The Insurance Regulatory and Development Authority (IRDA) Act of 1999 created the IRDA as the regulatory body for the insurance industry, including health insurance. The provisions ofhealth insurance are:

1. Section 2AA ofthe IRDA Act, 1999

The Authority shall prioritise the applicant's registration and provide a certificate of registration if the applicant consents, in the form and manner required by the Authority's rules, to engage in life insurance or general insurance business for the provision ofhealth coverage.

2. Section 14: Responsibilities, Authorities, and Functions of the Authority Section 14 empowers the IRDA to regulate, promote, and supervise the methodical advancement of the insurance sector. The IRDA establishes regulations in health insurance to protect policyholders' rights, regulate premium rates, and ensure that health insurance companies maintain solvency and transparency.

3. Section 25: Formation ofInsurance Advisory Committee.

The Authority may establish an Insurance Advisory Committee by issuing a notification. The Committee must consist of no more than 25 non-ex officio members representing diverse stakeholders, including commerce, industry, transport, agriculture, consumers, surveyors, agents, intermediaries, safety organisations, research institutes, and employee associations within the insurance sector. The Chairperson and members of the Authority shall automatically serve as the Chairperson and members of this Committee. The Committee's principal role is to counsel the Authority on formulating regulations in accordance with Section 26. The Committee may further provide the Authority with assistance on other pertinent matters as indicated.

4. Section 26: Power to make regulations

The Insurance Regulatory and Development Authority of India (IRDAI) may create an Insurance Advisory Committee to provide regulatory counsel. The Committee comprises representatives from many stakeholders in the insurance business. The IRDAI has the jurisdiction to formulate regulations that dictate the operations of the jurisdiction and the insurance industry. The Committee's suggestions are crucial for establishing these laws and ensuring a fair and transparent insurance market.

5.7.6 IRDA Regulation Concerning Health Insurance

The Insurance Regulatory and Development Authority (IRDAI) is essential for the effective operation and expansion of the health insurance sector, regulating and supervising health insurance businesses and intermediaries in India. Sector in India. It establishes protocols and laws to guarantee equitable procedures, safeguard consumers, and maintain the general stability of the insurance industry. It also fosters advancement and innovation within the industry to more effectively address the needs of policyholders. This regulatory structure sustains trust and confidence in health insurance products and services among consumers.

IRDA has introduced several regulations to ensure the smooth functioning ofhealth insurance in India.

1. IRDA (Health Regulation) Regulations, 2016

These regulations define key aspects of health insurance, such as product design, disclosures, portability, and claims procedures. It ensures that health insurance policies are consumer-friendly and offer transparency in terms of coverage, exclusions, and premiums.

2. IRDA Guidelines on Standardization in Health Insurance, 2013

These guidelines aim to standardize definitions, policy wordings, and claim procedures in health insurance policies, so that policyholders have a clear understanding of what their health insurance covers. For example, terms like "pre-existing diseases," "hospitalization," and "critical illness" have been standardized to avoid confusion.

3. IRDA (Protection ofPolicyholder’s Interest ) Regulations, 2017

These regulations aim to safeguard policyholders against inequitable practices by health insurance providers, guarantee prompt claims payment, provide adequate disclosure of terms and conditions, and establish user-friendly grievance resolution processes.

4. Resolution of claims pursuant to IRDAI Regulations, 2017

Regulations of 2017 In accordance with regulation 14 (2)(i) of the IRDAI (Policy holder's Interest) Regulations of 2017,, an insurer must resolve a claim within thirty days after obtaining all necessary papers, including any requested clarifications. The insurance company may adopt a policy to expedite claim payments. If the claim necessitates further investigation, the insurer must finalise its procedures promptly, but no later than 90 days after receiving the claim notification, and the claim must be resolved within 30 days. In India, the IRDAI is pivotal to the regulation of the health insurance industry. To ensure equitable procedures, consumer protection, and transparency, regulations have been established. These regulations pertain to grievance resolution, claim adjudication, and product development. The efforts of IRDAI contribute to sustaining a resilient and transparent health insurance industry in India.

5.7.7 The Employees State Insurance Act, 1948

The Employees State Insurance Act, 1948 provides health insurance to workers in India. One important piece ofIndian legislation that offers workers full social security benefits, including health insurance coverage, is the Employees' State Insurance (ESI) Act, 1948.

1. Section 46: Benefits Provided to Insured Persons

Section 46 stipulates medical benefits, sickness benefits, and maternity benefits for covered employees. The ESI Act provides health insurance for workers and their families, guaranteeing access to healthcare services like as hospitalisation, expert consultations, and diagnostic tests.

2. Section 56: Medical Benefit Council

Section 56 establishes the Medical Benefit Council, which advises the ESI Corporation on the quality of healthcare services provided under the scheme. It ensures that insured workers receive appropriate and timely medical care.

For employees and their families, the ESI Act guarantees full healthcare coverage, which includes diagnostics, hospital stays, and consultations with specialists. In order to guarantee that insured employees receive prompt and appropriate medical treatment, the Medical Benefit Council monitors the caliber of healthcare services rendered.

5.7.8 The Workmen’s Compensation Act. 1923

The Workmen’s Compensation Act, 1923 deals with compensation for injury or illness arising out of employment. While it is not health insurance per se, it provides workers with financial compensation in case of workplace-related injuries or diseases.

1. Section 3: Employer’s Liability for Compensation

This clause holds the employer accountable for compensating any damage or sickness incurred by the worker while engaged in working activities. This is not a health insurance program; nonetheless, it indirectly safeguards workers' health by offering reimbursement for medical costs and income loss resulting from injuries.

2. Section 4: Amount of Compensation

This section specifies the amount of compensation that must be provided in case of disability or death due to injury at work, covering medical costs and future income loss. Although it is not a direct health insurance program, the Workmen's Compensation Act of 1923 indirectly improves worker well-being by offering monetary compensation for illnesses or injuries sustained on the job. This promotes worker health and safety by guaranteeing that employees may obtain medical care and minimizing financial damages.

5.7.9 The General Insurance (Nationalization) , 1972

The General Insurance (Nationalization) Act, 1972 nationalized general insurance businesses, which include health insurance.

1. Section 10: Control of General Insurance Business

Section 10 gives the government the power to manage and control general insurance businesses, including health insurance. It ensures that health insurance schemes, especially public ones, operate in the best interest of policyholders.

2. Section 11: Powers of General Insurers

Section 11 outlines the powers of general insurance companies in managing their business, which includes offering health insurance products. It provides them the authority to develop and offer health insurance policies to the public under regulated conditions.

The General Insurance Business (Nationalisation) Act of 1972 subjected health insurance and other general insurance firms to government oversight. This provides a structure for the development and dissemination ofhealth insurance products, ensuring that health insurance operates in the optimal interests of policyholders.

5.7.10 The Public Liability Insurance Act,1991

The Public Liability Insurance Act,1991 is primarily meant for compensating victims of accidents or hazardous incidents. Although not directly related to health insurance, it covers some aspects ofhealth coverage in the event of public accidents.

1. Section 3: Liability to Give Relief

Section 3 mandates that in case of an accident involving hazardous substances, the owner of the enterprise must provide immediate relief, which may include covering medical expenses for injuries suffered. While not traditional health insurance, it ensures immediate financial aid for medical treatment.

2. Section 4: Duty to Take Insurance

Section 4 requires companies handling hazardous materials to take out insurance policies that cover medical and other liabilities in case of accidents. This section is relevant to public health protection by ensuring that industries are financially capable of compensating individuals affected by accidents.

By guaranteeing prompt financial assistance for medical bills in the event of incidents involving hazardous materials, the Public Liability Insurance Act of 1991 indirectly supports health care. By guaranteeing monetary compensation for impacted parties, it also requires insurance policies to pay liabilities resulting from such accidents, safeguarding the public's health.

5.8 Impact On Policyholders

The landscape of health insurance policyholders can be greatly influenced by various factors ranging from legislative changes to shifts in market dynamics. One significant aspect that impacts policyholders is the regulatory environment. Changes in healthcare laws, such as modifications to the affordable care act or new regulations governing insurance practices, can directly affect the coverage options available to policyholders. For instance, alterations in pre­existing condition protections or essential health benefits could influence the comprehensiveness and affordability of insurance plans.

Moreover, fluctuations in premium costs can profoundly impact policyholders' financial well­being. Rising premiums may strain household budgets, forcing individuals to make difficult decisions about their healthcare coverage. Conversely, decreases in premiums could alleviate financial burdens and make health insurance more accessible to a broader population. Policyholders closely monitor premium trends and seek out affordable options that provide adequate coverage for their healthcare needs.

Beyond premium costs, changes in coverage options and benefits can also affect policyholders' experiences. Insurance companies may adjust their plan offerings, such as introducing new types of plans or modifying existing ones, to adapt to market demands or regulatory requirements. These changes can lead to shifts in the availability of certain benefits, networks ofhealthcare providers, or out-of-pocket expenses for policyholders.

Furthermore, advancements in healthcare technology and treatment modalities can impact health insurance policyholders by influencing coverage decisions and reimbursement policies. Innovations such as telemedicine, personalized medicine, and new pharmaceutical treatments may offer opportunities for improved care but may also present challenges in terms of coverage and affordability. Policyholders may need to navigate complex coverage determinations and advocate for access to emerging treatments and services.

The evolving landscape of healthcare delivery, including changes in provider networks and care delivery models, can also have implications for health insurance policyholders. Network changes may affect access to preferred healthcare providers and facilities, potentially requiring policyholders to reassess their coverage choices and healthcare utilisation patterns. Additionally, shifts towards value-based care and alternative payment models may impact the quality and cost-effectiveness of care received by policyholders

5.8. Financial Strain Due to Denied Claims

Financial strain due to denied insurance claims is a significant concern for health insurance policyholders, often leading to unexpected out-of-pocket expenses and challenges in accessing necessary healthcare services. When insurance claims are denied, policyholders are typically responsible for covering the full cost of medical treatment, which can result in financial hardship and stress. Denied claims can stem from various reasons, including errors in documentation, lack of pre-authorization, or disputes over coverage eligibility.

One of the primary consequences of denied claims is the financial burden placed on policyholders. Without insurance coverage for medical expenses, individuals may struggle to afford essential healthcare services, leading to delayed or forgone treatments. This can have serious implications for health outcomes, as untreated medical conditions may worsen over time, resulting in more significant health problems and higher costs down the line.

Denied insurance claims can also erode trust and satisfaction in the insurance system. Policyholders may feel frustrated and disillusioned when their claims are denied, especially if they believe they have followed all the necessary procedures and requirements. This lack of trust can impact the perceived value of health insurance and may lead individuals to question the reliability and fairness of insurance coverage.

Moreover, the appeals process for denied claims can be time-consuming and complex, further exacerbating financial strain for policyholders. Navigating the appeals process often requires significant time and effort to gather supporting documentation, communicate with healthcare providers and insurers, and follow specific procedures outlined by the insurance company. During this period, policyholders may continue to face mounting medical bills and uncertainty about coverage, adding to their financial stress.

Denied insurance claims can also have broader societal implications, contributing to disparities in healthcare access and exacerbating financial inequality. Policyholders who lack the resources or knowledge to appeal denied claims effectively may be disproportionately impacted, further widening existing gaps in healthcare outcomes. Additionally, the financial strain experienced by individuals and families due to denied claims can have ripple effects on economic stability and well-being, affecting overall health and quality oflife.

5.8.1 Loss of Trust in Health Insurance Providers

The loss of trust in health insurance providers is a consequence of various factors that can erode policyholders' confidence in the reliability, transparency, and fairness of insurance coverage. One significant contributor to this loss of trust is the experience of denied or delayed claims. When policyholders encounter obstacles in accessing the coverage they believe they are entitled to, whether due to denied claims, unexpected out-of-pocket expenses, or complex billing processes, it can lead to feelings of frustration, disillusionment, and mistrust.

In addition to denied claims, opaque and confusing insurance policies and practices can further undermine trust in health insurance providers. Policyholders may struggle to understand their coverage options, benefits, and cost-sharing requirements, leading to confusion and uncertainty about what is covered under their insurance plan. This lack of clarity can create a sense of vulnerability and suspicion, as policyholders may fear hidden costs or unexpected coverage limitations.

Moreover, perceived disparities in treatment and outcomes among policyholders can contribute to a loss of trust in health insurance providers. When individuals perceive that certain groups receive preferential treatment or better access to healthcare services, while others face barriers or discrimination, it can undermine confidence in the fairness and impartiality of the insurance system. This can be particularly pronounced in cases where marginalised or vulnerable populations experience disparities in healthcare access and outcomes.

Furthermore, frequent changes in insurance policies, networks, and coverage options can contribute to uncertainty and instability for policyholders, further eroding trust in health insurance providers. Policyholders may feel frustrated by disruptions in their coverage, such as changes in network providers or formulary restrictions, which can impact their ability to access preferred healthcare services and treatments. These fluctuations can foster a sense of insecurity and skepticism about the reliability of insurance coverage.

The prevalence of administrative errors and inefficiencies in the claims process can also undermine trust in health insurance providers. Policyholders may encounter difficulties in resolving billing disputes, receiving timely reimbursement for covered services, or accessing accurate information about their coverage. These administrative challenges can lead to feelings of frustration and distrust, as policyholders question the competence and integrity of the insurance company in managing their healthcare needs.

Lastly, public perception of health insurance providers can be influenced by broader societal factors, such as media coverage of insurance industry practices, regulatory enforcement actions, or public scandals involving insurers. Negative publicity or high-profile cases of misconduct can fuel skepticism and cynicism among policyholders, reinforcing perceptions of insurance companies as profit-driven entities prioritizing shareholder interests over the well-being of policyholders

5.8.2 Legal and Emotional Consequences

Legal and emotional consequences can arise for health insurance policyholders when they face challenges such as denied claims, disputes over coverage, or inadequate access to healthcare services. From a legal perspective, policyholders may experience frustration and stress when navigating the complex landscape of insurance regulations, contract terms, and appeals processes. Denied claims, in particular, can lead to legal disputes between policyholders and insurance companies, as individuals seek to enforce their rights under their insurance policies and pursue remedies for coverage denials.

One significant legal consequence of denied claims is the potential for policyholders to pursue legal action against their insurance providers. This may involve filing formal appeals, engaging in mediation or arbitration, or even initiating lawsuits to challenge coverage denials or seek compensation for damages resulting from delayed or denied claims.

Furthermore, disputes over coverage and denied claims can strain the relationship between policyholders and healthcare providers, leading to tensions and disagreements over treatment decisions, billing practices, and reimbursement issues. Policyholders may feel caught in the middle of disputes between their healthcare providers and insurance companies, exacerbating feelings of frustration and helplessness. In some cases, policyholders may be forced to choose between pursuing necessary medical treatments and risking financial hardship due to coverage denials or limitations imposed by their insurance plans.

From an emotional standpoint, the consequences of denied claims and coverage disputes can be profound for health insurance policyholders. Dealing with the uncertainty and stress of navigating the insurance claims process, facing unexpected out-of-pocket expenses, and grappling with the prospect of denied coverage can take a significant toll on individuals' mental and emotional well-being. Policyholders may experience feelings of anxiety, anger, sadness, or helplessness as they struggle to obtain the healthcare services they need while grappling with financial and legal challenges.

Moreover, the emotional impact of denied claims can extend beyond the immediate circumstances of the coverage dispute, affecting policyholders' overall trust and confidence in the healthcare system. Experiences of denied claims or disputes with insurance providers can shake individuals' faith in the fairness, reliability, and accessibility of healthcare coverage, leading to feelings of disillusionment and mistrust. This loss of trust can have long-term consequences for individuals' willingness to seek medical care, adhere to treatment plans, or engage with the healthcare system more broadly.

In addition to the legal and emotional consequences for individual policyholders, denied claims and coverage disputes can also have broader societal implications, contributing to disparities in healthcare access and outcomes. Policyholders who lack the resources or knowledge to navigate the insurance appeals process effectively may be disproportionately impacted, further exacerbating existing inequities in healthcare access and quality. Addressing the legal and emotional consequences of denied claims requires efforts to improve transparency, accountability, and accessibility within the healthcare and insurance systems, as well as support mechanisms to assist policyholders in navigating the complex landscape ofinsurance coverage and disputes.

5.9 Resolution Mechanisms

In India, insurance is provided as an indemnity agreement between the insurer and the policyholder. The majority of insurance disputes are primarily civil; nevertheless, they may sometimes have a criminal dimension owing to their emphasis on contractual terms and interpretation, as well as the extent of coverage. Insurance functions as a societal mechanism that works in conjunction with other social structures to alleviate the financial risks linked to the loss of life or property. This instrument consolidates a sufficient number of exposure units to predict the total losses they may sustain. By consenting to remit periodical payments, the insured person incurs a little financial loss to protect against the potential of a significant, unforeseen financial detriment arising from designated uncertain occurrences. This structure guarantees the possibility of recuperating from such losses.

This technique is regarded as an essential element of efficient financial planning and risk management. India has one of the lowest worldwide insurance penetration rates, with over 80% of the population without life insurance coverage. The health insurance industry in India, crucial for the welfare of its population, often encounters problems stemming from claim rejections, policy misinterpretations, and service delays. The legal structure regulating these issues is complex, supported by many rules and statutes, and the incorporation of effective dispute resolution systems is essential for preserving the sector's integrity and reliability.

“Section 2 (6C) of the Insurance Act, 1938 delineates "health insurance business" as the establishment of contracts that provide benefits for illness, alongside covering for medical, surgical, or hospital charges, applicable to both in-patient and out-patient care, inclusive of travel and personal accident insurance. All life, general, and health insurance companies licensed with the IRDAI provide health insurance coverage. General and Health Insurance Companies provide both indemnity-based and benefit-based health insurance policies, whereas Life Insurance Companies exclusively offer benefit-based plans in accordance with current Health Insurance Regulations. All General and Health Insurance Companies provide Personal Accident Policies, Domestic Travel Policies, and Overseas Travel Policies.”

Legal Framework Governing Health Insurance in India

The regulatory framework for health insurance in India is primarily overseen by the Insurance Regulatory and Development Authority of India (IRDAI). The IRDAI is tasked with protecting policyholder interests and promoting the organised development of the insurance industry. Health insurance plans are governed by the Indian Contract Act, 1872, which delineates the principles of contracts and the responsibilities of insurers and insured individuals.

Common Disputes and Legal Provisions

Disputes in the health insurance sector usually revolve around claim rejections, partial settlements, discrepancies in terms and conditions, and the applicability of exclusions within the policies. Such conflicts can escalate due to the ambiguous language of policy documents or differing interpretations of policy clauses by insurers and insured.

To combat these issues, Indian law provides several avenues for dispute resolution:

1. The Consumer Protection Act, 1986/2019: This statute enables consumers to file grievances against insurers in consumer courts at the district, state, and national levels, depending on the claim amount. The Consumer Protection Act is crucial for addressing grievances related to product defects, service inadequacies, and unjust commercial practices.
2. Insurance Ombudsman: Established by the Government ofIndia, the Ombudsman system offers a free and effective platform for policyholders to resolve grievances about services provided by insurers. The Ombudsman's authority include mediation and the provision of recommendations or rewards based on the merits of the case.
3. Judicial Litigation: The courts can be approached as a last resort when other mechanisms fail. Disputes that involve complex legal questions or significant claim amounts often end up in litigation.

Alternative resolution mechanism:

The employment of dispute resolution techniques has yielded numerous favourable results. Alternative Dispute Resolution (ADR) serves as a means to resolve conflicts or issues without resorting to the lengthy and intricate litigation process. ADR takes various forms such as mediation, arbitration, conciliation, negotiation, and collaborative law, enabling parties to settle disputes outside the traditional legal framework.

Recognizing the need for more specialized and expedient resolution mechanisms, there is a growing push towards integrating Alternative Dispute Resolution (ADR) techniques such as arbitration, mediation, and conciliation in the health insurance sector. The advantages of ADR include confidentiality, speed, reduced costs, and potentially preserving a positive relationship between the insurer and the insured.

1) Arbitration: The Arbitration and Conciliation Act, 1996, which governs arbitration proceedings, can be utilized if the insurance policy includes an arbitration clause. However, the enforceability of mandatory arbitration clauses in insurance contracts is often subjecttojudicial scrutiny.
2) Mediation and Conciliation: These methods are less formal and allow for more creative solutions, tailored to the specifics of the insurance dispute. They can be facilitated through the establishment of mediation cells by IRDAI or as part of the judicial process.

The main objective of using these tools is to circumvent the lengthy and onerous litigation procedure. In India, Alternative Dispute Resolution (ADR) has been acknowledged as one of the most efficacious means for settling conflicts. In light of the persistent epidemic, an escalation in economic conflicts is probable, which might be effectively addressed via ADR processes in India. Alternative Dispute Resolution (ADR) offers an effective method for resolving conflicts outside the conventional and sometimes arduous litigation procedure. Alternative Dispute settlement (ADR) is executed using many modalities, including arbitration, mediation, conciliation, negotiation, and collaborative law, therefore optimising the settlement process within the legal framework. The pandemic has enhanced the significance and potential of the ADR mechanism, providing an opportunity to examine its comprehensive capabilities and scrutinise its constraints. ADR facilitates expedited conflict settlement, hence alleviating the strain on India's judicial system. By expediting conflict resolution, ADR guarantees the prompt delivery ofjustice, upholding the maxim that "justice delayed isjustice denied." A more concentrated strategy for conflict resolution is, hence, required.

The Indian healthcare industry is increasingly compelled to include Alternative Dispute Resolution (ADR) methods owing to a notable surge in medical litigation, as shown by a recent study conducted by the National Law School of India University (NLSIU). This research indicated a 400% rise in medical lawsuits, mostly due to heightened consumer knowledge. The persistent epidemic indicates that this tendency will likely persist, highlighting the need for the prompt and successful implementation of Alternative Dispute Resolution (ADR) to resolve medical disagreements. Numerous healthcare providers are already contemplating the incorporation of pre-conflict alternative dispute resolution provisions in their admission agreements. These provisions often include negotiation, mediation, or arbitration, indicating a transition from conventional litigation to alternative dispute resolution (ADR) owing to the intricate and specialised nature of healthcare conflicts. Such conflicts often include matters such as incorrect treatment, medical malpractice, and violation of trust and confidence, necessitating representatives with specialised experience in the medical domain. In India, organisations like the Medical Council of India and the Indian Medical Association function as dispute resolution authority, offering panels of seasoned specialists to assist in the ADR process. This method differs from those of other nations where specialised professional groups manage conflict settlement in healthcare.

To further promote ADR in healthcare, it is crucial to incorporate specific clauses and provisions into agreements between healthcare providers and patients at the time of admission. These should mandate the use of negotiation, mediation, or arbitration in the event of a dispute. Furthermore, the ADR procedures should be governed by principles that are reasonable, equitable, and uphold the integrity of all parties involved, ensuring that resolutions are achieved fairly and expeditiously. The health insurance industry is essential for facilitating access to healthcare services for people and families globally. However, like any complex industry, disputes can arise between policyholders, healthcare providers, and insurance companies. Effectively resolving these disputes is essential for maintaining trust, ensuring fairness, and upholding the integrity of the health insurance system.

5.9.1 Dispute Resolution Process

In the increasingly complex world of healthcare, disputes between policyholders and health insurance providers are commonplace. These conflicts often arise over claim denials, coverage disputes, and misunderstandings regarding policy terms. Traditional litigation has long been the recourse for such disputes, but the growing use of Alternative Dispute Resolution mechanisms presents a more efficient and less adversarial solution. This essay explores the role of ADR in resolving health insurance disputes, examining its benefits, challenges, and potential improvements.

The Need for ADR in Health Insurance

The health insurance sector involves multiple stakeholders including insurance companies, policyholders, healthcare providers, and regulatory bodies. The relationships among these parties are governed by complex contracts and regulations, which can lead to disputes that are not only financially but also emotionally draining. Litigation, while comprehensive, is costly, time-consuming, and can strain relationships.

Forms of ADR in Health Insurance

To address disputes effectively, the health insurance sector employs various mechanisms of dispute resolution. These include internal grievance procedures, external review processes, mediation, arbitration, and litigation. Internal grievance procedures allow policyholders to escalate their complaints within the insurance company, seeking resolution through administrative channels.

External review processes, mandated by regulatory authorities, provide an independent evaluation of disputed claims to ensure compliance with contractual obligations and regulatory standards. Mediation and arbitration offer alternative methods of resolving disputes outside the courtroom, emphasizing negotiation and consensus-building to reach mutually acceptable outcomes. However, litigation remains a last resort for parties unable to resolve their disputes through other means, involving formal legal proceedings in a court oflaw.

The main methods of alternative dispute resolution (ADR) used in health insurance conflicts include mediation, arbitration, and negotiation.

l.Mediation entails a neutral third party facilitating communication between conflicting parties to assist them in achieving a consensual agreement. It is non-binding, maintaining connections and allowing adaptable solutions customised to the requirements of both parties. 2. Arbitration: This process is more formal than mediation and includes one or more arbitrators who evaluate both parties' arguments and provide a ruling that is typically binding. It is more expedient and less formal thanjudicial processes, making it a compelling choice for many.

3. Negotiation: This is the most direct method of Alternative Dispute Resolution (ADR), when parties engage in direct dialogue to address their concerns and strive to achieve a consensus without third-party intervention.

Benefits of ADR in the Health Insurance Sector

The primary benefit of ADR is its efficiency. Resolving disputes through ADR can be significantly faster than going through court proceedings, which is crucial in health-related matters where time can be of the essence. Additionally, ADR is cost-effective, reducing legal fees and other costs associated with court cases. Another significant advantage is the preservation of relationships. ADR, particularly mediation, is designed to be collaborative rather than adversarial, helping maintain or even strengthen business relationships between insurance providers and policyholders. Furthermore, ADR offers privacy, as proceedings are generally confidential, unlike court cases which are public.

Challenges

Despite its advantages, ADR is not without challenges. One major concern is the potential imbalance of power in some negotiations, where insurance companies might have more resources and better legal counsel compared to an individual policyholder. Ensuring fairness and the absence of coercion is critical. There is also the issue of awareness and accessibility. Many policyholders may not be aware of ADR options or understand how to initiate the process. There is a need for increased education and accessibility to ensure that all parties know their rights and the mechanisms available to them.

Conflicts in the health insurance business may originate from several factors, such as rejected claims, coverage disagreements, billing inaccuracies, and the interpretation of policy provisions. A major difficulty is the information gap between policyholders and insurance firms, sometimes resulting in misunderstandings or disputes over coverage and payment. Moreover, the complexity of healthcare services and insurance policies can further complicate dispute resolution processes, requiring specialized knowledge and expertise.

Implementing effective dispute resolution mechanisms in the health insurance sector faces challenges such as lack of awareness among consumers their legal rights, the complexity of insurance documents, and the perceived bias of certain ADR mechanisms towards insurers.

To enhance the efficacy of dispute resolution in health insurance, it is essential to:

• Increase transparency and simplify the language of health insurance policies.
• Strengthen the regulatory framework to ensure that both ADR proceedings and consumer court verdicts are implemented effectively.
• Promote awareness campaigns to educate consumers about their rights and the available channels for dispute resolution.

5.9.2 Mediation and Arbitration in Claim Disputes

Arbitration

Arbitration is essential in adjudicating health insurance claims disputes in India, providing a more efficient and cost-effective alternative to conventional litigation. In the realm of health insurance, arbitration serves as a method for settling disputes between policyholders and insurers outside the conventionaljudicial system. An examination of the function of arbitration in health insurance claims disputes in India:

• Voluntary Agreement:

Arbitration in health insurance claims disputes typically occurs when both parties, the policyholder, and the insurance company, voluntarily agree to resolve their differences through arbitration. This agreement may be included in the insurance policy itself or agreed upon after a dispute arises.

Arbitration Clause:

Many health insurance policies include an arbitration clause, which stipulates that any disputes arising from the policy will be resolved through arbitration rather than litigation. These clauses are often enforceable under Indian law, provided they meet certain legal requirements.

• Independence and Neutrality:

Arbitration provides a degree of independence and impartiality advantageous for settling complex health insurance issues. Arbitrators are often selected by both parties or designated by a mutually accepted body, guaranteeing that the adjudicators are unbiased and possess experience in insurance issues.

• Speed and Efficiency:

Arbitration processes in health insurance claims disputes may be swifter and more efficient than conventional court litigation. The arbitration procedure facilitates more adaptable scheduling and often entails less procedural formalities, resulting in expedited conflict resolution.

• Confidentiality:

Arbitration proceedings are generally private and confidential, offering both parties a level of discretion that may not be available in open court proceedings. This confidentiality can be particularly valuable in health insurance disputes, where sensitive medical and financial information may be involved.

• Expertise and Specialization:

Arbitration allows parties to choose arbitrators who are well-versed in health insurance law and practice, ensuring that disputes are resolved by someone knowledgeable about the complexities of the sector. This specialism may provide more informed and nuanced judgements.

• Enforceability of Awards:

Arbitration awards in health insurance claims disputes are generally enforceable under Indian law, providing parties with a legally binding resolution to their dispute. This enforceability adds certainty and finality to the arbitration process.

Role of Arbitration in Health Insurance Claims Disputes in India

Arbitration has progressively emerged as a favoured method for dispute resolution across multiple sectors, including health insurance. In India, arbitration's function in health insurance claims disputes is influenced by the overarching legal framework and the particular characteristics of the insurance sector. This essay examines the application of arbitration in health insurance claims disputes in India, its advantages, and the obstacles it encounters.

Legal Framework for Arbitration in Health Insurance

The primary legislation governing arbitration in India is the Arbitration and Conciliation Act, 1996, which provides a thorough procedural framework for both domestic and international arbitration. The Insurance Regulatory and Development Authority ofIndia (IRDAI) mandates that health insurance agreements have clear and transparent terms and conditions, include clauses for dispute settlement. Nonetheless, it is crucial to acknowledge that the incorporation of arbitration clauses in health insurance contracts is less prevalent in India compared to certain other jurisdictions. The conventional methods for resolving issues in health insurance have included the Insurance Ombudsman, consumer courts created under the Consumer Protection Act, 2019, and civil litigation. However, there are situations in which arbitration may be utilised, particularly in conflicts involving substantial claims or intricate matters necessitating specialised expertise.

Advantages of Arbitration in Health Insurance Disputes

Expertise: Arbitration allows for the appointment of arbitrators who have specific expertise in health insurance, which is beneficial for technical disputes that require specialized knowledge. Efficiency: Arbitration procedures can be faster than traditional court proceedings, which is crucial in health insurance disputes where timely resolution can be critical for the claimant’s health and financial well-being.

Confidentiality: Unlike court proceedings, which are public, arbitration offers confidentiality. This is particularly important in health insurance disputes where sensitive medical and personal information is discussed.

Flexibility: Parties in arbitration can have more control over the process, including choosing arbitrators and setting timelines, which can lead to more satisfactory dispute resolution.

Enforceability: Awards from arbitration are generally final and binding, and under the Arbitration and Conciliation Act, they are enforceable as same as the court judgment.

Challenges and Considerations

Awareness and Acceptance: There is a lack of awareness among policyholders and sometimes even among insurers about the benefits of arbitration. Moreover, insurers and policyholders may prefer more familiar routes like litigation or ombudsman processes.

Cost: Arbitration can be expensive, especially if the disputes involve high stakes and require expert arbitrators.

