Pamantasan ng Lungsod ng Pasig

College of Business and Accountancy

12-B Alcalde Jose Kapasigan Pasig City

Specialized Industry

Audit of Insurance Industry including HMO

Prepared by:
De Vera, Kyle C.
Evangelista, Cristalyn B.
Gabriel, Rosemarie C.
Parlan, Andrea Maey M.
Suelto, Joanne V.

Submitted to:
Prof. Sande Amor

May 2021
 Insurance Company
Learnings Outcomes:
At the end of the lesson, the students are expected to:
1. Understand the definitions, distinctions, and types of insurance.
2. Be able to define insurance audit.
3. Determine the different audit procedure in Profit or Loss Account and in Balance Sheet of
insurance companies.
4. Determine the steps taken by the auditor in auditing an insurance company.
5. Obtain information about the contents of an auditor’s report aside from the normal
contents prescribed for ‘Limited Companies’
6. Distinguish the difference between PhilHealth, Private Health Insurance, and HMO.
7. Understand the examination cycle in auditing HMO businesses.
What is insurance?
Insurance is a contract between two parties whereby one party agrees to undertake the
risk of another in exchange for consideration known as premium and promises to pay a fixed sum
of money to the other party on happening of an uncertain event (death) or after the expiry of a
certain period (in case of life insurance) or to indemnify the other party on happening of an
uncertain event (in case of general insurance). The party bearing the risk is known as the 'insurer
or 'assurer and the party whose risk is covered is known as the 'insured' or 'assured'.
The insurance industry occupies a very important place among financial services all over
the world. Today insurance affects people from all walks of life. Individuals as well as business
firms turn to insurance for managing various risks. Everyday new coverage is added to the existing
policy. The expanding scope of insurance highlights the growing importance of insurance to
individuals and organizations alike. A proper appreciation of what insurance is and what it can do
to help an individual or an organization is therefore necessary.
Distinctions of Insurance
There are 2 distinctions of insurance, namely Life Insurance and General Insurance.
a. Life Insurance
Life insurance promises specific financial compensation to the beneficiary in case
of the demise of the insured person. To avail the insurance benefits, the policyholder is
liable to pay the premium amounts regularly and timely, as per the policies of the chosen
plan.
Types of Life Insurance are:
♡ Term/Protection Insurance
♡ Endowment/Pure Endowment
♡ Money Back Plan
♡ Whole Life Insurance Product
♡ Unit Linked Insurance Plan
♡ Pension or Retirement Plans
 ♡ Annuities
♡ Group Insurance
♡ Others

b. General Insurance
General insurance is a general term used for all the insurance plans that safeguard
things other than life, such as your health and valuables against theft, natural disasters,
accidents, etc. Timely premiums are to be paid for the value of protection chosen by you.
The insurance company is then liable to pay you the assured sum if any damage or theft
happens to the insured entity.
Types of General Insurance are:
♡ Health Insurance
♡ Motor Insurance
♡ Home Insurance
♡ Travel Insurance
What is an insurance audit?
An insurance audit is the carrier’s way of determining how much risk they actually insured
over the past year. The company could’ve undergone a drastic change over that whole year your
policy was in effect.
What is the role of Insurance auditors in Insurance audit?
♡ The Central and Branch Auditors of an insurance company are appointed at the Annual
General Meeting of the Company.
♡ Before making the appointment an appointment from the Comptroller and Auditor
General must be received.
♡ The insurers as per the guidelines of the Insurance Act, 1938, and the Companies Act, 2013
must comply with the provisions with regard to the appointment of auditors.
♡ As per the recommendation of the Audit Committee, the board appoints the statutory
auditors, subject to the shareholder's approval at the general meeting of the Indian
Insurance Company.
♡ The appointment of branch auditors is made to conduct the audit of the divisions having
the same rights and obligations as per the statute. The branch auditors submit their report
to the statutory auditors.
♡ However, at the division level, the branch auditors certify the Trial balance and incorporate
the financial statements of the branches under the divisions.
♡ The insurer does not have the power to remove the statutory auditor without taking the
approval of the authority.
♡ An audit firm cannot audit more than three insurers (Life insurance or Health Insurance or
Reinsurer or Non-Life Insurance) at a time.
♡ They made an appointment that can be canceled if it is found that the appointment of
auditors by the insurers is not as per the proposed guidelines.
What is Checked during Insurance Audit in the Company Balance Sheet
The essential points considered during an insurance audit in the Balance Sheet of Company
are as follows:

