I

C27HEALTHI
NSURANCEEXAM -04

Q(
1):
Wit
hregar
dst
oCr
edi
tRi
sk,
whi
choft
hebel
owopt
ionsi
scor
rect?

Likeinanyotherbusi
nesswit
hfi
nanci
alt
ransacti
ons,
ther
eisar
iskofdef
aul
tbybusi
ness
associ
atesl
ikerei
nsurer
s,pr
ovi
der
sandsupplier
s

Operati
onal
andotherr
isksl
i
keriskofl
osi
ngkeyhumanr
esour
ces,
risksoff
rauds,
riskofnot
keepi
ngupwitht
echnol
ogyetc.

Al
thougheachr
iskbyi
tsel
fisnotv
eryl
argebutt
her
est
il
lexi
stst
her
iskofconcent
rat
ion.

Credi
tri
skmismatchr
educest
hei
nsur
ersabi
l
ityt
ogetadequat
ecasht
opayi
tsl
i
abi
l
iti
esata
shor
tter
m not
ice

Thought
hei
nsur
ermayhol
dgoodqual
i
tyasset
s,hol
dingl
ongt
erm debtcanl
eadt
oli
qui
dit
y
r
isk

Repor
tthi
sQuest
ion?

Q(2)
:Whi
chdocumenthel
psacompanyt
ocol
l
ectdet
ail
sli
keheal
thst
atus,
income,
premi
um
et
c?

SAPRepor
t

Sal
esr
epor
ts

Pr
oposal
for
m

Medi
cal
repor
ts

Fi
nanci
aldocument
s

Repor
tthi
sQuest
ion?

Q(
3):
Dat
aisusedbyGov
ernment
sfor_
__.

anal
yzi
ngcl
aim set
tl
ement
s

anal
yzi
ngt
heov
eral
lper
for
manceoft
hesect
or

f
ormul
ati
ngsoci
alschemes

keepi
ngt
rackofmar
ketdev
elopement
s
benchmar
kingt
heper
for
manceofunder
wri
ti
ngof
fi
ces

Repor
tthi
sQuest
ion?

Q(4)
:Whatis/
arethereason/sforHealt
hI nsur
ancebecomingthef ast
estgr
owingsegment?1.
Duet
oordersbytheGov er
nmentmaki ngitcompulsar
y2.Mor efocusonmar ket
ingbyt
he
i
nsur
ancecompanies3.Increasei
nawar enessamongt hegener
al publ
ic

Onl
yst
atement1i
scor
rect

Onl
yst
atement2i
scor
rect

Onl
yst
atement3i
scor
rect

Onl
yst
atement
s1and2ar
ecor
rect

Onl
yst
atement
s2and3ar
ecor
rect

Repor
tthi
sQuest
ion?

Q(5):
Seemawaspr epari
ngforhermedi
calentr
anceexamsandwasst ayi
nginahost eli
nKota.
Unf
ortunat
elyshewasnotsel ect
edandt
ri
edt ocommitsui
cide.Howevershesur
vivedbutgot
manyinjur
iesandthetreat
mentandhospi
tali
zati
oncostRs20000.Shehadamedi clai
m ofRs1
l
ac.Howmuchwi l
ltheinsur
ancecompanyreimburse?

Rs1l
ac

Rs20000

Rs20000+phy
siot
her
apyexpenses

Rs50000

NI
L

Repor
tthi
sQuest
ion?

Q(6):Di
stri
buti
onofnumberofclai
mspaidandthecor
respondi
ngcl
aim amountpai
dfor
di
ff
erentrangesofsum i
nsur
ed'-canbeseenf
rom whi
cht y
peofanal
ysi
s?

NetPr
emi
um pai
danal
ysi
s

Cl
aimsanal
ysi
sbysum i
nsur
ed
Cl
aimspr
obabi
l
itydi
str
ibut
ion

Ear
nedpr
emi
um

Cl
aimsanal
ysi
sbyagebands

Repor
tthi
sQuest
ion?

Q(7):Fi
ll
inthebl
anks:
Prescr
ibi
ngoft
hecor
rectqual
i
ficat
ionshel
pst
o__
_andot
hermar
ket
conducti
ssues.

ensur
ethati
nsur
erscannotar
bit
rar
il
ydecl
i
ner
enewal
sandcancel
pol
i
cies

pr
eventmi
s-sel
l
ing

hav
eacaponwai
ti
ngper
iodsandcostshar
ingpr
ovi
sions

pr
otectt
heaccessr
ightt
oconsumer
s

mai
ntai
nst
andar
dizat
ionofdef
ini
ti
ons/t
erms

Repor
tthi
sQuest
ion?

Q(8):Mr.Sur
ajhadinsuredhim sel
fagai
nstaccidentbyt
aki
ngt woBENEFITPOLI CI
ES.Het
ook
onefrom CompanyXf orRs25000andonef rom CompanyYf orRs40000.Laterhemetwit
han
acci
dentandwashospi t
ali
zed.Thehospi
tal
izat
ionexpenseswer eRs40000.Whatamountwil
l
bepaidbyboththecompani es?