Arbitration Clause Validity: The enforceability of arbitration clauses in insurance contracts can be contested in courts, particularly if they are perceived to be unfairly imposed on the consumer or if they contravene specific provisions of consumer protection laws.

Mixed Experience with Arbitrators: The lack of a standardised approach to selecting arbitrators who specialize in insurance disputes can lead to inconsistencies in the quality of arbitration and the decisions rendered. Arbitration plays a crucial role in resolving health insurance claims disputes in India by offering a voluntary, efficient, and confidential alternative to traditional litigation. By providing parties with a forum to resolve their differences outside of the courtroom, arbitration promotes fairness, expediency, and expertise in the resolution of complex health insurance disputes.⁸⁴, ⁸⁵, ⁸⁶, ⁸⁷

Insurance arbitrations are commercial in nature and typically involve large insurance companies as one of the parties. These companies expect the proceedings to be resolved swiftly and place a high emphasis on maintaining confidentiality as a fundamental aspect of the process. “The commercial nature of the insurance agreement is also enumerated by the Supreme Court of India in the case of Vikram Greentech India Ltd, rs. New India Assurance Company Ltd.^[88] In India insurance cases are increasing continuously and an arbitration clause paves a way to the alternative method other than the courts. A specific feature of insurance law is that an insurance policy or deed which is issued confirming the agreement is an evidence of the existence of the agreement unlike the other where the registered agreement itself is evidence.” Advantages of the Arbitration Clause in Insurance

“Disputes Discussing thejudges most applied principle in the insurance cases, the principle of contra proferentem , derived from insurance contracts, says that if the term of a contract can be interpreted in more than one way, the Court will prefer the interpretation that is more favourable to the party that did not write the contract in other words directs the interpretation of clause against the party that inserted it and in India in some situations where the arbitration provisions are interpreted against the author, this principle of contra proferentem is found eliminated by the court. Arbitration awards are binding, and final, an appeal possible only in exceptional cases for the parties. The enforceability of foreign arbitration awards is easy compared to foreign court judgments because there are many states that have mutually recognised the contracting parties through the New York Convention.”⁸⁹

Further, procedural flexibility of arbitration offers the freedom to agree on procedures and rules for finality. Autonomy of the parties is one of the biggest advantages that allows the choice of a neutral jurisdiction and, therefore, avoids the biases available to the other parties. Reputation is the fuel of survival in the commercial market and many large insurers choose arbitration because of its confidentiality and the companies preserve their reputation in the market.

Issues in the condition of the Arbitration in Insurance Disputes

Disputes regarding the seat of arbitration and particularly, selection of neutral arbitrator are one of the challenging processes of the arbitration. Subsequently, insurance agreements sometimes provide the arbitration clauses along with the specific mentioning of participation of insurance experts who are not interested, but there is still a conflict of interest. Generally, insurance arbitrators are unwilling to strictly enforce the rule of law. Lastly, failure to provide clear instructions on how to add the third party to arbitration results in inconsistent judgments and incomplete dispute resolution.

Settlement Intimation Voucher and IRDA Circulars

The issuance of discharge vouchers is common in the Indian general insurance sector for the disbursement of covered amounts, with payments contingent upon the receipt of such vouchers. The general norm of the insurance sector became a contentious obstacle when it began prohibiting arbitrations, resulting in challenges to several arbitration verdicts in courts and forums. Multiple rulings emerged from the discharge certificate, prompting the Insurance Development and Regulatory Authority of India to publish a circular in 2015, updated in 2016, for general insurers. The method remains prevalent in the insurance sector for claims settlement.

Mediation

Mediation assumes a progressively significant role in settling conflicts within the health insurance industry in India, providing a feasible alternative to the sometimes protracted and intricate litigation procedure. With the rise in health insurance coverage and the corresponding increase in claim disputes, mediation has emerged as a practical solution to handle conflicts efficiently and amicably. This method benefits policyholders, insurers, and the broader healthcare system by providing a quicker, cost-effective, and less adversarial means of dispute resolution.

Understanding Mediation in Health Insurance Claims

Mediation is a kind of alternative dispute resolution (ADR) in which a neutral third party, the mediator, assists conflicting parties in reaching a mutually agreeable conclusion. In contrast to arbitration or judicial processes, the mediator does not enforce a result but rather fosters dialogue and resolution between the parties. Mediation is especially advantageous in the realm of health insurance claims in India, given the technical complexities of disputes that often include interpretations of policy language, medical terminology, and treatment procedures.

Benefits of Mediation in Health Insurance Claims Disputes

Speed and Efficiency: Mediation is typically faster than going through court proceedings. This speed can be crucial in healthcare-related disputes where timely resolution can significantly impact the parties involved, particularly the insured who may need funds for medical treatment. Cost-Effectiveness: It is generally less expensive to engage in mediation than to cover the costs associated with court cases, including legal fees and long-term indirect costs due to delays.

Confidentiality: In contrast to court trials, which are public, mediation processes are confidential. This anonymity is essential for maintaining the professional reputation of the parties, especially in delicate medical circumstances.

Preservation of Relationships: Mediation helps maintain and sometimes even strengthen relationships between insurers and policyholders by promoting communication and mutual understanding, rather than fostering a combative environment.

Flexibility and Control: Parties in mediation retain control over the outcome. This is particularly advantageous in health insurance disputes, as the parties can agree on solutions that a court might not be able to legally impose.

Legal and Regulatory Frmework Supporting Mediation

The legal framework for mediation in India has been developing, with significant recognition and support for the process under various laws, including the Arbitration and Conciliation Act, 1996, and the Consumer Protection Act, 2019. The latter has introduced mediation as a mandatory first step before the filing of a complaint in the consumer courts. This legislative support underscores the importance of mediation in consumer-related disputes, including those involving health insurance.

Moreover, the Insurance Regulatory and Development Authority of India , encourages the resolution of disputes through mediation. It has set guidelines and has been involved in setting up mechanisms to facilitate such processes, recognizing the unique advantages mediation offers in the insurance domain.

Challenges

Despite its advantages, mediation in health insurance claims faces challenges such as a lack of awareness among consumers about this option, reluctance from insurers to participate in mediation, and a need for more trained mediators who specialize in insurance and healthcare disputes. To overcome these challenges, there needs to be greater advocacy and education about the benefits of mediation. Insurance companies and regulatory bodies like IRDAI should actively promote mediation as a dispute resolution mechanism. Furthermore, developing a panel of expert mediators trained specifically in health insurance and related medical issues would also enhance the effectiveness of mediation in this sector.

The significance of mediation in addressing health insurance claims disputes in India is crucial and expanding. The expansion and evolution of the health insurance market need the integration of efficient dispute resolution procedures, such as mediation, to improve conflict management within the industry. This helps notjust the involved parties but also enhances the stability and trustworthiness of the health insurance system overall, hence facilitating wider access to healthcare.

5.9.3 Role of Ombudsman and Grievance Redressal Mechanisms

The Insurance Ombudsman, inspired by the Swedish concept of "ombudsman," provides a structured mechanism for resolving insurance-related grievances in India. Established under the Redressal of Public Grievances Rules (1998) and now governed by the Insurance Ombudsman Rules (2017, updated in 2018 and 2021), it includes both life and general insurance. Seventeen ombudsman centres function around the nation, including one in Chennai, each with specified geographicaljurisdiction. The Council of Insurance Ombudsman, consisting of industry and IRDAI representatives, supervises the system. Ombudsmen are selected for three-year periods by the Council, following the recommendations of a Selection Committee. The Ombudsman addresses grievances concerning inadequate service by insurers, agents, and brokers, including delayed claims or denials, but only after the complaint has been initially submitted to the insurer. This no-cost and informal procedure provides an alternative to judicial processes, benefiting policyholders throughout India, particularly those in Chennai and Tamil Nadu, by guaranteeing equitable and accessible dispute settlement.

5.10 Case Studies and Analysis (Judicial Response)

Role of judiciary in resolving insurance claims

Thejudiciary plays a crucial role in resolving insurance claims, particularly in disputes where policyholders and insurance companies have differing interpretations of contract terms, by enforcing the “principle of good faith”, by awarding compensation and penalties, and promoting consumer rights and welfare. It has set precedents that ambiguous clauses in insurance policies should be interpreted in favor of the insured, provided there's a valid claim.

5.10.1 Unfair Terms and conditions or ambiguous terms

“The Indian Contract Act of 1872 regulates all contracts in India, encompassing insurance transactions. Under this Act, ambiguous contractual phrases are generally construed contra proferentem, signifying against the party that draughted the contract (normally the insurance company).

The Insurance Regulatory and Development Authority of India (IRDAI) oversees the operations of insurance businesses in India. If an insurance business use unclear terminology unjustly, the IRDAI standards against unfair trade practices may be invoked, providing the insured with a basis for redress. Rule 9 of the IRDAI (Protection of Policyholders' Interests) Regulations, 2017, stipulates that policy terms shall be explicitly articulated, eschewing unclear or deceptive language that may disadvantage policyholders. Under the Consumer Protection Act, 2019, insurance is classified as a service, allowing disputes related to unclear policy terms and rejected claims to be submitted to Consumer Courts. This Act grants the insured (as a consumer) the ability to lodge complaints over service deficiencies or unfair trade practices, encompassing problems stemming from ambiguous policy language.”

The Life Insurance Corporation of India v. Dharam Vir Anand^[90] , case focused on interpretating the ambiguous terms in an insurance policy and whether the insurer had clearly communicated these terms to the insured. The primary issue was whether the unclear language in the insurance policy should be construed in favour of the insured, especially given the insurer's assertion that the provisions were clearly elucidated prior to the contract's execution. The Supreme Court found in favour of the insured, determining that confusing provisions in an insurance contract should be construed to benefit the insured, particularly when the insurer fails to demonstrate that these terms were adequately clarified prior to the contract's execution. The Court based its decision on the principle of contra proferentem, a rule of contract interpretation favoring the party that did not draft the contract. Since the insurer is responsible for drafting the policy terms, any ambiguity should be resolved against them. The Court reasoned that insurance contracts are often complex and contain specialized language that laypersons may not fully understand. This case is significant because it established a precedent in Indian insurance law, reinforcing those ambiguities in policy terms will generally be resolved in favor of the insured. The principle of contra proferentem ensures greater protection for policyholders and compels insurers to draft clear, comprehensible policies or risk the court ruling against them in cases of ambiguity.

5.10.2 Delayed Claims and Non-Payment of Claims in health insurance

The Star Health And Allied Insurance Co. Ltd. v. A. Chokkar^[91] , focused on the delayed claims and non-payment of claims in health insurance. The issue was whether the insurer could delay the settlement of a valid claim without a legitimate reason. The insured argued that the delay in processing their claim caused significant financial hardship. The insurer, on the other hand, may have presented reasons for the delay, though these reasons were not publicly disclosed. The court, utilising the concept of contra proferentem, which benefits the non­drafting party, found in favour of the insured. The court ruled that unclear provisions in an insurance policy must be construed in favour of the insured, particularly where the insurer fails to definitively demonstrate that these provisions were elucidated prior to the contract's execution. The court determined that the delay in settling the claim was unwarranted and mandated the insurance to disburse the claim together with interest. This case is significant as it reinforces the principle that insurance contracts should be clear and unambiguous. It also emphasizes the insurer's duty to process claims immediately and fairly. This decision has set a precedent in Indian insurance law, providing greater protection to policyholders and ensuring that insurers are held accountable for their obligations.

The United India Insurance Company Ltd. v. S.Marimuthu^[92] cantered around the interpretation of pre-existing conditions in health insurance policies. The insured, S. Marimuthu, filed a claim with United India Insurance Company Ltd., which was denied on the grounds of a pre-existing condition. The issue was whether the insurer could deny a claim based on a pre-existing condition that had not manifested during the policy period. The court, concluded that insurers cannot deny claims for pre-existing conditions that have not caused any health problems during the policy term. The court emphasized the importance of clear policy wording and fair interpretation of terms. This case serves as a landmark judgment, protecting the interests of policyholders and ensuring that they receive due benefits.

In Shri Mukut Lal Duggal v. United India Insurance Co.^[93] “ The insuerd Shri Mukut Lal Duggal sought cashless treatment at a network hospital under his health insurance policy with United India Insurance Co. However, the insurer denied the claim. The issue was whether the insurer could deny cashless treatment at a network hospital without valid reasons. The insured argued that the policy terms clearly outlined the entitlement to cashless treatment at network hospitals. The insurer, on the other hand, may have cited technical reasons or policy exclusions tojustify the denial. The court, in itsjudgment, sided with the insured. It was held that insurers are obligated to provide cashless treatment at network hospitals as per the policy terms. The court emphasized the importance of cashless treatment in ensuring timely and affordable healthcare for policyholders. The insurer's denial of the claim was deemed unjustified, as it caused undue financial burden and inconvenience to the insured. This case has significant implications for health insurance policyholders. It reinforces the rights of policyholders to avail cashless treatment at network hospitals and discourages insurers from arbitrarily denying such claims. By upholding the principle of cashless treatment, the court has strengthened consumer protection in the health insurance sector.”

In Jacob Punnen v. United India Insurance Co. Ltd[9],[4] The insured, Jacob Punnen, made a claim with United India Insurance Co. Ltd. for hospital bills he had to pay because of a health problem. But the insurance company turned down the claim, saying that it wasn't covered by the policy. The issue was whether the insurance company could turn down the claim based on how these limits were interpreted. The insured person said that the policy's limits were not clear and should be read in their favour. They said that the hospital bills were covered by the policy and that the insurance company's refusal was wrong. On the other hand, the insurance company said that the limits were very clear and that the claim did not fall under the policy's coverage. It was decided that the Supreme Court agreed with the insurer. The court declared that insurance terms that aren't clear should be interpreted in the insured's favour. The court in this case thought that the insurance exclusions were not clear, so the claim was valid. The insurance company was told to pay out on the claim. People who have health insurance will be affected by this decision in a big way. It backs up the principle of contra proferentem, which says that vague words in a contract should be taken to mean the person who wrote it. When it comes to insurance, this idea means that policy terms that aren't clear should be interpreted in the insured's favour. This case makes it easier for other cases to follow and protects insurers' rights.⁹⁴

In Director of Pension v. B.Sarada ,^[95] B. Sarada, the insured, went to the United India Insurance Company and asked them to pay for his hospital bills. But the insurance company turned down the claim because the patient hadn't told them about any pre-existing medical problems. The issue in question was whether not telling about a pre-existing condition that didn't change the risk significantly could be a reason to deny a legal claim. The insured said that the conditions that weren't revealed weren't important to the risk and didn't change the insurer's mind about giving the policy. The insurance company said that failing to disclose pre­existing illnesses, no matter how important they were, was enough to deny the claim. That is, the Supreme Court decided in favour of the insured. The court said that it is up to the insurance company to show that the information that wasn't shared was important to the risk and affected its choice to give the policy. In this case, the insurance company failed to show how important the conditions that weren't revealed were. In insurance arrangements, the court stressed how important it is to be fair and honest. This decision is very important for people who have health insurance because it protects their rights by making sure that insurers can't just refuse claims for technical reasons.

5.10.3 Pre-existing Conditions clause in health insurance

In Vijay Kumar v. Oriental Insurance Co. Ltd ^[96] This case centred on a health insurance claim submitted by Vijay Kumar for medical expenses incurred following a hospitalization due to a serious illness. The insurer, Oriental Insurance, denied the claim, alleging that Kumar had not disclosed a pre-existing condition in his application for insurance, which they claimed constituted fraudulent misrepresentation. The primary issue involved whether the insurer could deny the claim based solely on this assertion of non-disclosure without providing clear and compelling evidence of fraudulent intent. Relevant provisions included the Insurance Act, 1938, which outlines the obligations of both insurers and insured individuals regarding disclosure of material facts. Vijay Kumar contended that he had accurately reported his medical history and that the insurer’s denial was unjustified. The Supreme Court ruled in favour of Kumar, stating that Oriental Insurance had failed to establish any substantial proof of fraud or concealment of relevant information. The ratio decidendi emphasized that the burden of proof rests on the insurer to demonstrate fraudulent behaviour, and mere suspicion or assumptions are insufficient to deny valid claims. This ruling reinforced the rights of policyholders and the necessity for insurers to adhere to principles of fairness and transparency.

In Tarlok Chand Khanna v. United India Insurance Co. Ltd^[97] The insured, Tarlok Chand Khanna, made a claim with United India Insurance Co. Ltd. for hospital bills he had to pay because of a health problem. But the insurance company turned down the claim because of policy exclusions, such as a rule about pre-existing conditions. The issue in question was how to read the policy's "pre-existing condition" phrase and whether the insurance company could refuse the claim because of it. The insured said that the pre-existing condition didn't change the risk and that the insurance hadn't made it clear what the clause meant. The insurance company said that the policy's terms were clear and that the claim should have been turned down. It was decided that the Supreme Court agreed with the insurer. The court said that insurers need to tell customers what the policy terms mean, especially when it comes to pre-existing illnesses. In this case, the insurance company didn't explain the rule well enough, so the claim was granted. This decision stresses how important it is for insurers and clients to communicate clearly, especially when it comes to pre-existing conditions and policy exclusions.

The Pradeep Kumar Garg v. National Insurance Co. Ltd,^[98] case dealt with the issue of delayed claim settlement and the insurer's liability to pay interest on delayed payments. The insured, Pradeep Kumar Garg, filed a claim with National Insurance Co. Ltd. for medical expenses. However, the insurer delayed the settlement of the claim. The issue was whether the insurer was justified in delaying the claim settlement and whether the insured was entitled to interest on the delayed payment. The insured argued that the delay was unjustified and caused financial hardship. The insurer may have presented reasons for the delay, but the court found these reasons insufficient. The Supreme Court, in its judgment, ruled in favour of the insured. The court held that insurers cannot unreasonably delay the settlement of valid claims. In this case, the delay was unjustified, and the insurer was directed to pay interest on the delayed amount. Thisjudgment emphasizes the importance of timely claim settlement and the insurer's obligation to process claims efficiently.

5.10.4 Treatment in health insurance

In Sukhdeep Singh Bhinder v. Star Health and Allied Insurance^[99] The complainants purchased a health insurance policy on November 30, 2018, disclosing a pre-existing condition ofhigh blood pressure. Following a medical emergency on January 13,2019, Sukhdeep Singh underwent coronary angiography at Fortis Hospital on January 14, 2019, but the report mistakenly indicated the date as December 14, 2018. The insurance company denied cashless treatment, claiming the condition was pre-existing and within the policy’s 30-day waiting period. The issue was whether the insurance company was justified in denying cashless treatment on the grounds that the patient's condition was pre-existing and within the 30-day waiting period, despite the incorrect date on the angiography report. Complainants argued that they contended that the insurance company incorrectly interpreted the dates on the angiography report and that Sukhdeep Singh had not undergone any prior procedures. They argued that the erroneous date should not penalize the insured, especially given the life-threatening situation he faced. The complainants claimed that the insurance company failed in its duty to provide service by denying the preauthorization for cashless treatment. The claimant argued that the insurance company argued that the claim was rightly denied based on the initial report showing a pre-existing condition that fell within the waiting period. They insisted that the date mentioned in the report constituted sufficient grounds for denial of the cashless treatment claim. The court ruled in favour of the complainants, emphasizing that the insurer failed to properly verify the corrected date and could not hold the complainant accountable for the medical staffs error. The court determined that the denial constituted a deficiency in service, highlighting that the insurer's actions were unreasonable given the serious circumstances and the timely correction of the report's date.

In M/S. Care Well Hospital v. Anil Arora & Orsl[0] ° Anil Arora, holding a Mediclaim policy from National Insurance, fell ill and was admitted to Care Well Hospital, believing it was a cashless treatment facility under his insurance. Assured of coverage, he proceeded with treatment, incurring expenses of Rs. 2,71,579. However, at discharge, he was asked to pay out- of-pocket and subsequently received only partial reimbursement (Rs. 1,71,579) from the insurance. This led him to file a consumer complaint seeking the unpaid balance. Whether Care Well Hospital (OP-3) wrongfully denied cashless treatment to the complainant, Anil Arora, causing him to incur medical costs despite his policy covering cashless treatment at panel hospitals. Complainant argues that the claimed Care Well Hospital was on the insurer's panel and thus obligated to provide cashless treatment. Respondents argued that the OP-1 (insurer) argued that the claim was processed per policy terms, and there was no oral cashless approval. OP-3 denied providing any cashless assurance and claimed it informed the complainant immediately. The District Forum held that Care Well Hospital was indeed a panel hospital for¹⁰⁰ cashless treatment. It found OP-3’s denial of cashless treatment constituted a service deficiency and harassment. Care Well Hospital’s refusal to honor the cashless treatment assurance, despite being on the insurer’s panel, amounted to a failure in providing the agreed service, compelling the complainant to bear unnecessary expenses.

In Harpreet Singh Kand v. Max Super Specialty Hospital^[101] The complainant, Harpreet Singh Kand, filed a consumer complaint against Max Super Specialty Hospital and others. His father, a retired IPS officer and Central Government Health Scheme (CGHS) cardholder, was admitted to the hospital in an emergency but was denied cashless treatment despite the CGHS entitlements. Instead, the hospital charged over Rs. 43 lakh, forcing the family to pay in instalments. The core issue was whether the hospital was obliged to provide cashless treatment under the CGHS scheme. The complainant argued that the hospital’s refusal to offer cashless treatment constituted unfair trade practice and service deficiency. The hospital countered, claiming that they required a CGHS referral slip for cashless treatment, which was absent in this case. The court cited the CGHS guidelines that mandated cashless treatment for pensioners in empanelled hospitals, especially in emergencies. The court noted the hospital’s failure to inform the family of any procedural deficiencies or to pursue clearance with CGHS, deeming their actions as unjust and negligent. Relying on precedents like Peerless Hospital v. Gopal Chandra Mukherjee^[102], the court ordered the hospital to refund the complainant with interest and awarded compensation for mental harassment. The decision highlighted the hospital's obligation to honor CGHS provisions and ensure fair treatment practices.

In Darshan Kaur v. M.D. India Healthcare Services ^[103] The appellant, Darshan Kaur, challenged the denial of her reimbursement claim under the Bhai Ghanhaya Sehat Sewa Scheme (BGSSS) by various service providers, including M.D. India Healthcare Services and Fortis Hospital. Kaur, aged over 60, underwent knee replacement surgery at Fortis Hospital, incurring expenses of Rs. 3,04,273. The hospital and insurance provider refused cashless treatment and reimbursement, leading Kaur to allege service deficiency under the Consumer Protection Act, 1986. The issue was whether the appellant was entitled to cashless treatment or reimbursement under the BGSSS, despite allegedly not following procedural requirements, such as showing her card upon admission. The relevant provisions included the terms of the BGSSS policy, which mandated pre-authorization for cashless claims. The appellant argued denial of claim was arbitrary, as her eligibility was evident. The defence argued that Kaur did not fulfil policy requirements, and thus her claim was invalid. The defence cited General Assurance Society Ltd. v. Chandmull Jain[1114], asserting that courts cannot override contractual terms. The State Commission directed Kaur to submit her claim within a month, for respondents to process within two months, aligning with policy conditions. The court upheld the requirement for claim submission, marking this as ratio decidendi, but noted no deficiency in service.

In National Insurance Company (NIC) vs Himanshu^{[104] [105]} The respondents, minor children of deceased Kashmir Kaur, sought insurance reimbursement under the Bhai Ghanhiya Sehat Sewa Scheme after incurring substantial medical expenses during her illness and subsequent death. The claim was rejected by National Insurance Company (NIC) and Med Save Healthcare (TPA) on the grounds of procedural lapses in cashless treatment requests. Whether the rejection of the claim by NIC and Med Save Healthcare for not adhering to procedural timelines was justified under the insurance policy. Section 15¹⁰⁶ of the Consumer Protection Act, 1986, concerning the rights of consumers in cases of unfair or deficient service by insurers. NIC argued that requests for cashless treatment were submitted late, exceeding the 30-day and 50-day limits set in the policy, thereby justifying claim denial. The respondents argued that intimation was provided within the requisite period and that treatment costs were valid and payable under the policy. The judgment referenced the principle that minor procedural delays should not override substantial compliance in fulfilling insurance claims. The court upheld the District Forum's order directing NIC and Med Save to pay Rs. 2 lakhs plus interest, Rs. 20,000 as compensation, and Rs. 2000 in litigation costs. The court reasoned that the purpose of the policy was to provide timely medical relief, and minor procedural lapses should not defeat legitimate claims. It emphasized fair treatment and consumer rights in enforcing insurance policies, particularly when substantial compliance was met.

5.10.5 Reimbursement ofMedical Expenses

In N.K.Mathavaraj Ganesan v. Government of Tamil Nadu,^[107]

The petitioner, a retired Superintending Engineer with over 33 years of service in the Tamil Nadu Public Works Department, sought reimbursement under the New Health Insurance Scheme (NHIS) implemented by the state government for its employees. The scheme, outlined in G.O.Ms.No.174 dated April 28, 2008, provided coverage for medical treatments through a tie-up with Star Health and Allied Insurance Company, allowing cashless treatments at designated hospitals. Despite this, the petitioner claimed that he was denied reimbursement for medical expenses incurred at M/s. Apollo Hospitals, which was listed as a network hospital under the scheme. He argued that the scheme’s provisions assured medical coverage and reimbursement, asserting the government and the insurance provider’s obligation to honour such claims. The petitioner thus filed a writ petition seeking judicial intervention to secure his entitled reimbursement, highlighting issues of administrative lapses and potential gaps in the scheme’s implementation affecting retired employees. The Madurai bench of Madras High Court held that the petitioner, a retired government employee, was entitled to medical reimbursement even though he received treatment in a non-empanelled hospital. The bench referred the Supreme court decision in paragraph 10.The Honourable Supreme Court in the case of Shiva Kant Jha vs Union of India^[108], reported in, with reference to reimbursement of medical claim under Central Government Health Scheme, specifically observed that treatment availed in emergency circumstances to save life of Government employee can be considered and the Government employee should be reimbursed. This Court had also an occasion to deal with similar issue and the practical difficulty of Government employees, who have undergone treatment during service or after retirement. In most of the cases, the Insurance Company rejected the claim simply because the treatment is not in a network hospital or on the ground that the treatment undergone by the employee is not for the ailment found place in the agreement entered into between Government and private Insurance Company.

In Muthuraman v. The New India Assurance Co. Ltd^[109] The appellant Muthuram, whose wife was diagnosed with ovarian cancer, and the insurance company regarding claims for medical expenses. The appellant had initially purchased a health insurance policy, valid from July 7, 2007, to July 6, 2008, and had renewed it several times until July 6, 2012. After his wife’s diagnosis, he submitted claims for treatment expenses incurred between January 19, 2008, and September 19, 2008, but the insurance company repudiated these claims, alleging non-disclosure of a pre-existing condition, rheumatic heart disease, in the proposal form. The District Forum ruled in favour of the appellant, ordering the insurance company to reimburse the treatment expenses with interest, while the National Commission upheld this order but set aside the direction for renewal of the policy, arguing that the renewal beyond July 6, 2009, was improper, thereby nullifying any claims made after that date.

In Sandeep Shukla V. Star Health and Allied Insurance Company Ltd.^[110] The complainant purchased a health insurance policy that was later denied cashless treatment for his mother, leading to significant out-of-pocket expenses totaling Rs. 3,67,820. The issue involved was the insurance company’s refusal to reimburse the medical costs, citing pre­existing conditions (Asthma, Diabetes, and Hypertension) as grounds for denial. The relevant provisions section 71¹¹¹ and 72(1)¹¹² include the Consumer Protection Act, 2019, and the stipulations within the insurance policy regarding pre-existing diseases. The complainant argued that the denial was unjustified as the cited conditions were lifestyle diseases unrelated to the reason for hospitalization, while the insurer contended that the claim was rightly repudiated due to non-disclosure of medical history. The court ultimately decided in favour of the complainant, ordering the insurance company to reimburse Rs. 1,45,002 with interest, along with compensation for harassment and litigation costs. The ratio decidendi highlighted that the insurer’s grounds for denial were inadequate, as lifestyle diseases should not automatically void insurance coverage and emphasized the need for insurers to act transparently and fairly, reinforcing that the non-disclosure of past medical conditions did not warrant a claim denial when no direct link to the current treatment was established.

The Shri Ashok Kumar v. Delhi Jal Board^[113] case concerning the applicant who incurred medical expenses of Rs. 12,93,036 for his wife’s cancer treatment, which she received at multiple hospitals before her death on November 24, 2009, the issue was the reimbursement of medical expenses under the Central Government Health Scheme (CGHS) and CS(MA) Rules, 1944. The relevant provisions included an Office Memorandum dated February 19, 2009, which stipulated that beneficiaries could claim reimbursement from both their insurance agency and the CGHS, provided they first sought reimbursement from the insurance agency, and that the total reimbursement did not exceed the actual expenditure. The applicant argued that he complied with this process, receiving Rs. 6,83,479 from the insurance company, but the DJB only reimbursed Rs. 4,54,422 of the remaining balance, leaving Rs. 1,55,136 unpaid. The Court ruled in favour of the applicant, emphasizing that the DJB’s failure to reimburse the full amount violated the provisions of the Office Memorandum, as it was intended to provide full coverage of medical expenses incurred by the beneficiaries. The ratio decidendi highlighted that the reimbursements should adequately reflect the actual costs borne by the applicant, and the DJB was mandated tofulfilits obligations under the applicable rules.

The Reliance General Insurance Company v. Vijay Kumar & Another^[114]

In the case concerning medical reimbursement for the treatment of the applicant’s late wife, the applicant incurred a total medical expenditure of Rs. 12,93,036 after her diagnosis with malignant cancer, for which she received treatment at multiple hospitals before passing away on November 24, 2009. The issue involved was whether the applicant was entitled to full reimbursement of the medical expenses from the Delhi Jal Board (DJB) after receiving partial reimbursement of Rs. 6,83,479 from the insurance company as mandated by an Office Memorandum dated February 19, 2009, allowing claims from both the insurance agency and CGHS, subject to certain conditions. The applicant argued that the DJB’s reimbursement of only Rs. 4,54,422 was insufficient, leaving a balance of Rs. 1,55,136 still unpaid. The court decided in favour of the applicant, ruling that he was entitled to the remaining reimbursement amount. The ratio decidendi emphasized that the applicant’s claim was valid under the provisions of the Office Memorandum, which aimed to ensure that beneficiaries could fully recover their medical expenses without being unfairly short-changed by the procedures established for reimbursement.

5.10.6 Policy Exclusions in health insurance

In Shri Mukut Lal Duggal v. United India Insurance Co. Ltd.^[115] The petitioner Shri Mukut Lal Duggal and his wife held a Medi-claim Insurance Policy with United India Insurance Company from 1995-96. Over time, Mukut Lal Duggal, the primary insured, made several claims, including for coronary treatment in 1998, an angioplasty in 2001, a minor operation in 2002, and a bypass surgery in December 2002. Although the insurer reimbursed the medical expenses initially, it delayed payment for the bypass surgery and ultimately refused policy renewal in 2003, citing a high claim ratio. Notably, the wife, ajoint insured, had not made any claims under the policy. The main issue was whether the insurance company could deny renewal solely due to frequent claims, despite timely payment of renewal premiums. The insurer argued that, similar to critical illness insurance policies, Medi-claim coverage could be cancelled after substantial claims. However, the petitioners argued this refusal was arbitrary, as they were prepared to continue paying premiums. The court ruled that high claims alone do not justify refusal of Medi-claim renewal and that insurers must uphold renewal requests unless premiums are reasonably adjusted. The decision emphasized that insurers cannot unreasonably deny renewal, especially under ajoint policy, thereby upholding contractual obligations.