Figure 2: Audit in Balance Sheet

1. Investments
The auditor must follow the following prescribed provisions with regards to the
investments. At the time of the inspections of the investments of the insurance company:
a. An insurance company can invest only in approved securities. However, it can also
invest in securities other than approved securities if the following conditions are
satisfied:
♡ The investment made must not exceed 25% of the total investments made.
♡ The investment must be made with the consent of the board of directors.
b. An insurer must not invest in shares or debentures of an insurance or investment
company over least of the following:
♡ 10% of its own total calculated assets
♡ 2% of the subscribed share capital or debentures of the investee.
c. An insurance company must not invest in the share or debentures of a company other
than an insurance or investment company above at least the following:
♡ 10% of its own total calculated assets.
♡ 10% of the subscribed share capital or debentures of the investee.
d. An insurance company is not allowed to invest in the shares and debentures of a
private company.
e. The insurance companies are not permitted to invest in funds of their policyholders
outside the country.
 2. Cash and Bank Balances
a. The auditor shall during insurance audit prepare Bank reconciliation statements.
b. The auditor must obtain the confirmation of Bank Balances for all the operative and
inoperative accounts.
c. The auditor shall physically verify the Term Deposit Receipts that is issued by the
bankers.
d. The auditor shall verify the deposits and withdrawal transactions and also check of the
account is operated by authorized persons only.
e. In case of funds that is in transit, the auditor must verify that same amount is
appropriately reflected in a reconciliation statement.

3. Outstanding Premium and Agents’ Balance

The audit procedure that may be followed in an agent’s balance are as follows:
a. Verify whether the agent’s balances as well as outstanding balances in the outstanding
premium accounts have been listed, analyzed, and reconciled for the purpose of audit.
b. Verify whether the recoveries of large and outstanding deposits have been made
during post-audit period.
c. Check if there are any old outstanding debts or credit balances at the year-end which
need adjustments.
d. Check the agent’s balances that do not include employee’s balances as well as balances
of other insurance companies.
e. Verify that there is no credit of commission is given to agents for businesses.

What are the Essential Points Checked in a Profit & Loss Account During Insurance Audit?
The essential points to look in Profit and Loss Account while conducting insurance audit
are as follows:

Figure 1: Audit in Profit or Loss Account

1. Verification of Premium
♡ Insurance Premium is the amount paid to the insurance company for payment
of the insurance contract obtained.
Audit Procedure:
a. Auditor must look into the internal control and compliance which is laid down
for the collection and recording of premium.
b. The cover notes must be numbered serially.
c. The auditor needs to check if the premium registers are maintained
chronologically.
d. The auditor verifies if the premium register is equal to the amount shown in the
General Ledger.
e. Lastly, the auditor also verifies if the installments due on or before the balance
sheet date has been received or not and if it has been accounted as premium
income under the year which the financial statement is audited.

2. Verification of Claims
♡ Insurance Claims is a formal request by a policyholder to an insurance company
for coverage or compensation for a covered loss or policy event.
Audit Procedure:
a. The auditor shall verify and check for the unsettled claims.
b. Auditor must also check if the provision made with the company for the claims
is legally liable.
c. Then, check if the provision made is not more than the insured amount.
d. Lastly, check the co-insurance arrangement which contains the company’s
provision with respect to its own share of anticipated liability.

