Auto insurance principles should be applied to health insurance

Many Americans rely on their automobiles to get to work. No automobile means no job, no rent or mortgage money, no food. A single parent, struggling to make ends meet in the suburbs with 100,000 miles on the odometer, would presumably welcome the guaranteed opportunity for low-priced insurance that would take care of every possible repair on her auto until the day that it reaches 200,000 miles or falls apart, whichever comes first. Especially if the insurance is valid regardless of whether she even changes the oil in the interim.

So why aren't the auto insurance companies writing such coverage, either directly or through used auto dealers? And given the importance of reliable transportation, why isn't the public demanding such coverage? The answer is that both auto insurers and the public know that such insurance can't be written for a premium the insured can afford, while still allowing the insurers to stay solvent and make a profit. As a society, we intuitively understand that the costs associated with taking care of every mechanical need of an old automobile, particularly in the absence of regular maintenance, aren't insurable. Yet we don't seem to have these same intuitions with respect to health insurance.

If we pull the emotions out of health insurance, which is admittedly hard to do even for this author, and look at health insurance from the economic perspective, there are several insights from auto insurance that can illuminate the design, risk selection, and rating of health insurance.

Auto insurance comes in two forms: the traditional insurance you buy from your agent or direct from an insurance company, and warranties that are purchased from auto manufacturers and dealers. Both are risk transfer and sharing devices and I'll generically refer to both as insurance. Because auto third-party liability insurance has no equivalent in health insurance, for traditional auto insurance, I'll examine only collision and comprehensive insurance -- insurance covering the vehicle -- and not third-party liability insurance.

Bumper to Bumper

The following are some commonly accepted principles from auto insurance:

* Bad maintenance voids certain insurance. If an automobile owner never changes the oil, the auto's power train warranty is void. In fact, not only does the oil need to be changed, the change needs to be performed by a certified mechanic and documented. Collision insurance doesn't cover cars purposefully driven over a cliff.

* The best insurance is offered for new models. Bumper-to-bumper warranties are offered only on new cars. As they roll off the assembly line, automobiles have a low and relatively consistent risk profile, satisfying the actuarial test for insurance pricing. Furthermore, auto manufacturers usually wrap at least some coverage into the price of the new auto in order to encourage an ongoing relationship with the owner.

* Limited insurance is offered for old model autos. Increasingly limited insurance is offered for old model autos. The bumper-to-bumper warranty expires, the power train warranty eventually expires, and the amount of collision and comprehensive insurance steadily decreases based on the market value of the auto.

* Certain older autos qualify for additional insurance. Certain older autos can qualify for additional coverage, either in terms of warranties for used autos or increased collision and comprehensive insurance for vintage autos. But such insurance is offered only after a careful inspection of the automobile itself.

* No insurance is offered for normal wear and tear. Wiper blades need replacement, brake pads wear out, and bumpers get dings. These aren't insurable events. To the extent that a new car dealer will sometimes cover some of these costs, we intuitively understand that we're "paying for it" in the cost of the automobile and that it's "not really" insurance.

* Accidents are the only insurable event for the oldest automobiles. Accidents are generally insurable events even for the oldest autos; with few exceptions service work isn't.

* Insurance doesn't restore all vehicles to pre-accident condition. Auto insurance is limited. If the damage to the auto at any age exceeds the value of the auto, the insurer then pays only the value of the auto. With the exception of vintage autos, the value assigned to the auto goes down over time. So whereas accidents are insurable at any vehicle age, the amount of the accident insurance is increasingly limited.

* Insurance is priced to the risk. Insurance is priced based on the risk profile of both the automobile and the driver. The auto insurer carefully examines both when setting rates.

* We pay for our own insurance. And with few exceptions, automobile insurance isn't tax deductible. As a result, the fear of increasing insurance rates due to traffic violations and/or accidents changes our driving behavior and we sometimes select our automobiles based on their insurability.

Each of the above principles is supported by solid actuarial theory. Although most Americans can't describe the underlying actuarial theories, most everyone understands the above principles of auto insurance at the intuitive level. For sure, as indispensable automobiles are to our lifestyles, there is no loud national movement, accompanied by moral outrage, to change these principles.

Unsustainable Market

In contrast, similar principles are routinely violated in health insurance. To demonstrate this, let's return to the same suburban mother from the opening paragraph. She's busy working, driving to and from work, and driving her kids to school and activities. She ends each day exhausted, sitting on the couch with fast food. She's obese, has a sedentary life, a bad diet, and hasn't taken the time to go to the doctor in years. After a simple injury doesn't heal for weeks, she turns up at the emergency room and learns she has type II diabetes. Although type II diabetes is controllable, changing diet and exercise habits and properly tracking her condition takes time and effort and she's never quite successful in implementing the necessary lifestyle changes.

So the initial emergency room visit is only the first of a long list of health care related to non-controlled diabetes and other problems associated with obesity. Whether she has individual or group insurance, her insurance pays for each episode of care, without singling her out for a premium increase, and without charging her any more cost sharing than is charged to the healthiest and most medically diligent insureds. Her coverage continues until she voluntarily changes insurance companies and/or employers or becomes eligible for Medicare. If she's covered under group insurance she may not even pay any premium. Her insurance continues unabated, even though the disease was caused by neglecting her body and she maintains her poor lifestyle even after the disease becomes known.

This just wouldn't happen in auto insurance. This scenario is the auto insurance equivalent of guaranteed access to low-priced auto insurance that takes care of every possible repair, including damage already done, until the day the car falls apart so completely it's unsalvageable (death) or reaches 200,000 miles (Medicare), regardless of whether she even changes the oil (takes care of herself) in the interim.

As a society, we don't expect this in private-market auto insurance, but we expect it in private-market health insurance. Furthermore, there's a chorus of national and state interests, which continuously pushes us further away from the auto insurance principles.