In Purnima Prasad And Ors. v. The Oriental Insurance Company Limited,^[116] The deceased Anjani Kishore Prasad held a Mediclaim policy from Oriental Insurance Company, renewed annually from 1996 until it lapsed on December 3, 2004. In 2003, Prasad was diagnosed with cancer and reimbursed for treatment costs under the policy. When the company agent failed to collect the renewal premium in December 2004, Prasad sent written requests for renewal, but the insurer did not respond. After his death in 2006, his heirs filed a writ petition seeking policy renewal from December 2004 to his date of death. The key issue was whether the insurer was obligated to renew the lapsed policy given Prasad’s willingness to pay the premium and his pre-existing condition. The petitioners argued that non-renewal was improper as Prasad had complied with payment obligations and that the insurer’s agent caused the lapse. The insurer countered that it was not bound to renew a lapsed policy, particularly where a serious pre­existing illness was involved. The court held that as long as Prasad was willing to pay the premium, the insurer had no grounds to deny renewal, directing the insurer to renew the policy retrospectively, collect premiums from his widow, and process claims. The court reasoned that the insurer's refusal, based on the agent’s failure or pre-existing illness, was unjustified.

In Oriental Insurance Co. Ltd. v. Premlata Shukla ,^[117] The insured, Premlata Shukla, held a Mediclaim policy with Oriental Insurance and was hospitalized due to a brain haemorrhage. She sought reimbursement ofher medical expenses, but the insurer denied the claim under the policy's exclusion clause for pre-existing conditions, arguing that her brain haemorrhage was linked to pre-existing hypertension. The main issue was whether the insurer was justified in rejecting the claim based on the exclusion clause. The insurer contended that the insured’s hypertension, which was diagnosed before policy issuance, directly contributed to her condition, making the claim ineligible. The insured argued that her condition was not caused solely by hypertension and that she was not adequately informed about the exclusion clause's scope. The Supreme Court upheld the insurer’s decision, emphasizing that insurance policies are contracts that must be enforced as written. The Court ruled that the pre-existing disease exclusion was applicable since the insured’s hypertension significantly influenced her current condition, and such clauses are binding when explicitly stated in the policy terms. The case highlighted the importance of clear exclusions in health policies and the responsibility of policyholders to understand these provisions.

In New India Assurance Co. Ltd. v. Hilli Multi Specialty Hospital^[118] The insured, a patient, underwent treatment for severe respiratory distress and submitted a claim for reimbursement under a health insurance policy. The insurer denied the claim, citing a specific exclusion for treatment related to pre-existing respiratory conditions. The issue was whether the insurer could deny the claim based on this exclusion, given that the insured had not disclosed any prior respiratory issues. The insurer argued that the exclusion clearly covered such conditions, justifying the denial of the claim. The insured contended that there was no evidence of pre­existing conditions that directly led to the treatment and that the denial was arbitrary. The Supreme Court held in favour of the insurer, reaffirming the enforceability of exclusion clauses in health insurance contracts. The Court reasoned that clear exclusions serve to delineate the scope of coverage, and policyholders must disclose any relevant medical history during the application process. The ruling emphasized that insurance companies are entitled to deny claims when pre-existing conditions are explicitly excluded in the policy, thereby underscoring the importance of full disclosure and the binding nature of policy terms.

5.10.7 TPA Disputes in health insurance

In Lataben Maheshbhai Matiya v. Oriental Ins.Co.Ltd^[119], The complainant, Lataben Maheshbhai Matiya, held a health insurance policy from Oriental Insurance covering herself and her husband. During the policy period from October 14, 2021, to October 13, 2022, her husband underwent cataract surgery, incurring a medical bill of Rs. 40,000. She submitted a claim for reimbursement; however, Oriental Insurance, through its Third Party Administrator

(TPA), reimbursed only Rs. 21,600, deducting Rs. 20,841 as “reasonable and customary” charges. Lataben challenged this deduction, arguing that the TPA had no authority to finalize reimbursement amounts and that the basis for the deduction was unclear. Dissatisfied with the District Commission’s rejection of her claim, she filed an appeal under Section 15 of the Consumer Protection Act, 1986. In response, Oriental Insurance argued that the TPA had calculated the reimbursement in line with the policy terms. The court, however, found that TPAs under IRDA regulations can only provide recommendations, not make binding claim decisions. The court ordered Oriental Insurance to pay an additional Rs. 16,597 with 9% interest from the date of complaint filing, Rs. 10,000 for mental agony, and Rs. 5,000 for litigation costs, emphasizing the insurer's duty to ensure transparent and fair settlement practices.

In Dr. Sudarshan Jindal v. United India Insurance Company Limited^[120] Dr. Sudarshan Jindal, a policyholder with United India Insurance, sought reimbursement for ?2,83,131 in medical expenses incurred during a cardiac procedure at Medanta Hospital, Gurgaon, in December 2015. The policy he held included a cashless treatment facility, which his wife attempted to access at the time of his hospitalization. However, this request was denied by the insurance provider’s Third-Party Administrator (TPA), who cited a clause in the policy excluding coverage for pre-existing conditions within the first 48 months. When Dr. Jindal subsequently filed a reimbursement claim, it was rejected on similar grounds, alleging that his coronary artery disease had predated the policy’s inception. Dr. Jindal contended that the TPA lacked the authority to deny his claim, as per the Insurance Regulatory and Development Authority (IRDA) regulations, which prohibit TPAs from directly rejecting claims. The court agreed, emphasizing that only the insurer itself may reject claims. Furthermore, the insurer failed to produce clear evidence that Dr. Jindal’s condition qualified as pre-existing under the policy terms. Consequently, the court ordered United India Insurance to pay the claimed amount with 9% interest from the date of repudiation, alongside compensation of ?20,000 for mental agony and ?10,000 for litigation costs. This judgment highlighted the TPA’s restricted role in claims processing, affirming that TPAs cannot act independently in denying claims, and highlighted the need for insurers to substantiate exclusions based on pre-existing conditions with adequate evidence.

In The Oriental Insurance Company Ltd. v. Gopal And Ors^[121]. The dispute arose from a health insurance claim involving a Third-Party Administrator (TPA), MD India Health Insurance TPA Pvt. Ltd. The complainant, Gopal B. S., had an active health insurance policy with the Oriental Insurance Company and underwent treatment at a hospital, where he availed himself of cashless treatment. Initially, the TPA approved the pre-authorization for the cashless treatment; however, after the treatment, the TPA raised objections regarding the admissibility of the claim and ultimately denied the full amount, citing policy violations that were not communicated prior to treatment. This led to a significant dispute over whether the TPA's denial constituted a deficiency in service. The District Consumer Disputes Redressal Forum ruled in favour of the complainant, emphasizing that the TPA's initial approval bound the insurance company and could not be revoked arbitrarily after the treatment had been rendered. The forum highlighted the necessity for TPAs to maintain clear communication regarding policy conditions and exclusions with both the insured and healthcare providers. The ruling established that insurers are accountable for the actions of their TPAs, reinforcing the importance of transparency and timely communication to prevent service deficiencies and disputes in health insurance claims management.

In Pankaj Kumar v. HDFC ERGO General Insurance Company Ltd.^[122] This case involved a dispute over health insurance claims processed through a Third-Party Administrator (TPA). Pankaj Kumar had purchased a health insurance policy from HDFC ERGO and was admitted to a hospital for treatment, anticipating the use of cashless benefits. The TPA provided a pre­authorization letter assuring the hospital that the treatment would be covered. However, post­treatment, the TPA contested the validity of the claim, citing that the treatment did not meet their approval criteria, ultimately denying the full claim amount. Kumar subsequently filed a complaint with the consumer forum, arguing that the denial was unwarranted given the prior approval from the TPA. The District Consumer Disputes Redressal Forum ruled in favour of Kumar, stating that the TPA's pre-authorization was binding and could not be disregarded by the insurance company. The forum emphasized that the TPA has a responsibility to communicate all relevant information regarding the policy and claims process clearly to the insured.

5.10.8 Room Rent Limits in health insurance

In Mr. Purshotam Murarka vs New India Assurance Co. Ltd.,^[123] The appellant, Mr. Purshotam Murarka, claimed reimbursement for hospitalization expenses incurred due to pneumonia, potentially related to COVID-19. The insurance company, New India Assurance, denied part of the claim, stating that room rent was capped at 1% of the sum insured per day and that the hospitalization was unjustified for three days, leading to a partial settlement of the claim. The District Consumer Commission dismissed the complaint at the admission stage, stating that the appellant failed tojustify the denial of the total claimed amount of Rs. 1,18,915. The appellant contended that the Commission erred in failing to recognize the deficiency in service and the merits of the case, while the insurer argued that they acted within the terms of the policy and that the appeal lacked sufficient evidence for a claim of negligence. The appellate court found that the District Commission dismissed the case without addressing its merits and emphasized that the appellant had a valid cause of action due to alleged deficiencies in the insurer's service. It overturned the District Commission's decision, restoring the complaint for a full hearing. The court reasoned that the appellant's right to seek redress for inadequate services warranted adjudication rather than dismissal at the initial stage.

In United India Insurance Co. Ltd. v. Harshad Bhai K. Dhaduk^[124] The Supreme Court addressed the issue of whether an insurer could limit reimbursement for medical expenses based on the insured's choice of a room exceeding the policy's specified rent limit. The claimant underwent necessary medical treatment and filed a claim, but the insurer contended that it was entitled to reduce the reimbursement according to the room rent cap outlined in the policy. The Court ruled in favour of the insured, emphasizing that the medical necessity of treatment should take precedence over room category restrictions. It held that insurers have a duty to honor claims based on the principle of reasonable expectations and that limitations related to room rent should not penalize patients seeking essential healthcare. This decision underscores the importance of clear communication regarding policy terms and the insurer's obligation to cover medically necessary treatments regardless of room selection.

In HDFC ERGO General Insurance Co. Ltd. v. Dinesh Kumar Bhargava^[125] The complainant, Dinesh Kumar Bhargava, held a health insurance policy that stipulated a room rent limit of ?3,000 per day. He was hospitalized for a kidney ailment, incurring daily charges of ?5,000, leading to a total claim of ?1,50,000. The insurance company denied the claim, asserting that Bhargava had exceeded the room rent limit specified in the policy. The issue at hand was whether the insurer could deny a valid claim solely based on the room rent limit. The High court examined the implications of such a restriction, emphasizing that while insurers can impose limits, these must not result in unjust outcomes for policyholders seeking essential medical treatment. The ruling favoured the complainant, stating that the insurer's rejection of the claim based on the room rent limit was unreasonable and unjustified, as it ultimately affected the insured's ability to receive necessary medical care. The court reinforced the principle that insurance companies must provide clear terms and ensure coverage that reflects the realities of healthcare costs, thereby holding that the room rent limit should not be a barrier to fulfilling valid claims under health insurance policies.

In B. Shah v. Presiding Officer, Labour Court, Coimbatore,^[126] “ The appellant, B. Shah, contested a decision denying her maternity benefits, which had been calculated on a weekly basis rather than daily, effectively reducing her entitled leave period. She argued that under the Maternity Benefit Act, 1961, she was entitled to full maternity leave based on calendar days, not just workdays. The issue was whether maternity leave should be counted on the basis of calendar days or restricted to actual working days, as interpreted by the employer. The Maternity Benefit Act, 1961, particularly Sections 5¹²⁷ and 9¹²⁸, which outline maternity leave and benefits for eligible female employees. The appellant argued that maternity leave under the Act should be comprehensive, covering all calendar days to support the health and well-being of the mother and child, while the employer maintained that it should only apply to workdays. The Supreme Court ruled in favour of B. Shah, stating that maternity benefits should be calculated on calendar days, which includes weekends and holidays, to ensure comprehensive maternity relief. The ratio decidendi emphasized that the Maternity Benefit Act is a welfare legislation, intended to provide full, fair support for women during maternity, and its provisions should be interpreted liberally in favour of employees to uphold their right to ajust and humane work environment. This ruling highlighted thejudiciary’s commitment to protecting women’s rights in the workplace by ensuring fair maternity entitlements.

In State of Haryana v. Smt. Santra ¹²⁹ The case arose when Smt. Santra, a woman employed as a teacher, claimed maternity benefits under the Haryana Government’s policy, which provided maternity leave to its female employees. However, her claim was denied on the grounds that she had not completed the required service period of two years, which the government deemed necessary for eligibility. The issue involved was whether the condition of a two-year service requirement for maternity benefits was discriminatory and violated the rights of women under Articles 14¹³⁰ and 16¹³¹ of the Indian Constitution. The relevant provisions of section 5¹³² and 9¹³³ of the Maternity Benefit Act, 1961, which promotes maternity rights for women employees, and the provisions ensuring equality in employment. The appellant argued that the two-year requirement was arbitrary and effectively denied her a fundamental right to maternity benefits, while the State contended that the policy aimed to ensure that only long­term employees benefitted from the scheme, thereby managing public resources efficiently. The Supreme Court ruled in favour of the appellant, stating that imposing a two-year service condition was discriminatory against women and violated their rights to equality. The ratio decidendi emphasized that maternity benefits are crucial for women’s health and social welfare and should be provided without unreasonable conditions. The Court highlioghted the need to protect women’s rights in the workplace, ensuring that policies do not impose arbitrary restrictions that hinder their access to essential maternity benefits.

In Seema Sharma v. Oriental Insurance Co. Ltd.,^[134] Seema Sharma, a policyholder, filed a complaint against Oriental Insurance for denying her maternity claim under her health insurance policy. The insurer rejected the claim on the grounds that maternity benefits were not covered in the policy, which only provided for hospitalization due to illnesses and accidents. The issue was whether the insurance policy’s exclusion of maternity benefits constituted an unfair trade practice and whether the insurer was obligated to provide maternity coverage. The Insurance Act, 1938, which governs insurance practices in India, and consumer protection laws aimed at preventing unfair practices by service providers. Seema Sharma argued that the policy’s wording was ambiguous and did not explicitly exclude maternity benefits, thereby misleading consumers, while Oriental Insurance contended that maternity coverage was not included in the policy terms, and thus they were not liable to pay. The Supreme Court ruled in favour of complainant stating that the ambiguity in the insurance policy should be interpreted in favour of the insured. The Court emphasized that insurers must clearly state exclusions in a manner that does not mislead policyholders. The ratio decidendi highlighted that insurance contracts should be constructed to protect the interests of policyholders, particularly in matters related to health and maternity, affirming that maternity benefits must be adequately addressed in health insurance policies to prevent consumer exploitation.

5.10.9 Mental Health Treatment in health insurance

In Shikha Nischal v. National Insurance Company Limited ^[135] The Petitioner had regularly obtained health insurance policies from respondent NICL, with the latest policy purchased on 29th May 2020, providing coverage of Rs. 3,95,000 until 28th May 2021. The issue at hand was the Petitioner’s claim for medical expenses amounting to Rs. 5,54,636, whichNICL argued exceeded the maximum coverage of the policy. The Section 14¹³⁶ of the IRDAI Act, 1999 included the terms of the health insurance policy and the direction from the Insurance Regulatory and Development Authority of India (IRDAI) for NICL to settle the claim. The Petitioner contended that the expenses incurred should be fully covered, while NICL maintained that it had complied by paying the insured sum of Rs. 3,95,000, citing that the excess claim was not payable. The court ruled in favour of respondent, affirming that the claim was correctly settled according to the policy limits. The ratio decidendi highlighted that insurance claims must adhere strictly to the terms and limits established in the policy, and any amount beyond the insured sum is not legally recoverable, reinforcing the principle that insurers are bound to the coverage limits agreed upon in the insurance contract.

In Parveen Vij v. M/S Apollo Munich Health Insurance ^[137] The complainant had purchased a health insurance policy from the Insurance Company, which was renewed multiple times, with coverage extending until December 19, 2015. After being admitted to Fortis Hospital, Ludhiana, for investigation of a suspected condition, the complainant submitted a claim for reimbursement of medical expenses. The Insurance Company repudiated the claim on the grounds that the admission was primarily for evaluation, which was not covered under the policy terms, and argued that the complainant had failed to provide the necessary documentation to support his claim despite several requests. The issue involved whether the Insurance Company was justified in denying the claim based on the policy’s coverage terms. The relevant provisions pertained to the conditions of coverage outlined in the insurance policy. The complainant argued that he was entitled to reimbursement and that the Insurance Company had not adequately explained the denial, while the Insurance Company maintained that the claim was invalid as it did not meet the policy’s requirements and that there was no deficiency in service. The court ruled in favour of the Insurance Company, concluding that the complainant’s hospitalization was indeed for investigation purposes only and not for treatment, thus falling outside the coverage of the policy. The ratio decidendi highlighted that the complainant’s claim did nonfulfilled essential conditions of the insurance policy, thereby justifying the repudiation of the claim based on the contractual terms.

5.10.10 Dental Treatment in health insurance

In Surinder Kumar Aggarwal v. New India Assurance Company Ltd. & Anr.^[138] The petitioner Surinder Kumar Aggarwal argued against New India Assurance Company Ltd. under Section 21(b)¹³⁹ he was challenging the order from June 29, 2020, from the State Consumer Disputes Redressal Commission, Punjab, which said his case about a denied medical claim was not valid. The petitioner bought a medi-claim insurance coverage for ¿1,000,000 and paid a premium of ¿9,505. On January 25, 2018, they were hurt in a car accident and had to have extensive dental surgery. The patient submitted a claim for ¿150,000 for the treatment, but the insurance company denied the claim because the treatment was done as an outpatient and did not require hospitalisation. The petitioner said that the claim was wrongly rejected because the relevant policy clause didn't require 24-hour hospitalisation for dental surgery after an accident. At first, the District Forum sided with the petitioner, but the State Commission later changed its mind, saying that the petitioner hadn't shown enough proof that the accident happened. The petitioner said that the State Commission made a mistake because it didn't give enough thought to the insurance policy's terms and the principle of uberrima fides, which says that insurance arrangements must be made in the strictest good faith. He tried to show that his care and the claim were legal under the terms of the insurance policy by pointing to examples of how insurers have been required to handle claims properly in the past. But the respondents said that the claim was properly denied because there wasn't enough proof to back it up and the person wasn't hospitalised properly. It has been said many times by the Supreme Court that the National Commission's power to review decisions is very limited, and it should only be used in the situations allowed by the law. For example, if the State Commission did something illegal or seriously wrong while exercising its legal authority, or if it failed to do something that was legally allowed, or if it did something that was illegal or seriously wrong while exercising its authority, the National Commission should only use its power to review decisions. It's only when these decisions are found to be completely wrong, against the law, the claims, or the evidence that they were made that a case for interference can be made at the second appellate (revisional) level. The orders of the State Commission are upheld because they are not illegal, there are no major problems, and there was no mistake in the exercise of authority. So, the Revision Petition is thrown out.

In Tata Employees Union v. Union Of India^[140] This case concerns original petitions challenging amendments to the Employees State Insurance (Central) Rules, 1950, effective April 1, 1992. The amendments raised the wage ceiling for coverage under the Employees State Insurance Act from Rs. 1,600 to Rs. 3,000 per month and reduced contribution rates for employers and employees. Petitioners, who earned between Rs. 1,600 and Rs. 3,000, argued they received superior medical benefits from their employers and feared losing these if included in the ESI scheme. They contended that the amendments violated Section 9A¹⁴¹ of the Industrial Disputes Act,1947 regarding service condition changes and claimed there was no quid pro quo for the imposed contributions. Additionally, they asserted the notification was arbitrary and violated Article 14 of the Constitution, ensuring equality. The court recognized the petitioners' concerns and directed the Employees State Insurance Corporation (ESIC) to consider further exemption requests. The court stayed the impugned notification, ordering its implementation for petitioners only from November 1, 1992. This ruling emphasized the need to protect existing superior benefits while balancing regulatory requirements and employee rights within the ESI framework.

5.10.11 Policy Renewals and Cancellation in health insurance

In Biman Krishna Bose v. United India^[142] The appellant, along with his wife Smt. Alka Bose, purchased a Mediclaim insurance policy from the respondent on December 14, 1990. After Smt. Bose fell ill and was hospitalized on August 14, 1991, the appellant submitted a claim for Rs 8,243 on August 30, 1991. The Insurance Company refused to renew the policy, citing an exclusion clause for pre-existing diseases. The primary issues were whether the refusal to renew the Mediclaim policy was unfair and arbitrary, and the sustainability of the High Court's order directing the appellant to take a fresh policy. The High Court deemed the Insurance Company’s refusal to renew the policy as unfair and arbitrary, emphasizing that entities deemed "the State" under Article 12 of the Constitution must act fairly. The Court noted that the exclusion clause for pre-existing diseases should not invalidate the appellant's claim. Furthermore, the High

Court’s direction for the appellant to obtain a new policy was found unsustainable in law. Consequently, the High Court’s order was set aside, the appeal was allowed, and the appellant was awarded costs quantified at Rs 5,000.

In United India Insurance Company Limited v. Manubhai Dharmasinhbhai Gajera and Others^[143] The case at hand addresses whether the renewal of a Mediclaim policy is automatic upon the timely payment of the premium. Governed by the General Insurance Business (Nationalisation) Act, 1972, and related regulations, the appellants, subsidiaries of the General Insurance Corporation of India, operate within a monopolized framework for general insurance while being subject to the Insurance Act, 1938, and the Insurance Regulatory and Development Authority Act, 1999. The primary issues involved whether insurers can refuse renewal based on diseases contracted during the policy period, and whether government insurance companies can arbitrarily cancel or refuse to renew existing policies. The ruling clarifies that Mediclaim policies must be renewed without excluding diseases covered under existing policies, even if the insured contracts a disease during the previous policy period. It further states that such companies, as "State" entities under Article 12 of the Constitution of India, must act fairly and reasonably, ensuring that the right to refuse renewal is confined solely to exclusionary clauses within the policy. Ultimately, the court established that the renewal process should not become burdensome for the insurer due to the insured's medical history, and affirmed the obligation of insurance companies to conduct their operations fairly, in accordance with established regulations and principles of equity.

5.10.12 Fraudulent Claims in health insurance

In K.Subramanian @A.K.Subbu v. The State Rep.^[144] case involving Kandasamy’s death due to a motorcycle accident on July 9, 2001, the issue was the fraudulent insurance claims filed by legal representatives on behalf of Kandasamy’s heirs, which led to a CBI investigation. The relevant provisions included Section 304A¹⁴⁵ of the IPC concerning negligent acts causing death, as well as provisions related to conspiracy and forgery. The prosecution argued that the claims were based on forged documents and a conspiracy involving multiple individuals, including an advocate who allegedly orchestrated the fraudulent claim process. The defence contended that the accused acted based on client instructions without knowledge of any wrongdoing and highlighted that the original case had been disposed of, questioning the legality of reopening the investigation. The court ultimately found that the accused and others were complicit in filing the false insurance claim, leading to a ruling that upheld the prosecution’s arguments. The ratio decidendi emphasized the need for accountability in legal practices and highlighted the importance of addressing fraudulent claims to maintain the integrity of the insurance system.

In Life Insurance Corporation of India v. Smt. Bina Joshi^[146] ’ The facts involved the denial of a life insurance claim by LIC after the insured's death due to health complications. The issue cantered on allegations of non-disclosure and misrepresentation, as LIC contended that the insured had failed to disclose previous medical conditions when applying for the policy. The relevant provisions included Section 45¹⁴⁷ of the Insurance Act, 1938, which addresses misrepresentation and non-disclosure. The arguments from LIC emphasized that the non­disclosure was material to the risk assessment, justifying the repudiation of the claim. Conversely, appellant argued that LIC did not prove that the alleged misrepresentation was significant enough to affect the insurer’s decision to issue the policy. The National Consumer Disputes Redressal Commission ultimately ruled in favour of the appellant, stating that LIC failed to establish the materiality of the non-disclosed facts. The court emphasized that the insurer holds the burden of proof in cases of fraudulent claims, affirming that mere suspicion is insufficient for claim denial. This judgment reinforced the principle that insurers cannot reject claims without substantial evidence, highlighting the consumer's right to claim benefits under the policy. Thus, the ruling highlighted the importance of a fair adjudication process, ensuring that consumers are protected against arbitrary repudiation of legitimate insurance claims.

5.10.13 Misrepresentation and Non-Disclosure in health insurance

In Star Health and Allied Insurance Company Limited v. Sh. Amit Kumar,^[148] The insurance company repudiated the claim made by the insured, citing misrepresentation and non-disclosure of material facts regarding her health, specifically alleging that she failed to disclose her pre­existing condition of Ulcerative Colitis. The repudiation was based on a discharge summary from Kanishk Surgical & Super Speciality Hospital, which indicated that the insured was hospitalized for treatment from May 16, 2017, to May 29, 2017. The insurance policy was taken out on June 23, 2016. However, the insurance company did not provide any documentary evidence showing that the insured had previously been treated for the mentioned illness before obtaining the policy. The tribunal concluded that the insured could not be held responsible for misrepresentation, as there was no evidence of prior treatment for Ulcerative Colitis, and thus the insurer’s repudiation of the claim was unjustified. Although the insurance company refunded the premium amount of Rs. 2,541, this did not absolve them of their obligation to honor the legitimate claim made by the insured, leading to a finding of deficiency in service on the part of the insurance company.

In Reliance General Insurance Co. Ltd. v. M/s. Pramod Kumar Gupta^[149] The case revolved around a claim made by Pramod Kumar Gupta for hospitalization expenses after undergoing surgery. The insured had secured a health insurance policy from Reliance General Insurance, which he believed would cover his medical expenses. However, the insurer denied the claim, alleging that appellant had submitted fraudulent documents and misrepresented facts regarding his medical history. The issue was whether the insurer could reject the claim based solely on suspicions of fraud without substantial evidence to support such claims. Appellant argued that he had fully disclosed his medical history and that the insurer’s refusal to pay was unfounded and based on baseless assumptions. Reliance General contended that they had legitimate grounds to question the validity of the claim based on discrepancies in the medical documentation provided. The court ruled in favour of Gupta, emphasizing that the insurer had not provided any concrete evidence of fraudulent intent or misrepresentation. The judgment highlighted that the mere suspicion of fraud is insufficient to deny an insurance claim. The ratio decidendi highlighted that the burden of proof for establishing fraudulent claims lies with the insurer, which must demonstrate clear evidence of any wrongdoing rather than relying on conjecture. The Supreme Court reaffirmed the principle that insurance companies cannot deny legitimate claims without compelling proof, thereby protecting the rights of policyholders against arbitrary and unjust denial of claims based on mere suspicion of fraud. This case set a significant precedent in reinforcing the duty of insurers to substantiate claims of fraud adequately.

In Ms Geo Chem Laboratories Pvt. Ltd v. United India Insurance Co.^[150] The insured party filed a claim under an insurance policy, but the insurance company denied liability, citing non­disclosure and misrepresentation of material facts. Although the Delhi High Court had previously issued an order regarding the insurer’s liability, it had not conclusively settled the issue of liability or ruled out the insurer’s grounds of misrepresentation and non-disclosure. The issue was whether the Tribunal could adjudicate on the insurer’s grounds for denying the claim under the policy’s arbitration clause. Relevant provisions included Clauses 4, 13, and 15 of the policy, which outlined the insurer’s rights regarding non-disclosure and the limits of the Tribunal’s jurisdiction. The claimant argued that the insurance company was barred from asserting non-disclosure after the High Court’s order, while the insurer maintained it had reserved the right to invoke non-disclosure and misrepresentation grounds. The Tribunal, referencing Jumbo Bags v. New India Insurance (2016 )¹⁵¹, concluded it could not assess the reasonableness of the insurer’s denial due to Clause 15, which restricted itsjurisdiction in such cases. The decision left the claimant free to pursue the matter in a court with appropriate jurisdiction. The ratio decidendi was that, under similar policy clauses, the Tribunal lacks authority to review the insurer’s grounds for repudiation, as those matters fall under the jurisdiction of other legal forums.

5.10.14 Policy Coverage Disputes in health insurance

In United India Insurance Co. Ltd. v. Dinesh Kumar Bansal,^[152] The case involved a claim made by Dinesh Kumar Bansal for medical expenses incurred due to hospitalization after a serious illness. The Insured filed a claim under his health insurance policy with United India Insurance, which was subsequently denied by the insurer. The insurer alleged that the Insured had provided false information regarding his medical history and claimed that this constituted fraudulent misrepresentation. The issue was whether the insurer could deny the claim based solely on alleged misrepresentation without presenting substantial evidence of fraud. Relevant provisions included the Insurance Act, 1938, which governs the conduct of insurance companies in India. The Insured argued that he had been truthful about his medical history and that the denial of his claim was unjustified. The Supreme Court ruled in favour of Bansal, stating that the insurer failed to prove the allegations of fraud. The ratio decidendi emphasized that the burden of proof for establishing fraudulent claims rests with the insurer, and mere suspicion or conjecture cannotjustify the denial of a legitimate claim. Thisjudgment reinforced the principle that insurers must substantiate their claims of fraud with clear evidence to protect the rights of policyholders.

In Poonam Sood v. New India Assurance Co. Ltd.^[153] The case revolved around a claim made by Poonam Sood for reimbursement of medical expenses incurred during her hospitalization for a surgery. After undergoing treatment, she filed a claim under her health insurance policy with New India Assurance, which was initially rejected by the insurer. The rejection was based on the grounds that the surgery was pre-existing and thus not covered under the policy terms. The issue in this case was whether the insurer could deny the claim based on the allegation of a pre-existing condition without providing sufficient evidence to substantiate this claim. Relevant provisions included the Insurance Act, 1938, and the terms of the health insurance policy regarding coverage exclusions. Poonam argued that she had disclosed her medical history accurately and that the surgery was necessary and covered by her policy. The National Consumer Disputes Redressal Commission (NCDRC) ruled in favour ofPoonam, by referring the paragraph 10 thus, keeping in view the principle of law laid down by the Hon'ble National Commission, in the cases, referred to above, if interest @12% on the deposited amount for the period of delay, till delivery of possession of the unit, is awarded, that would meet the ends of justice." Not only as above, in H.P. Housing Board Vs. Janak Gupta [2009] INSC 627 (26 March 2009) (Civil Appeal No. 6346 of 2002), it was clearly held by the Hon'ble Supreme Court of India that in the cases of delay, in delivery of possession, award of interest @ 12% per annum, on the deposited amount, for the period of delay, would meet the ends of justice. Furthermore, under similar circumstances, where there was delay of around three years in handing over possession of the unit, the National Commission inM/s. Apex Buildtech Ltd. Vs. Madhu Talreja, Revision Petition No. 739 of 2017, decided on 10 April 2017, upheld grant of interest @18% p.a. on the deposited amount, for the period of delay. Relevant part of the said order reads thus: stating that the insurer failed to provide adequate proof of the alleged pre­existing condition and that the denial of the claim was unjustified. The ratio decidendi highlighted that the burden of proof lies with the insurer to demonstrate any exclusions in the policy effectively. This judgment reaffirmed that insurers cannot deny legitimate claims without substantial evidence and must adhere to principles of fair play and transparency in their dealings with policyholders.

