IRDAI IC38 (Insurance Agent) Health Insurance Syllabus

Health Insurance syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Health Insurance in IRDAI IC38 (Insurance Agent), not a summary of it.

1. 1

   Health Insurance Fundamentals

   4 topics

   • Need for health insurance and rising healthcare costs
   • Structure of the Indian healthcare and health-financing system
   • Key terms
     • Sum insured, room rent limits and sub-limits
     • Pre-existing diseases and waiting periods
     • Co-payment, deductible and restoration benefit
   • IRDAI Health Insurance Regulations and standardisation
2. 2

   Health Insurance Products

   5 topics

   • Indemnity-based hospitalisation (Mediclaim) policies
   • Family floater and individual cover
   • Defined-benefit products
     • Critical illness cover
     • Hospital cash / daily cash benefit
   • Senior citizen and disease-specific policies
   • Government health schemes and group health cover
     • Ayushman Bharat and state schemes
3. 3

   Health Underwriting and Claims

   5 topics

   • Health underwriting and the proposal stage
   • Role of Third Party Administrators (TPAs)
   • Cashless vs. reimbursement claims
     • Pre-authorisation for cashless treatment
     • Documents required for reimbursement
   • Portability and migration of health policies
   • Tax benefits on health insurance premiums

Health Insurance flashcards for IRDAI IC38 (Insurance Agent)

20 of 50 cards from the Health Insurance deck — real questions with worked answers.

1. Why is health insurance increasingly necessary in India today?

   Because medical inflation runs much higher than general inflation (roughly 12-15% a year), advanced treatments are costly, lifestyle/non-communicable diseases are rising, and over 60% of healthcare spending in India is out-of-pocket. Health insurance protects savings from being wiped out by a single hospitalisation.

2. What is 'medical inflation' and how does it compare to general inflation?

   Medical inflation is the rate at which the cost of healthcare (hospital charges, drugs, procedures) rises. In India it is typically around 12-15% per year, roughly double the general consumer price inflation, which is why sum insured needs periodic enhancement.

3. What does 'out-of-pocket expenditure' mean in health financing, and why is it a problem in India?

   Out-of-pocket expenditure is money individuals pay directly for healthcare at the point of use (not reimbursed by insurance or government). In India it is very high (over half of total health spend), pushing many families into poverty due to 'catastrophic health expenditure'.

4. What are the main pillars of the Indian healthcare delivery system?

   A mix of public providers (government hospitals, primary health centres, community health centres) and a large private sector (corporate hospitals, nursing homes, clinics). Healthcare financing comes from government schemes, employer/group cover, private health insurance, and out-of-pocket payments.

5. What are the four main methods of financing healthcare?

   (1) Out-of-pocket payments by the patient, (2) Voluntary/private health insurance, (3) Social or government-sponsored health insurance schemes, and (4) Direct government provision of free/subsidised healthcare. Health insurance shifts the burden away from out-of-pocket payment.

6. Define 'hospitalisation' as used in a health insurance policy.

   Admission to a hospital as an inpatient for a minimum continuous period (usually 24 hours), on the advice of a registered medical practitioner, for treatment of an illness or injury. The 24-hour minimum is waived for specified daycare procedures.

7. What is a 'day-care procedure/treatment' in health insurance?

   A medical treatment or surgery that, due to technological advancement, requires less than 24 hours of hospitalisation (e.g. cataract surgery, dialysis, chemotherapy, lithotripsy). It is covered even though the 24-hour inpatient requirement is not met.

8. Distinguish between 'pre-hospitalisation' and 'post-hospitalisation' expenses.

   Pre-hospitalisation expenses are medical costs incurred before admission (e.g. tests, consultations), typically covered for 30 days prior. Post-hospitalisation expenses are follow-up costs after discharge, typically covered for 60 days, provided both relate to the same condition that caused hospitalisation.

9. What is a 'sub-limit' in a health insurance policy?

   A cap on the amount payable for specific expense categories within the overall sum insured, such as a limit on room rent per day, ICU charges, or a particular procedure. Claims beyond the sub-limit must be borne by the insured even if the sum insured is not exhausted.

10. Differentiate a 'deductible' from 'co-payment' in health insurance.

    A deductible is a fixed amount the insured pays first before the insurer pays anything. Co-payment (co-pay) is a fixed percentage of each claim the insured must bear, with the insurer paying the rest. Both reduce premium and the insurer's outgo.

11. What is the 'free-look period' for health insurance policies?

    A period (15 days, or 30 days for policies sold through distance/electronic mode) from receipt of the policy during which the policyholder may review terms and cancel for a refund of premium (less proportionate risk/medical/stamp charges) if not acceptable.

12. What is a 'waiting period' in health insurance, and name the common types?

    A period during which certain claims are not payable. Common types: (1) Initial waiting period (usually 30 days for all illnesses except accidents), (2) Specific disease waiting period (e.g. 2 years for cataract, hernia), and (3) Pre-existing disease (PED) waiting period.

13. Under current IRDAI norms, what is the maximum waiting period for pre-existing diseases (PED)?

    A pre-existing disease must be covered after a maximum waiting period of 36 months (3 years) of continuous coverage. After this period, claims for that PED cannot be rejected on the ground of it being pre-existing.

14. How is a 'pre-existing disease (PED)' defined under IRDAI standardisation?

    Any condition, ailment, injury or disease that was diagnosed by a physician within 48 months prior to the policy's first issue, or for which medical advice/treatment was recommended by or received from a physician within 48 months prior to issue.

15. What is the role of IRDAI in regulating health insurance?

    IRDAI (Insurance Regulatory and Development Authority of India) is the statutory regulator that frames Health Insurance Regulations, mandates standard definitions, prescribes product norms (e.g. lifelong renewability, PED waiting limits), protects policyholders, and approves products before sale.

16. What is the purpose of IRDAI's standardisation of definitions and exclusions in health insurance?

    To ensure uniformity across insurers so that key terms (hospital, PED, day-care, etc.) and a list of permanent and standard exclusions mean the same thing everywhere, reducing disputes and helping customers compare and understand policies easily.

17. What is 'lifelong renewability' as mandated by IRDAI for health policies?

    IRDAI requires that individual health insurance policies be renewable for the lifetime of the insured. An insurer cannot deny renewal except on grounds of fraud, misrepresentation, or moral hazard - not merely because the insured has aged or made claims.

18. Name three standard IRDAI-prescribed health insurance products.

    Arogya Sanjeevani (a standard indemnity health policy), Corona Kavach (indemnity COVID cover) and Corona Rakshak (defined-benefit COVID cover), and Saral Suraksha Bima (standard personal accident cover). These have uniform features across all insurers.

19. What is an indemnity-based (Mediclaim) health insurance policy?

    A policy that reimburses the actual hospitalisation expenses incurred (medical bills) up to the sum insured. It is based on the principle of indemnity - the insured is restored to the financial position before the loss but cannot profit, so payment equals actual cost, not a fixed sum.

20. What expenses does a typical Mediclaim hospitalisation policy cover?

    Room/boarding charges, nursing, ICU, doctors' and surgeons' fees, anaesthesia, blood, oxygen, operation theatre, medicines, diagnostic tests, prosthetics/implants used in surgery, plus pre- and post-hospitalisation expenses and specified day-care procedures, up to the sum insured.

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