The current private health insurance market isn't sustainable. Prices have been consistently increasing faster than inflation for decades. Each year, insureds use more health care than ever before and more people have no insurance at all. Most actuaries and other people in the private health insurance market don't want national health insurance with its bureaucracy and one-size-fits-all benefits. Yet, we're trying to sustain a private insurance system, which violates the very principles we know are necessary for private insurance markets.

Yes, health insurance involves the sacredness of human life and is therefore different from auto insurance. But if we're to sustain a private-market solution to health insurance, actuaries need to explain to the larger society, in terms that society understands, the rationale for the following principles:

* As sacred as health care is, it's still an economic transaction that has to be balanced by individuals and societies, against other economic choices. It can't be unlimited. Sometimes it will be secondary to other choices. On a given day, for example, the mother in our scenario may value her car more than her health.

* Insurance premiums should be paid by the individual and tied to controllable risk factors. This will provide the best incentive for the control of risk factors.

* Although it's hard to draw the line between abuse, neglect and ignorance, self-abuse shouldn't be insured and we need to draw that line somewhere.

* The private market can't provide unlimited, self-directed health insurance.

* Routine care and ongoing treatments of chronic conditions can be pre-funded, can even be subsidized, but they don't constitute "insurable events."

* Insurance can't be expected to keep every human body in pristine condition. No amount of health care will prevent everyone's ultimate death.

* Comprehensive, unlimited, non-subsidized private-market coverage isn't possible for people with severely impaired health.

* The private health market can provide limited non-subsidized health insurance, such as protection from accidents, to even health-impaired individuals.

* Individuals who can afford to do so and who take good care of themselves should be able to "buy up" to better coverage. People have the option of buying up for everything else in life.

Discussion of these principles is lacking from most of the current health insurance debate. If society can intuitively understand how similar principles apply to health insurance, then they should be able understand the principles in the health insurance context. We need to initiate the debate.

This commentary is solely the opinion of its author. It does not express the official policy of the American Academy of Actuaries; nor does it necessarily reflect the opinions of the Academy's individual officers, members, or staff

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Insurance Law - An Indian Perspective

INTRODUCTION

"Insurance should be bought to protect you against a calamity that would otherwise be financially devastating."

In simple terms, insurance allows someone who suffers a loss or accident to be compensated for the effects of their misfortune. It lets you protect yourself against everyday risks to your health, home and financial situation.

Insurance in India started without any regulation in the Nineteenth Century. It was a typical story of a colonial epoch: few British insurance companies dominating the market serving mostly large urban centers. After the independence, it took a theatrical turn. Insurance was nationalized. First, the life insurance companies were nationalized in 1956, and then the general insurance business was nationalized in 1972. It was only in 1999 that the private insurance companies have been allowed back into the business of insurance with a maximum of 26% of foreign holding.

"The insurance industry is enormous and can be quite intimidating. Insurance is being sold for almost anything and everything you can imagine. Determining what's right for you can be a very daunting task."

Concepts of insurance have been extended beyond the coverage of tangible asset. Now the risk of losses due to sudden changes in currency exchange rates, political disturbance, negligence and liability for the damages can also be covered.

But if a person thoughtfully invests in insurance for his property prior to any unexpected contingency then he will be suitably compensated for his loss as soon as the extent of damage is ascertained.

The entry of the State Bank of India with its proposal of bank assurance brings a new dynamics in the game. The collective experience of the other countries in Asia has already deregulated their markets and has allowed foreign companies to participate. If the experience of the other countries is any guide, the dominance of the Life Insurance Corporation and the General Insurance Corporation is not going to disappear any time soon.

The aim of all insurance is to compensate the owner against loss arising from a variety of risks, which he anticipates, to his life, property and business. Insurance is mainly of two types: life insurance and general insurance. General insurance means Fire, Marine and Miscellaneous insurance which includes insurance against burglary or theft, fidelity guarantee, insurance for employer's liability, and insurance of motor vehicles, livestock and crops.

LIFE INSURANCE IN INDIA

"Life insurance is the heartfelt love letter ever written.

It calms down the crying of a hungry baby at night. It relieves the heart of a bereaved widow.

It is the comforting whisper in the dark silent hours of the night."

Life insurance made its debut in India well over 100 years ago. Its salient features are not as widely understood in our country as they ought to be. There is no statutory definition of life insurance, but it has been defined as a contract of insurance whereby the insured agrees to pay certain sums called premiums, at specified time, and in consideration thereof the insurer agreed to pay certain sums of money on certain condition sand in specified way upon happening of a particular event contingent upon the duration of human life.

Life insurance is superior to other forms of savings!

"There is no death. Life Insurance exalts life and defeats death.

It is the premium we pay for the freedom of living after death."

Savings through life insurance guarantee full protection against risk of death of the saver. In life insurance, on death, the full sum assured is payable (with bonuses wherever applicable) whereas in other savings schemes, only the amount saved (with interest) is payable.

The essential features of life insurance are a) it is a contract relating to human life, which b) provides for payment of lump-sum amount, and c) the amount is paid after the expiry of certain period or on the death of the assured. The very purpose and object of the assured in taking policies from life insurance companies is to safeguard the interest of his dependents viz., wife and children as the case may be, in the even of premature death of the assured as a result of the happening in any contingency. A life insurance policy is also generally accepted as security for even a commercial loan.

NON-LIFE INSURANCE

"Every asset has a value and the business of general insurance is related to the protection of economic value of assets."

Non-life insurance means insurance other than life insurance such as fire, marine, accident, medical, motor vehicle and household insurance. Assets would have been created through the efforts of owner, which can be in the form of building, vehicles, machinery and other tangible properties. Since tangible property has a physical shape and consistency, it is subject to many risks ranging from fire, allied perils to theft and robbery.