In Vishal Gupta v. ICICI Lombard General Insurance Co. Ltd^[154]. The Supreme Court addressed a dispute arising from the rejection of a claim for theft of a vehicle insured under a comprehensive motor insurance policy. After Vishal Gupta's vehicle was stolen, he filed a claim with ICICI Lombard, which was denied on the grounds that the insured did not provide sufficient proof of theft and that there were inconsistencies in his claim documentation, particularly regarding the police report. The central issue was whether the insurer’s repudiation was justified given the alleged deficiencies in insured claim. The court ruled in favour of insured, asserting that the insurer could not reject the claim based solely on minor discrepancies. The Supreme Court emphasized the principle of good faith in insurance contracts, stating that the insured should not be penalized for insignificant documentation errors when they had made reasonable efforts to comply with the policy requirements. The court emphasised the need of contextualising the claim, so affirming the insured's right to coverage under the policy and ensuring that technicalities do not compromise the fundamental objective ofinsurance, which is to safeguard against loss.

5.10.15 Network Hospitals in health insurance

In Star and Allied Insurance Co. Ltd. v. R. S. Dhanraj^[155] The case concerned a health insurance claim filed by R. S. Dhanraj for medical expenses incurred due to a cardiac procedure. The insurer, Star Health, denied the claim, alleging that respondent had concealed critical information regarding his pre-existing medical conditions during the policy application process. The issue at stake was whether the insurer could deny the claim based on alleged concealment without providing sufficient evidence to support its assertions. The Insurance Act, 1938, which mandates insurers to establish clear grounds for denying claims based on non­disclosure or misrepresentation. Dhanraj contended that he had accurately disclosed his medical history and that the insurer’s denial was unwarranted. The Supreme Court ruled in favour of respondent, emphasizing that the burden of proof for proving fraudulent concealment lies with the insurer. The court held that mere suspicion or conjecture is inadequate to deny legitimate claims, reinforcing the principle that insurers must substantiate their allegations with clear and compelling evidence. This judgment underscores the protection of policyholders’ rights in insurance contracts.

In Smt. Poonam Kumari v. New India Assurance Co. Ltd.^[156] The Supreme Court addressed the denial of an insurance claim following the accidental death of Smt. Poonam Kumari's husband, who was riding a two-wheeler insured under a policy from New India Assurance. The insurance company repudiated the claim on the grounds that the insured was not wearing a helmet at the time of the accident, which they argued was a violation of the policy terms. The issue was whether this alleged violation justified the insurer's refusal to pay the claim. The court ruled in favour of Smt. Poonam Kumari, emphasizing that while adherence to safety regulations is important, minor infractions should not automatically result in the denial of a legitimate claim. The Supreme Court highlighted the principle of indemnity in insurance contracts, stating that the insurer must demonstrate that the breach of policy terms directly caused or contributed to the loss. The ruling reinforced the idea that policy conditions should not be interpreted in a way that denies rightful compensation to the insured, thereby upholding the purpose of insurance as protection against unforeseen losses and ensuring fairness in the treatment of policyholders.

In Vishal Gupta v. ICICI Lombard General Insurance Co. Ltd.^[157], The case involved a health insurance claim made by Vishal Gupta for expenses incurred during hospitalization due to an accident. After submitting his claim, ICICI Lombard denied the reimbursement, alleging that claimant had made false representations regarding the details of the incident leading to his hospitalization. The insurer contended that the discrepancies in Gupta's statements constituted fraudulent behaviour, thusjustifying the denial of the claim. The issue was whether the insurer could refuse to honour the claim based on allegations of misrepresentation without presenting substantial evidence to support its position. The claimant argued that he had provided accurate information regarding the accident, and the insurer's denial was both arbitrary and unjustified. The Supreme Court ruled in favour of claimant, holding that the insurer had failed to prove any fraudulent intent. The ratio decidendi established that the burden of proof for establishing fraud lies with the insurer, reaffirming that claims cannot be denied on mere suspicion and emphasizing the importance of transparency and fairness in insurance dealings.

5.10.16 Claim Settlement Ratios in health insurance

In Life Insurance Corporation of India v. Anuradha.^[158] Anuradha, the insured, had acquired a life insurance policy, but her claim was rejected by the Life Insurance Corporation (LIC) due to the non-disclosure of pertinent health information following her demise. The central question in the case was whether the insured had concealed any pertinent facts that would warrant the denial of the claim. Applicable sections encompassed the Insurance Act and the contractual duties for the disclosure of information by the insured. The LIC contended that the insured did not disclose a pre-existing medical condition, which they asserted was essential for their underwriting decision. Conversely, insured representatives asserted that all pertinent information had been revealed, and the claim ought to be fulfilled. The Supreme Court ruled in favour of Anuradha, asserting that the insurer must present unequivocal evidence of non­disclosure and its relevance to the risk. The ratio decidendi determined that mere non-disclosure does not inherently result in the repudiation of a claim unless it is demonstrated that the non­disclosure was important and affected the risk assessment, hence maintaining the principles of fair play and good faith in insurance contracts.

In HDFC Ergo General Insurance Co. Ltd. v. Shyam Sundar Choudhary.,^[159] The Supreme Court of India addressed the repudiation of a health insurance claim involving hospitalization expenses for a serious medical condition. The insurance company denied the claim, alleging that the insured had failed to disclose a pre-existing condition during the policy application process. The insurer contended that knowledge of this condition would have influenced their decision to issue the policy, either denying it or altering its terms. The Supreme Court examined the doctrine of utmost good faith, which requires insured individuals to disclose all relevant medical history. However, the Court clarified that mere non-disclosure does not automatically justify repudiation. It emphasized that insurers must prove that the undisclosed information was material enough to affect their risk assessment. After reviewing the case details, the Court determined that the insurer failed to demonstrate the significance of the alleged pre-existing condition to the underwriting process. Consequently, it ruled in favour of insured person deeming the repudiation unjustified and ordering the insurer to settle the claim with interest. This decision reinforced the obligation of insurers to substantiate their grounds for repudiation while balancing the duty of disclosure expected from policyholders.”

In Dhananjay Chaturvedi v. Oriental Insurance Co. Ltd.^[160] The Supreme Court of India examined a dispute regarding the repudiation of a Mediclaim insurance policy by Oriental Insurance Co. Ltd. The case arose when the complainant, Dhananjay Chaturvedi, filed a claim for hospitalization expenses incurred by his wife following an accident. The insurance company rejected the claim, citing that the treatment was received at a non-government hospital, which was against the terms of the policy. The issue was whether the repudiation of the claim was justified under the policy’s terms. The Supreme Court held that the insurer's denial was not valid. It emphasized that the primary objective of health insurance is to provide financial protection to the insured during medical emergencies. The Court noted that the complainant had been a long-term policyholder without prior claims and stressed the importance of a liberal interpretation of insurance contracts in favour of the insured. The Court ultimately ruled in favour of the insured ordering Oriental Insurance Co. Ltd. to pay the claimed amount, along with interest and costs. This case highlighted the need for insurance companies to adhere to fair practices and protect the interests of policyholders.

5.10.17 No-Claim Bonuses in health insurance

In Oriental Insurance Co. Ltd. v. K. B. Reddy, ^[161]

The insured, K. B. Reddy, challenged the refusal of Oriental Insurance Company to grant him a No-Claim Bonus (NCB) after a claim was made that allegedly misrepresented his claim history. The issue was whether the insurer could deny the NCB based on inaccuracies in the claims made by the insured. Relevant provisions included the Insurance Act and consumer protection laws, which safeguard the rights of policyholders. The insurer contended that the misrepresentations invalidated the eligibility for the NCB, arguing that such inaccuracies were significant. Conversely, the insured maintained that the NCB should be honoured regardless of the claim history, as it constituted a reward for being claim-free over the years. The National Consumer Disputes Redressal Commission adjudicated in favour of the insured, citing the judgement of the Bench in New India Assurance Company Limited vs. Asha Rani & Ors. [2001 (6) SCC 724], which determined that the ruling in Satpal Singh's case (2000 (1) SCC 237) was incorrectly decided. The Tribunal and the High Court were unjustified in determining that the insurer bore the responsibility to fulfil the award. It emphasizing that an insured person has a right to the NCB as part of their contract, and that minor inaccuracies should not negate such entitlements. The ratio decidendi established that insured individuals should be protected and rewarded for maintaining a claim-free record, reaffirming the importance of honouring contractual agreements and promoting responsible insurance behaviour. This ruling reinforced the principle that consumer rights must be upheld in the insurance sector.

In Srnt. Ranjana Roy v. National Insurance Co. Ltd.,^[162] The petitioner, Smt. Ranjana Roy, who was the widow of the deceased, Mr. Anil Kumar Roy, for compensation under the Motor Vehicles Act, 1988, following his death in a motor vehicle accident. The deceased was traveling as a passenger in a bus owned by the respondent, National Insurance Co. Ltd., which was insured under a policy that covered third-party liability. The vehicle was involved in an accident leading to fatal injuries to the deceased. The petitioner filed a claim for compensation under Section 166¹⁶³ of the Motor Vehicles Act,1988 seeking compensation for the death caused by the accident. The Insurance Company contested the claim, raising various defences, including that the vehicle was not carrying any passengers, as per the terms of the insurance policy. The Motor Accident Claims Tribunal, however, after evaluating the facts, awarded compensation in favour of the petitioner, ruling that the insurance company was liable to pay the compensation amount. Thejudgment also emphasized the importance of the insurance policy's terms and the liability of the insurer when a third-party claim is made under the provisions of the Motor Vehicles Act.

5.10.18 Waiting Periods in health insurance

In Dr. Kunal Kumar v. Reliance General Insurance Co. Ltd.^[164] The petitioner, Dr. Kunal Kumar, wasinjured while traveling as a passenger in a private car involved in an accident due to the negligent driving of the offending vehicle. The Claimant filed a compensation claim under Section 166¹⁶⁵ of the Motor Vehicles Act, 1988, seeking compensation for medical expenses and injuries sustained. Reliance General Insurance, the insurer of the offending vehicle, contested the claim, arguing that the insurance policy did not cover injuries to passengers in private vehicles, as the vehicle was not a public transport vehicle. The insurer invoked Section 147¹⁶⁶ of the Motor Vehicles Act, asserting that its liability did not extend to passenger injuries in private vehicles. The Motor Accident Claims Tribunal (MACT) ruled in favor of claimant, holding the insurance company liable to compensate for the injuries. The Tribunal observed that under the Motor Vehicles Act, the insurer's liability for accident-related injuries is automatic, irrespective of the passenger's status, as long as the accident resulted from the negligence of the driver. The Tribunal further noted that the insurer could not escape liability on the grounds that the injured party was a passenger in a private car. Consequently, the insurer was directed to compensate claimant for the injuries sustained.

In Smt. Usha Kumari v. New India Assurance Co. Ltd. ^[167] The case revolved around a claim for compensation under a motor vehicle insurance policy following a road accident resulting in the death of the insured. The issue was whether the insurer was liable to pay the compensation despite the policy's stipulations regarding the driver's qualifications. The relevant provisions included Sections 145¹⁶⁸ and 147¹⁶⁹ of the Motor Vehicles Act, 1988 which mandate coverage for third-party liability. The claimant argued that the insurer's denial of liability was unjustified, as the vehicle was being driven by a person with a valid license, while the insurer contended that the policy was void due to a breach of conditions regarding the driver’s qualifications. The Supreme Court held that the insurer could not escape liability as the policy was issued and the insured had complied with its terms. The ratio decidendi emphasized that insurers are bound to honour claims if the insured complied with policy terms, irrespective of the driver's qualifications, thereby promoting the public policy of compensating victims of road accidents. In Rakesh Kumar v. Oriental Insurance Co. Ltd^[170]. The incident originated from a lethal collision involving a vehicle covered by Oriental Insurance. The claimant, the father of the dead, requested reimbursement under the motor vehicle insurance policy, contending that the insurer was obligated to compensate for the death resulting from the insured car. The question was whether the insurer might reject liability due to the insured's non-disclosure of previous incidents. Applicable provisions encompassed Sections 146¹⁷¹ and 149¹⁷² of the Motor Vehicles Act, which regulates insurance obligations and third-party liability. The claimant asserted that the prior accidents were irrelevant to the claim, however the insurer maintained that the failure to disclose constituted a violation of the policy conditions. The Supreme Court found in favour of the claimant, holding that the insurer could not evade obligation due to prior accidents that did not affect the claim's validity.. The ratio decidendi highlighted that the insurer must establish how the non-disclosure materially affected the risk and that mere previous accidents did notjustify denial of compensation for third-party claims, upholding the principle of protecting victims of road accidents.

5.10.19 Sub-limits and Co-payment in health insurance

In Smt. Leela Wadhwa v. New India Assurance Co. Ltd. ^[173] The Supreme Court of India considered a case involving the refusal of an insurance claim relating to the hospitalization of the complainant, Smt. Leela Wadhwa. The complainant had bought a Mediclaim insurance from New India Assurance Co. Ltd. and incurred expenses for hospitalization due to a serious sickness. The insurance company denied the reimbursement claim, asserting that the treatment was not included in the policy coverage. The primary question was whether the denial of the claim was warranted according to the limitations and stipulations of the insurance policy. The Supreme Court determined that the insurer's denial of the claim was unlawful. It underscored the notion of indemnity in insurance agreements, asserting that the principal aim of insurance is to safeguard policyholders from financial losses resulting from unexpected medical situations. The Court emphasised that the insurer failed to sufficiently prove that the claim was excluded from the policy's coverage. Ultimately, the Supreme Court found in favour of the insured, mandating the insurance company to settle the claim and compensate for the accrued medical expenses. This ruling underscored the significance of equitable practices in the insurance industry and the duty of insurers to fulfil legitimate claims submitted by policyholders.

5.10.20 Policy Cancellation Charges in health insurance

In Reliance Life Insurance Co. Ltd. & Anr. v. Rekhaben Nareshbhai Rathod ^[174] The Supreme Court examined a pivotal matter regarding the denial of an insurance claim due to the failure to disclose pre-existing medical issues. The case pertained to Rekhaben Nareshbhai Rathod, who acquired a life insurance policy from Reliance Life Insurance Co. The insurance company rejected the claim following the policyholder's death, contending that she had not disclosed her medical history, which encompassed a significant pre-existing condition, during the policy application process. The central issue before the Court was the justification of the insurer's denial of the claim, considering the policyholder's failure to disclose her prior medical conditions. The Court emphasised the importance of the norm of absolute good faith in insurance contracts, which requires both parties to reveal significant facts pertinent to the covered risk. Nonetheless, the Court underscored that the insurer must prove that the non­disclosure was both wilful and significant to the risk evaluation. The Supreme Court determined that the insurer failed to adequately demonstrate that the non-disclosure influenced its decision to offer coverage. The Supreme Court ultimately found in favour of the insured, instructing Reliance Life Insurance Co. to disburse the insurance claim, including interest. This ruling emphasised that although policyholders are obligated to reveal material facts, insurers are also required to demonstrate that such non-disclosure substantially affected the policy's terms and conditions. The ruling emphasised the significance of equity in insurance transactions and the safeguarding of consumer rights.

In Oriental Insurance Co. Ltd. v. T.H. Abdul Kade^[175] The respondent, T.H. Abdul Kader, was engaged in a vehicular collision while operating a motorbike insured by Oriental Insurance Company. Subsequent to the collision, he had injuries and sought compensation under the insurance coverage. The central question was whether the insurer was obligated to provide compensation for the injuries incurred by the insured, considering the policy terms and the purported violation of conditions by the insured. Section 149 of the Motor Vehicles Act, 1988, along with the pertinent clauses of the insurance contract about coverage and exclusions. The insurance company said that the motorbike was operated by an individual lacking a valid driving licence, thereby breaching the policy terms. Conversely, the insured argued that the driver possessed a valid licence and that the insurer was obligated to indemnify him irrespective of the purported violation. The Supreme Court found in favour of the insured, concluding that the insurance company could not evade its liability due to technical infractions when the insured had made reasonable efforts to adhere to the policy conditions. The ratio decidendi underscored the idea of safeguarding the insured against unjust repudiation and stressed the necessity for insurers to unequivocally demonstrate a breach of policy terms to avoid liability.

5.10.21 Policy Lapse and Revival in health insurance

In Sri Benson George v. Reliance General Insurance Co. Ltd^[176]. The Supreme Court evaluated the legitimacy of an insurance claim concerning motor vehicle insurance. The appellant, Sri Benson George, submitted a claim for damages subsequent to a motor accident involving his car, covered by Reliance General Insurance Co. Ltd. The insurer denied the claim, asserting that the car was operated by an unlicensed driver during the accident, which they contended violated the insurance policy's conditions. The primary legal issue was whether the lack of a valid driving licence for the vehicle operator at the time of the accident nullified the insurance coverage. The Court determined that although possessing a valid driving licence is a fundamental prerequisite for the validity of an insurance coverage, it should be assessed in light of the particular circumstances of the case. The Court underscored that the insurer is required to demonstrate that the violation of this condition was significant to the cause of the accident or that it would have affected the insurer's decision to extend coverage. The Court found in favour of the insured, determining that the insurer did not prove that the absence of a valid driving licence was directly connected to the circumstances of the accident. Consequently, the Court directed Reliance General Insurance Co. Ltd. to honour the claim and provide compensation for the damages incurred. Thisjudgment highlighted the principle that insurance companies must act fairly and substantiate their claims of policy breaches, ensuring consumer protection within the insurance framework.

In LIC of India v. Dharam Vir Anand^{[177] [178]} The policyholder acquired a life insurance policy from the Life Insurance Corporation of India (LIC). Subsequent to his death, the claimant pursued the insurance benefits; however, LIC rejected the claim citing non-disclosure of a pre­existing medical condition. The central question was whether the insurer may legitimately deny the claim due to the insured's purported non-disclosure of pertinent health information. Section 45 of the Insurance Act, 1938, and the principles of utmost good faith that regulate insurance contracts. The claimant contended that he had revealed all relevant facts and that the LIC's reliance on non-disclosure was unwarranted. The Supreme Court found in favour of the policyholder, determining that the LIC had not demonstrated that the insured had intentionally withheld material information or misrepresented his health condition. The court asserted that simple non-disclosure does not inherently grant the insurer the right to reject the claim unless it is demonstrated that the non-disclosure was deliberate and materially influenced the insurer's risk evaluation. The ratio decidendi emphasised the significance of equitable treatment in insurance claims, underscoring that insurers bear a substantial burden of proof when asserting non-disclosure as a basis for repudiation.

5.10.22 Grievance Redressal in health insurance

In BS Jaisimha v. Reliance General Insurance Company.[1711], The case concerns a claim by B.S. Jaisimha for damages to his vehicle resulting from an accident, which Reliance General Insurance denied, alleging the non-disclosure of pertinent information regarding the driver's qualifications and the vehicle's modifications. The central issue was the validity of the claim's denial based on the claims of non-disclosure. Section 45 of the Insurance Act, 1938 encompasses the obligations of disclosure mandated by the Insurance Act, 1938, as well as the specific stipulations of the insurance policy. The insured asserted that he had supplied all requisite information and that the insurer failed to demonstrate that any purported non­disclosure significantly impacted the risk. The court determined that Reliance General Insurance did not sufficiently prove that the non-disclosure was both material and wilful, resulting in a decision favouring the insured. The ratio decidendi emphasised that insurers must demonstrate that any non-disclosure directly influences the underwriting decision to validate claim repudiation, highlighting the principles of good faith and the obligation for insurers to operate equitably in the claims procedure.

In Om Prakash Ahuja v. Reliance General Insurance Co. Ltd.^[179], The case of Om Prakash Ahuja versus Reliance General Insurance Co. Ltd. pertains to the determination of culpability under an insurance policy subsequent to a motor vehicle collision. The case was to a compensation claim under a motor insurance policy following a vehicular accident, in which the insured, Om Prakash Ahuja, sought damages against Reliance General Insurance business, contending that the business neglected to fulfil the claim as stipulated in the policy conditions. The primary legal question was whether the insurance company was obligated to indemnify the insured, considering the policy terms and the details of the incident. The court assessed whether the insurer had complied with section 45¹⁸⁰ the Insurance Act, 1938, and relevant provisions of the section 149¹⁸¹ of the Motor Vehicles Act, 1988. The court determined that the insurance company was obligated to fulfil the claim, as it had not presented adequatejustification for the policy's repudiation. Thejudgement confirmed the duty ofinsurers to handle claims fairly and reasonably, in accordance with the statutory requirements of the Insurance Act and the Motor Vehicles Act.

5.10.23 Policy Wordings and Brochures in health insurance

In Biman Krishna Bose v. United India Insurance Co. Ltd.^[182], The Supreme Court addressed the issue of delay in honouring an insurance claim. The brief facts of the case were that Biman Krishna Bose had a shop insurance policy with United India Insurance to cover damage or loss to his shop. His shop was burgled, and he immediately filed a claim. However, despite repeated follow-ups, the insurance company delayed the settlement for an extended period. The issue involved was whether the prolonged delay in claim settlement constituted deficiency of service. The Consumer Protection Act, 1986, concerning consumer rights and remedies for service deficiencies. The insured argued that the insurance company’s delay amounted to a deficiency of service, violating his rights as a consumer, while United India Insurance contended that they were justified in their procedural delays due to verification requirements. The Court ruled in favour of insured , determining that undue delay in processing and settling insurance claims is indeed a deficiency in service and violates consumer rights. The ratio decidendi was that insurance companies have a duty to process claims in a reasonable timeframe, and failure to do so, without valid reasons, constitutes deficient service under consumer protection laws. This case highlighted the obligation of insurers to immediately fulfil their commitments to policyholders.

In National Insurance Co. Ltd. v. Seema Malhotra & Ors^[183]. Seema Malhotra submitted a claim to National Insurance Co. Ltd., which was rejected due to purported non-disclosure of pertinent information. The matter at hand was thejustification of National Insurance's rejection of the claim due to the insured's alleged non-disclosure. The pertinent legal elements were the principles of good faith in insurance contracts and consumer protection legislation, which protect against unjust claim denials. The claimant contended that she had supplied all requisite information during the policy application, and the rejection of her claim was unjustified. National Insurance asserted that the claim was invalid owing to the non-disclosure of certain health problems. The court ruled in favour of the claimant, saying that the insurer could not deny the claim without clear and compelling evidence of intentional deception or fraud by the insured. The ruling affirmed that insurers are obligated to fulfil legitimate claims, and any uncertainties must be interpreted in favour of the policyholder. The court emphasised the necessity for transparency and equitable conduct by insurers, especially in the interpretation and application of policy exclusions or conditions.

In United India Insurance Co. Ltd. v. M/s. Sharma and Sons^[184] M/s. Sharma and Sons, a partnership firm, requested reimbursement from United India Insurance Co. Ltd. for products lost to theft. The insurance company denied the claim due to purported non-disclosure of significant facts and breach of policy conditions. The central question was whether the insurer had legitimate reasons to reject the claim due to purported non-compliance with the policy terms and misrepresentation. The tenets of insurance contract law, namely pertaining to disclosure and policy stipulations. The complaint contended that all requisite information had been submitted and that the insurer's denial was unwarranted. The court ruled in favour of the insured and his sons, determining that the insurer did not substantiate the claims of non­disclosure and that the repudiation lacked sufficient evidence. The ruling underscored that insurers are required to not only comply with the standards of utmost good faith but also to furnish unequivocal evidence of any violations of policy conditions by the insured. The court's ratio decidendi emphasised the insurer's duty to prove that any claimed non-disclosure significantly affected the risk, so strengthening consumer protection in insurance issues.

5.10.24 Principle of Good Faith (Uberrimaefedai) in health insurance

In Satwant Kaur Sandhu v. New India Assurance Co. Ltd^[185] The Supreme Court examined the insurer's authority to deny an insurance claim based on the insured's failure to disclose material facts. Satwant Kaur, the policyholder, possessed a Mediclaim policy with New India Assurance and filed a claim for medical expenses associated with her cardiac ailment. The insurance company denied the claim, asserting that she failed to reveal her history of heart disease and diabetes medication in the application form. The matter at hand was whether the non-disclosure of her pre-existing medical issues could warrant the repudiation of the claim. The pertinent rules encompassed the principle of absolute good faith in insurance contracts, mandating the insured to reveal all material information that could affect the insurer's decision to offer coverage. The insured contended that the omission was unintentional and should not result in the denial of the claim. Nonetheless, the insurer contended that had it been aware of these medical concerns, it may have refused coverage or enforced elevated prices. The Court ruled in favour of the insurer, determining that the insured's non-disclosure of known, material information constitutes a violation of the obligation of greatest good faith, which is fundamental to insurance contracts. The ratio decidendi held that the insured's omission of known, material facts constituted misrepresentation, enabling the insurer to legitimately reject the claim, as the undisclosed information substantially influenced the insurer's risk evaluation. This decision underscored the necessity for complete and precise disclosure by the insured in all insurance agreements.

In Mithoolal Nayak v. Life Insurance Corporation of India^[186] The Supreme Court evaluated the ramifications of fraudulent deception inside an insurance contract. The essential facts of the case indicate that Mithoolal Nayak acquired a life insurance policy from LIC but neglected to reveal his medical history of tuberculosis. Following his demise, LIC rejected the policy, citing substantial non-disclosure and fraud. The matter at hand was whether LIC was warranted in rejecting the claim due to Mithoolal's failure to disclose his sickness. The pertinent sections encompassed the principles regulating fraudulent deception and the obligation of disclosure in insurance agreements. The appellant stated that the exclusion of his medical history was not meant to deceive the insurer, but LIC asserted that the misrepresentation influenced its risk assessment and policy issuance decision. The Court ruled in favour of LIC, determining that Mithoolal's deliberate non-disclosure of a substantial health problem amounted to fraud. The ratio decidendi established that in insurance contracts, any misrepresentation or concealing of material information by the insured may nullify the policy, especially if it would have affected the insurer's choice to assume the risk. This case underscored the significance of complete and truthful disclosure in insurance contracts.

5.11 Conclusion

The court plays a vital role in adjudicating health insurance claims by establishing a legal framework to settle disputes between policyholders and insurance companies. Individuals may initiate legal action to get compensation or assert their rights when an insurance provider denies a claim or fails to make timely payment. To guarantee that both parties meet their contractual duties, courts interpret the terms and circumstances of health insurance contracts. Thejudiciary can offer clarification in situations where policy language is vague or ambiguous by applying a fair interpretation to the policyholder. Additionally, by holding insurers responsible for unfair or dishonest conduct, like unwarranted claim delays or denials, thejudiciary protects consumer rights. Courts also make guarantee that laws and rules aimed at protecting consumers which requires specific protections for policyholders are followed. The Court rulings establish legal precedents that direct future health insurance claim processing, promoting uniformity and equity in the sector. The judiciary not only interprets and also upholds the contracts but also functions as a check on the influence of insurance firms, making sure that big businesses don't take advantage of policyholders. In the end, the legal system plays a crucial role in preserving public confidence in health insurance programs and guaranteeing that people can obtain the coverage to which they are legally entitled.

CHAPTER VI DATA ANALYSIS AND INTERPRETATION

In this chapter, the data related to characteristics of respondents is analyzed and the findings are presented and discussed. Socio-economic status of study respondents, awareness and understanding about health insurance schemes, awareness and elements/ aspects of health insurance products, reasons for choosing health insurance policy, policy holder experiences, nature of breach, main reasons for breach. Impact of breach of contract, the impact of fraudulent, legal and regulatory framework, current settlement claim process, suggestions and recommendations are described in detailed here.

TABLE 6.1 DISTRIBUTION OF THE STUDY POPULATION BY GENDER

The term “Gender” is socially constructed, and it denotes the characteristics, roles, attitudes, cultural behaviours and social behaviour of being a men and women. Moreover, the social behaviours related to gender may vary depending on the society.

Abb. in Leseprobe nicht enthalten

Source: Field Data

Table 6.1 indicates that a great proportion of the study respondents are male, with 48% of study population being female. Thus, the survey concludes that major proportions of male were interested in participating in the research survey and it displays a gender disproportion in the study.

TABLE 6.2 DISTRIBUTION OF STUDY RESPONDENTS BY THEIR AGE GROUP

Age is considered as important and significant unit of analysis in all social statistical survey.

Abb. in Leseprobe nicht enthalten

Source: Field Data

From the above Table 6.2, we can understand that the main percentage of the study participants comes under the age group of 31-40 years old, followed by 18-30 years (21%), 41-50 years (20%), 51-60 years (19%), and 61 and above (2%). So, the study demonstrates that a greater number of study participants are from 31 years old to 40 years old.

The average age (Mean) of this legal survey is 32 years old.

Abb. in Leseprobe nicht enthalten

FIGURE 6.1: RESIDENTS OF STUDY POPULATION

Abb. in Leseprobe nicht enthalten

Source: Field Data

Figure 6.1 above illustrates the residential distribution of the study respondents. Among the selected study population, a major number of selected respondents (70%) are from urban areas, whereas the remaining of them (30%) reside in rural areas. This data pointed out a major urban representation within the sample, with a smaller percentage of study respondents coming from rural places. The survey gives an insight into the topographical contextual of the study respondents in the research.

TABLE 6.3 THE BELOW TABLE PRESENTS THE OCCUPATION OF STUDY RESPONDENTS

Abb. in Leseprobe nicht enthalten

Source: Field data

It is evident from the above Table 6.3 that the majority (43%) of study respondents are employed in the private sector, followed by advocates (25%), academicians, and doctors (13%), business (4%), and public servants (2%). Thus, the study concludes that a greater number of selected study respondents are working in the private sector, as well as this survey depicting the lower interest of the study respondents in engaging in their own business in the study area.

TABLE 6.4 DISTRIBUTION OF THE STUDY RESPONDENTS BY THEIR EDUCATIONAL QUALIFICATION

Education is a fundamental factor in the development and upliftment of the society. Education eliminates the ignorance from the people and enhance knowledge and skills of people. Every country has their own education system.

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above Table 6.4 reveals that sixty-two percent of the study respondents have an undergraduate degree, followed by 20.3% with a postgraduate degree, 15.2% with a professional degree, and 2.5% with a higher secondary education. The survey highlights that more than half of the study respondents have degrees in various streams.

Abb. in Leseprobe nicht enthalten

TABLE 6.5 REPRESENTS THE MARITAL STATUS OF THE STUDY POPULATION

Marriage is considered one of the important social institutions that regulates the behaviours of human being. Marriage is sanctioned and recognized by the law. According to law, marriage is legal or customary unification between the people. In India, marriage system varies by the religion. According to the honorable Supreme court of India, a marriage certificate is mandatory for the couples to legally recognize their marriage.

Abb. in Leseprobe nicht enthalten

Source: Field Data

Out of the total 315 study participants, the majority of the study population are married, followed by unmarried (18%) and widowed (2%). Thus, the study concludes that the greater number of study respondents are married.

Abb. in Leseprobe nicht enthalten

TABLE 6.6 DISTRIBUTION OF THE STUDY RESPONDENTS BY THEIR ANNUAL INCOME

Abb. in Leseprobe nicht enthalten

Source: Field Data

Table 6.6 reveals that less than half of the study participants (46%) earn less than Rs.250,000 annually, followed by Rs.250,001-500,000 (28%), Rs.500,001-1,000,000 (21%), and above Rs.1,000,001 (5%). Hence, the survey concludes that very few study respondents earn above Rs. 100,000 in the selected study area.