3. Verification of Commission
♡ Insurance Commission is a certain percentage of premium produced that is
retained as compensation by insurance agents and brokers.
Audit Procedure:
a. The auditor shall verify the voucher disbursement entries with regards to the
disbursement voucher with the copies of commission bills and statement.
b. The auditor also checks if the vouchers are authorized by the officers-in-charge
and also if the income tax is deducted.
c. Then, check the amount of commission allowed.
d. Lastly, check the accounting period of commission.

4. Verification of Operating Expenses

Audit Procedure:
a. The auditor must check the operating expenses that are more than 500,000 or
1% of the net premium, whichever is higher, that should be shown separately.
b. The auditor must also check the expenses that are not directly related to the
insurance business and must be shown separately.
While auditing the accounts of Insurance Company, which steps should be taken by the auditor?
Following steps should be taken by the auditor while auditing the accounts of insurance
company:
1. Internal Check Inspection
2. Verify the Premium
3. Inspect the Claim Register
4. Cash Balances
5. Examine the Final Accounts
6. Verify the Payable Commission
7. Examine the Investment
8. Insurance Act 1938 Application
9. Checking of Bonus
10. Provision of Depreciation
11. Examine Insurance Policies
12. Accrued Interest Checking
13. Allocation of Surplus
14. Expenses Allocation
15. Deposits in State Bank
16. Balances of Agency
17. Loans Against Policy

Content of Auditor’s Report

Apart from normal contents of Auditors report, as prescribed for 'Limited Companies' IRDA
has prescribed the certain matters to be dealt with by the Auditors' in their Report vide Regulation
3 under Schedule C of IRDA (Preparation of Financial Statements and Auditor's Report of Insurance
Companies) Regulations, 2002. The Schedule C is reproduced below –

"The report of the auditors on the financial statements of every insurer shall deal with the specified
herein- “

A. (a) That they have obtained all the information and explanations which, to the best of their
knowledge and belief, were necessary for the purposes of their audit and whether they
have found them satisfactory;

(b) Whether proper books of account have been maintained by the insurer so far as
appears from an examination of those books;

(c) Whether proper returns, audited or unaudited, from branches and other offices have
been received and whether they were adequate for the purpose of their audit;

(d) Whether the Balance Sheet, Revenue Accounts and Profit and Loss Account dealt with
by the report and the Receipts and Payments Account are in agreement with the books of
account and returns; and
 (e) Whether the actuarial valuation of liabilities is duly certified by the appointed actuary,
including to the effect that the assumptions for such valuation are in accordance with the
guidelines and norms, if any, issued by the authority and/or the Actuarial Society of India
in concurrence with the Authority.

B. The auditors shall express their opinion on:

(a) (i) Whether the Balance Sheet gives a true and fair view of the insurers affairs as at the
end of the financial year/period;

(ii) Whether the Revenue Account gives a true and fair view of the surplus or the deficit
for the financial year/period;

(iii) Whether the Profit and Loss Account gives a true and fair view of the profit or loss
for the financial year/period;

(iv) Whether the Receipts and Payments Account gives a true and fair view of the
receipts and payments for the financial year/period.

(b) The financial statements stated at (a) above are prepared in accordance with the
requirements of the Insurance Act, 1938 (4 of 1938), the Insurance Regulatory and
Development Authority Act,1999 (41 of 1999) and the Companies Act, 1956 (1 of 1956)
[now Companies Act, 2013), to the extent applicable and in the manner so required.

(c) Investments have been valued in accordance with the provisions of the Act and the
Regulations.

(d) The accounting policies selected by the insurer are appropriate and are in compliance
with the applicable Accounting Standards and with the accounting principles, as prescribed
in these Regulations or any order or direction issued by the Authority in this behalf.

C. The auditors shall further certify that:

(a) they have reviewed the management report and that there is no apparent mistake or
material inconsistencies with the financial statements; and

(b) the insurer has complied with the terms and conditions of the registration stipulated
by the Authority.