Few of the General Insurance policies are:

Property Insurance: The home is most valued possession. The policy is designed to cover the various risks under a single policy. It provides protection for property and interest of the insured and family.

Health Insurance: It provides cover, which takes care of medical expenses following hospitalization from sudden illness or accident.

Personal Accident Insurance: This insurance policy provides compensation for loss of life or injury (partial or permanent) caused by an accident. This includes reimbursement of cost of treatment and the use of hospital facilities for the treatment.

Travel Insurance: The policy covers the insured against various eventualities while traveling abroad. It covers the insured against personal accident, medical expenses and repatriation, loss of checked baggage, passport etc.

Liability Insurance: This policy indemnifies the Directors or Officers or other professionals against loss arising from claims made against them by reason of any wrongful Act in their Official capacity.

Motor Insurance: Motor Vehicles Act states that every motor vehicle plying on the road has to be insured, with at least Liability only policy. There are two types of policy one covering the act of liability, while other covers insurers all liability and damage caused to one's vehicles.

JOURNEY FROM AN INFANT TO ADOLESCENCE!

Historical Perspective

The history of life insurance in India dates back to 1818 when it was conceived as a means to provide for English Widows. Interestingly in those days a higher premium was charged for Indian lives than the non-Indian lives as Indian lives were considered more risky for coverage.

The Bombay Mutual Life Insurance Society started its business in 1870. It was the first company to charge same premium for both Indian and non-Indian lives. The Oriental Assurance Company was established in 1880. The General insurance business in India, on the other hand, can trace its roots to the Triton (Tital) Insurance Company Limited, the first general insurance company established in the year 1850 in Calcutta by the British. Till the end of nineteenth century insurance business was almost entirely in the hands of overseas companies.

Insurance regulation formally began in India with the passing of the Life Insurance Companies Act of 1912 and the Provident Fund Act of 1912. Several frauds during 20's and 30's desecrated insurance business in India. By 1938 there were 176 insurance companies. The first comprehensive legislation was introduced with the Insurance Act of 1938 that provided strict State Control over insurance business. The insurance business grew at a faster pace after independence. Indian companies strengthened their hold on this business but despite the growth that was witnessed, insurance remained an urban phenomenon.

The Government of India in 1956, brought together over 240 private life insurers and provident societies under one nationalized monopoly corporation and Life Insurance Corporation (LIC) was born. Nationalization was justified on the grounds that it would create much needed funds for rapid industrialization. This was in conformity with the Government's chosen path of State lead planning and development.

The (non-life) insurance business continued to prosper with the private sector till 1972. Their operations were restricted to organized trade and industry in large cities. The general insurance industry was nationalized in 1972. With this, nearly 107 insurers were amalgamated and grouped into four companies - National Insurance Company, New India Assurance Company, Oriental Insurance Company and United India Insurance Company. These were subsidiaries of the General Insurance Company (GIC).

The life insurance industry was nationalized under the Life Insurance Corporation (LIC) Act of India. In some ways, the LIC has become very flourishing. Regardless of being a monopoly, it has some 60-70 million policyholders. Given that the Indian middle-class is around 250-300 million, the LIC has managed to capture some 30 odd percent of it. Around 48% of the customers of the LIC are from rural and semi-urban areas. This probably would not have happened had the charter of the LIC not specifically set out the goal of serving the rural areas. A high saving rate in India is one of the exogenous factors that have helped the LIC to grow rapidly in recent years. Despite the saving rate being high in India (compared with other countries with a similar level of development), Indians display high degree of risk aversion. Thus, nearly half of the investments are in physical assets (like property and gold). Around twenty three percent are in (low yielding but safe) bank deposits. In addition, some 1.3 percent of the GDP are in life insurance related savings vehicles. This figure has doubled between 1985 and 1995.

A World viewpoint - Life Insurance in India

In many countries, insurance has been a form of savings. In many developed countries, a significant fraction of domestic saving is in the form of donation insurance plans. This is not surprising. The prominence of some developing countries is more surprising. For example, South Africa features at the number two spot. India is nestled between Chile and Italy. This is even more surprising given the levels of economic development in Chile and Italy. Thus, we can conclude that there is an insurance culture in India despite a low per capita income. This promises well for future growth. Specifically, when the income level improves, insurance (especially life) is likely to grow rapidly.

INSURANCE SECTOR REFORM:

Committee Reports: One Known, One Anonymous!

Although Indian markets were privatized and opened up to foreign companies in a number of sectors in 1991, insurance remained out of bounds on both counts. The government wanted to proceed with caution. With pressure from the opposition, the government (at the time, dominated by the Congress Party) decided to set up a committee headed by Mr. R. N. Malhotra (the then Governor of the Reserve Bank of India).

Malhotra Committee

Liberalization of the Indian insurance market was suggested in a report released in 1994 by the Malhotra Committee, indicating that the market should be opened to private-sector competition, and eventually, foreign private-sector competition. It also investigated the level of satisfaction of the customers of the LIC. Inquisitively, the level of customer satisfaction seemed to be high.

In 1993, Malhotra Committee - headed by former Finance Secretary and RBI Governor Mr. R. N. Malhotra - was formed to evaluate the Indian insurance industry and recommend its future course. The Malhotra committee was set up with the aim of complementing the reforms initiated in the financial sector. The reforms were aimed at creating a more efficient and competitive financial system suitable for the needs of the economy keeping in mind the structural changes presently happening and recognizing that insurance is an important part of the overall financial system where it was necessary to address the need for similar reforms. In 1994, the committee submitted the report and some of the key recommendations included:

o Structure

Government bet in the insurance Companies to be brought down to 50%. Government should take over the holdings of GIC and its subsidiaries so that these subsidiaries can act as independent corporations. All the insurance companies should be given greater freedom to operate.