Abb. in Leseprobe nicht enthalten

TABLE 6.7 REPRESENTS THE POLICY HOLDER OF HEALTH INSURANCE

Abb. in Leseprobe nicht enthalten

Source: Field data

Among the selected study respondents, a larger portion of study respondents have health insurance policies, and only nine percent of the total population do not have health insurance policies. Thus, Table 6.7 concludes that people are more conscious about their health and invest money to protect themselves from more medical expenses for surgery, treatments, etc.

TABLE 6.8 DEPICTS THE TYPE OF HEALTH INSURANCE POLICY

Abb. in Leseprobe nicht enthalten

Source: Field Data

Among 287 health insurance policyholders, the majority of the study respondents (44%) have family floater health insurance, followed by individual health insurance (24%) and group health insurance (23%). The findings of the survey demonstrate that a significant percentage of study participants select family floater plans.

FIGURE 03: MODE OF PAYING HEALTH INSURANCE PREMIUM

Abb. in Leseprobe nicht enthalten

Source: Field Data

Out of a total of 315 individuals, 92 (29%) pay their health insurance premium annually, making it the most common payment frequency. This is followed by quarterly payments (28%), monthly payments (27%), and half-yearly payments (16%). Thus, the figure 6.2 reveals the preferred payment schedules of the participants, with yearly payments being the most popular choice among them.

TABLE 6.9 DISTRIBUTION OF THE STUDY RESPONDENTS BY THE SOURCE OF AWARENESS ABOUT HEALTH INSURANCE

Health insurance policies or schemes are playing an inevitable role in protecting the health care for the people. More resources are being assigned to spread the advertisements regarding health insurance policies. Social medias, agents, advertisements in television are the major platforms for promoting the health insurance schemes. The Government of India has also launched Ayushman bharat -Pradhan Mantri Jan Arogya Yojana to provide the health care to the unreachable.

Abb. in Leseprobe nicht enthalten

Source: Field Data

Based on the collected data from Table 6.9, it is evident that more than half of the study respondents (52%) became aware of health insurance through agents followed by banks (25%), social media (20%) and others (friends, wats app group, neighbors, users). In the concluding remarks, the study highlights the role of agents as the primary source of information about health insurance for the majority of participants.

AWARENESS ON THE ELEMENTS/ASPECTS OF HEALTH INSURANCE PRODUCT

Health insurance is a contract between the insurer and the policyholder. It provides coverage to policyholders, protecting them from financial burdens when they incur medical expenses. All the responses related to the awareness on the elements/ aspects ofhealth insurance product is presented in the Table numbers 6.10, 6.11, 6.12,6.13, 6.14, 6.15, 6.16, 6.17, and 6.18.

TABLE 6.10 REPRESENTS THE TYPE OF HEALTH INSURANCE PRODUCT

Abb. in Leseprobe nicht enthalten

Source: Field Data

The collected data from Table 10 reveals that thirty percent of the study respondents have a moderate awareness about the types of health insurance products, followed by strongly aware (28%), not aware (26%) very aware (10%), and extremely aware (6%). Hence, the survey indicates varying levels of awareness among the participants regarding health insurance products.

TABLE 6.11 DEPICTS AWARENESS ON THE COVERAGE OF HEALTH INSURANCE

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the awareness ofhealth insurance coverage among the study respondents, 40 percent of the study respondents reported being slightly aware, followed by 31% who are moderately aware, 13% who are very aware, 10% who are not aware, and 6% who are extremely aware. Thus, the study indicates that a particular portion of the study respondents only have a basic awareness and understanding about the health insurance coverage. The findings highlight the need for increased efforts to educate the public and raise awareness about the details and benefits ofhealth insurance policies.

TABLE 6.12 REPRESENTS INCLUSION (DISEASE COVERAGE)

Abb. in Leseprobe nicht enthalten

Source: Field Data

From the above Table 6.12, we can observe that thirty percent of the study population are moderately aware of the inclusion of disease coverage under the health insurance schemes that they bought, followed by slightly aware (29%), very aware (18%), not aware (13%), and extremely aware (4%). Thus, the study indicates that the health insurance companies or the agents should explain to the insurance holder the disease coverage. Because, when the insurance holders are suffering while they are claiming their insurance, the same findings were also reflected in the study of Rajarama et al. (2019); there is a gap between the rural health insurance holders and urban insurance holders.

TABLE 6. 13 PORTRAYS THE AWARENESS ON EXCLUSIONS (DISEASES NOT COVERED)

Abb. in Leseprobe nicht enthalten

Source: Field data

From the above Table 6.13, we can get to know about the awareness level of study respondents on the exclusion of diseases not covered under their health insurance schemes: twenty- nine percent of the study respondents are slightly aware (29%), followed by moderately aware (28%), very aware (18%), not aware (17%), and extremely aware (7%). Thus, the survey concludes that a very low number of the study population is only aware of the health insurance schemes’ diseases not covered.

TABLE 6.14 EXPLAINS THE AWARENESS LEVEL OF STUDY RESPONDENTS REGARDING THE HOSPITAL LINKED WITH HEALTH INSURANCE SCHEMES

Abb. in Leseprobe nicht enthalten

Source: Field Data

From the above Table 6.14, we can get to know that thirty- three percent of the study respondents are slightly aware of the hospital linked with the health insurance schemes, followed by moderately aware (27%), not aware (17%), very aware (14%), and extremely aware (9%). Therefore, the study concludes that effective measures should be taken to spread awareness about the health insurance schemes and whether the health insurance schemes are connected with hospitals or not in their locality, which will help the clients use their insurance properly.

TABLE 6.15 DEMONSTRATES NON-PAYMENT VOIDS

Abb. in Leseprobe nicht enthalten

Source: Field Data

The collected data in the Table 6.15 illustrates that thirty percent of the selected study respondents reported that they are slightly aware followed by moderately aware (27%), very aware (20%), not aware (18%), and extremely aware (4%). Therefore, the study concludes that very less number of the study respondents in the research area are aware the non-payment voids.

TABLE 6.16 INDICATES THE CASHLESS PAYMENT FACILITY

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the cashless payment facility, thirty-eight percent of the study respondents are moderately aware, followed by slightly aware (24%), very aware and not aware (14%), and 266 extremely aware (10%). Thus, the study concludes that the least number of people from the total study respondents of 315 are extremely aware of the cashless payment facility in the study area. This cashless payment facility will prevent the people from the fraudulent. Moreover, the government of India also has introduced the scheme “Pradhan Mantri Gramin Digital Saksharta Abhiyan” to encourage digital literacy and make awareness for the secure transaction in the rural areas also.

TABLE 6.17 DEMONSTRATES THE DIFFERENT PROMOTIONAL EVENTS

Promotional events in the insurance fields are the significant techniques to convey the offers and coverage of insurance schemes to the new customers. Recently, health summit was conducted by the confederation of Indian Industry on October 22, 2024 in Mumbai to address the issues and challenges in the insurance sectors.

Abb. in Leseprobe nicht enthalten

Source: Field Data

Now a days, promotional events are very common everywhere that helps to sale their health insurance products. Regarding the various promotional events, the Table 6.17 displays that thirty two percent of the study respondents are aware followed by moderately aware (30%), not aware (18%), very aware (14%) and extremely aware (6%). Therefore, the study concludes that more than 70 percent of the study respondents are aware about the promotional events in the study area.

TABLE 6. 18 DISPLAYS THE AWARENESS ABOUT CLAIM SETTLEMENT

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above Table 6.18 depicts the claim settlement procedures. Among the 315-study population, thirty two percent of the study respondents are moderately aware followed by slightly aware (25%), not aware (21%), very aware (13%), extremely aware (9%). Thus, the study concludes that 79 percent of the study respondents are aware of claim settlement, but only 9 percent of the people only having more awareness rather than others. Therefore, the study recommends that the health insurance agents have to give detailed explanation about the claim settlement as well as they have to assist their policy holders during claim settlement process.

OPINION OF THE STUDY RESPONDENTS ABOUT THE REASONS FOR TAKING HEALTH INSURANCE POLICY ARE PRESENTED IN THE BELOW TABLES 6.19, 6.20, 6.21, 6.22, 6.23 AND 6.24.

TABLE 6.19 DEPICTS THE TAX SAVING INSTRUMENT

Abb. in Leseprobe nicht enthalten

Source: Field Data

Out of the total study population, thirty one percent of the study respondents are strongly agreed that the health insurance policy was taken for tax saving purposes followed by agree (30%), neutral (24%), disagree (10%) and strongly disagree (4%). Therefore, the study concludes that only thirty percent of the total population only accepted that health insurance scheme is taken for income tax saving purposes.

TABLE 6.20 INDICATES FAMILY HEALTH NEEDS

Abb. in Leseprobe nicht enthalten

Source: Field Data

Of the total population, less than half of the study respondents agree that health insurance policy was taken for only health care needs followed strongly agree (28%), neutral (22%), disagree (3%) and strongly disagree (2%). Hence, the study shows in the concluding remarks that a greater number of people give priority to the health care of their own family members.

TABLE 6. 21 INDICATES THE AVAILING GOOD QUALITY MEDICAL TREATMENT

Abb. in Leseprobe nicht enthalten

Source: Field Data

Among the total population (315), thirty four percent of the study population agreed with the statement about availing good quality medical treatment followed by neutral (33%), strongly agree (25%), disagree (7%), strongly disagree (2%). Based on the collected data, the survey concludes that the study respondents personally feel that they are getting good medical treatment, particularly through the use of their health insurance products.

TABLE 6. 22 DEPICTS THE ATTRACTIVE INSURANCE POLICY

Abb. in Leseprobe nicht enthalten

Source: Field Data

Of the total population, 109 study respondents with 35% were neutrally about the selection of an attractive health insurance policy followed by agree (29%), disagree (17%) strongly agree (17%) and strongly disagree (2%). Based on the conclusion, the study depicts that less number of study respondents only selected their health insurance product based on the offer and easy claims settlement process.

Abbildung in dieser Leseprobe nicht enthalten

TABLE 6.23 REPRESENTS RISK COVERAGE AGAINST OLD AGE ILLNESS

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the reasons for choosing their health insurance product/ policies, 30 percent of the study respondents agreed with the statement about risk coverage against old -age illness followed by neutral (28%), strongly agree (28%), strongly agree (8%) and disagree (7%). Therefore, the study concludes that more than half of the study respondents selected their health insurance products based on whether the insurance company offered full health care coverage for old age illness.

TABLE 6. 24 SHOWS RISK UNEXPECTED ILLNESS IN THE FUTURE

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above Table 6.24 reveals that thirty seven percent of the study respondents agreed with the statement about the risk unexpected illness in the future followed by neutral (26%), strongly agreed (24%), disagree (8%) and strongly disagree (4%). Hence, the study found that the study participants have chosen their health insurance product to protect their health from the unexpected risk ofhealth issues or illness in future.

TABLE 6.25 INDICATES ASPECTS REGARDING WHILE CHOOSING HEALTH INSURANCE POLICY

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the aspects measured when choosing health insurance policy, 99 respondents with 31% are satisfied with existing customers followed by services are provided effectively by the insurance executives (19%), reputation of the insurance company (19%), ability and knowledge of employees, brokers & agents (17%), salary tax deduction, health linkage of company / TPA with hospitals. Based on the collected data, the study concludes that 30 percent of the study respondents are fulfilled with their standing as present clients.

THE ANSWERS ARE PRESENTED IN THE TABLE 6. 26 REGARDING WHETHER THE INSURER INFORMED THE STUDY RESPONDENTS ABOUT THE ALL MATTERS CONNECTED WITH SETTLEMENT OF CLAIMS AT THE TIME OF ENTERING INTO THE CONTRACT.

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding whether the insurer informed the study respondents about the matters connected with settlement of claims at the time of entering into the contract, forty -three percent of the study population answered positively and stating that insurer disclosed all matters connected with claim settlement during contract formation followed by Partially -Insurer provides limited information on claim settlement aspects (29%), No- Insurer does not inform about claim settlement details at contract formation (21%) and Depends -Disclosure is up to the insurer and is guided by regulatory requirements (7%). Thus, the study concludes that less than half of the study respondents only answered favorably.

TABLE 6.27 SHOWS WHETHER EVER AVAILED (OR) TRIED CLAIM WITH THE INSURANCE COMPANY

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above analysis shows that a greater number of study respondents are positively replied that they tried to get claim with the insurance company and while rest of the survey participants did not get themselves of claim. Based on the data, the study completes that the higher proportion of the study respondents have approached the insurance company for a medical claim.

TABLE 6.28 PRESENTS THE RATING ABOUT CLAIM PROCESS

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the ratings given to the claim process, thirty percent of the study population rated the clarity of communication regarding claim requirements and the timeliness of claim processing as satisfactory and met expectations, respectively. It was followed by the fairness of claim settlement amount was adequate (26%), ease of submitting necessary documentation for the claim was convenient (9%) and overall satisfaction with the handling of the claim process was high (5%).

THE RESPONSES ARE PRESENTED IN THE TABLE 6. 29 REGARDING WHETHER THE INSURER PROVIDES CLEAR GUIDELINES FOR APPEALING DENIED CLAIMS.

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding whether the insurer provides clear guidelines for appealing denied claims, most of the study respondents (60%) positively answered while the remaining of the study respondents replied negatively (40%). In the concluding remarks, the study shows that more than half of the study respondents have received proper guidelines from their agents or health insurance company about appealing denied medical claims.

TABLE 6. 30 SHOWS THE MISINTERPRETATION OF THE POLICY TERMS BY THE INSURANCE COMPANY

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above analysis explains that majority of the study respondents (75%) responses are positively reflected on the statement that the breach was instigated by the insurance company due to a misinterpretation of the policy terms and while the remaining of the survey participants disagreed the statement. Therefore, the study concludes that most of the study respondents felt that the insurance companies provide a misinterpretation of the product terms.

TABLE 6. 31 WHETHER INSURANCE COMPANY PROVIDING VALID REASON FOR THE DENIAL OR PARTIAL PAYMENT OF YOUR CLAIM.

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above Table 6.31 indicates that a greater number of the study population negatively replied to the statement regarding whether the insurance company provides valid reasons for the denial or partial payment of their claim, while the rest of the participants positively replied, indicating that they received favorable answer from the insurance company. Therefore, the study says that larger number of the study population did not receive any proper explanation and notification for partial payment of their medical claim.

TABLE 6. 32 INDICATES WHETHER THE INSURANCE COMPANY PROVIDING CLEAR POLICY TERMS

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above analysis shows that majority of the study respondents (60%) are positively replied that they received clear information about the terms and conditions of their health insurance policy when they purchased and rest of the study people reported negatively, indicating that they did not get clarity about the terms and conditions of their health insurance policy.

TABLE 6. 33 DENOTES ESCALATING THE BREACH TO A HIGHER AUTHORITY WITHIN THE INSURANCE COMPANY

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the escalating the breach to a higher authority within the insurance company, fifty three percent of the study respondents positively answered, while the rest of the study respondents replied negatively. Based on the conclusion, the study indicates that fifty three percent of the study respondents are answered positively.

TABLE 6.34 DENOTES THE SETTLEMENT TIMING

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the insurance claim settlement timing, the above Table 34 shows that thirty six percent of the study respondents answered that it would take 90 to 180 days followed by above 180 days (30%), 30 to 90 days (15%), less than 30 days (11%) and not yet settled (8%). Thus, the study concludes that settlement time varies and depends on the medical expenses and the nature ofhealth insurance policies.

TABLE 6. 35 ISSUES RELATED TO HEALTH INSURANCE POLICY WHILE SETTLEMENT

Abb. in Leseprobe nicht enthalten

Source: Field Data

The collected data in Table 35 reveals that 244 study respondents with 77.5% reported facing problems when tried to get health insurance settlement, while the rest of the study respondents have not faced any issues during claims settlement process in the study area. Based on the above data, the study concludes that a greater number of the study respondents faced issues during medical claim settlement.

TABLE 6. 36 INDICATES THE NATURE OF BREACH

Abb. in Leseprobe nicht enthalten

Source: Data Collection

Among the 244 study respondents who faced problems during health insurance claim settlement process, the above Table 36 indicates that thirty nine percent of the study respondents mentioned the lack of an efficient grievance redressal system as the key issues followed by more disease out of coverage (exclusion), low cooperation ofinsurance executives (15%), tendency to charge high rates for medical services (10%), excessive & complicated documentation (8%) and delay or denials in claim settlement (5.5%).

TABLE 6.37 PORTRAYS THE DIFFICULTIES IN CLAIM SETTLEMENT PROCESS

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above table 6.37 explains the difficulties in the claim settlement process. Out of the total population, 86 study respondents with 27.3% stated complications in understanding policy terms and coverage limitations followed by submitting required documentation and paper work (27%), communicating with insurance representatives of claims adjusters (24.4%), resolving disputes/disagreements over claim decisions and waiting for claim approval or processing delays (7.6%). Therefore, the study concludes that all the respondents stated difficulties during health insurance claim settlement. Among them, 27.3 percent of the people identified the policy terms and coverage as the main limitations for a medical claim settlement.

TABLE 6. 38 INDICATES THE MAIN REASONS FOR BREACH

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the main reasons for breach, the Table 38 discloses that twenty five percent of the study respondents cited ambiguous policy terms followed by claim settlement beyond the time limit (22.5%), ineffective regulations (20.3%), incorrect or incomplete data (14.9%), insufficient necessary documentation (10.2%) and non-disclosure of pre-medical history (6.7%). Therefore, the study recommends that strict regulations are needed to address this breach in health insurance policy.

TABLE 6. 39 ILLUSTRATES THE COMMON CHALLENGES

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the common challenges, the Table 39 reveals that 25 percent of the study respondents stated that delays in receiving necessary documentation and inadequate customer services followed by disputes over coverage limitations or exclusions (22%), difficulties in medical billing and coding (20.3%), complexity in understanding policy terms and conditions (18%), lack of clear communication, and hidden fees and other charges (6%).

TABLE 6. 40 EXPLAINS THE TRANSPARENCY OF POLICY TERMS

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above analysis represents the transparency of health insurance policy. From the above Table 40, it is observed that forty three percent of the selected study respondents responded neutrally followed by satisfied (23%), dissatisfied (13%), very dissatisfied (11%), and very satisfied (10%). Therefore, the study concludes that more number of the study respondents answered neutrally regarding the transparency of policy terms.

TABLE 41 SHOWS BREACHES OF CONTACT IN HEALTH INSURANCE

Abb. in Leseprobe nicht enthalten

Source: Field Data

About the breaches of contact in health insurance, it is shown in the above Table 6.41, thirty percent of the study respondent reported a moderately decrease trust followed by no impact on trust (27%), moderately increase trust (25%), significantly increase trust (11%), significantly decreases trust (7%). Thus, the study found that thirty percent of the respondents stated moderate decrease in faith

TABLE 6.42 SHOWS THE IMPACT OF INSURANCE POLICY HOLDERS FROM REJECTION CLAIM

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above table 6. 42 portrays the impact of claims’ rejection on health insurance policy holders. Thirty six percent of the study respondents reported economic distress followed by psychological disorder (23.8%), mental distress (19.4%), social humiliation (12.4%), legal and ethical consideration (8.2%). Thus, the study concludes economic distress is the main impact of medical claim rejection. So, the study recommends that IRDAI take actions to reduce medical claim rejection by the insurance company.

TABLE 6.43 EXPLAINS THE IMPACT OF FRAUDULENT CLAIMS ON THE SETTLEMENT PROCESS

Abb. in Leseprobe nicht enthalten

Source: Field Data

About the impact of fraudulent claims on the settlement process, the above Table 43 reveals that less than half of the study respondents with a health insurance scheme or policy experienced moderate impact, periodic audits, and investigations, followed by significant impact, stringent fraud detection measures (26%), minimal impact, trust in policyholder honesty (24.8%), and not applicable, no fraudulent claims encountered. Thus, the study suggests that the strict regulatory approach of the insurance sector needs an additional combined approach like the banking sector.

TABLE 6. 44 DEPICTS ABOUT SEEKING LEGAL HELP

Abb. in Leseprobe nicht enthalten

Source: Field Data

From the above Table 6. 44, we can understand that seventy six percent of the stud respondents said that they are approached legal help and remaining of the study respondents said did not. Thus, the study concludes that a greater number of study respondents seek legal assistant when they face any crisis during medical claim and settlement process.

TABLE 6.45 SHOWS THE AWARENESS ABOUT LEGAL RIGHTS

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the awareness of legal rights, a greater number of the study population (74%) are aware oflegal rights related to health insurance schemes, and the rest of the study respondents are not familiar with any legal rights. Thus, the research concludes that the majority of the study respondents are aware of the legal rights.

TABLE 6.46 DEPICTS THE COMPLAINT WITH THE INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA.

Abb. in Leseprobe nicht enthalten

Source: Field Data

It reveals from the above Table 46 that, more than half of the selected study respondents in the study area (53%), made a complaint with the insurance regulatory and development Authority of India and rest of the respondents do not have any complaints. Insurance policies are considered as significant part of each economy and it helps the people to protect their life from the financial issues. The IRDA frames some rules that are needed for all insurance firms. Moreover, this IRDA encourages the well-being of India’s health insurance/ policy bazaar. The rules and regulation ofIRDA is defined in the Insurance Act of 1938 and Section 114A.

TABLE 6.47 INDICATES THE EFFECTIVENESS OF REGULATORY BODIES

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the effectiveness of regulatory bodies, forty four percent of the study respondents are neutrally answered followed by somewhat effective (26%), some what ineffective (14%), very effective (13%), and very ineffective (3%). From the above analysis, the study concludes that the effectiveness of regulatory bodies is normal in their function. The IRDA was established in the year of 2000 with the recommendation of Malhotra committee to monitor and legalize the insurance sectors. The main goal of this set up is to safeguard the interest of policy holders as well as the development of policy sectors. The IRDA has brought tremendous transformations in the insurance sectors, before the establishment of IRDA, LIC only ruled life insurance sectors. (Mukadam and Deo, 2016).

TABLE 6. 48 PORTRAYS THE RESPONSES ABOUT THE INADEQUATE COMMUNICATION OF POLICY TERMS & CONDITIONS

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above analysis explains the inadequate communication of policy terms and conditions. From that survey we can observe that forty four percent of the study population strongly agreed with the above statement followed by agree (38%), neutral (16%) and strongly disagree (2%). Health insurance is one of the leading and rising division of insurance business/ industry, at the same time consumers or insurance holders have more complaints about the insurance companies regarding the insurance basic terms and conditions, claims ration. Therefore, the study concludes that the relevant and needed information should be given to the policy holders by the insurance companies. For the strong development and growth of insurance companies, all the shareholders should work with trustworthiness and not encompass in any scam actions, which destroy health insurance professional (Devi and Nehra, 2015).

TABLE 6. 49 PRESENTS THE AMBIGUOUS OR MISLEADING POLICY LANGUAGE

Abb. in Leseprobe nicht enthalten

Source: Field Data

About the ambiguous or misleading policy language, the following responses are gathered from the study area. The study shows that forty nine percent of the study respondents agreed with the above statement followed by neutral (21%), strongly agree (20%), disagree (8%), and strongly disagree (2%). Regarding the interpretation of policy, the honorable Supreme Court has given judgments. Case laws are:1. Bajaj Allianz General insurance co Ltd Vs The State of Madhya Pradesh, 2. Haris Marine Products vs ECGC Ltd. Thus, the analysis concludes that the insurance companies have to use simple and clear terms or language in proper way with short and understandable sentences.

TABLE 6.50 SHOWS THE INEFFECTIVE COMPLAINT/ GRIEVANCE RESOLUTION MECHANISMS

Abb. in Leseprobe nicht enthalten

Source: Field Data

From the result of the survey, it is found that thirty three percent of the study respondents are neutral with the ineffective complaint/ grievance resolution mechanism followed by agree (30%), strongly agree (26%), disagree (7%) and strongly disagree (4%). Therefore, the study indicates that 95 respondents with 30 percent have consented about the ineffective compliant/grievance resolution mechanism.

TABLE 6. 51 INDICATES THE INEFFECTIVE REGULATORY OVERSIGHT

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the ineffective regulatory oversight, from the result, it is seen that 127 respondents with 40 percent are agree with the above statement followed by neutral (22%), strongly agree (17%), disagree (14%) and Strongly agree (6%). Thus, the study concludes that less than half of the study respondents only agreed with the statement about ineffective regulatory oversight.

TABLE 6. 52 PRESENTS THE RESPONSES ABOUT ENFORCING STRICT

PENALTIES FOR DELAYED SETTLEMENTS

Abb. in Leseprobe nicht enthalten

Source: Field Data

It is observed from the above Table 6.52 that fifty one percent of the study population said that penalty for delayed settlements by the insurance company is very ineffective and rest of the people said somewhat ineffective. Therefore, the study concludes that IRDAI should address/ deals these issues to rectify the condition.

TABLE 6.53 PRESENTS THE RESPONSES OF STUDY RESPONDENTS ABOUT THE REGULAR AUDITS AND OVERSIGHT

Abb. in Leseprobe nicht enthalten

Source: Field Data

From the above result, it is revealed that more than half of the study respondents (64.5%) said that regular audits and oversight was somewhat ineffective, followed by very ineffective (32%), somewhat effective (2%) and neutral (1.5%).

TABLE 6.54 PRESENTS THE RESPONSES ABOUT PROVIDING GUIDELINES FOR

BEST PRACTICES IN CLAIMS MANAGEMENT

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the providing guidelines for best practices in claims management, from the result, it is revealed that 176 respondents with 56 percent said that it is somewhat ineffective followed by very ineffective (40%), neutral (2%), somewhat effective (1%), and very effective (1%).

TABLE 6.55 PRESENTS STRICTER PENALTIES FOR HEALTH INSURANCE COMPANIES FOUND GUILTY OF BREACHING CONTRACTS

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above table 6.55 depicts that 134 respondents with 42.5 percent replied about the strict penalties for health insurance companies found guilty of breaching contracts is moderately strict followed by significantly stricter (39.2%), no current penalties are sufficient (14.2%) and not sure (4.1%).

TABLE 6.56 PRESENTS THE OPINION ABOUT TAKING MEASURES TO PREVENT BREACHES OF CONTRACT

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the opinion about taking measures to prevent breaches of contract, it is observed from the above Table 6.56 that 137 respondents with 43 percent opined that enhance transparency in policy terms followed by strengthen internal oversight and compliance (26%), improve communication with policyholders (25%), and effective regulative authorities.

TABLE 6.57 PRESENTS THE COMPENSATION OR PUNITIVE DAMAGES IN CASES OF PROVEN BREACH OF CONTRACT BY HEALTH INSURANCE COMPANIES

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the support that policyholders should receive compensation or punitive damages in cases of proven breach of contract by health insurance companies, it is shown from the above Table 58, 137 study respondents with 43.5 percent support compensation in certain circumstances followed by always (36%), no, compensation is not necessary (16.5%) and no (4%).

TABLE 6.58 PRESENTS THE RESPONSES ABOUT THE HANDLING DISPUTES OR

DISAGREEMENTS WITH POLICYHOLDERS REGARDING CLAIM SETTLEMENTS

Abb. in Leseprobe nicht enthalten

Source: Field Data

From the above Table 6.58, it is shown that 86 study respondents with 27.3 percent stated that they will seek legal opinion when handling disputes or disagreements with policyholders regarding claim settlements followed by conduct a detailed review and reassessment (22.9%), refer to external arbitrators (20.3%), mediation or negotiation (20.0%), and referring to senior management (9.5%).

TABLE 6.59 ADDRESSES THE DISCREPANCIES OR ERRORS IN CLAIM SUBMISSIONS FROM HEALTHCARE PROVIDERS OR POLICYHOLDERS

Abb. in Leseprobe nicht enthalten

Source: Field Data

About discrepancies or errors in health care policy claim submissions from healthcare providers or policyholders, the above Table 6.59 denotes that 109 respondents with 35% proposed that additional information or clarification should be provided, followed by reject claims outright (24%), investigate and resolve discrepancies (21%), uncertainty or never encountering/ facing such an issue (15%) and referring to legal opinion (5%).

TABLE 6.60 SHOWS THE RESPONSES ABOUT THE INSURERS MANAGE BOTH COMMUNICATING CLAIM SETTLEMENT DECISIONS TO POLICYHOLDERS AND HANDLING APPEALS OR DISPUTES

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above Table 61 indicates how insurer manage both communicating claim settlement decisions to policy holders and handling appeals or disputes. Thirty five percent of the study respondents replied that brokers/insurers offer appeal options with designated procedures, followed by Provides access to external grievance redressal mechanisms (27%), Written notifications with clear explanations (26%), not sure, never faced appeals or disputes (12%).

TABLE 6.61 PRESENTS THE SUGGESTIONS TO ENHANCE THE EFFICIENCY OF THE HEALTH INSURANCE CLAIM SETTLEMENT PROCESS

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the suggestions to enhance the efficiency of the health insurance claim settlement process, the above Table 6.61 reveals that thirty nine percent of the study respondents recommended that faster claim processing system should to medical insurance claim settlement process followed by improving communication channels between insurers and policy holders (30.8%), Streamlining documentation requirements (16.8%), and clear policy language (13%). Based on the findings, the study recommends that the medical insurance claim process should be complete easier and faster.

TABLE 6.62 PRESENTS THE ROLE SHOULD INSURANCE AGENTS OR

INTERMEDIARIES PLAY IN FACILITATING SMOOTHER CLAIM SETTLEMENTS

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above Table 6.62 indicates that the higher proportion of the study respondents opined that the insurance agents can help to the policy holders with medical claim documentation and submission, and rest of the study respondents suggested that the health insurance policy agents would educate the policy holders about the medical claim procedures. Thus, the study concludes that most of the health insurance policy holders are struggling in getting /securing medical claim. Hence, the study suggests that policy agents should take proactive role and come forward in addressing these issues.

TABLE 6.63 PRESENTS THE RECOMMENDATION REGARDING FOR INSURERS TO IMPROVE THEIR RESPONSIVENESS TO POLICYHOLDER INQUIRIES AND GRIEVANCES DURING CLAIM SETTLEMENT

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the recommendation for insurers to improve their responsiveness to policyholder inquiries and grievances during claim settlement, the above Table 6.63 portrays that thirty five percent of the study respondents suggested to develop and organize comprehensive training programme followed by offering multiple communication channels (Phone, email, chat) (27%), Implementing automated updates on claim status (26%) and Streamline claim processing procedures (12%). Based on the above suggestions given by the study respondents, the study concludes the health insurance agencies as well insurers should consider the suggestions of the policy holders for enhancing communication between the policy holders and agents.

TABLE 6.64 LISTED THE RESPONSES REGARDING THE IMPLEMENTING ELECTRONIC HEALTH RECORD INTEGRATION

Abb. in Leseprobe nicht enthalten

Source: Field Data

It is observed from the above Table 65 that forty-six percent of the study respondents strongly agreed with the statement of implementing electronic health record integration, followed by agree (27%), neutral (23%), disagree (3%), and strongly agree (1%). Based on the findings of the study, the survey reveals that a large number of study respondents felt that the implementation of electronic health record integration does not improve the insurers’ collaboration and coordination with health care providers to accelerate the claim settlement.