CompanyX-Rs16000,
CompanyY-Rs.24000

Rs20,
000byeachcompany

CompanyX-Rs25000,
CompanyY-Rs.40000

CompanyX-NI
L,CompanyY-Rs.40000

Asment
ionedi
nthei
nsur
ancepr
oposal

Repor
tthi
sQuest
ion?

Q(
9):
Namet
hemeasur
e(s)underhumani
nter
face/pr
ocessi
mpr
ovi
sat
ionf
orf
raudpr
event
ion.

Compr
ehensi
vecl
aimsi
nfor
mat
ion
Audi
ts

Cont
rol
busi
nesswhenf
raudi
snotmanageabl
e

Vi
gil
ance,
Compl
i
ancechecks

Abi
l
ityt
odet
ectf
raudef
fect
ivel
y

Repor
tthi
sQuest
ion?

Q(
10)
:Whol
i
stenst
otheappeal
sagai
nstt
heor
der
sofanyDi
str
ictFor
um wi
thi
ntheSt
ate?

St
ateCommi
ssi
on

Di
str
ictFor
um

Ombudsman

Nodal
off
icer

Nat
ional
Commi
ssi
on

Repor
tthi
sQuest
ion?

Q(11)
:Whichofthefoll
owingst
atement
sis/
areTRUEwi
thr
egar
dst
o'heal
thsav
ingson
i
nvest
mentli
nkedplans'?

Alt
houghtheri
skpremium i
sall
ocatedtoheal
thinsur
ancecoverage,
theinv
est
mentamounti
s
di
vert
edtotheuni
tli
nkedfundswhichshal
lpayforthefut
urehealt
hcosts

Thesepr
oductscanal
soof
ferot
herbenef
it
sli
kecr
it
ical
il
lnessbenef
it
s,hospi
tal
i
zat
ion
al
l
owancesetc.

I
nsuchpl
ans,
thet
otal
premi
um i
sspl
i
tupi
ntor
iskpr
emi
um andi
nvest
mentamount

Theset
ypeofpr
oduct
sdi
scour
agesav
ingsf
orexpect
edhi
ghcost
sofmedi
cal
car
eint
he
f
utur
e

St
atement
s1,
2and3al
lar
ecor
rect
,St
atement4i
sIncor
rect

Repor
tthi
sQuest
ion?

Q(
12)
:Consi
deranexampl
e-Acedanthasa10-
li
nesur
plust
reat
ywhi
chi
ssubj
ectt
oa
maximum cessi
onof1,000,
000.Whatwi
llbemaximum gr
osscapaci
tyoft
hecedantf
orasi
ngl
e
r
isk,
ifnootherr
einsur
ancecover
ageisi
nf or
ce?

50000

1,
10,
00,
000

1,
00,
00,
000

11,
00,
000

1,
00,
000

Repor
tthi
sQuest
ion?

Q(13):UnderCri
ti
calI
ll
nessbenef
it,
____amounti
sgiv
entothei
nsuredont hediagnosi
sof
cr
it
ical
ill
nessli
kecancer,
kidneyf
ail
ureoronunder
goi
ngofcert
ainprocedures.

Reasonabl
e

Pr
opor
ti
onat
e

Lumpsum

Fi
xed

Sur
viv
albenef
it

Repor
tthi
sQuest
ion?

Q(
14)
:Towhi
chcount
rydot
hei
nsur
anceschemesCSMBS,
UCSSSSbel
ongt
o?

I
ndi
a

Bangl
adesh

Thai
l
and

Japan

USA

Repor
tthi
sQuest
ion?
Q(
15)
:Whor
uns/
gov
ernst
heRasht
ri
yaSwast
hyaBi
maYoj
ana(
RSBY)?

Commer
ceMi
nist
ry

I
nsur
ers

I
RDA

TheSt
akehol
der
s

Gov
ernment

Repor
tthi
sQuest
ion?

Q(
16)
:Howi
stheheal
thcar
eser
vicespr
imar
il
yfundedi
nUK?

Thr
oughcommer
cial
heal
thi
nsur
ance

Taxf
undedsy
stem

Byoutofpocketpay
ment
s

Soci
alheal
thi
nsur
ance

Soci
alwel
far
eor
gani
zat
ion

Repor
tthi
sQuest
ion?

Q(
17)
:Fr
om t
hebel
owopt
ions,
whi
chonei
snotakeyt
ool
forunder
wri
ti
ng?

Fi
nanci
aldocument
s

Medi
cal
repor
ts

Commi
ssi
onr
epor
ts

Sal
esr
epor
ts

Pr
oposal
for
m

Repor
tthi
sQuest
ion?