Competition

Private Companies with a minimum paid up capital of Rs.1 billion should be allowed to enter the sector. No Company should deal in both Life and General Insurance through a single entity. Foreign companies may be allowed to enter the industry in collaboration with the domestic companies. Postal Life Insurance should be allowed to operate in the rural market. Only one State Level Life Insurance Company should be allowed to operate in each state.

o Regulatory Body

The Insurance Act should be changed. An Insurance Regulatory body should be set up. Controller of Insurance - a part of the Finance Ministry- should be made Independent.

o Investments

Compulsory Investments of LIC Life Fund in government securities to be reduced from 75% to 50%. GIC and its subsidiaries are not to hold more than 5% in any company (there current holdings to be brought down to this level over a period of time).

o Customer Service

LIC should pay interest on delays in payments beyond 30 days. Insurance companies must be encouraged to set up unit linked pension plans. Computerization of operations and updating of technology to be carried out in the insurance industry. The committee accentuated that in order to improve the customer services and increase the coverage of insurance policies, industry should be opened up to competition. But at the same time, the committee felt the need to exercise caution as any failure on the part of new competitors could ruin the public confidence in the industry. Hence, it was decided to allow competition in a limited way by stipulating the minimum capital requirement of Rs.100 crores.

The committee felt the need to provide greater autonomy to insurance companies in order to improve their performance and enable them to act as independent companies with economic motives. For this purpose, it had proposed setting up an independent regulatory body - The Insurance Regulatory and Development Authority.

Reforms in the Insurance sector were initiated with the passage of the IRDA Bill in Parliament in December 1999. The IRDA since its incorporation as a statutory body in April 2000 has meticulously stuck to its schedule of framing regulations and registering the private sector insurance companies.

Since being set up as an independent statutory body the IRDA has put in a framework of globally compatible regulations. The other decision taken at the same time to provide the supporting systems to the insurance sector and in particular the life insurance companies was the launch of the IRDA online service for issue and renewal of licenses to agents. The approval of institutions for imparting training to agents has also ensured that the insurance companies would have a trained workforce of insurance agents in place to sell their products.

The Government of India liberalized the insurance sector in March 2000 with the passage of the Insurance Regulatory and Development Authority (IRDA) Bill, lifting all entry restrictions for private players and allowing foreign players to enter the market with some limits on direct foreign ownership. Under the current guidelines, there is a 26 percent equity lid for foreign partners in an insurance company. There is a proposal to increase this limit to 49 percent.

The opening up of the sector is likely to lead to greater spread and deepening of insurance in India and this may also include restructuring and revitalizing of the public sector companies. In the private sector 12 life insurance and 8 general insurance companies have been registered. A host of private Insurance companies operating in both life and non-life segments have started selling their insurance policies since 2001

Mukherjee Committee

Immediately after the publication of the Malhotra Committee Report, a new committee, Mukherjee Committee was set up to make concrete plans for the requirements of the newly formed insurance companies. Recommendations of the Mukherjee Committee were never disclosed to the public. But, from the information that filtered out it became clear that the committee recommended the inclusion of certain ratios in insurance company balance sheets to ensure transparency in accounting. But the Finance Minister objected to it and it was argued by him, probably on the advice of some of the potential competitors, that it could affect the prospects of a developing insurance company.

LAW COMMISSION OF INDIA ON REVISION OF THE INSURANCE ACT 1938 - 190th Law Commission Report

The Law Commission on 16th June 2003 released a Consultation Paper on the Revision of the Insurance Act, 1938. The previous exercise to amend the Insurance Act, 1938 was undertaken in 1999 at the time of enactment of the Insurance Regulatory Development Authority Act, 1999 (IRDA Act).

The Commission undertook the present exercise in the context of the changed policy that has permitted private insurance companies both in the life and non-life sectors. A need has been felt to toughen the regulatory mechanism even while streamlining the existing legislation with a view to removing portions that have become superfluous as a consequence of the recent changes.

Among the major areas of changes, the Consultation paper suggested the following:

a. merging of the provisions of the IRDA Act with the Insurance Act to avoid multiplicity of legislations;

b. deletion of redundant and transitory provisions in the Insurance Act, 1938;

c. Amendments reflect the changed policy of permitting private insurance companies and strengthening the regulatory mechanism;

d. Providing for stringent norms regarding maintenance of 'solvency margin' and investments by both public sector and private sector insurance companies;

e. Providing for a full-fledged grievance redressal mechanism that includes:

o The constitution of Grievance Redressal Authorities (GRAs) comprising one judicial and two technical members to deal with complaints/claims of policyholders against insurers (the GRAs are expected to replace the present system of insurer appointed Ombudsman);

o Appointment of adjudicating officers by the IRDA to determine and levy penalties on defaulting insurers, insurance intermediaries and insurance agents;

o Providing for an appeal against the decisions of the IRDA, GRAs and adjudicating officers to an Insurance Appellate Tribunal (IAT) comprising a judge (sitting or retired) of the Supreme Court/Chief Justice of a High Court as presiding officer and two other members having sufficient experience in insurance matters;

o Providing for a statutory appeal to the Supreme Court against the decisions of the IAT.

LIFE & NON-LIFE INSURANCE - Development and Growth!

The year 2006 turned out to be a momentous year for the insurance sector as regulator the Insurance Regulatory Development Authority Act, laid the foundation for free pricing general insurance from 2007, while many companies announced plans to attack into the sector.

Both domestic and foreign players robustly pursued their long-pending demand for increasing the FDI limit from 26 per cent to 49 per cent and toward the fag end of the year, the Government sent the Comprehensive Insurance Bill to Group of Ministers for consideration amid strong reservation from Left parties. The Bill is likely to be taken up in the Budget session of Parliament.

The infiltration rates of health and other non-life insurances in India are well below the international level. These facts indicate immense growth potential of the insurance sector. The hike in FDI limit to 49 per cent was proposed by the Government last year. This has not been operationalized as legislative changes are required for such hike. Since opening up of the insurance sector in 1999, foreign investments of Rs. 8.7 billion have tipped into the Indian market and 21 private companies have been granted licenses.