TABLE 6.65 PRESENTS THE RESPONSES ABOUT THE ESTABLISHING DIRECT BILLING AGREEMENTS

Abb. in Leseprobe nicht enthalten

Source: Field Data

The above Table 66 reveals that forty-eight percent of the study respondents agree with the statement regarding establishing direct billing agreements, followed by neutral (24%), strongly disagree (21%), disagree (6%), strongly agree (1%).

TABLE 6.66 SHOWS THE STREAMLINING OF PROVIDER CREDENTIALING PROCESSES

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the streamlining of provider credentialing processes, 112 study respondents with 36% percent agreed with the above statement followed by disagree (34%), strongly agree (28%) and strongly disagree (3%). Therefore, the study shows that a smaller number of people only believe that streamlining of provider credentialing processes certainly impacts the claim settlement process. On the other level, 34 percent are disagreed and more study respondents may not think this initiative will create a considerable result on the medical insurance claim settlement process.

TABLE 6.67 PRESENTS THE RESPONSES ABOUT CONDUCTING RISK ASSESSMENTS AND SCENARIO PLANNING

Abb. in Leseprobe nicht enthalten

Source: Field Data

As shown in the above Table 68, 130 study respondents (41.3%) strongly agreed with the statement regarding conducting risk assessment and scenario planning followed by disagree (32.1%), neutral (24.4%), and strongly disagree (2.2%). Therefore, the study concludes that less than half (41.3%) of the study respondents only trust that conducting risk assessments and scenario planning deliberately impact the claim settlement process, while an important portion either neutral or disagree on the matter.

TABLE 6.68 INDICATES THE COLLABORATION WITH INDUSTRY PEERS FOR INSIGHTS AND BEST PRACTICES

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the collaboration with industry peers for insights and best practices, the above Table 69 depicts that 154-study population with 49 percent disagreed with the statement followed by neutral (29%), strongly agree (20%) and strongly disagree (2%).

TABLE 6.69 SHOWS THE RESPONSES ABOUT THE ADAPTATION OF POLICIES AND PROCEDURES TO MITIGATE RISKS

Abb. in Leseprobe nicht enthalten

Source: Field Data

About the adaptation of policies and procedures to mitigate risks, 111 study population with 35 percent are neutral followed by disagree (35%), strongly agree (26%) and strongly disagree (4%). Based on the data, the study concludes that very a smaller number of study respondents only believe that policies and procedures can mitigate the risks, at the same time large portion of the study respondents (35%) either neutral or disagree, showing a lack of confidence in the efficiency of the existing guidelines and procedures for risk mitigation.

TABLE 6.70 SHOWS THE RESPONSES ABOUT THE RECOMMENDATION FOR THE INSURERS TO PREVENT FRAUDULENT ACTIVITIES DURING CLAIM SETTLEMENTS

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the suggestive recommendation to prevent fraudulent activities during claim settlements for the welfare of the insurers, the above Table 6.70 shows that more than half of the study population responded that conducting regular audits and investigations followed by enhancing verifications processes for claims (24%), implementing robust fraud detection algorithms (22%) and others (2%).

TABLE 6.71 PRESENTS THE SUGGESTIONS FOR MAKING THE DISPUTE RESOLUTION PROCESS MORE ACCESSIBLE

Abb. in Leseprobe nicht enthalten

Source: Field Data

Regarding the recommendations for making the dispute resolution process more accessible, the above analysis shows that thirty four percent of the study respondents preferred an internal complaint and redressal mechanism followed by simplified procedures (33%), legal action and settlement (25.4%) and ADR method (7.6%). Therefore, the study concludes that the answers from the study population are mixed, indicating various preferences and suggestions for resolving dispute during medical claim settlement process.

TABLE 6.73 HYPOTHESIS ON THE FREQUENT DENIAL OF INSURANCE CLAIMS BY INSURANCE COMPANIES CONTRIBUTES TO INCREASED LEVELS OF MENTAL DISTRESS AND PSYCHOLOGICAL DISORDERS AMONG POLICY HOLDERS.

Alternative Hypothesis H(l): There is an association between the Gender of the policy holders and the mental distress instigated by the rejection of health insurance claim by insurance company.

Gender * The impact on insurance policy holders from rejection claim by the insurance companies.

Crosstabulation

Count

Abb. in Leseprobe nicht enthalten

Chi-Square Tests

Abb. in Leseprobe nicht enthalten

a. 5 cells (33.3%) have expected count less than 5. The minimum expected count is .08.

Result

The proposed alternative hypothesis is accepted in the present research as the P- value is less than the significance value 0.05, (P < 0.05). The result reveals that all the medical insurance policy holders, irrespective of gender, face financial distress when the insurance company denies their medical claim forms frequently. Therefore, the study indicates there is a significant association between the frequent denial of insurance claims by insurance companies and increased levels of mental distress and psychological disorders among health insurance policy holders.

TABLE 6.74 HYPOTHESIS ON THE FREQUENT DENIAL OF INSURANCE CLAIMS BY INSURANCE COMPANIES CONTRIBUTES TO INCREASED LEVELS OF MENTAL DISTRESS AND PSYCHOLOGICAL DISORDERS AMONG POLICY HOLDERS.

Alternative Hypothesis (Hl): There is an association between the occupation of policyholders and the mental distress caused by the denial of medical claims by insurance companies.

Occupation * The impact on insurance policy holders from rejection claim by the insurance companies. Crosstabulation

Count

Abb. in Leseprobe nicht enthalten

Chi-Square Tests

Abb. in Leseprobe nicht enthalten

a. 12 cells (40.0%) have expected count less than 5. The minimum expected count is .17.

Result:

The proposed alternative hypothesis is accepted in the present research as the P- value (.003) is less than the significance value 0.05, (P < 0.05). The result indicates that all the health insurance policy holders, irrespective of occupation, face financial distress when the health insurance companies deny their policy holders’ medical claim forms often. Therefore, the study highlights there is a considerable relationship between the frequent rejection of health insurance claims by health insurance companies and increased levels of psychological disorders and economic distress among health insurance policy holders.

TABLE 6.75 HYPOTHESIS ON THE FREQUENT DENIAL OF INSURANCE CLAIMS BY INSURANCE COMPANIES CONTRIBUTES TO INCREASED LEVELS OF MENTAL DISTRESS AND PSYCHOLOGICAL DISORDERS AMONG POLICY HOLDERS.

Alternative Hypothesis (hl): Married people experience distress when health insurance companies deny their medical claim forms.

Chi-Square Tests

Abb. in Leseprobe nicht enthalten

a. 6 cells (40.0%) have expected count less than 5. The minimum expected count is .08.

Results: the proposed alternative hypothesis is rejected, as P value is greater than significant value 0.05. Therefore, the study shows that policy holders who approach the medical insurance companies for medical claim getting stress when their medical claims are denied. Hence, the study highlights that, irrespective of marital status, all health insurance holders experience economically and emotionally distresses when their claim requests are rejected by the insurance companies.

TABLE 6.76 HYPOTHESIS ON THE FREQUENT DENIAL OF INSURANCE CLAIMS BY INSURANCE COMPANIES CONTRIBUTES TO INCREASED LEVELS OF MENTAL DISTRESS AND PSYCHOLOGICAL DISORDERS AMONG POLICY HOLDERS.

Alternative Hypothesis (hl): There is an association between the income of policyholders and the mental distress caused by the rejection of health insurance claims by insurance companies.

Income (in Rupees)- Per Year * The impact on insurance policy holders from rejection claim by the insurance companies. Crosstabulation

Count

Abb. in Leseprobe nicht enthalten

Chi-Square Tests

Abb. in Leseprobe nicht enthalten

a. 4 cells (20.0%) have expected count less than 5. The minimum expected count is 1.32.

Results: The proposed alternative hypothesis is rejected, as P value (.004) is greater than significant value 0.05. Therefore, the study shows that policy holders who approach the medical insurance companies for medical claim getting stress when their medical claims are denied. Hence, the study highlights that, irrespective of income level, all health insurance holders experience economically and emotionally distresses when their claim requests are rejected by the insurance companies. Whether they policy holders have more annual income or less annual income, they offended when their claim is rejected or cancelled by the insurance companies.

Impact oflnsurance Claim Denial: Analysis by Demographic Factors

In Fig 6.73, The Chi-Square test (Asymp. Sig. (2-sided) = .004, which is less than .05) confirms a statistically significant association between gender and the type of distress experienced after insurance claim rejection, meaning this relationship is unlikely due to chance. Consequently, it can be concluded that the rejection of insurance claims has a significant and differential impact on policyholders based on their gender. Specifically, females are disproportionately affected by economic and social consequences (financial distress and social humiliation), while males tend to experience higher levels of mental distress. This disparity underscores the importance of addressing the distinct social and economic vulnerabilities faced by different genders, particularly women, when insurance claims are denied.

In Fig 6.74, The Chi-Square test (Asymp. Sig. (2-sided) = .003, p < .05) reveals a statistically significant association between occupation and the type of distress experienced after insurance claim rejection, indicating this relationship is unlikely due to chance. Consequently, it can be concluded that the rejection of insurance claims has a significant and differential impact on policyholders based on their occupation. Notably, private employees, academics/students, and advocates report higher instances of economic distress, while private employees and advocates also experience more psychological disorders and mental distress. This disparity underscores the importance of considering occupational context when addressing the vulnerabilities of policyholders whose insurance claims are denied.

In Fig 6.75, The Chi-Square test results (Asymp. Sig. (2-sided) = .513, p > .05) indicate that there is no statistically significant association between marital status and the experience of distress following health insurance claim denial; therefore, the alternative hypothesis (that married people experience distress when their medical claims are denied) is rejected. The study concludes that irrespective of marital status, all health insurance holders experience economic and emotional distress when their claim requests are rejected by insurance companies, highlighting the pervasive negative impact of claim denials across this demographic.

In Fig 6.76, The Chi-Square test (Asymp. Sig. (2-sided) = .044, p < .05) reveals a statistically significant association between income and the type of distress experienced after insurance claim rejection, indicating this relationship is unlikely due to chance. Consequently, it can be concluded that the rejection of insurance claims has a significant and differential impact on policyholders based on income level. While all income groups experience distress, those earning less than Rs. 250,000 and between Rs. 500,001-1,000,000 report higher instances of economic distress, and those earning less than Rs. 250,000 also report higher instances of psychological disorders, suggesting greater vulnerability among these income brackets. This underscores the importance of considering income level when addressing the vulnerabilities of policyholders whose insurance claims are denied.

6.77 ANOVA

NULL HYPOTHESIS: THERE IS NO SIGNIFICANT MEAN DIFFERENCE BETWEEN THE OCCUPATION OF THE STUDY RESPONDENTS AND SATISFACTION WITH THE TRANSPARENCY OF POLICY TERMS AND CONDITIONS PROVIDED BY HEALTH INSURANCE COMPANIES

Descriptive

How satisfied are you with the transparency of policy terms and conditions provided by health insurance companies

Abb. in Leseprobe nicht enthalten

ANOVA

How satisfied are you with the transparency of policy terms and conditions provided by health insurance companies

Abb. in Leseprobe nicht enthalten

Result

The proposed null hypothesis is accepted in the study, as the P value is greater than the significant value (P > 0.05). Hence, the study reveals that the consumer fulfilment or satisfaction was influenced by the transparency of terms and conditions of health insurance policy. Moreover, the study shows that if the terms and conditions are transparent, consumers will be satisfied.

Empirical Findings

This section presents the study's empirical findings on breach of health insurance contracts, analysed from the policyholder's perspective and considering relevant demographic factors. The analysis focuses on several key aspects: policyholders' awareness and understanding of their coverage; their overall experiences with the insurance process; and the specific nature and impact of contract breaches by insurance companies. Furthermore, the section examines the existing legal and regulatory framework governing health insurance. These empirical findings, providing valuable data and statistical insights, directly support and inform the study's hypotheses and objectives, culminating in targeted suggestions and recommendations for improvement.

I. Awareness and Understanding

• The fact that a large number of people have health insurance coverage and it suggests that individuals are becoming increasingly concerned about their health and are ready to make financial investments to safeguard it.
• The findings of the survey demonstrate that a significant percentage of study participants select family floater plans.
• The respondents in the study predominantly preferred yearly payment schedules.
• The primary finding is that insurance agents are the most significant source of health insurance information .
• The data indicates varying levels of awareness about health insurance products among the study respondents. A significant portion demonstrated moderate awareness, closely followed by those who were strongly aware. A notable segment reported being unaware, while smaller groups expressed being very aware or extremely aware.
• The findings highlight the need for increased efforts to educate the public and raise awareness about the details and benefits ofhealth insurance policies.
• The study suggests that health insurance companies or their agents should clearly explain disease coverage to policyholders. This recommendation stems from findings that policyholders experience difficulties during the claims process. The study also identified a disparity between rural and urban health insurance holders
• The findings indicate a general lack of strong awareness among the respondents regarding the specific diseases not covered by their health insurance schemes
• The findings indicates that a general lack of clear understanding among policyholders about which hospitals accept their insurance, highlighting the need for improved communication and dissemination of this information.
• The findings suggest a generally low to moderate level of awareness regarding cashless payment facilities, with very few respondents demonstrating a high level of understanding.
• This findings indicates that the health insurance agents have to give detailed explanation about the claim settlement as well as they have to assist their policy holders during claim settlement process.
• The tax benefits are a significant driver for health insurance adoption for a majority of the studied population, although not the sole reason for everyone. The respondents prioritize family healthcare and generally perceive the medical treatment received, especially through insurance, as positive. While offers and easy claims were less of a deciding factor, a majority chose their health insurance based on coverage for old age illnesses. This highlights that the primary motivation for selecting health insurance is to protect against future health risks and associated financial burdens. Therefore, future health protection is the key driver for health insurance adoption within the studied population.
• A minority of respondents reported full disclosure of claim settlement information by their insurers during contract formation. A substantial portion received only partial information, while a further segment received no information at all. This indicates a significant communication gap regarding the claims process.

II. Policyholder Experience

• This study completes that the higher proportion of the study respondents have approached the insurance company for a medical claim.
• The communication and timeliness were generally viewed positively and there's room for improvement in the ease of documentation and overall satisfaction with the claims process.
• The findings emphasized that there is a need for the improved communication to ensure all policyholders are adequately informed.
• This study concludes that most of the respondents felt that the insurance companies provide a misinterpretation of the product terms.
• The major findings are that larger number of the study population did not receive any proper explanation and notification for partial payment of their medical claim.
• A significant minority reported that they are not receiving the clear information, indicating a lack of clarity regarding policy details for a substantial portion of policyholders.
• The finding is that claim settlement time is not uniform and varies depending on both the amount of medical expenses incurred and the specific type of health insurance policy held.

III. Nature ofBreach of Contract

• The finding is that a significant portion of the respondents had experienced the problems during the medical claim settlement process.
• Among respondents who faced claim settlement problems, the most frequently cited issue was the lack of an efficient grievance redressal system. Other significant issues included diseases being excluded from coverage, low cooperation from insurance executives, tendencies to overcharge for medical services, excessive and complicated documentation requirements, and delays or denials in claim settlement.
• This study reveals that the respondents are facing difficulties during health insurance claim settlement.
• The study finds that stricter regulations are needed to address breaches in health insurance policies.
• The respondents faced key challenges such as delays in documentation, inadequate customer service, and disputes over coverage limitations, compounded by difficulties with medical billing and complex policy terms. These issues point to systemic problems within the health insurance process, affecting both administrative procedures and policy clarity.

IV. Impact of Breach of Contract

• The study reveals that the largest proportion of respondents neither agreed nor disagreed about the transparency of policy terms, indicating a lack of strong opinions either way, or perhaps a lack of clear understanding or experience to form a strong opinion.
• The study concludes that a moderate decrease in trust is the most common reaction to breaches of contract. However, it's important to note the considerable number of respondents who reported no impact or even a moderate increase in trust, suggesting varied experiences and interpretations ofbreaches.
• This study finds that economic distress is the main impact of medical claim rejection. So, the study recommends that IRDAI take actions to reduce medical claim rejection by the insurance company.
• The study finds that the insurance sector's current strict regulatory approach would benefit from incorporating elements of the banking sector's regulatory approach. This suggests a need for a combined or hybrid regulatory model.

V. Legal and Regulatory Framework

• The study concludes that a greater number of study respondents seek legal assistant when they face any crisis during medical claim and settlement process.
• The research concludes that the majority of the study respondents are aware of the legal rights.
• A majority of the respondents in the study area had filed a complaint with the

Insurance Regulatory and Development Authority of India (IRDAI). This signals a notable level of interaction with the regulatory body.

• The study concludes that the effectiveness of regulatory bodies is normal in their function. It highlights the establishment of the IRDA in 2000, based on the Malhotra committee's recommendations, to monitor and regulate the insurance sector. The IRDA's primary goals are identified as safeguarding policyholder interests and fostering the development of the insurance sector. The study also notes the significant transformations brought about by the IRDA, particularly the shift from a previously LIC-dominated life insurance sector.
• This research finds that insurance companies need to provide relevant and necessary information to policyholders using simple, clear language and concise, understandable sentences. The analysis also reveals that a significant portion of respondents (30%) expressed concern about ineffective complaint/grievance resolution mechanisms. Consequently, the research indicates that less than half of the respondents agreed with the statement regarding ineffective regulatory oversight.
• This study finds that the IRDAI needs to address existing issues to improve the current situation. The results reveal that a majority of respondents perceived regular audits and oversight as somewhat ineffective. Similarly, respondents indicated that the provision of guidelines for best practices in claims management is also somewhat ineffective.

VI. Suggestions & Recommendations

• The study finds that the penalties for health insurance companies found guilty ofbreaching contracts are perceived as moderately strict.
• The study found that enhancing transparency, strengthening internal oversight, improving communication, and having effective regulatory authorities are seen as important steps to prevent breaches of contract in health insurance.
• The finding is that the study addresses the support for policyholders receiving compensation or punitive damages when health insurance companies are found to have breached their contracts.
• The respondents are in favour for more formal and external methods of dispute resolution, such as legal counsel and arbitration, over internal escalation within the company.
• The study finds that a preference for initially seeking clarification or investigating discrepancies before resorting to more drastic measures like outright rejection or legal action.
• The findings suggest that the insurers are increasingly adopting formal procedures to manage claims settlements, appeals, and disputes.
• The study recommends that the medical insurance claim process should be complete easier and faster.
• The study finds that most health insurance policyholders experience difficulties in securing medical claim settlements, highlighting the need for policy agents to take a more proactive role in assisting policyholders with these issues.
• The study finds that health insurance agencies and insurers should consider policyholders' suggestions for improving communication between policyholders and agents.
• The survey reveals mixed opinions regarding the impact of various initiatives on claim settlement. A large number of respondents felt that electronic health record integration does not improve insurer collaboration with healthcare providers to accelerate claim settlement. However, there was agreement regarding the benefits of establishing direct billing agreements. In contrast, streamlining provider credentialing processes was not widely seen as impactful on claim settlement, with a majority of respondents disagreeing that it would have a considerable effect.
• The study finds that only a minority (41.3%) of respondents believe that risk assessments and scenario planning have a significant impact on claim settlement. A substantial portion of respondents expressed neutrality or disagreement on this point. Similarly, only a small number believe that existing policies and procedures effectively mitigate risks, with a large segment (35%) again expressing neutrality or disagreement, indicating a general lack of confidence in current risk mitigation strategies.
• To prevent fraudulent activities during claim settlements, the study suggests several measures: to conducting regular audits and investigations, enhancing verification processes for claims, and implementing robust fraud detection algorithms. These recommendations aim to strengthen insurers' ability to detect and prevent fraud, safeguarding their financial well-being.
• Regarding recommendations for accessible dispute resolution, the study found diverse preferences among respondents. While a plurality favored internal complaint mechanisms (34%) and simplified procedures (33%), a notable portion preferred legal action (25.4%). Alternative Dispute Resolution (ADR) methods were the least preferred (7.6%), indicating a range of opinions on the most effective approach to resolving claim disputes.

CHAPTER- VII CONCLUSION, SUGGESTION AND RECOMMENDATIONS

7.1 Introduction

This concluding chapter synthesizes the research on breaches of health insurance contracts by insurance companies. By utilizing both secondary data and empirical findings, the study investigated policyholders' awareness and understanding of their coverage, their experiences with the insurance process, and the specific issue of contract breaches. The analysis explored the nature and impact of these breaches and examined the relevant legal and regulatory framework. The findings are categorized as either doctrinal or empirical, providing a comprehensive understanding of the issues. This chapter thoroughly analyses these findings, elucidates their implications, and offers recommendations for future action. Crucially, it explains how these findings relate to the study's hypotheses, drawing meaningful conclusions aimed at strengthening policyholder protection.

7.2 Doctrinal Findings

The researcher has reviewed pertinent laws, precedents, papers, and government reports in order to answer the research questions. Furthermore, the researcher has undertaken substantial research using these sources. Listed below are the results of the investigation that was conducted.

Firstly this study points out the vital significance of health insurance as a financial safeguard, shielding people and families from unexpected medical costs. Despite the evolution of health insurance in India, substantial obstacles remain, as indicated by the study's principal results. This involves limited information among policyholders concerning policy specifics and advantages, insufficient healthcare infrastructure, especially in rural regions, resulting in access obstacles, and disparities in premiums between urban and rural locales, rendering insurance less affordable for rural communities. The findings indicate systemic flaws within the health industry that affect its overall efficacy and accessibility, including regulatory deficiencies, poor claims processing, and information asymmetry. These obstacles have extensive social ramifications, exacerbating health disparities and financial difficulties; cultural ramifications, indicating differing degrees of health literacy and trust in insurance; and economic ramifications, affecting household finances and obstructing economic progress. Consequently, the study underscores the pressing necessity for extensive reforms to rectify these findings and enhance the efficacy ofhealth insurance as a financial safety net.

Secondly this study finds breaches of contract by health insurance companies as a key issue, evident in erroneous claim denials, delays in claim processing, and unclear policy language. This analysis reveals that these breaches have substantial consequences for policyholders in various aspects. Socially, they undermine faith in the insurance business, resulting in heightened stress and worry among policyholders who depend on this safeguard. Culturally, these violations can undermine established health practices and traditions, since individuals may be compelled to abandon essential treatments owing to financial limitations resulting from refused or delayed claims. This study reveals that such breaches frequently result in significant financial difficulties, compelling individuals to incur substantial out-of-pocket medical costs, which may culminate in debt and financial instability. These findings highlight the critical necessity for enhanced accountability and equity in the health insurance industry to safeguard policyholders and uphold public confidence.

The regulatory framework regulating health insurance in India, chiefly delineated in the Indian Contract Act of 1872 and the Insurance Act of 1938, offers remedies for contract violations, including damages, specific performance, and injunctions. The Insurance Regulatory and Development Authority of India (IRDAI) is essential in protecting policyholder rights and ensuring adherence to regulations. This analysis identifies those deficiencies in the enforcement of existing legal provisions and the absence of standardized policy words constitute substantial obstacles. This conclusion indicates that although the legal structure provides redress in theory, its practical implementation is hindered by enforcement challenges and discrepancies in policy language among various insurers. Enhancing these legal and regulatory frameworks, particularly by rectifying enforcement deficiencies and fostering increased standardization of policy words, is crucial for improving consumer protection and reinstating confidence in the business.

The primary finding of this research highlights the enormous effect that frequent claim rejections have on policyholders' mental health. According to the findings of the research, policyholders often feel psychological anguish and even develop disorders because of the uncertainty and financial pressure that is created by breaches of contract, especially incorrect claim rejections. This research provides clear evidence for the concept that frequent claim rejections by insurance firms lead to greater mental anguish among policyholders. This finding adds an important dimension to the effects that are associated with such breaches. To address these difficulties, it is necessary to not only implement a more stringent enforcement of legal requirements by insurers in order to reduce the number of violations, but also to implement a claims settlement procedure that is more robust and transparent in order to reduce the psychological effect on policyholders in the event that disputes do occur.

Lastly to address all the problems that were discovered in the research, it is recommended that an overall approach be used, which would include addressing several aspects of the health insurance ecosystem. According to the findings of the research, it is essential to provide policyholders with information on their rights and duties as outlined in their policies. This will enable them to traverse the system in an efficient manner and prevent misunderstandings that might result in disagreements. Moreover, the research highlights the need of simplifying policy terminology and language, making them more accessible and readily intelligible to the typical policyholder. This would result in a reduction in ambiguity and the possibility of misunderstanding. The need of ensuring that claim settlements are made in a timely manner is another important conclusion. Delays are a substantial contributor to the misery of policyholders and destroy faith in the system. The research concludes that deliberate investments in healthcare infrastructure are necessary to bridge the gap in access to excellent healthcare services, hence making insurance coverage more relevant and effective. This is in recognition of the infrastructure deficit, which is especially prevalent in rural regions. The final finding of the study is that the utilization of advanced technologies, such as data analytics and artificial intelligence, for the purpose of detecting and preventing fraudulent claims has the potential to significantly improve operational efficiency, reduce costs, and enhance fairness within the system for both legitimate policyholders and legitimate insurers. The research concludes that India's health insurance market has the potential to be converted into a more dependable, egalitarian, and efficient way of preserving and promoting the health and financial security of its residents if these broad approaches are implemented.

7.3 Suggestions

7.3.1 New Developments in the Administration ofHealth Insurance Claims

The management of health insurance claims in India is changing dramatically as a result of new regulations, changing consumer expectations, and technology breakthroughs. These are some of the new developments that will influence how health insurance claims are handled in the nation going forward.

Digitalisation is now the foundation of contemporary claims administration. Technology is being used by insurers more and more to automate claims procedures, which minimises errors, cuts down on manual interaction, and expedites the time it takes to resolve claims. Routine jobs like data entry and claims status updates are being handled by automation solutions like robotic process automation (RPA).

Remote assessments for claims processing have increased in popularity as telemedicine has grown, especially since the COVID-19 pandemic. This includes virtual diagnostics and consultations, which can serve as a foundation for processing claims without requiring policyholders to physically visit the hospital, thereby expediting and improving the procedure. Smartwatches and fitness trackers are examples of wearable health technology that is beginning to be used in the processing of health insurance claims. The information gathered from these devices can be utilised to continuously track the health and well-being of policyholders, which may help with preventive healthcare and expedite the processing of claims.

Chatbots and virtual assistants are being used by insurers to offer round-the-clock customer support, including answering questions about claims. These technologies can improve customer satisfaction and speed up processing times by helping clients initiate claims, giving them progress updates, and guiding them through the claims process.

Health insurers and healthcare providers are placing more emphasis on portability and interoperability as regulatory frameworks change. This entails making certain that patient and claims information can be safely transferred between platforms, which may result in better patient care continuity and more effective claims processing.

Health insurers are concentrating on enhancing data security and privacy procedures in light of laws like the Personal Data Protection Bill. Building customer trust and maintaining a safe environment for handling private financial and health data depend heavily on compliance with these regulations.

Offering insurance plans that emphasise preventive healthcare as well as disease and hospitalisation is becoming more and more popular. In order to lower long-term claims costs by enhancing the general health of the insured population, insurers are including coverage for wellness initiatives, regular physicals, and immunisations.

7.3.2 Improving Contractual Clarity and Transparency

Despite the existence of various dispute resolution mechanisms, challenges persist in achieving timely, fair, and cost-effective resolutions in the health insurance sector. To improve dispute resolution processes, several strategies can be considered:

Insurance companies should strive to improve transparency in their policies, clearly outlining coverage terms, limitations, and claims procedures. Effective communication with policyholders can help prevent misunderstandings and reduce the likelihood of disputes.

Regulatory authorities can promote standardization of claims processing and dispute resolution practices across the health insurance industry. Standardized procedures can streamline the resolution process, reduce administrative burden, and enhance consistency and fairness in decision-making.

The adoption of technology, such as electronic claims processing systems and online dispute resolution platforms, can expedite the resolution process and improve accessibility for policyholders. Automation and digitization can also enhance data accuracy, reduce errors, and facilitate communication between parties.

Policyholders should be educated about their rights and responsibilities under their health insurance policies, as well as the available avenues for resolving disputes. Empowering consumers with knowledge and resources can help them navigate the claims process more effectively and advocate for their interests when disputes arise.

Stakeholders in the health insurance sector, including insurers, healthcare providers, regulators, and consumer advocacy groups, should collaborate to identify and address systemic issues affecting dispute resolution. By working together, they can develop innovative solutions, share best practices, and promote continuous improvement in the resolution process.

7.3.3 Strengthening Consumer Protection Measures

Strengthening consumer protection in the health insurance sector in India is crucial for enhancing trust, improving service quality, and ensuring fair practices. Given the complexities ofhealth insurance products and the critical nature of the services they cover, robust consumer protection measures are essential.

Implement standardized terms and definitions across all health insurance policies to avoid confusion and misinterpretation. Ensure all policy terms, conditions, exclusions, and benefits are communicated clearly and transparently. Insurers can use simpler language and visual aids to make information more accessible.

The Insurance Regulatory and Development Authority of India (IRDAI) should enhance its monitoring of how insurers comply with policy guidelines, especially concerning claim settlements and policy renewals. Conduct regular audits and performance reviews of health insurance providers to ensure compliance with regulatory standards and to promote best practices.

Strengthen the grievance redressal mechanisms within insurance companies by ensuring they are easily accessible, responsive, and effective at resolving issues. Promote and enhance the usage of IRDAI's centralized grievance management system, which allows consumers to lodge complaints directly with the regulator if not satisfied with the insurer’s resolution.

Ensure that sales practices are fair, ethical, and transparent, with stringent penalties for mis­selling and deceptive marketing tactics. Regular training and certification for insurance agents and brokers to uphold high ethical standards and provide accurate product information.

Strengthen the role and reach of the Insurance Ombudsman to ensure consumers across the country have easy access to free and fair conflict resolution. Establish fast-track dispute resolution panels within existing judicial frameworks to handle insurance claims disputes efficiently.

7.3.4 Suggestion for Insurance Companies

To promote healthy competition and highlight the dearth of innovation in insurance products, insurance companies should create, develop, and launch several new and creative products. The representative should have regular adequate training to comprehend the needs of the customer and to explain the many features and aspects of the policies. The three main elements that influence policyholders' purchasing decisions are their financial attitude, service quality, and policy appeal. Therefore, when creating and promoting health insurance policies, the companies ought to pay these elements special consideration. When policyholders require them, health insurance firms must offer both core and value-added services. For the agents to be up to date on the latest information and insist that the policyholder recommend that the agent be the primary source of future policyholder awareness, the company should regularly provide them with manuals or guidelines regarding the health insurance policy. Given that policyholders cited the internet as their primary information source, the business should endeavor to diversify its activities through online offerings. The internet should be used more to invite policy applications, pay premiums, settle claims, and access various insurance services, among other things. In remote areas without branch offices, insurance companies should establish several service centres to facilitate easy access to their health insurance policies. To promote health insurance, appealing marketing campaigns had to be launched. The insurance Businesses should focus on advertising while taking policyholders' requirements and preferences into account. Bank deposit plans, UTI, NSC, and other short-term policies and products should be introduced by insurance companies as soon as possible. The insurance businesses should offer insurance plans with full coverage, even those that have "exclusion of pre-existing diseases" condition clauses.

7.3.5 Suggestions to Hospitals

To ensure a consistent pattern among healthcare providers, the tariff and health care prices should be accredited and standardized. Physicians and other medical personnel who offer various health care services to insured individuals should get regular training and orientation. Because policyholders have claimed that hospitals charge various rates from insured patients, hospitals should treat policyholder and non-policyholder patients equally during the hospitalization process and refrain from charging insured patients extra.