D. A certificate signed by the auditors (which is in addition to any other certificate or report
which is required by law to be given with respect to the balance sheet) certifying that:

(a) they have verified the cash balances and the securities relating to the insurer's loans,
reversions and life interests (in the case of life insurers) and investments;
 (b) the extent, if any, to which they have verified the investments and transactions relating
to any trusts undertaken by the insurer as trustee; and

(c) no part of the assets of the policyholders' funds has been directly or indirectly applied
in contravention of the provisions of the Insurance Act 1938 (4 of 1938) relating to the
application and investments of the policyholders' funds.

From above, it is clear that the auditor has to examine the contents of the management
report with a view to certify that there are no material inconsistencies in the same with the
financial statements. The auditor should, based upon the audit conducted and information and
explanations gathered during the course of the audit, verify that there are no material
misstatements in the management report. As far as certification of compliance with the terms and
conditions of the registration stipulated by the Authority is concerned, the auditor should ask for
the relevant documents from the management of the company and conduct an examination
thereof. Based on his observation, the auditor should certify the aforesaid compliance.

The auditor also has to state in the report that reliance has been placed on the certificate
obtained from the appointed Actuary in respect of IBNR/IBNER, PDR and other reserves certified
by the appointed Actuary of the company.

The auditor also has to issue a separate certificate on verification of cash, cheques in hand
and other securities as required by the Regulations.

Signatures and Reports to be attached with the Accounts and Statements

Sub-section (3) of section 11 of the Insurance Act, 1938 provides that the accounts and
statements referred to in sub-section (1) should be signed, in the case of a company, by the
chairman, if any, and two directors and the principal officer of the company. It further provides
that the accounts and statements should be accompanied by a statement containing the names,
descriptions and occupations of, and the directorships held by, the persons in charge of the
management of the business during the period to which such statements refers and by a report
on the affairs of the business during that period.

HMO Companies

One of the most common types of insurance offered in the Philippines is the health insurance, but
what is health insurance?

Health insurance is a form of financial service that provides financial security in the midst
of an illness or when health calls for it. It is a form of insurance that covers medical and surgical
costs, either by preventive or corrective means. In most cases, individuals who have health
insurance literally pay nothing after a procedure is done. In order to enjoy such benefits, the
insured pays a premium. While health insurance is mandatory in the country through PhilHealth,
its coverage leaves a lot to be desired.
What is the Difference Between Private Health Insurance, PhilHealth, and HMO?
There are three types of medical insurance in the Philippines that you can choose from.
Let’s take a look at what each offer and what their differences are:

✓ PhilHealth

The Philippine Health Insurance Corporation or PhilHealth is a government-run

insurance provider. Compared to private providers, this type of insurance is more
affordable.

PhilHealth has an established insurance program that provides financial assistance

to Filipino citizens who are employed or otherwise, and in need of medical attention or
surgery.

If you are an employee, half of your monthly contribution will be shouldered by

your employer and the other half will be deducted from your salary.

Senior citizens aged 60 and over are automatically covered by PhilHealth, and
recently, the Republic Act 11228 has been passed, which means Persons with Disabilities
in the country will also receive special benefits from PhilHealth.

How much financial assistance will you get as a PhilHealth member? It depends on
the illness or medical condition.

PhilHealth, which is the most affordable of the three will cost you P1,400 to P6,600
a year. This depends on how much you earn, and whether you are under the formal or
informal (voluntary) bracket. If you are employed, half of the contribution should be
covered by your company.

✓ Private Health Insurance

Unlike HMOs that offer access to a limited network of healthcare providers, private
health insurance companies offer access to a more extensive network.

It is not that common for companies to offer this type of insurance as a part of their
benefits package, although there are a few that do.

Private health insurance premiums can be a little pricey. They are fully paid for by
individuals voluntarily if they want to be insured.

If you want your family members to be covered, that would be at an additional cost.
Note that this only applies to immediate family members.

These private health insurance companies are comparable to international ones

and some of their policies still apply even when the insured member is out of the country.
 The most well-known private health insurance providers in the country include
Manulife, PRU Life U.K., and Sun Life.