The involvement of the private insurers in various industry segments has increased on account of both their capturing a part of the business which was earlier underwritten by the public sector insurers and also creating additional business boulevards. To this effect, the public sector insurers have been unable to draw upon their inherent strengths to capture additional premium. Of the growth in premium in 2004-05, 66.27 per cent has been captured by the private insurers despite having 20 per cent market share.

The life insurance industry recorded a premium income of Rs.82854.80 crore during the financial year 2004-05 as against Rs.66653.75 crore in the previous financial year, recording a growth of 24.31 per cent. The contribution of first year premium, single premium and renewal premium to the total premium was Rs.15881.33 crore (19.16 per cent); Rs.10336.30 crore (12.47 per cent); and Rs.56637.16 crore (68.36 per cent), respectively. In the year 2000-01, when the industry was opened up to the private players, the life insurance premium was Rs.34,898.48 crore which constituted of Rs. 6996.95 crore of first year premium, Rs. 25191.07 crore of renewal premium and Rs. 2740.45 crore of single premium. Post opening up, single premium had declined from Rs.9, 194.07 crore in the year 2001-02 to Rs.5674.14 crore in 2002-03 with the withdrawal of the guaranteed return policies. Though it went up marginally in 2003-04 to Rs.5936.50 crore (4.62 per cent growth) 2004-05, however, witnessed a significant shift with the single premium income rising to Rs. 10336.30 crore showing 74.11 per cent growth over 2003-04.

The size of life insurance market increased on the strength of growth in the economy and concomitant increase in per capita income. This resulted in a favourable growth in total premium both for LIC (18.25 per cent) and to the new insurers (147.65 per cent) in 2004-05. The higher growth for the new insurers is to be viewed in the context of a low base in 2003- 04. However, the new insurers have improved their market share from 4.68 in 2003-04 to 9.33 in 2004-05.

The segment wise break up of fire, marine and miscellaneous segments in case of the public sector insurers was Rs.2411.38 crore, Rs.982.99 crore and Rs.10578.59 crore, i.e., a growth of (-)1.43 per cent, 1.81 per cent and 6.58 per cent. The public sector insurers reported growth in Motor and Health segments (9 and 24 per cent). These segments accounted for 45 and 10 per cent of the business underwritten by the public sector insurers. Fire and "Others" accounted for 17.26 and 11 per cent of the premium underwritten. Aviation, Liability, "Others" and Fire recorded negative growth of 29, 21, 3.58 and 1.43 per cent. In no other country that opened at the same time as India have foreign companies been able to grab a 22 per cent market share in the life segment and about 20 per cent in the general insurance segment. The share of foreign insurers in other competing Asian markets is not more than 5 to 10 per cent.

The life insurance sector grew new premium at a rate not seen before while the general insurance sector grew at a faster rate. Two new players entered into life insurance - Shriram Life and Bharti Axa Life - taking the total number of life players to 16. There was one new entrant to the non-life sector in the form of a standalone health insurance company - Star Health and Allied Insurance, taking the non-life players to 14.

A large number of companies, mostly nationalized banks (about 14) such as Bank of India and Punjab National Bank, have announced plans to enter the insurance sector and some of them have also formed joint ventures.

The proposed change in FDI cap is part of the comprehensive amendments to insurance laws - The Insurance Act of 1999, LIC Act, 1956 and IRDA Act, 1999. After the proposed amendments in the insurance laws LIC would be able to maintain reserves while insurance companies would be able to raise resources other than equity.

About 14 banks are in queue to enter insurance sector and the year 2006 saw several joint venture announcements while others scout partners. Bank of India has teamed up with Union Bank and Japanese insurance major Dai-ichi Mutual Life while PNB tied up with Vijaya Bank and Principal for foraying into life insurance. Allahabad Bank, Karnataka Bank, Indian Overseas Bank, Dabur Investment Corporation and Sompo Japan Insurance Inc have tied up for forming a non-life insurance company while Bank of Maharashtra has tied up with Shriram Group and South Africa's Sanlam group for non-life insurance venture.

CONCLUSION

It seems cynical that the LIC and the GIC will wither and die within the next decade or two. The IRDA has taken "at a snail's pace" approach. It has been very cautious in granting licenses. It has set up fairly strict standards for all aspects of the insurance business (with the probable exception of the disclosure requirements). The regulators always walk a fine line. Too many regulations kill the motivation of the newcomers; too relaxed regulations may induce failure and fraud that led to nationalization in the first place. India is not unique among the developing countries where the insurance business has been opened up to foreign competitors.

The insurance business is at a critical stage in India. Over the next couple of decades we are likely to witness high growth in the insurance sector for two reasons namely; financial deregulation always speeds up the development of the insurance sector and growth in per capita GDP also helps the insurance business to grow.

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21+ Useful Insurance Terms You Should Know

INSURED - A person or a corporation who contracts for an insurance policy that indemnifies (protects) him against loss or damage to property or, in the case of a liability policy, defend him against a claim from a third party.

NAMED INSURED - Any person, firm or corporation specifically designated by name as an insured(s) in a policy as distinguished from others who, though unnamed, are protected under some circumstances. For example, a common application of this latter principle is in auto liability policies wherein by a definition of "insured", coverage is extended to other drivers using the car with the permission of the named insured. Other parties can also be afforded protection of an insurance policy by being named an "additional insured" in the policy or endorsement.

ADDITIONAL INSURED - An individual or entity that is not automatically included as an insured under the policy of another, but for whom the named insureds policy provides a certain degree of protection. An endorsement is typically required to effect additional insured status. The named insureds impetus for providing additional insured status to others may be a desire to protect the other party because of a close relationship with that party (e.g., employees or members of an insured club) or to comply with a contractual agreement requiring the named insured to do so (e.g., customers or owners of property leased by the named insured).