7.3.6 Suggestions for Health insurance policyholders

At a very young age, policyholders should purchase a family floater health insurance policy. Additionally, they ought to understand the policy's numerous terms and conditions, as well as its inclusions and exclusions. They ought to be aware of the different health insurance plans and the various providers of these plans. Policyholders should always have a preventive health care mindset. They should carefully consider their options before making judgements on the insurance, sum assured, premium paid, etc. They must receive health care services in accordance with laws and regulations and pay the premium on time. When obtaining insurance, a person discloses any pre-existing conditions they may have. If they have any problems or issues, they should use the grievances cell.

7.3.7 Suggestions for IRDA

The current analysis demonstrates that the role outlined by the IRDA differed on a few aspects. Therefore, the IRDA should concentrate on those factors to eliminate the challenges policyholders have while filing claims. It ought to endeavor to preserve the current insurance system's transparency. The IRDA should employ external auditors who will undoubtedly continue to monitor different insurance providers. Since public businesses' percentage market share of the health insurance industry is declining annually, IRDA ought to concentrate on these public insurers. Following IRDA's thorough review and analysis, private companies should be granted insurance licenses to launch health insurance businesses. To resolve policyholder complaints and win their allegiance to the insurance industry, IRDA should oversee and guide the insurance ombudsman. To gain a significant portion of the market, IRDA should do all in its power to raise public knowledge ofhealth insurance.

7.3.8 Suggestions for/to Government

Giving careful attention to health insurance as a unique area of the insurance market. Lower the capital needed to register health insurance companies. Educate physicians, healthcare professionals, hospital administrators, record keepers, TPAs, agents, and others on new insurance terms and technologies. Encourage improvements in the public health care system and upgrade the medical infrastructure. launching an incentive program for providers and insurers who reach or surpass the goal. The media should raise public awareness of the importance of health insurance. Encourage public-private collaboration in a setting of healthy competition.

Future Research Related to Health Insurance

The health insurance sector offers a wide range of opportunities for additional research, including

• A comparative study between private and public insurance companies may be conducted.
• A comprehensive examination of general insurance businesses' service quality is available.
• The research can be conducted on the insurers & hospitals regarding health insurance products and services.
• Research on health insurance policyholders' awareness and satisfaction levels can be conducted

7.4 Conclusion

This study explores into the critical issue of breach of contract by health insurance companies in India, focusing specifically on the experiences and challenges faced by policyholders in 328

Tamil Nadu. Through a comprehensive analysis of policy documents, regulatory frameworks, case studies, and empirical data gathered from policyholders and stakeholders, the research has illuminated the multifaceted nature of contractual breaches and their detrimental impact on individuals and the healthcare system. The findings reveal a concerning prevalence of contractual breaches by health insurers, ranging from denial of legitimate claims and delays in claim settlement to unfair policy exclusions and misrepresentation of policy terms. These breaches often stem from ambiguities in policy language, inadequate grievance redressal mechanisms, and a power imbalance between insurers and policyholders. The study underscores the vulnerability of policyholders, particularly those from marginalized and economically disadvantaged backgrounds, who often lack the resources and awareness to effectively challenge unfair practices. The research also highlights the critical role of regulatory bodies, such as the Insurance Regulatory and Development Authority of India (IRDAI), in ensuring compliance and protecting policyholders' rights. However, the study suggests that there is scope for strengthening regulatory oversight, enhancing transparency in policy disclosures, and promoting greater accountability within the health insurance industry. Furthermore, the study has examined the specific context of Tamil Nadu, shedding light on the unique challenges and opportunities within the state's health insurance landscape. The findings indicate a growing awareness of health insurance among the population, coupled with rising expectations regarding quality and affordability. However, the prevalence of contractual breaches undermines trust in the industry and hinders the realization of universal health coverage goals. The main motive of the health insurance industry should be "health coverage to all." Insurance companies should use cost-cutting strategies and provide easy access to medical facilities. In the current liberal economic environment, health insurance will increase. However, a less regulated health insurance market can only draw in and focus on a tiny segment of the population. Assisting the poor segments of society with the financing of their medical treatment is the primary task facing the health insurance industry. Soon, the idea of health insurance will reach new heights and India will be the healthiest country in the world if the government, service providers, health care industry, insurance companies, health insurance customers, IRDA, etc., implement all the recommendations made in the study.

To effectively address the persistent issue of contractual breaches within the health insurance industry, a multi-pronged approach is essential. Firstly, enhancing policy transparency and standardization is crucial. Clear and unambiguous policy language can prevent misinterpretations and disputes, while standardized policy templates and simplified benefit structures empower policyholders to make informed decisions. Secondly, strengthening grievance redressal mechanisms is vital for resolving contractual disputes efficiently. Insurers should establish dedicated channels for addressing policyholder complaints, and regulatory bodies must ensure timely and impartial resolution of grievances. Thirdly, empowering policyholders through education and awareness is key. Promoting health literacy and awareness about policyholders' rights and responsibilities enables individuals to navigate the complexities of health insurance contracts and challenge unfair practices. Fourthly, strengthening regulatory oversight and enforcement is necessary. Regulatory bodies should proactively monitor insurer conduct, enforce compliance with regulations, and penalize errant insurers. Finally, promoting ethical practices and industry self-regulation is crucial. The health insurance industry should prioritize ethical conduct and adopt self-regulatory measures to ensure fair and transparent practices, fostering a culture of accountability and consumer protection.

REFERENCES

Abu Samhadaneh, A., & Al-Rafai’e, A. (2023), The condition under which the insurer has the right to terminate the insurance contract by his own willingness according to the Jordanian legislation : Its meaning and legitimacy. Jordanian Journal of Law and Political Science, 14 (4). https://doi.org/10.35682/ijlps.vl4i4.373.

Adefulu, A., & Banmore, O. (2023), Claims managementpractices andfirmprofitability of listed insurance companies in Nigeria. International Journal of Advanced Studies in Economics and Public SectorManagement, 11 (1), 139-153. https://doi.org/10.48028/iiprds/ijasepsm.v11.i1.11.

Adzakpah, G., & Dwomoh, D. (2022), Impact of Digital Health Technology on Error Margins of Health Insurance Claims in Ghana: A Quasi-Experimental Study. https://doi.org/10.21203/rs.3.rs-1845697/v1.

Aiyar, A., & Sunder, N. (2024), Health Insurance and Child Mortality: Evidence from India. Health Economics. https://doi.org/10.1002/hec.4798.

Alam, A., & Prybutok, V. R. (2024), Use of responsible artificial intelligence to predict health insurance claims in the USA using machine learning algorithms. Exploration of Digital Health Technologies, 30-45. https://doi.org/10.37349/edht.2024.00009.

Alan, B., & Avci, E. (2022), Determinants of reinsurance costs for Turkish non-life insurance companies. Pressacademia. https://doi.org/10.17261/pressacademia.2022.1557.

Ali, A., & Mohamed. , C. (2023), A study of the impact of written premiums and paid claims on the financial solvency of insurance companies in the Kingdom of Saudi Arabia. International Journal for Scientific Research, 2 (5), 126-161. https://doi.org/10.59992/ijsr.2023.v2n5p5.

Ali, I., Akhtar, S. N., Chauhan, B. G., Malik, M. A., & Singh, K. D. (2022), Health insurance support on maternal health care: Evidencefrom survey data in India. Journal of Public Health, 45 (2), 368-378. https://doi.org/10.1093/pubmed/fdac025.

Anam, S., Guci, A. N., Widhiatmoko, F., Kurniawaty, M., & Wijaya, K. A. (2023), Development of health insurance claim prediction method based on support vector machine and Bat Algorithm. BAREKENG: Jurnal Ilmu MatematikaDan Terapan, 17 (4), 2281-2292. https://doi.org/10.30598/barekengvol17iss4pp2281-2292.

Army, S. A., & Nahda, K. (2023), Analyzing the effects of the health BPJS Regulation on the insurance companies performance and efficiency. Jurnal Indonesia Sosial Teknologi, 4 (8), 949-959. https://doi.org/10.59141/jist.v4i8.658.

Asbjorn, S., Linda, L., & Terje, H. (2007), What Characterizes Companies That Buy Private Health insurance?, 2673.

Aswin, Suhendro, & Indra Afrita. (2021), Settlement of defaults in the life insurance policy between the insurer and the insured. JILPR Journal Indonesia Law and Policy Review, 2 (2), 57-72. https://doi.org/10.56371/jirpl.v2i2.44.

Ayebazibwe Babrah, & Alex Irumba. (2023), The Effect of Risk Management on Financial Performance of insurance Companies in Uganda. A Case Study of Aar Health insurance Serviceskid. Metropolitan Journal OfBusiness & Economics , 2 (5), 94-119.

Ayuba, B., Isyaka, M.S., & Agugua, A.G. (2018), impact of Claim Settlement on Performance of General insurance Businesses: Evidence From Federal Capital Territory, Abuja. The International Journal ofManagement , 4, 329.

Baker, T. (2006), Medical Malpractice insurance Reform: ^Enterprise insurance” and some alternatives. Medical Malpractice and the U.S. Health Care System, 267-290. https://doi.org/10.1017/cbo9780511617836.015.

Bakshi, A. (2020), Voluntary Health insurance in india:trend analysis of public and private insurance companies. Mudra : Journal ofFinance and Accounting, 7 (1), 68. https://doi.org/10.17492/mudra.v7i1.195416.

Banmore, Adefulu, & Makinde,. (2023), Claims management andfirm performance of insurance companies in Nigeria: Moderating effect of marketingfactors. Journal Of Economics, Finance and Management Studies, 06 (06). https://doi.org/10.47191/jefms/v6-i6-67.

Barannyk, L., & Kachula, S. (2023), Compulsory health insurance as an element of the population’s Social Security System. University Economic Bulletin, (56), 155-162. https://doi.org/10.31470/2306-546x-2023-56-155-162.

Basaula, D. (2018), Customers satisfaction towards life insurance claim settlement in Nepal. Janapriya Journal ofInterdisciplinary Studies, 6, 29-44. https://doi.org/10.3126/jjis.v6i0.19307.

Bawazir, S. A., Alkudsi, M. A., Al Humaidan, A. S., Al Jaser, M. A., & Sasich, L. D. (2013), Pharmaceutical policies used by private health insurance companies in Saudi Arabia. Saudi Pharmaceutical Journal, 21 (3), 267-276. https://doi.org/10.1016/j.jsps.2012.10.005.

Berger, F., Anindya, K., Pati, S., Ghosal, S., Dreger, S., Lee, J. T., & Ng, N. (2024), The moderating effect of mental health and health insurance ownership on the relationships between physical multimorbidity and healthcare utilisation and Catastrophic Health Expenditure inindia. BMC Geriatrics, 24 (1). https://doi.org/10.1186/s12877-023-04531-8.

Born, P. H., & Karl, J. B. (2016), The effect of tort reform on medical malpractice insurance market trends. Journal of Empirical Legal Studies, 13 (4), 718-755. https://doi.org/10.1111/jels.12131.

Cady, T. C., Andrews, A, Cuppett, D, & Glover, M. (1998), The Law of Insurance Company Claim Misconduct in West Virginia, 101 (1).

Chaurasia, D. (2023), Adoption of digital strategy in Health Insurance Sectorwith Special Reference toBhopal City. BSSS Journal Of Commerce, 15 (1), 107-124. https://doi.org/10.51767/joc1514.

Choudhary, & Dr-Pooja. (2016), Status of Death Claims Settlement in Life Insurance Business in India: An Analytical Study. A Journal ofBusiness Research , 1.

Christine H . Monahan. (2017), Private Enforcement of the Affordable Care Act: Toward an "ImpliedWarranty ofLegality”inHealthInsurance. YaleLawJournal, 126 (4), 908-1241.

Crocker, K. J., & Tennyson, S. (2002), Insurancefraudand Optimal Claims Settlement Strategies. The Journal ofLaw and Economics, 45 (2), 469-507. https://doi.org/10.1086/340394.

Danzon, P. M., Epstein, A. J., & Johnson, S. J. (2004), The "Crisis” in Medical Malpractice Insurance. Brookings- Wharton Papers on Financial Services, 2004 (1), 55-96. https://doi.org/10.1353/pfs.2004.0006

Davey, J. (2007), Chapter 8. once more unto the breach: Remedies for the non-payment of insurance claims after Blake. Re-Examining Contract and Unjust Enrichment, 133-153. https://doi.org/10.1163/ej.9789004155633.i-342.39

Debnath, P., & . Dey, B. Kr. D. K. (2023), Customer Satisfaction towards Insurance Policies India: A Study with Special Reference to Dima Hasao, Assam, North East India. Bloomsbury Publishing India Pvt. Ltd.

Dimov, T. (2018), Subrogation in insurance contract. Knowledge International Journal, 28 (6), 1985-1991. https://doi.org/10.35120/kij28061985t.

Dr D Renukadevi, & Devarajan Santhanakrishnan. (2023), Artificial Intelligence in Banking and Insurance. In A Study on Performance of Health Insurance Schemes in India (pp. 144-146). Coimbarote.

Dr.HerambNayak.(2019), Effectiveness of insurance contract in insurance. International Journal ofResearch in Social Sciences, 9 (6), 476-603.

Dr.Ramya. N.(2023), Why Do Health Insurance Policyholders Prefer Standalone Health Insurance Companies?-A Study In Erode District. ShodhaPrabha (UGC CARE Journal) , (48), 83-94.

Dr-Pooja. (2019), Status of Death Claims Settlement in Life Insurance Business in India: An AnalyticalStudy. Journal OfBusiness Research, 1 (1), 51-59.

Duque, L. P., Silva, J. F., & Cohen, M. (2019), Impacts of corporate social responsibility on companies performance: Empirical testing on Brazilian Health and Dental Insurance Companies. Revista Ibero-Americana de Estrategia, 18 (2), 188-204. https://doi.org/10.5585/riae.v18i2.15158.

Dutta, M. M. (2020), Health Insurance Sector in India: An analysis of its performance. Vilakshan - XIMB Journal of Management, 17 (1/2), 97-109. https://doi.org/10.1108/xjm-07-2020-0021.

Fadun, O. S. (2023), Analysis of the impacts of insurance claims settlement on economic growth: The case of Nigeria. International Journal of Business Ecosystem &amp; Strategy (2687-2293), 5 (3), 51-59. https://doi.org/10.36096/ijbes.v5i3.424.

Fadun, O. S. (2023), Analysis of the impacts of insurance claims settlement on economic growth: The case ofnigeria. International Journal of Business Ecosystem &amp; Strategy (2687-2293), 5 (3), 51-59. https://doi.org/10.36096/ijbes.v5i3.424.

Freund, K. M., Isabelle, A. P., Hanchate, A. D., Kalish, R. L., Kapoor, A., Bak, S., Mishuris, R. G., Shroff, S. M., & Battaglia, T. A. (2014), The impact of health insurance reform on insurance instability. Journal of Health Care for the Poor and Underserved, 25 (1A), 95-108. https://doi.org/10.1353/hpu.2014.0061.

Garnick, D. W., Swartz, K., & Skwara, K. C. (1998), Insurance agents: Ignored players in Health InsuranceReform. Health Affairs, 17 (2), 137-143. https://doi.org/10.1377/hlthaff.17.2.137.

Gestwick, Evan D, & Barnas, Brian D Preview author details . (n.d.). Dismissed As Duplicative: Claims for Breach of Insurance Contract and the Implied Covenant of Good Faith and Fair Dealing. Scholarly Journal, 52 (2), 38-45.

Ghosh, M. (2021). Mental Health Insurance Scenario in India: Where does India stand? Indian Journal ofPsychiatry, 63 (6), 603. https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry 148 21.

Gunarto, G., Intanida, I., & Mashdurohatun, A. (2023), Reconstruction of Life Insurance Agent Work Contract Regulations based on justice value. Scholars International Journal of Law, Crime and Justice, 6 (09), 479-484. https://doi.org/10.36348/sijlcj.2023.v06i09.003.

Hall, M. A. (2010), The factual bases for constitutional challenges to federal health insurance reform. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.1717781.

He, X., Alqahtani, S., & Gamble, R. (2018), Toward privacy-assured health insurance claims. 2018, IEEE International Conference on Internet of Things (iThings) and IEEE Green 334

Computing and Communications (GreenCom) and IEEE Cyber, Physical and Social Computing (CPSCom) and IEEE Smart Data (SmartData), 1634-1641. https://doi.org/10.1109/cybermatics 2018.2018.0Q273.

Hermawan, I., Achsani, N. A., & Asyanti, L. D. (2022), Evaluating the strategy to optimize the retakaful Treaty Property Insurance: In the perspective of the Sharia General Insurance Company in Indonesia. International Journal of Research and Review, 9 (1), 378-391. https://doi.org/10.52403/ijrr.20220145.

Holmes, E. M. (1980), ThirdPartylnsuranceLiabilityandItsAvoidance. Arkansas LawReview, , 34 (4), 525-588.

Huang, J., Cruz, B. L., Rosales, D., Chuang, J., & Cruz, R. (2024), Health Insurance Knowledge and health insurance self-efficacy in adolescents and young adults with IBD. Inflammatory Bowel Diseases, 30(Supplement_1). https://doi.org/10.1093/ibd/izae020.101.

Ige-Gbadeyan, O., & Johannes Swanepoel, M. (2023 ), Determinants of operational efficiency on the financial health of non-life insurance companies in South Africa. Insurance Markets and Companies, 14 (1), 121-135. https://doi.org/10.21511/ins.14(1).2023.11.

Isimoya, O. A., & Oluwaleye, T. O. (2024), Analyzing the impact of liability insurance on the financial performance of insurance companies in Nigeria. Gusau International Journal of Management and Social Sciences, 6 (3), 1-21. https://doi.org/10.57233/gijmss.v6i3.1.

Iskandar, A., & Hadiprajitno, P. B. (2023), The influence of foreign insurance affiliates, market share, own retention ratio, claims ratio and cost ratio on the performance of General Insurance Companies in Indonesia. Journal ofBusiness Social and Technology, 4(2), 187-199. https://doi.org/10.59261/jbt.v4i2.147.

Jain, A., Swetha, S., Johar, Z., & Raghavan, R. (2014), Acceptability of, and willingness topayfor, community health insurance in rural India. Journal of Epidemiology and Global Health, 4 (3), 159. https://doi.org/10.1016/ijegh.2013.12.004.

Jain, P., Kumar, A., & Agarwal, N. (2022), Missing middle: Extending health insurance coverage in India. International Journal for Research in Applied Science and Engineering Technology, 10 (5), 1331-1339. https://doi.org/10.22214/ijraset.2022.42382.

K. Arivalagan, & Dr. R. Perumal. (n.d.). Health Insurance In India. International Journal of Advanced Research in Management and Social Sciences, 4(10), 84-104. https://doi.org/https://garph.co.uk/IJARMSS/Oct2015/7.pdf.

K. Raji Reddy, & V. Harini. (2021), Policyholder’s Perception towards Health Insurance Services-.-] Study. Eureka Journals , 5 (1), 1-9.

Kadyan, S., Bhasin, N., & Madhukar, V. (2022), Impact of claim settlement procedure of health insurance companies on customer satisfaction during the pandemic: A case of third-party administrators. InsuranceMarkets and Companies, 13 (1), 66-80. https://doi.org/10.21511/ins.13(1).2022.06.

Kamath, R., Brand, H., Nayak, N., Lakshmi, V., Verma, R., & Salins, P. (2023), District-level patterns of health insurance coverage and out-of-pocket expenditure on caesarean section deliveries in public health facilities in India. Sustainability, 15 (5), 4608. https://doi.org/10.3390/su15054608.

Kamath, R., Brand, H., Ravandhur Arun, H., Lakshmi, V., Sharma, N., & D’souza, R. M. (2023), Spatial patterns in the distribution of hypertension among men and women in India and its relationship with health insurance coverage. Healthcare, 11 (11), 1630. https://doi.org/10.3390/healthcare11111630.

Kamath, R., Lakshmi, V., & Brand, H. (2022), Health index scores and health insurance coverage across India: A State level spatiotemporal analysis. Clinical Epidemiology and Global Health, 18,101185. https://doi.org/10.1016Zi.cegh.2022.101185.

Kaminskyi, B., & Kaminska, O. (2021), Role of assistance and insurance companies while providing travel, healthand TransportationServices. Economic Analysis, (31(4)), 19 https://doi.org/10.35774/econa2021.04.019.

Kapungu, I., Evarest, E., Shaban, N., & Mwakisisile, A. J. (2023}, Modelling and forecasting claim payments of Tanzania National Health Insurance Fund. Tanzania Journal of Science, 49 (4), 911-920. https://doi.org/10.4314/tjs.v49i4.12.

Karl, J. B., Born, P. H., & Viscusi, W. K. (2016), The relationship between the marketsfor health insurance and medical malpractice insurance. Applied Economics, 48 (55), 5348-5363. https://doi.org/10.1080/00036846.2016.1176119.

Kaur, K., & Chandhok, A. (2022 ). Impact of coronavirus on insurance sector in India. International Journal of Science, Engineering and Management, 9 (3), 7-11. https://doi.org/10.36647/ijsem/09.03.a002.

Kenechukwu, N. I., Anyachebelu, K. T., & Abdullahi, M., Umar. (2023), Detection of fraudulent health insurance claims based on decision tree with principal component analysis. Asian Journal ofResearch in Computer Science, 16 (4), 49-66. https://doi.org/10.9734/ajrcos/2023/v16i4370.

Khabiri, R. (2023), The health insurance situation in Iran: A brief overview. Depiction of Health, 14 (4), 393-396. https://doi.org/10.34172/doh.2023.30

Khan, P. K., Perkins, J. M., Kim, R., Mohanty, S. K., & Subramanian, S. V. (2021), Multilevel population and socioeconomic variation in health insurance coverage in India. Tropical Medicine &amp; International Health, 26 (10), 1285-1295. https://doi.org/10.1111/tmi.13645.

Khatooni, E., Ahmadnezhad, E., Olyaeemanesh, A., & Majdzadeh, R. (2023), The dilemma of underutilized health insurance: A matched case-control study investigating reasons in Iran’s free universal health insurance. Iranian Journal ofPublic Health. https://doi.org/10.18502/ijph.v52i12.14325.

Kiranmayi, V., Venkateswara Kumar, K. S., & Naik V, S. (2023), Non-communicable diseases in India: The Growing Public Health Challenge and the role of Health Insurance. Health Behavior and Policy Review, 1422-1433. https://doi.org/10.14485/hbpr.10.6.2.

Kononenko, G. I. (2023), Contemporary trends in insurance under martial law. Journal of Strategic Economic Research, (4), 57-66. https://doi.org/10.30857/2786-5398.2022.4.6.

Korir, E. K. (2020), Health Insurance in Kenya. Volume 5 - 2020, Issue 9 - September, 5 (9), 963­966. https://doi.org/10.38124/ijisrt20sep694.

Korzh, D. E., & Svyatoshnyuk, A. L. (2021), Legal consequences of violation of the voluntary health insurance contractunderUkrainian law. Constitutional State, (41), 44-53. https://doi.org/10.18524/2411-2054.2021.41.225579

Kuckreja, J., Nigde, P., & Patil, Pranjal. (2021), Health Insurance Claim Using Blockchain. International Research Journal ofEngineering and Technology, 8 (5), 2406-2409.

Kullberg, L., Blomqvist, P., & Winblad, U. (2019), Health Insurance for the healthy? Voluntary Health Insurance in Sweden. Health Policy, 123 (8), 737-746. https://doi.org/10.1016/i.healthpol.2019.06.004.

Kumar, Dr. S. A. S., & R. Ramamoorthy. (2013), Health Insurance Market in India - The Way Forward. SSRNElectronicJournal, 13, 178-193. https://doi.org/10.2139/ssrn.1797888.

Kumar, S. (2022), A critical analysis of health insurance business in India. SSRN Electronic Journal, 22-26. https://doi.org/10.2139/ssrn.4292373.

Lefebvre, B. (2023), Health insurance coverage in India. Demographic Transformation and Socio- EconomicDevelopment, 175-182. https://doi.org/10.1007/978-3-031-47847-5 17.

Lei, Y., & Browne, M. J. (2017), Underwriting strategy and the underwriting cycle in medical malpractice insurance. The Geneva Papers on Risk and Insurance - Issues and Practice, 42 (1), 152-175. https://doi.org/10.1057/gpp.2015.24.

Li, Y., & Mamon, R. (2023), Modelling health-data breaches with application to Cyber Insurance. Computers &amp; Security, 124, 102963. https://doi.org/10.1016/j.cose.2022.102963.

Li, Z., Chen, Y., & Ding, J. (2023). Impact of health insurance equity on poverty vulnerability: Evidence from urban-Rural Health Insurance Integration in rural China. Frontiers in Public Health, 11. https://doi.org/10.3389/fpubh.2023.1328265.

Looi, J. C., Allison, S., Bastiampillai, T., Maguire, P. A., Kisely, S., & Looi, R. C. (2023), Mitigating the consequences of electronic health record data breaches for patients and healthcare workers. Australian Health Review, 48 (1), 4-7. https://doi.org/10.1071/ah23258.

Madhavi, Dr. N. (2012), Insurance sector in India: Challenges and opportunities. Global Journal ForResearch Analysis, 3 (1), 45-46. https://doi.org/10.15373/22778160/january2014/73.

Madushani, D. D. L., & Buddhika, H. J. R. (2022), Determinants of customer satisfaction on health insurance in SriLanka. Sri Lankan Journal ofBanking and Finance, 5 (1), 23-41. https://doi.org/10.4038/sljbf.v5i1.25.

Malhotra, R., Malhotra, D. K., & Dania, A. (2017), Evaluating the health of life and health insurance companies. Applications ofManagement Science, 93-108. https://doi.org/10.1108/s0276-897620170000018005.

Manoj Kumara N.V., Bhagyalakshmi. K. (2023 ),“underwriting profit/loss and premium earned: A Study on Health Insurance Sector in India.” Tuijin Jishu/Journal of Propulsion Technology, 44 (6), 2646-2654. https://doi.org/10.52783/tjipt.v44.i6.3754.

Manurung, Q. F. (2023), Legal protlegal protection for customers of CECTION for customers of conventional insurance companies that convert into Sharia general insurance. Awang Long LawReview, 6 (1), 168-175. https://doi.org/10.56301/awl.v6i1.1024.

Martinez, A.L.,& Carvalho, F. A. (2021), Earnings management by health insurance companies in Brazil. European Journal ofManagement and Business Economics, 31 (4), 453-468. https://doi.org/10.1108/ejmbe-01-2021-0023.

Meenakshi, A., & Shree, S. V. (2019), Customer satisfaction on Health Insurance inIndia-A study. Indian Journal ofPublic Health Research &amp; Development, 10 (4), 334. https://doi.org/10.5958/0976-5506.2019.00713.7.

Meitei, M. H., & Singh, H. B. (2021 ), Coverage and correlates of health insurance in the north- easternstatesofIndia. Journal ofHealthResearch, 36 (6), 1091-1103. https://doi.org/10.1108/ihr-07-2020-0282

Mohammadi , Mojtaba, & Mohammad Hadi javaherkalam , M. H. javaherkalam. (2022), Adjusting Remedy Of Duty Of Representation In Insurance Contracts (Comparative Study On Iran And England Law). The Judiciarys Law Journal, 86 (117), 277-297. https://doi.org/10.22106/JLJ.2021.134850.3605.

Mohi, Mahdi, Kazim, & Fatima. (2022), The impact of determinants of financial health on the success of companies "an analytical study in the insurance sector.” Al-Ghari Journal of Faculty of Administration and Economics , 509-536.

Momoh, O. A., & Oyetunji, O. I. (2021), Poor claims settlement and demandfor insurance policies in Nigeria. Advances in Social Sciences Research Journal, 8(4), 53-64. https://doi.org/10.14738/assrj.84.9938.

Mrs. E. Jeevitha, & Premkumar , Dr. M. D. (2020), Challenges Faced By Life Insurance Policy Holders In India With Reference To The Marketing Mix Adopted By The Life Insurance Companies. Journal OfThe GujaratResearch Society, 21 (16), 363-368. https://doi.org/http://dx.doi.org/10.13140/RG.2.2.35859.30247.

Mrs. K. Pandieswari, & Dr. U. Arumugamhh. (2023), Ethical Consideration in the Issuance of Health Insurance in Tamilnadu. Nternational Journal of Humanities & Social Science Studies (IJHSSS)., 3 (4), 348-351.

Mulhadi, M., & Harianto, D. (2022), Breach of contract by insurer as insurancefraud. Proceedings of the 1st International Conference on Social, Science, and Technology, ICSST 2021, 25 November 2021, Tangerang, Indonesia, 203-216. https://doi.org/10.4108/eai.25-11- 2021.2318837.

Mulyatno Budhi Hartanto, T. (2020), Legal responsibilities of pt. insurance of Indonesian services in completion of claim insurance of transportation of goods in sea. IJLLE (International Journal ofLaw and Legal Ethics), 1 (1), 10-19. https://doi.org/10.47701/ijlle.v1i1.955.

Murzalieva, E., Askarova, A., Abdyldaeva, U., Abdyrakhmanova, G., & Khalilov, A. (2023), State of Personal Insurance in the Kyrgyz Republic at the present stage of development in the conditions of the COVID-19pandemic. E3S Web of Conferences, 403, 08022. https://doi.org/10.1051/e3sconf/202340308022.

Muthu, & M.Vinoth. (2019), A Study On Health Insurance Schemes Of Select Health Insurance Companies In India.

N. Nagalakshmi, & M. Vinoth. (2019), Claim Settlement Ratio And Process Of Selected Life Insurance Companies. International Journal of Research and Analytical Reviews (IJRAR), 6 (1), 1718-1732.

Nasution, R. U., & Rahma, T. I. (2022), Analysis and mechanism of settlement of insurance claims of PT Prudential syariah prestasi binjai. Jurnal Ekonomi, Manajemen, Akuntansi Dan Keuangan, 3 (2). https://doi.org/10.53697/emak.v3i2.554.

Neale, F. R., Eastman, K. L., & Peterson Drake, P. (2009), Dynamics of the market for Medical Malpractice insurance. Journal of Risk and Insurance, 76 (1), 221-247. https://doi.org/10.1111/i.1539-6975.2009.01295.x.

Nil, S., & Nil, S. (2024), The influence ofjob security and psychological contract fulfilment on organisational citizenship behaviour in Indian Private Life Insurance Sector. International Journal ofBanking, Risk and Insurance, 12 (1), 1-8. https://doi.org/10.21863/ijbri/2024.12.1.001.

Nishida, Y., Anzai, T., Takahashi, K., Kozuma, T., Kanda, E., Yamauchi, K., & Katsukawa, F. (2023), Multimorbidity patterns in the working age population with the top 10% medical cost from exhaustive insurance claims data of Japan Health Insurance Association. PLOS ONE, 18 (9). https://doi.org/10.1371/journal.pone.0291554.

Niv, Y., & Tal, Y. (2023), Medical Professional Liability Insurance. Patient Safety and Risk Management in Medicine, 111-116. https://doi.org/10.1007/978-3-031-49865-7 9.

Okamoto, E. (2014), Linkage rate between data from health checks and health insurance claims in the Japan National Database. Journal of Epidemiology, 24 (1), 77-83. https://doi.org/10.2188/iea.je20130075.