For private health insurance, the lowest plan you can get would cost you P40,000
per year.

✓ HMO

HMO or Health Maintenance Organizations are private organizations providing

healthcare insurance to members.

Their difference from private health insurance is that they have a network of
doctors and healthcare providers. Their members can only avail of the benefits from those
within that network.

The plans that are offered by HMOs are often customizable but there is usually a
limit to how much financial assistance you can get in a year. The higher the premium you
are paying, the bigger your annual allowance will be, too.

There are several HMO providers in the country but the most popular ones are
Maxicare and MediCard. HMO membership is usually provided by private companies to
their employees on top of their PhilHealth contribution.

The cost of HMO premiums varies depending on the coverage you’re getting. The
plans would cost anywhere from P10,000 to 60,000 per year.

PhilHealth, HMOs, and private health insurance providers share the same goal of
covering their member’s medical bills and expenses. It is their approach or their method
of transmitting their services that vary.

To see closely what is included in the audit procedure, we will use HMO's audit as an
example.

Audit Procedure of HMO’s

Examination Cycle

A. Administrative Guidelines
"Section 4d and f of the E.O. 192 provides that the Insurance Commission (IC) shall
have the authority to:
d. Regulate, supervise and monitor the operations and management of HMOs to
ensure compliance with this Order, existing laws, rules and regulations and such
other directives and circulars issued by the Insurance Commission.
f. Order the examination of documents, papers, files, tax returns, books of accounts
and other records, in whatever form, of any entity, person, or any HMO under
investigation, including persons, entities and/or corporations with related interest.
B. Submission and Verification of HMO's Quarterly Interim Financial Statements
Section 2.2 of CL 2016-41 requires all HMOs to submit reportorial requirements on
or before the 1Sth day of the month following the end of each quarter starting 15 October
2016, to wit:
a. Interim Financial Statements (IFS)
b. Computation of Acid-Test Ratio and Net Worth
c. Starting 2017, the submission for each quarter is due on or before the following
dates:
Quarterly Ending (as of) Due Date

March 31 April 15

June 30 July 15

September 30 October 15

December 31 January 15

Upon receipt of the above submission, verify and prepare the schedule of
Computation of Compliances with the following requirements of CL 2016- 41:
a. Section 1.2 Deposit Requirements
b. Section 1.3 Risk-Based Capitalization
c. Section 1.4 Net Worth Requirement
d. Section 1.4 Liquidity Requirement

C. Annual Filing of Audited Financial Statements

Section 2.1 of CL 2016-41 and CL 2017-32 requires all HMOs to submit their
respective Audited Financial Statements as of 31 December 2O_together with other
requirements on or before 31 May of each year.

The above submitted reportorial requirements will be subject to the annual

examination of the Insurance Commission either on-site or off-site examination.

D. On-site Examination
Preparations
On the first day of on-site examination, the examiners present the designation
letter to the President of the HMO company authorizing them to conduct the said
examination. The examiners are then endorsed by the President to the Chief Accountant
who will be responsible in bringing them to the department where they will be working
and in introducing them to the respective officers of said department. The examiners then
expect that they will be given a permanent area where they can work and leave in place
the records/documents they are using throughout their audit.
 The team leader gives the listing of requirements, i.e., the
books/records/documents, etc. that they will be using in the examination to the
officer/employee in charge.

E. Concluding the Examination

One week before terminating the examination, the supervisor should write a letter
advising the company of the conclusion of the examination and reminding them of any
record/document not yet submitted/presented to the examiner.

On the last day of examination, the examiner with the supervisor will inform the
company of the termination of the examination and thank the management for the help
and cooperation extended to them during the examination.
A final report of the examination will be prepared and transmitted to the HMO company.

F. Off-site Examination (Verification)

Guided by the examination/verification procedure, the Insurance Specialist verifies
and analyses the accounts in the Audited Financial Statements together with the
supporting schedules and documents.