Q(18):
Manusmri
thi
andDhar
masast
rar
efert
o__
_oft
her
esour
cesand_
__t
hem dur
ingt
he
per
iodofcal
ami
ti
es.
col
l
ect
ion,
usage

st
ocki
ng,
dist
ri
but
ing

pool
i
ng,
dist
ri
but
ing

usage,
col
l
ect
ing

di
str
ibut
ion,
usi
ng

Repor
tthi
sQuest
ion?

Q( 19)
:Whatisthemai
ndisadv
antageoft
hissit
uat
ion:Duet
oasoftmar
ketconditi
on,a
rei
nsurert
akesadeci
siont
owithdrawi
tspart
ici
pat
iononatr
eat
yduetounsust
ainable
premium r
ates.

Wheneverthemarketcondi
ti
onsbecomesmor
efav
our
abl
e,i
tmaypr
ovedi
ff
icul
ttopar
ti
cipat
e
ont
hetr
eatyinf
uture.

Ast
her
einsur
erhaswi
thdr
awnf
rom at
reat
y,i
twi
l
laut
omat
ical
l
yloseot
herpr
ofi
tabl
ebusi
ness

Ther
einsur
ersr
etr
ocessi
onpr
ogr
am wi
l
ltendt
obecomemor
eexpensi
ve

Wheneverthemarketcondi
ti
onsbecomesl
essf
avour
abl
e,i
tmaypr
ovedi
ff
icul
ttopar
ti
cipat
e
ont
hetr
eatyinf
uture

Anycl
aimr
ecov
eri
est
hatar
eduet
other
einsur
erwi
l
lnol
ongerbepay
abl
e

Repor
tthi
sQuest
ion?

Q(20):Whichdepart
mentofi
nsur
ancecompani
esusedat
atobenchmar
ktheper
for
manceof
under
writ
ingoff
icesandst
affmembers?

HumanResour
cesDepar
tment

Fi
nanceDepar
tment

Under
wri
ter
sDepar
tment

Act
uar
iesDepar
tment

Mar
ket
ingDepar
tment

Repor
tthi
sQuest
ion?
Q(
21)
:Whi
choft
hef
oll
owi
ngst
atementi
scor
rect?

TheNRH( Nat
ional
ruralheal
th)mi
ssi
oni
sfundedbyt
heCent
reandusual
l
yimpl
ement
ed
t
hrought
heCentralmachiner
y

TheNRH( Nat
ionalr
ural
heal
th)mi
ssi
oni
sfundedbyt
hest
ateandusual
l
yimpl
ement
ed
t
hrought
hecentral
machiner
y

AsperI
ndi
anconst
it
uti
ont
hear
easofpubl
i
cheal
th,
hospi
tal
set
c.f
all
sint
heconcur
rentl
i
st

AsperI
ndi
anconst
it
uti
ont
hear
easofpubl
i
cheal
th,
hospi
tal
set
c.f
all
int
hegener
all
i
st

TheNRH( Nat
ional
rur
alheal
th)mi
ssi
oni
sfundedbyt
heCent
reandusual
l
yimpl
ement
ed
t
hrought
hestatemachi
nery

Repor
tthi
sQuest
ion?

Q(22)
:Thefr
audswhi
chareper
pet
rat
edbymedi
cal
ser
vicepr
ovi
der
sagai
nstani
nsur
ance
companyori
tspol
i
cyhol
dersar
eknownas_
___.

Medi
cal
frauds

I
nter
nal
fraud

Ext
ernal
fraud

Sof
tfr
aud

Har
dfr
aud

Repor
tthi
sQuest
ion?

Q(
23)
:Whi
chcoul
dbeameasur
eunder'
technol
ogyandpr
ocessi
nter
face'
forf
raudpr
event
ion?

Ef
fect
ivej
udi
cial
act
ion

RAGanal
ysi
s

Soundwhi
stl
ebl
owerpol
i
cy

Cr
eat
ionoff
rauddat
abase

Cr
eat
ionofconsumerawar
eness
Repor
tthi
sQuest
ion?

Q( 24):Mr.Sati
shboughtahealt
hinsur
ancecov
erofRs50000agai nstcr
it
ical i
l
lness
hospitali
zat
ion.Hecontr
actedmalar
iaandwashospi
tali
zedandthehospital
izati
oncharges
camet oRs20000.Consideri
nghi
spoli
cywasabenefitpr
oductwhichofthef ol
lowing
statementholdstrue?

MrSat
ishwaspai
dRs.20000byt
hei
nsur
er

MrSat
ishwaspai
dRs.50000byt
hei
nsur
er

MrSat
ishwaspai
dRs.70000byt
hei
nsur
er

MrSat
ishwaspai
dRs.10000byt
hei
nsur
er

Thei
nsur
err
eject
edMr
.Sat
ish'
scl
aim

Repor
tthi
sQuest
ion?

Q(
25)
:Inwhi
chy
earwer
etheI
RDAMi
croI
nsur
ancer
egul
ati
onsf
ramed?

2000

2003

2004

2005

2006

Repor
tthi
sQuest
ion?

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