Otieno, E., & Namyalo, J. (2024), The paradox of the Ugandan health insurance system: Challenges and opportunities for Health Reform. Journal of Preventive Medicine and Public Health, 57 (1), 91-94. https://doi.org/10.3961/ipmph.23.110.

Padmavathi, Mrs, & Karunanithi, Gurusamy. (2022), Policy Holders Perception Towards Health Insurance Services In Selected Insurance Companies In Mysore City. JOUR.

Pandele, A. L. (2023), Medical Malpractice Insurance: Protecting patients and healthcare professionals. Technium Social Sciences Journal, 45, 157-162. https://doi.org/10.47577/tssj.v45i1.9179.

Pandey, P. K. (2017), Demystifying insurance regulatory changes relating to commercial health insurance in India. The Journal of Insurance Institute of India, 4 (3), 1-24. https://doi.org/10.2139/ssrn.3019118.

Pareek, M. (2020). Prospects for growth and issues in marketing of Health Insurance in India. Journal of Management Research and Analysis, 5 (3), 298-303. https://doi.org/10.18231/2394- 2770.2018.0047.

Park, S. K., Thigpen, J., & Lee, I. J. (2020), Coverage of pharmacogenetic tests by private health insurance companies. Journal of the American Pharmacists Association, 60 (2). https://doi.org/10.1016/ijaph.2019.10.003.

Parwaiz, N. (2022), Medical tourism and Health insurance are image constructs of destination: A study oflndia. Indian Journal of Applied Hospitality and Tourism Research ,, 3-17.

Pattnaik, Mr. A., Misra, Dr. S., & Ghadai, Mr. S. (2019), Claim settlement: The moment of truth in health insurance. International Journal of Recent Technology and Engineering (IJRTE), 8 (2), 581-585. https://doi.org/10.35940/ijrte.b1626.078219.

Pattnaik, Mr. A., Misra, Dr. S., Kumar, Dr. A., & Ghadai, Mr. S. (2019), Customer satisfaction in health insurance: Evidence from India. International Journal of Innovative Technology and Exploring Engineering, 8 (9), 424-427. https://doi.org/10.35940/ijitee.i7738.078919.

Paul, S., & Sarkar, S. (2023), Health Insurance Business in India: Progress, issues and way forward. Journal ofHealth Management, 25 (4), 874-882. https://doi.org/10.1177/09720634231215389.

Pedersen, K. (2019), Thefinancial impact of medical malpractice claims after the Affordable Care Act on theproperty & Casualty Insurance Industry. The Boller Review, 4. https://doi.org/10.18776/tcu/br/4/114.

Polontoh, H. (2024a). Legal responsibility of the insurance companyfor unpaid participant claims. Journal ofWorld Science, 3 (1), 105-110. https://doi.org/10.58344/jws.v3i1.541.

Prawira, K. T., Hindarto, D., & Indrajit, E. (2023), Application of enterprise architecture in digital transformation ofinsurance companies. SinkrOn, 8 (2), 856-865. https://doi.org/10.33395/sinkron.v8i2.12302.

Probst, U. (2023). Health Insurance for the good European citizen? migrant sex workers’ quests for health insurance and the moral economy ofHealth Care. Social Science &amp; Medicine, 319, 115190. https://doi.org/10.1016/j.socscimed.2022.115190.

Rajeev, A. (2004), Health insurance for the poor in India. Economic and Political Weekly. https://doi.org/10.2307/4415263.

Rajendran, & Saroja Devi. (n.d .). Nalysis Of Claim Settlement Of Natural Catastrophes In India WithReference To GeneralAndHealthInsurance. Juni KhyatJournal, 12 (5), 134-142.

Ramadhani, A. S., & Muazaroh, M. (2023), The effect offinancial performance on the health level of General Insurance Companies. Almana : Jurnal Manajemen Dan Bisnis, 7 (1), 56-63. https://doi.org/10.36555/almana.v7i1.2099.

Rani, P., & Chauhan, P. (2022), Growth and development of health insurance in India. Journal of Commerce &amp; Trade, 17 (1), 19-23. https://doi.org/10.26703/jct.v17i1-4.

Rao, A. V. Narsimha. (2008a), Disclosures and Concealments: Legitimate Reflections on Insurance Contracts. ICFAI Journal ofInsurance Law , 6 (3), 26-40.

Reddy, P., Mrs, & Gurusamy, K. (2022), Policy Holders Perception Towards Health Insurance Services In Selected Insurance Companies In Mysore City, 5 (1).

Reshmi, B., Unnikrishnan, B., Parsekar, S. S., Rajwar, E., Vijayamma, R., & Venkatesh, B. T. (2021), Health Insurance Awareness and its uptake in India: A systematic review protocol. BMJ Open, 11 (4). https://doi.org/10.1136/bmjopen-2020-043122.

Roshani, P., Selvalakshmi, V., Sujatha, L., Shinde, G., Siddiqui, M. F., & Mengesha, E. A. (2022), Analysis of consumer behaviour in health insurance sector. International Journal of Health Sciences, 1654-1668. https://doi.org/10.53730/ijhs.v6ns5.8955.

Rothstein, & William. (2003), The Metropolitan Life Insurance Company Health Education Programs. Public Health and the Risk Factor, 146-176. https://doi.org/10.1017/9781580466141.010.

S C Bansal, & Harneja, A. (n.d.). Health Insurance in India: Challenges and Opportunities. AtlanticPublishers &Distributors, Delhi, 288-306.

S Sreekanth, P Kavitha, & S Nagendra. (2023), Health Insurance Market in India - The Future. International Journal of Creative Research Thoughts (IJCRT), 8 (6), 1-8.

Sachan, A., & Srivastava, S. (2023), Financial Performance Evaluation of Indian General and standalone health insurance companies: A grey relational analysis approach. Research ReviewInternational Journal ofMultidisciplinary, 8 (8), 164-176. https://doi.org/10.31305/rrijm.2023.v08.n08.028.

Sadovei, N. (2023), The diversity of legal relations within the Compulsory Health Insurance System. StudiaUniversitatis Moldaviae. Seria Stiinte Sociale, 8 (168), 32-39. https://doi.org/10.59295/sum8(168)2023 05.

Samudera, B. T. (2021), Rejection of accident insurance claims by insurance companies. NORMA, 18 (2), 1-9. https://doi.org/10.30742/nlj.v18i2.1585.

Satyanarayana, Dr. M., & Swarupa, Dr. P. (2020), Growth andperformance of general insurance companies in India-premium rate and claim settlement perspective. International Journal of Recent Technology and Engineering (IJRTE), 8 (5), 2071-2073. https://doi.org/10.35940/ijrte.e4574.018520.

Saurabh Ingole, Vaishnavi Adhav, Prinshu Gupta, Vanisree Ramanathan, & Shruti Mahajan. (2022), The need of dental insurance plan in India-survey. International Healthcare Research Journal, 5 (12). https://doi.org/10.26440/ihrj/0512.03521.

Sawalka, S., Lahiri, A., & Saveetha, D. (2022), Ethinsurance: A blockchain based alternative approach for health insurance claim. 2022 International Conference on Computer 342

Communication and Informatics (ICCCI), 1-9. https://doi.org/10.1109/iccci54379.2022.9740765.

Schilling, R., Pavlova, M., & Karaman, A. (2023), Consumer preferences for health services offered by health insurance companies in Germany. Risks, 11 (12), 216. https://doi.org/10.3390/risks11120216.

Sengar, Dr. V., & Mittal, Dr. S. (2019), Recent Trends in Health Insurance Sector: Opportunities and Challenges in India. International Journal of Research and Analytical Reviews, 6 (2), 541­549.

Shoviana, E., & Rohmah, F. (2023 ), Comparative health analysis of insurance companies owned by Bumn during the COVID-19 pandemic in Indonesia. Business Management Analysis Journal (BMAJ), 6 (2), 185-202. https://doi.org/10.24176/bmaj.v6i2.11049.

Siddiqui, & Shoaib. (2023), Efficiency of Standalone Health Insurance Companies: Evaluating Evidence from India, 13. https://doi.org/10.4324/9781003315568-5.

Singh, V., Udmale, S. S., Pandey, A. K., & Singh, S. K. (2021), IOT for health insurance companies. IoT-Based Data Analytics for the Healthcare Industry, 139-147. https://doi.org/10.1016/b978-0-12-821472-5.00008-9.

Sood, K., Kaur, B., & Grima, S. (2022), Revamping Indian non-life insurance industry with a trusted network: Blockchain technology. Big Data: A Game Changer for Insurance Industry, 213-228. https://doi.org/10.1108/978-1-80262-605-620221014.

Sotivoldievich, B. M. (2022). Concept of voluntary health insurance contract. The American Journal ofPolitical Science Law and Criminology, 03 (01), 73-79. https://doi.org/10.37547/tajpslc/volume04issue01-12.

Sreeshailam, Mr. V., & Reddy, Dr. G. N. (28AD), Financial Performance Evaluation Of Select Private Sector Health Insurance Companies In India. EPRA International Journal of Multidisciplinary Research (IJMR), 7 (12), 211-219. https://doi.org/doi.org/10.36713/epra2013.

Stern, J. B. (1983), Will the tortofbadfaith breach of contract be extended to health maintenance organizations? Law, Medicine and Health Care, 11 (1), 12-21. https://doi.org/10.1111Zi.1748- 720x.1983.tb00804.x.

Stream, C. (1999), Health reform in the states: A model of state small group health insurance market reforms. Political Research Quarterly, 52 (3), 499. https://doi.org/10.2307/449147.

Subha T, & Dr R Saroja Devi. (2022), Analysis Of Claim Settlement Of Natural Catastrophes In India With Reference To General And Health Insurance. UGC Care Group I Listed Journal, 122 (5), 134-141.

Sugita, Y. (2013), Japan’s epoch-making health-insurance reforms, 1937-1945. Japan Forum, 25 (1), 112-133. https://doi.org/10.1080/09555803.2012.741141.

Surahio, M., Bhatti, P., Kumar, V. K., & Qureshi, R. (2019), Satisfaction level of health insured and financial profitability of health insurance companies from Health Insurance Product. Journal of Public Value and Administrative Insight, 2 (4), 17-20. https://doi.org/10.31580/jpvai.v2i4.1155.

Suto, M., Sugiyama, T., Imai, K., Furuno, T., Hosozawa, M., Ichinose, Y., Ihana-Sugiyama, N., Kodama, T., Koizumi, R., Shimizu-Motohashi, Y., Murata, S., Nakamura, Y., Niino, M., Sato, M., Taguchi, R., Takegami, M., Tanaka, M., Tsutsumimoto, K., Usuda, K., Takehara, K., ... Iso, H. (2023), Studies of Health Insurance Claims Data in Japan: A Scoping Review. JMA journal, 6 (3), 233-245. https://doi.org/10.31662/jmaj.2022-0184.

Suyoko, S., Sarwo, B., & Kuntjoro, T. (n.d.). Hospital responsibility for release of medical information of to claim the insurance in Telogorejo hospital Semarang. Soepra Jurnal Hukum Kesehatan. https://journal.unika.ac.id/index.php/shk/article/view/1649.

Svyatoshniuk, A. L. (2023), Regarding the specifics of the definition of “medical insurance ” and “Insurance medicine” in the legal field. Uzhhorod National University Herald. Series: Law, 1 (79), 232-235. https://doi.org/10.24144/2307-3322.2023.79.1.40.

Swati Sonal. (2022), Insurance Fraud Prevention Laws, A Need Of Time: A Critical Analysis. Indian Journal of Law and Legal Research, IV(IV), 1-32. https://doi.org/09.2022- 58326957/IJLLR/V4/I4/A181.

T. Lavanya Kumari, & B.N. Lalithchanadra. (2011), Benefit Amount Settlement Ratio: A better indicator for Measuring the Productivity of Insurance Companies. Journal of Research in Business and Management, 3 (4), 20-24.

Tengiz, V. (2023 ), Managed Competition and Health Insurance Reforms in Georgia. Bulletin of the Georgian National Academy of Sciences, 17.

Thanga, J. L., Lalremruati, A., & Lalmuanpuia. (2023), Relationship between economic growth and life insurance: The determining factors of life insurance policy demand in India. Journal ofLaw and Sustainable Development, 11 (9). https://doi.org/10.55908/sdgs.v11i9.1052.

Tkachenko, N., & Kyrylenko, S. (2023), Insurance Companies As Producers Of Investment Financial Services. World Of Finance, (2(75)), 31-44. https://doi.org/10.35774/sf2023.02.031.

Tu, J. (2016), Health insurance regime as differentiation and discipline: The Chinese Health Insurance Reforms. Hygiealnternationalis, 12 (2), 51-72. https://doi.org/10.3384/hygiea.1403- 8668.1612251.

Van der Aa, M. J., Paulus, A. T., Klosse, S., Evers, S. M., & Maarse, J. A. (2019), The impact of reforms of national health insurance on Solidarity in the netherlands: Comparing Health Care Insurance and long-term care insurance. Journal of Long-Term Care, 0(2019), 143. https://doi.org/10.31389/jltc.22.

Vandali, V. (2018), An overview study of health insurance in India. Journal of Clinical and Nursing Research, 2 (2). https://doi.org/10.26689/jcnr.v2i2.324.

Vasilevskaya, N. S., & Bailo, O. V. (2019), Medical Insurance as a direction of reforming the Health System in Ukraine. Wiadomosci Lekarskie, 72 (5), 897-902. https://doi.org/10.36740/wlek201905131.

Voroneanu-Popa, R. V., Constantinescu, R., Ciocan, V., Lazar, M., & Ioan, B. G. (2022 ), Study on medical malpractice insurance in Romania. Romanian Journal of Legal Medicine, 30 (2), 143­148. https://doi.org/10.4323/rjlm.2022.143.

Wijanto, W. (2023), The regulatory improvement of Insurance Law Reform in order to pursue the legal certainty for the people and the insurance company. Global Legal Review, 3 (2), 162. https://doi.org/10.19166/glr.v3i2.7433.

Worku, A. T., Bayleyegne, Y. W., & Tafere, Z. B. (2024), Determinants of profitability of insurance companies in Ethiopia: Evidence from insurance companies from 2011 to 2020 years. Journal of Innovation and Entrepreneurship, 13(1). https://doi.org/10.1186/s13731-023- 00357-1.

Yadav, R. K., & Mohania, S. (2015), Claim settlement process of life insurance policies in Insurance Services - A Comparative Study ofLIC of India and ICICI Prudential Life Insurance Company. International Letters of Social and Humanistic Sciences, 49, 21-29. https://doi.org/10.18052/www.scipress.com/ilshs.49.21.

Yani, Andi & Hidayat, Andi & Susanti, Gita. (2023), Assessing The National Health Insurance System: A Study of The Implementation of Health Insurance Policy in Indonesia. Public Policy and Administration , 2023/02/04 VL - 21, SP - 511EP - 525, DOI- 10.13165/VPA-22-21-4-13.

Yasid, M., Siregar, G. T., Lubis, M. A., & Devi, R. S. (2024), Legal responsibility of insurance companies for actions of default in insurance agreements. Pena Justisia: Media Komunikasi DanKajianHukum, 22 (3), 710. https://doi.org/10.31941/pj.v22i3.3951.

Yassine, A., Hangouche, A. J., El Malhouf, N., Maarouf, S., & Taoufik, J. (2020), Assessment of the medical expenditure of the basic health insurance in Morocco. Pan African Medical Journal, 35. https://doi.org/10.11604/pamj.2020.35.115.13076.

Yastori, Mrs. (2022), Cases of dispute andpending claims in hospitals in the era of National Health Insurance. Proceeding International Conference on Medical Record, 2 (1), 32-38. https://doi.org/10.47387/icmr.v2i1.152.

Yoo, J. (2022), A legal study on simplification of ClaimsforMedical Insurance: Focusing on the amendment (draft) of the Insurance Business Act. Korean Insurance Law Association, 16 (3), 139-162. https://doi.org/10.36248/kdps.2022.16.3.139.

Zaki, M., LaSala, R., Saltmarsh, D., Gem, A., & Eloy, J. A. (2021), Understanding your malpractice insurance policy. Litigation in Otolaryngology, 51-57. https://doi.org/10.1007/978-3-030-64418-5 6.

Zallman, L., Nardin, R., Sayah, A., & McCormick, D. (2015), Perceived affordability of health insurance and medical financial burdens five years in to Massachusetts Health Reform. International Journal for Equity in Health, 14 (1). https://doi.org/10.1186/s12939-015-0235-2.

ANNEXURES

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

Abb. in Leseprobe nicht enthalten

[...]

---

¹ https://www.bhartiaxa.com/life-insurance/types-of-insurance.

² Duty of the State to raise the level of nutrition and the standard of living and to improve public health.

³ Jugal Kishore (2005). National health programs of India: national policies & legislations related to health. Century Publications. ISBN 978-81-88132-13-3.

⁴ International Institute for Population Sciences and Macro International (September 2007). "National Family Health Survey (NFHS-3), 2005-06" (PDF). Ministry of Health and Family Welfare, Government of l ndia. pp. 436-440.

⁵ Rejda, G. E. (2018). Principles ofRisk Management and Insurance (13th ed.).

⁶ Swiss Re Institute. (2021). Insurance and its role in economic stability.

⁷ Tennyson, S.,& Fombonne, P. (2020). The Economic Impact of Insurance on Consumer Behavior. Journal of Risk and Insurance, 87(3), 457-474.

⁸ Browne, M. J., & Kim, K. (2019). The Contribution of the Insurance Industry to Economic Growth. Journal of Financial ServicesResearch, 56(1), 1-20.

⁹ Browne, M. J., & Kim, K. (2019). The Contribution of the Insurance Industry to Economic Growth. Journal of Financial ServicesResearch, 56(1), 1-20.

¹⁰ National Insurance Academy. (2020). The Role ofInsurance in Social Welfare and Economic Development. National Insurance Academy, India.

¹¹ "WHO South-East Asia Region: India statistics summary (2002 - present)". World Health Organization. https://pmc.ncbi.nlm.nih.gov/articles/PMC4047799/. RetrievedOl January 2025.

¹² "Four factors that impacted health insurance industry in 2013". Financial Express. 30 December 2013. Retrieved 13 January 2014.

¹³ https://iris.who.int/bitstream/handle/10665/376869/9789240094703-eng.pdf.

¹⁴ Insurance Regulatory and Development Authority of India (IRDA). Annual Report 2016-17. https://irdai.gov.in/annual-reports.

¹⁵ https://www.bajajfinserv.in/insurance/what-are-the-factors-affecting-health-insurance-premium, 02.01.2025.

¹⁶ https://economictimes.indiatimes.com/wealth/personal-finance-news/heath-insurance-claim-43-policyholders- faced-difficulties-some-had-to-wait-an-extra-day-at-hospital-survey/articleshow/109789790.cms?from=mdr, 01.1.2025.

¹⁷ https://www.zadehfirm.com/faqs/what-is-a-breach-of-insurance-contract-.cfm, 01..1.2025.

¹⁸ https://irdai.gov.in/about-consumer-affairs.

¹⁹ Dr Naresh Mahipal “ An introduction to Insurance Laws”, Central Law Publications, Allahabad, 2nd Edition 2017,atp.1.

²⁰ Ibid.

²¹ Ibid.

²² Dr Naresh MahipaLAn introduction to Insurance Laws, Central Law publications, Allahabad, 2nd edition 2017.

²³ Section-23 oflndian Contract Act, 1872, “ Whatconsiderations and objects are lawful, and whatnot”.

²⁴ (1911) 1K.B. 1024.

²⁵ Section 7 to 17 ofthe Marine Insurance Act, “INSURABLE INTEREST”.

²⁶ [1911-13] AllERp.444.

²⁷ [I960] 2 Lloyd's Rep. 325.

²⁸ 191 S.C. 233 )S.C.1938).

²⁹ [1958]EWCA CivJ1114-3.

³⁰ (2004) ACC 533.

³¹ https://irdai.gov.in/evolution-of-insurance.

³² https://nhsrcindia.org/sites/default/files/2021-04/Mukerji%20Committee%20Report%20Part-II.pdf.

³³ https://citeseerx.ist.psu.edu/document?repid=repl&type=pdf&doi=572fefd61b37dcfdcaacd985ad009eb7e3e4d701.

³⁴ (2021) SCC OnlineSC 751.

³⁵ [1986] AIR 220, 1986 SCR (1) 223.

³⁶ [1984] AIR 346, 1984 SCR (3) 595.

³⁷ Section-17 oflndianContractAct, 1872, “Fraud”.

³⁸ Section-18 oflndianContractAct, 1872, “Misrepresentation”.

³⁹ AIR 1959PATNA413.

⁴⁰ (2021) 2 SCC 50.

⁴¹ (2023) 5 SCC 723.

⁴² (2009) 5 SCC 599.

⁴³ AIR 1992 SC 767.

⁴⁴ https://www.karexpert.com/blogs/opd-vs-ipd-difference-between-opd-and-.

⁴⁵ https://irdai.gov.in/what-we-.

⁴⁶ (2001) 6 SCC 477.

⁴⁷ Article 12 , Definition ofstate.

⁴⁸ Civil Appeal No. 8386/2015.

⁴⁹ https://pib.gov.in/PressReleasePage.aspx?PRID=1744555.

⁵⁰ https://www.etnownews.com/personal-finance/new-india-assurance-to-increase-premiums-by-10-on-9-health- insurance-products-from-this-date-exclusive-article-112128450-01.01.2025.

⁵¹ R. Rajendran and B. Natarajan, The impact of liberalization, privatization, and globalization (LPG) on life insurance corporation ofIndia (LIC), Department of Business Administration, Annamalai University, New Delhi, India. April, 2010.

⁵² (1911) 22 M.L.J.71.

⁵³ AIR 1921 Bom 101.

⁵⁴ 2022 SCC Online SC 1451.

⁵⁵ 2015 SCC OnLine SC 123, para 5.

⁵⁶ https://www.investopedia.eom/terms/b/breach-of-contract.asp.

⁵⁷ https://apps.who.int/gb/bd/pdf/bd47/en/constitution-en.pdf-01.02.2025.

⁵⁸ Protecting ERISA Pre-emption: Retrieved from https://www.eric.Org/protecting-erisa-preemption/#: Last visited on 08th October 2024.

⁵⁹ (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (2) Motherhood and childhood are entitled to special care and assistance. All children, whetherborn in or out of wedlock, shall enjoy the same social protection.

⁶⁰ The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

⁶¹ State to secure a social order for the promotion of welfare of the people.

⁶² Certain principles of policy to be followed by the State.

⁶³ Provision forjust and humane conditions of work and maternity relief.

⁶⁴ Subject-matter of laws made by Parliament and by the Legislatures of States.

⁶⁵ Inconsistency between laws made by Parliament and laws made by the Legislatures of States.

⁶⁶ AIR 1811, 1995 SCC (5) 482.

⁶⁷ (C.A.No.952/77) onFebruary 22, 1995.

⁶⁸ AIR 2020 (NOC) 88 (DEL.).

⁶⁹ 1973 (1) Q.B. 400.

⁷⁰ https://pib.gov.in/PressReleaseIframePage.aspx?PRID=2058791.

⁷¹ https://www.bajajfinserv.in/insurance/what-is-health-insurance,01.01.2025

⁷² Establishment and incorporation of Life Insurance Corporation of India.—(1) With effect from such date as the Central Government may, by notification in the Official Gazette, appoint, there shall be established a Corporation called the Life Insurance Corporation of India. (2) The Corporation shall be a body corporate having perpetual succession and a common seal with power subject to the provisions of this Act, to acquire, hold and dispose of property, and may by its name sue and be sued.

⁷³ Board ofDirectors.

⁷⁴ Capital of Corporation.

⁷⁵ Functions of the Corporation.

⁷⁶ https://www.srdlawnotes.com/2018/03/establishment-constitution-and-capital.html.

⁷⁷ (1854) 15 CB 365; 139

⁷⁸ (1854) 15 CB 365; 139 ER 465.

⁷⁹ https://www.baiaifinserv.in/insurance/what-is-healthinsurance#:~:text=It%20is%20a%20contract%20between,%2C%20medications%2C%20and%20preventive%2 0care.01.01.2025.

⁸⁰ Deduction in respect of health insurance premia- offers tax deductions of up to ?25.000 on health insurance premiums paid in a financial year. The tax deduction limit increases to ?50.000 per fiscal year for senior citizens aged 60 years and above.

⁸¹ (1994)2 SCC413.

⁸² 2016) 3 CPJ 653 (NC).

⁸³ (2013) 10 SCC 536.

⁸⁴ (2009) 8 SCC 316.

⁸⁵ (2007) 5 SCC 428.

⁸⁶ (2019) 17 SCC 808.

⁸⁷ (2009) 8 SCC 316.

⁸⁸ AIR2009 SC 1213.

⁸⁹ Redfern & Hunter, Law and Practice ofIntemational Commercial Arbitration (5th ed., 2015).

⁹⁰ AIRONLINE 1998 SC 154.

⁹¹ 2010(2) CTC 627.

⁹² (2020) 5 MLJ 624.

⁹³ 93 (2005) 1 CPJ 48 (NC).

⁹⁴ 2002 ACJ 633 (Ker).

⁹⁵ (2017) 10 SCC 258.

⁹⁶ 2016)4SCC 128.

⁹⁷ (2011) 4 SCC 365.

⁹⁸ (2009) 1 SCC 693.

⁹⁹ (2021) SCC Online NCDRC 85.

¹⁰⁰ 2018CPJ 243 NC.

¹⁰¹ 2019CPJ21NC.

¹⁰² 2014CPJ348 NC.

¹⁰³ 2019(4)CPJ326

¹⁰⁴ 1996 (1) SCR 500.

¹⁰⁵ NIC 2019 (3) CPJ 172.

¹⁰⁶ Appeal.—Any person aggrieved by an order made by the District Forum may prefer an appeal against such order to the State Commission within a period of thirty days from the date of the order, in such form and manner as may be prescribed.

¹⁰⁷ WPNo 19578 of2016&WPNo 14117of2019.

¹⁰⁸ 2018 (5) MLJ317

¹⁰⁹ 2009 (4) CTC 189; MANU/TN/1108/2009.

¹¹⁰ 2019 SCC Online NCDRC 233.

¹¹¹ Enforcement of orders ofDistrict Commission, State Commission and National Commission.

¹¹² Notwithstanding anything contained in the Code of Criminal Procedure, 1973 (2 of 1974), the District Commission, the State Commission or the National Commission, as the case may be, shall have the power of a Judicial Magistrate of first class for the trial of offences under sub-section (1), and on conferment of such powers, the District Commission or the State Commission or the National Commission, as the case may be, shall be deemed to be a Judicial Magistrate of first class for the purposes of the Code of Criminal Procedure, 1973.

¹¹³ OANo. 3760/2010.

¹¹⁴ OANo. 1234/2020.

¹¹⁵ (2006 ACJ 1576).

¹¹⁶ (2007 ACJ 2213).

¹¹⁷ 13 SCC 476 (2007 AIR SCW 3591).

¹¹⁸ 5 SCC 740 (AIR 2020 SUPREME COURT 1267).

¹¹⁹ Consumer CP No. 874/2022 (National Consumer Disputes Redressai Commission).

¹²⁰ 2017 (5) TMI 1136 (NCDRC).

¹²¹ (2000 ACJ 255).

¹²² 2017 (6) TMI 535 (NCDRC).

¹²³ (1999 (1) CPR 157 (NC).

¹²⁴ AIR 2009 SUPREME COURT 446.

¹²⁵ 2020 (2) CTC551 (SC).

¹²⁶ AIR 1978 SC 12.

¹²⁷ Right to payment of maternity benefit.

¹²⁸ Leave for miscarriage, etc.

¹²⁹ AIR2000 SC 1888.

¹³⁰ Equality before law.

¹³¹ Equality of opportunity in matters of public employment.

¹³² Supra note 61.

¹³³

¹³⁴ (2007) 9 SCC 285.

¹³⁵ W.P.(C) 3190/2021.

¹³⁶ Duties, powers and functions of Authority.

¹³⁷ 2014 (3)CPJ 72(NC).

¹³⁸ 2009 (4)CLT313.

¹³⁹ to call for the records and pass appropriate orders in any consumer dispute which is pending before or has been decided by any State Commission where it appears to the National Commission that such State Commission has exercised ajurisdiction not vested in it by law, or has failed to exercise a jurisdiction so vested, or has acted in the exercise of itsjurisdiction illegally or with material irregularity.

¹⁴⁰ (1993) ILLJ580KER.

¹⁴¹ Notice of change.

¹⁴² AIRONLINE 2001 SC 525.

¹⁴³ AIR 2009 SUPREME COURT 446.

¹⁴⁴ (2020) 2 MLJ (Criminal) 432 (SC).

¹⁴⁵ Causing deathby negligence.

¹⁴⁶ (2000) 6 SCC 207

¹⁴⁷ Ibid.

¹⁴⁸ First Appeal No. 124 of 2020, decided on 27.09.2024, State Consumer Disputes Redressai Commission, [2024] SCDRC.

¹⁴⁹ 2018 (3) RCR (Civil) 353 (SC).

¹⁵⁰ (2013) 6 SCC41.

¹⁵¹ (2016)9SCC 76.

¹⁵² (2008) 5 SCC 194.

¹⁵³ 2017 SCC Online NCDRC 250.

¹⁵⁴ (2017) 3 SCC 109.

¹⁵⁵ (2020) 8 SCC 458.

¹⁵⁶ (2016) 7 SCC592.

¹⁵⁷ (2017) 3 SCC 109.

¹⁵⁸ (2004) 2 SCC 327.

¹⁵⁹ (2018) 2 SCC 75.

¹⁶⁰ (2018) 6 SCC 75.

¹⁶¹ 2010 (3) CPJ 198 (NC).

¹⁶² 2009 (1) CPJ 130 (NC).

¹⁶³ Application for compensation.

¹⁶⁴ (2018) 1 SCC 158.

¹⁶⁵ 165 Ibid.

¹⁶⁶ Requirements of policies and limits ofliability.

¹⁶⁷ (2015)6SCC326.

¹⁶⁸ An "authorised insurer" is an insurance company that has permission to operate in India because it has been registered by the Insurance Regulatory and Development Authority of India.

¹⁶⁹ For the removal of doubts, it is hereby declared that the death of or bodily injury to any person or damage to any property of a third party shall be deemed to have been caused by or to have arisen out of, the use of a vehicle in a public place notwithstanding that the person who is dead or injured or the property ...

¹⁷⁰ (2011) 2 SCC 123.

¹⁷¹ Necessity for insurance against third party risk.

¹⁷² Supra note 111.

¹⁷³ (2009) 1 SCC 142.

¹⁷⁴ (2019) 6 SCC 175.

¹⁷⁵ (2009) 7 SCC 636.

¹⁷⁶ (SC)-2022-2-94.

¹⁷⁷ 92018) 10 SCC341.

¹⁷⁸ (2014) 15 SCC 460.

¹⁷⁹ (2009) 12 SCC 681.

¹⁸⁰ Ibid.

¹⁸¹ Supranote 111.

¹⁸² (2001) 6 SCC 477.

¹⁸³ [2001 (3)CPR22],

¹⁸⁴ [2014 (5) CPR 156]

¹⁸⁵ (2009) 8 SCC316.

¹⁸⁶ AIR 1962 SC814.