The results of the verification are reviewed by the Supervising Insurance Specialist
and passed upon by Chief Insurance Specialist. Upon verification and review, there are
items considered as unaccounted assets and/or non leger liabilities which may be resulted
in a net worth deficiency and/or compliance with liquidity requirement.

A transmittal letter shall be transmitted to the company addressed to the

company's president advising them the results of the verification together with a schedule
of non-ledger assets, unaccounted assets, non-ledger liabilities, and computation of
compliances.

The company is given ten (10) days from the receipt of the said transmittal letter
to comply with the requirements, if any.

Minimum Verification Procedures (for IC examiners)

1. Check the figures in the audited FS against the figures in the adjusted trial balance.
Any difference should be reconciled.

2. Read Auditor's Report for possible audit exceptions which may affect the
company's financial statements. Read also the notes to financial statements for
disclosures made by the auditors regarding the assets, liabilities and net worth
accounts. These may necessitate adjustments. Example: assets pledged to secure.

3. a. Company Obligations –
i. If obligation is shown as a liability, then there is no need for adjustment.
ii. If not, take it up as additional liability.
 b. Sister/Affiliated or Third-Party Obligations
c. Significant Disclosures in Company's Operation.

4. Prepare a comparative balance sheet of current and previous years per Audited FS,
before unaccounted assets. Indicated sources of increase or decrease in assets,
liabilities and net worth accounts. Get ratios for each and every investment over
total assets, particularly those granted to sister/affiliated companies.

5. Refer to the latest examination/verification report for requirements not complied.

Always compare treatment of accounts and any variations must be explained.
Know the basis of considering an asset as unaccounted or accounted. It's being
accounted or unaccounted in previous years without knowing why, is not the
enough basis. Make it a point to analyze documents submitted by the company.

6. Verify all the accounts together with supporting documents, paying particular
attention to Investment, Cash accounts and other accounts which may be
considered as material items in the company's financial statements.

7. Prepare a worksheet for Working Balance Sheet together with the summary of
unaccounted assets and non-ledger liabilities. Indicate the reason for such
treatment.

8. Prepare the schedule of Computation of Compliances with the following

requirements of CL201641, to wit:
a. Section 1.2 Deposit Requirements
b. Section 1.3 Risk-Based Capitalization
c. Section 1.4 Net Worth Requirement
d. Section 1.4 Liquidity Requirement

9. Consolidate the results of the verification and prepare a transmittal letter to the
company. In case of compliance requirements, follow through until such
requirements are complied.

10. Arrange the verification folder together with the following:

a. Copy of transmittal letter and other correspondences between IC and
the company.
b. Working Balance Sheet, Summary of Unaccounted Assets Non-Ledger
Liabilities (if any), Schedule of Computation of Compliances and
Summary of adjustments/reconsiderations made, also included the
documents submitted during the Filing of 20- Audited Financial
Statements of HMOs.
c. Supporting documents of Asset, Liability and Net Worth accounts and
other submitted requirements.
References:

Audit of Insurance Company. (2018, September). The Institute of Chartered Accountants

of India. https://ca-final.in/wp-content/uploads/2018/09/Chapter-11-Audit-of-
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3lcvYmb5xjXxhI

Life Insurance and General Insurance: Top 5 Differences and Their Types. (2021, March
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How Insurance Premiums Work. (2020, August 19). Investopedia.

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Understanding Insurance Claims. (2020, August 19). Investopedia.

https://www.investopedia.com/terms/i/insurance_claim.asp#:%7E:text=Key%20T
akeaways-
,An%20insurance%20claim%20is%20a%20formal%20request%20by%20a%20polic
yholder,on%20behalf%20of%20the%20insured.

Commission | Insurance Glossary Definition | IRMI.com. (n.d.). IRMI.

https://www.irmi.com/term/insurance-
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Adrian, M. (2020, September 21). All You Need To Know About Health Insurance In
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