CO-INSURANCE - The sharing of one insurance policy or risk between two or more insurance companies. This usually entails each insurer paying directly to the insured their respective share of the loss. Co-insurance can also be the arrangement by which the insured, in consideration of a reduced rate, agrees to carry an amount of insurance equal to a percentage of the total value of the property insured. An example is if you have guaranteed to carry insurance up to 80% or 90% of the value of your building and/or contents, whatever the case may be. If you don't, the company pays claims only in proportion to the amount of coverage you do carry.

The following equation is used to determine what amount may be collected for partial loss:

Amount of Insurance Carried x Loss

Amount of Insurance that = Payment

Should be Carried

Example A Mr. Right has an 80% co-insurance clause and the following situation:

$100,000 building value

$ 80,000 insurance carried

$ 10,000 building loss

By applying the equation for determining payment for partial loss, the following amount may be collected:

$80,000 x $10,000 = $10,000

$80,000

Mr. Right recovers the full amount of his loss because he carried the coverage specified in his co-insurance clause.

Example B Mr. Wrong has an 80% co-insurance clause and the following situation:

$100,000 building value

$ 70,000 insurance carried

$ 10,000 building loss

By applying the equation for determining payment for partial loss, the following amount may be collected:

$70,000 x $10,000 = $8,750

$80,000

Mr. Wrong's loss of $10,000 is greater than the company's limit of liability under his co-insurance clause. Therefore, Mr. Wrong becomes a self-insurer for the balance of the loss-- $1,250.

PREMIUM - The amount of money paid by an insured to an insurer for insurance coverage.

DEDUCTIBLE - The first dollar amount of a loss for which the insured is responsible before benefits are paid by the insurer; similar to a self-insured retention (SIR). The insurer's liability begins when the deductible is exhausted.

SELF INSURED RETENTION - Acts the same way as a deductible but the insured is responsible for all legal fees incurred in relation to the amount of the SIR.

POLICY LIMIT - The maximum monetary amount an insurance company is responsible for to the insured under its policy of insurance.

FIRST PARTY INSURANCE - Insurance that applies to coverage for an insureds own property or a person. Traditionally it covers damage to insureds property from whatever causes are covered in the policy. It is property insurance coverage. An example of first party insurance is BUILDERS RISK INSURANCE which is insurance against loss to the rigs or vessels in the course of their construction. It only involves the insurance company and the owner of the rig and/or the contractor who has a financial interest in the rig.

THIRD PARTY INSURANCE - Liability insurance covering the negligent acts of the insured against claims from a third party (i.e., not the insured or the insurance company - a third party to the insurance policy). An example of this insurance would be SHIP REPAIRER'S LEGAL LIABILITY (SRLL) - provides protection for contractors repairing or altering a customer's vessel at their shipyard, other locations or at sea; also covers the insured while the customer's property is under the "Care, Custody and Control" of the insured. A Commercial General Liability policy is needed for other coverages, such as slip-and-fall situations.

INSURABLE INTEREST - Any interest in something that is the subject of an insurance policy or any legal relationship to that subject that will trigger a certain event causing monetary loss to the insured. Example of insurable interest - ownership of a piece of property or an interest in that piece of property, e.g., a shipyard constructing a rig or vessel. (See BUILDERS RISK above)

LIABILITY INSURANCE - Insurance coverage that protects an insured against claims made by third parties for damage to their property or person. These losses usually come about as a result of negligence of the insured. In marine construction this policy is referred to an MGL, marine general liability policy. In non marine circumstances the policy is referred to as a CGL, commercial general liability policy. Insurance policies can be divided into two broad categories:

First party insurance covers the property of the person who purchases the insurance policy. For example, a home owner's policy promising to pay for fire damage to the home owner's home is a first party policy. Liability insurance, sometimes called third party insurance, covers the policy holder's liability to other people. For example, a homeowners' policy might cover liability if someone trips and falls on the home owner's property. Sometimes one policy, such as in these examples, may have both first and third party coverage.
Liability insurance provides two separate benefits. First, the policy will cover the damage incurred by the third party. Sometimes this is called providing "indemnity" for the loss. Second, most liability policies provide a duty to defend. The duty to defend requires the insurance company to pay for lawyers, expert witnesses, and court costs to defend the third party's claim. These costs can sometimes be substantial and should not be ignored when facing a liability claim.

UMBRELLA LIABILITY COVERAGE - This type of liability insurance provides excess liability protection. Your business needs this coverage for the following three reasons:

It provides excess coverage over the "underlying" liability insurance you carry.
It provides coverage for all other liability exposures, excepting a few specifically excluded exposures. This subject to a large deductible of about $10,000 to $25,000.
It provides automatic replacement coverage for underlying policies that have been reduced or exhausted by loss.

NEGLIGENCE - The failure to use reasonable care. The doing of something which a reasonably prudent person would not do, or the failure to do something which a reasonably prudent person would do under like circumstances. Negligence is a 'legal cause' of damage if it directly and in natural and continuous sequence produces or contributes substantially to producing such damage, so it can reasonably be said that if not for the negligence, the loss, injury or damage would not have occurred.

GROSS NEGLIGENCE - A carelessness and reckless disregard for the safety or lives of others, which is so great it appears to be almost a conscious violation of other people's rights to safety. It is more than simple negligence, but it is just short of being willful misconduct. If gross negligence is found by the trier of fact (judge or jury), it can result in the award of punitive damages on top of general and special damages, in certain jurisdictions.

WILLFUL MISCONDUCT - An intentional action with knowledge of its potential to cause serious injury or with a reckless disregard for the consequences of such act.

PRODUCT LIABILITY - Liability which results when a product is negligently manufactured and sent into the stream of commence. A liability that arises from the failure of a manufacturer to properly manufacture, test or warn about a manufactured object.

