Insurance Agents (Health Insurance) Exam (India) Syllabus

SECTION I

CHAPTER 1: INTRODUCTION TO INSURANCE: 

Life insurance
- History and evolution
- History of insurance
- Insurance through the ages
- Modern concepts of insurance
- History of insurance in India
- Life insurance industry
- How insurance works
- Risk management techniques
- Risk avoidance
- Risk retention 
- Risk reduction and control
- Risk financing
- Insurance vs Assurance
- Insurance as a tool for managing risk
- Considerations before opting for Insurance
- Role of insurance in society
- Insurance and Social Security.

CHAPTER 2: CUSTOMER SERVICE: 

General concepts
- Why Customer Service 
- Quality of service
- Customer service and insurance
- Insurance agent’s role in providing great customer service
- The Point of Sale
- Best advice
- The proposal stage
- Acceptance stage
- The claim stage
- Grievance redressal
- Integrated Grievance Management System (IGMS)
- The Consumer Protection Act, 1986
- The Insurance Ombudsman
- Communication process
- Non-verbal communication 
- Ethical behavior.

CHAPTER 3: GRIEVANCE REDRESSAL MECHANISM: 
Consumer courts, Ombudsman
- Integrated Grievance Management System (IGMS)
- The Consumer Protection Act, 1986
- The Insurance Ombudsman.

CHAPTER 4: REGULATORY ASPECTS OF INSURANCE AGENT: 
Definitions
Appointment of Insurance Agent by the Insurer
- Appointment of Composite Insurance Agent by the insurer- Insurance Agency Examination
- Disqualification to act as an Insurance Agent
- Code of Conduct
- Suspension of Appointment of an Agent
- Procedure for Cancellation of Agency
- Effect of suspension/cancellation of Agency appointment
- Procedure to be followed in respect of resignation/surrender of appointment by an insurance agent

- General conditions for appointment of Agents by the insurer

CHAPTER 5: LEGAL PRINCIPLES OF AN INSURANCE CONTRACT: 
Insurance contracts
- Legal aspects and special features
- Legal aspects of an insurance contract
- Elements of a valid contract
- Insurance contracts
- Special features

- Uberrima Fides or Utmost Good Faith
- Measures implemented to reduce the risk

- Breach of Utmost Good Faith
- Insurable interest
- Gambling and insurance

- Proximate Cause
- Contract of Adhesion
- Indemnity
- Subrogation.

SECTION 2

CHAPTER 6: INTRODUCTION TO HEALTH INSURANCE: 
What is health care

– Definition of Health Determinants of Health
- Levels of Healthcare
- Levels of health care
- Types of health care
- Factors affecting the health systems in India – Evaluation of health insurance in India
- Employees State Insurance Scheme - Central Government health scheme
- Commercial health insurance
- Health Insurance Market
- Infrastructure Public health sector
- Private sector providers 
– Pharmaceutical industry
- Insurance Providers
- Intermediaries
- Insurance selling activities
- Insurance Servicing activities
- financial product distribution 
– Other important organizations which form part of the health insurance market.

CHAPTER 7: INSURANCE DOCUMENTATION: 
Proposal forms
- Standard form of Declaration
- Nature of questions in a proposal form
- Elements of Proposal – Medical Questionnaire
- Role of intermediary
- Duty of an intermediary towards prospect (client)
- Acceptance of the Proposal –(Underwriting)
- Note on underwriting and processing of proposals
- Premium receipts
- Definition  - Payment of premium in advance
- Method of payment of premium
- Policy Document
- Conditions and warranties
- Endorsements
- Specimen Endorsements
– Interpretation of policies
- Renewal Notice
- Anti –Money laundering and know your customer guidelines .

CHAPTER 8: HEALTH INSURANCE PRODUCTS: 
Classification of health insurance product
- Introduction
- Definition
- Features of health policies
- Broad classification of health insurance products
- IRDA guidelines on standardization in health insurance
- Hospitalization indemnity product
- Top up covers or high deductible insurance plans
- Senior citizen policy
- fixed benefit covers
- hospital cash
- critical illness
- hospital daily cash policy
- critical illness policy
- long term care insurance
- combi-products
- Package policies
- Micro insurance and health insurance for poor sections
- Rashtriya Swasthya Bima Yojana
- Pradhan Mantri Suraksha Bima Yojana
- Pradhan Mantri Jan-Dhan Yojana
- Personal accident and disability cover- overseas travel insurance
- Group health cover
- Special products
- Key terns in health policies.

CHAPTER 9: HEALTH INSURANCE UNDERWRITING: 
What is Underwriting – Definition – need
- Underwriting basic concepts
- File and use guidelines
- Other health insurance regulations of IRDAI
- Basic Principles of Insurance and tools for underwriting -Underwriting process
- Group health insurance
- Underwriting of overseas travel insurance
- Underwriting of personal accident insurance

CHAPTER 10: HEALTH INSURANCE CLAIMS: 
Claims management in insurance
– stakeholders in claim process
- Role of claims management in insurance company
- Management of health insurance claims
- Challenges in health insurance
- claims process in health insurance
- Documentation of health insurance claims
- Claims reserving
- Role of third party administrators
- Claims management 
– personal accident
- overseas travel insurance