MANUFACTURING DEFECTS - When the product departs from its intended design, even if all possible care was exercised.

DESIGN DEFECTS - When the foreseeable risks of harm posed by the product could have been reduced or avoided by the adoption of a reasonable alternative design, and failure to use the alternative design renders the product not reasonably safe.

INADEQUATE INSTRUCTIONS OR WARNINGS DEFECTS - When the foreseeable risks of harm posed by the product could have been reduced or avoided by reasonable instructions or warnings, and their omission renders the product not reasonably safe.

PROFESSIONAL LIABILITY INSURANCE - Liability insurance to indemnify professionals, (doctors, lawyers, architects, engineers, etc.,) for loss or expense which the insured professional shall become legally obliged to pay as damages arising out of any professional negligent act, error or omission in rendering or failing to render professional services by the insured. Same as malpractice insurance.

Professional Liability has expanded over the years to include those occupations in which special knowledge, skills and close client relationships are paramount. More and more occupations are considered professional occupations, as the trend in business continues to grow from a manufacturing-based economy to a service-oriented economy. Coupled with the litigious nature of our society, the companies and staff in the service economy are subject to greater exposure to malpractice claims than ever before.

ERRORS AND OMISSIONS - Same as malpractice or professional liability insurance.

HOLD HARMLESS AGREEMENT - A contractual arrangement whereby one party assumes the liability inherent in the situation, thereby relieving the other party of responsibility. For example, a lease of premises may provide that the lessee must "hold harmless" the lessor for any liability from accidents arising out of the premises.

INDEMNIFY - To restore the victim of a loss, in whole or in part, by payment, repair, or replacement.

INDEMNITY AGREEMENTS - Contract clauses that identify who is to be responsible if liabilities arise and often transfer one party's liability for his or her wrongful acts to the other party.

WARRANTY - An agreement between a buyer and a seller of goods or services detailing the conditions under which the seller will make repairs or fix problems without cost to the buyer.

Warranties can be either expressed or implied. An EXPRESS WARRANTY is a guarantee made by the seller of the goods which expressly states one of the conditions attached to the sale e.g.,"This item is guaranteed against defects in construction for one year".

An IMPLIED WARRANTY is usual in common law jurisdictions and attached to the sale of goods by operation of law made on behalf of the manufacturer. These warranties are not usually in writing. Common implied warranties are a warranty of fitness for use (implied by law that if a seller knows the particular purpose for which the item is purchased certain guarantees are implied) and a warranty of merchantability (a warranty implied by law that the goods are reasonably fit for the general purpose for which they are sold).

DAMAGES OR LOSS - The monetary consequence which results from injury to a thing or a person.

CONSEQUENTIAL DAMAGES - As opposed to direct loss or damage -- is indirect loss or damage resulting from loss or damage caused by a covered peril, such as fire or windstorm. In the case of loss caused where windstorm is a covered peril, if a tree is blown down and cuts electricity used to power a freezer and the food in the freezer spoils, if the insurance policy extends coverage for consequential loss or damage then the food spoilage would be a covered loss. Business Interruption insurance, extends consequential loss or damage coverage for such items as extra expenses, rental value, profits and commissions, etc.

LIQUIDATED DAMAGES - Are a payment agreed to by the parties of a contract to satisfy portions of the agreement which were not performed. In some cases liquidated damages may be the forfeiture of a deposit or a down payment, or liquidated damages may be a percentage of the value of the contract, based on the percentage of work uncompleted. Liquidated damages are often paid in lieu of a lawsuit, although court action may be required in many cases where liquidated damages are sought. Liquidated damages, as opposed to a penalty, are sometimes paid when there is uncertainty as to the actual monetary loss involved. The payment of liquidated damages relieves the party in breech of a contract of the obligation to perform the balance of the contract.

SUBROGATION - "To stand in the place of" Usually found in property policies (first party) when an insurance company pays a loss to an insured or damaged to the insureds property, the insurer stands in the shoes of the insured and may pursue any third party who might be responsible for the loss. For example, if a defective component is sold to a manufacturer to be used in his product and that product is damaged due to the defective component. The insurance company who pays the loss to the manufacturer of the product may sue the manufacturer of the defective component.

Subrogation has a number of sub-principles namely:

The insurer cannot be subrogated to the insureds right of action until it has paid the insured and made good the loss.
The insurer can be subrogated only to actions which the insured would have brought himself.
The insured must not prejudice the insurer's right of subrogation. Thus, the insured may not compromise or renounce any right of action he has against the third party if by doing so he could diminish the insurer's right of recovery.
Subrogation against the insurer. Just as the insured cannot profit from his loss the insurer may not make a profit from the subrogation rights. The insurer is only entitled to recover the exact amount they paid as indemnity, and nothing more. If they recover more, the balance should be given to the insured.
Subrogation gives the insurer the right of salvage.

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Insurance Appraisal Process - A Policyholder's Best Chance to Resolve an Insurance Claim Dispute!

Many homeowners and business owners find themselves disagreeing with their insurance company's analysis of their insurance claim. However, most are unaware that they can dispute the insurance company's findings via the insurance appraisal process! Even though the policyholder (you) submits a contractor's estimate, receipts for repairs or materials, or even photos showing damages that the insurance company did not include for repairs... they still won't budge.

Most policyholders are unaware of how to dispute and resolve their claim with the insurance company. Policyholders have a choice and a voice within their policy for this very purpose. It's called The Appraisal Clause - also know as The Appraisal Provision. Now, don't let this scare you. It may seem like a fancy clause that would take a law degree to understand. However, a simple way to understand it is that it's the insurance industry's version of arbitration. Although similar, the Appraisal Process is NOT an arbitration or mediation and the umpire is not an arbitrator, mediator, or judge. Insurance Appraisal, Mediation, and Arbitration are separate things.

In short; Arbitration requires attorneys and a legal process, where Insurance Appraisal does not require attorneys or a legal process. Arbitration is a dispute between two parties for any reason, where as, the Insurance Appraisal Process is a dispute between the "value or cost," to repair or replace property only - bee it an automobile, plane, train, couch, house, commercial building, etc.

Most Policies Have the Appraisal Clause

If you feel you're at a dead end with your insurance company and want to resolve your claim you'll need to check your policy for the Appraisal Clause. Most policies will have the provision listed under the "What to do after a loss," section or the "Conditions" section of the policy. Below, you will find a sample of a typical Insurance Appraisal Clause included in most policies. Keep in mind that policies can be different in each state. Therefore, you should read your own policy to see if this clause exists. It will say something similar to the following ;

"APPRAISAL - If you and we fail to agree on the amount of loss, either one can demand that the amount of the loss be set by appraisal. If either makes a written demand for appraisal, each shall select a competent, independent appraiser. Each shall notify the other of the appraiser's identity within 20 days of receipt of the written demand. The two appraisers shall then select a competent, impartial umpire. If the two appraisers are unable to agree upon an umpire within 15 days, you or we can ask a judge of a court of record in the state where the residence premises is located to select an umpire. The appraisers shall then set the amount of the loss. If the appraisers fail to agree within a reasonable time, they shall submit their differences to the umpire. Written agreement signed by any two of these three shall set the amount of the loss."

OK, But How Does the Insurance Appraisal Process Work?

The Appraisal Process allows the policyholder (you) to hire an independent appraiser to determine the value of their damages. In turn, the insurance company will also hire their own independent appraiser. The two appraisers will then get together and select an umpire. The umpire is basically the arbitrator, or what you might call the judge. If a disagreement between the two appraisers arises, they can present their differences to the umpire who will make a ruling.

OK; so far so good, the basics of the insurance appraisal process are beginning to come together. We have an independent appraiser for the policyholder. We have an independent appraiser for the insurance company. Finally, there is an Umpire. These three individuals are known as The Appraisal Panel. The object of the Appraisal Panel is to set or determine The Amount of Loss. The Amount of Loss is the total dollar amount needed to return the damaged property back to its original condition, either by repair or replacement.

Once the Appraisal Panel is set, the policyholder's chosen appraiser and the insurance company's chosen appraiser will review the documents, estimates, and differences between them. The two independent appraisers will try to discuss and resolve the differences in damage and in cost. For example; the insurance company may determine that brick on a home does not need to be replaced. Where as, the contractor or appraiser for the policyholder says that it does have to be replaced. The two appraisers will discuss their reasons for their position and try to come to an agreement, first if it should be repaired or replaced, and secondly the cost to return the brick back to it's original condition prior to the loss.

One benefit of the Insurance Appraisal Process is that the two independent appraisers have not been subject to the bickering and anger between the policyholder and the insurance company. Basically, it's the hope that cooler heads will prevail. All the appraisers really have is the amount of the damage and the difference between the two estimate numbers. They do not have the previous baggage or anger that led up to the Appraisal. The process was designed so that these two individuals, who have no interest in the outcome, could discuss a settlement based on the facts presented to them.

Sometimes issues arrive where the two independent appraisers can't agree on certain items. In this event, the two appraisers will submit their differences to the chosen umpire. The three will discuss the issues and try to reach an agreed settlement of the differences. As stated above; the settlement or final number is called The Amount of Loss. The final amount is known as the Appraisal Award. The Award is signed by the individuals who agree on The Amount of Loss. However, only TWO of the three individuals need to agree. (An agreement between the two independent appraisers, or the umpire and either appraiser) Once any TWO of the three individuals on the Appraisal Panel sign the award... the dispute is over! The amount on the Award binding and is paid by the insurance company, to the policyholder.

Can I Use An Insurance Attorney To Dispute My Claim?

The Appraisal Clause was initiated to lower the number of lawsuits filed against insurance companies. The courts found that many lawsuits were entering the legal system where the cost to repair or replaced damaged property was being disputed. In many cases the suites were being resolved when professional engineers and contractors could address the issues. The Appraisal Process was created to get such individuals together and keep these disputes out of the courtroom. Assuming you acquired an estimate of repair to your property for $100,000, from a contractor or insurance claims expert. Your insurance company has created an estimate for $30,000. This would be a clear dispute between the amounts of damage. This type of dispute is exactly what the Appraisal Clause was developed to resolve.

The clause allows parties on both sides of the insurance policy to dispute their differences using this less costly provision. Let's face it; the courts are filled with lawsuits. The Insurance Appraisal Process allows for the dispute to be settled out of court. Using Insurance Attorneys and lawsuits can have insurance claims tied up in court for years. The Appraisal Provision was designed to keep these disputes out of court for a less costly and timelier resolution.

Insurance Claim Attorneys will usually represent policyholders for bad faith practices. Bad Faith is a whole other issue and sometimes happens after the Appraisal Process has been completed. Bad Faith claims are for much larger suites against insurance companies when it is alleged that they did not act with good faith of the policy they sold to the policyholder. In summary; disputes between the amount of damages and repairs will follow the Appraisal Process before entering into the legal system. Many Insurance Attorneys will also advise the policyholder to engage in the Appraisal Process before any lawsuits will begin.

How Do I know if the Insurance Appraisal Process is a Good Option for My Claim?

If the Appraisal Clause is in your policy then it is always an option. However, it's wise to point out that Appraisal is usually an option when there is a substantial difference in the amount between the two estimate totals. For example; let's say a fire completely destroys a house and the homeowner's personal property within it (Know as the Contents). The differences between what the insurance company wants to pay and what you wish to receive is $5,000. In this situation, the Appraisal Process is not the best idea. After paying the fees involved for the appraisal, you may not end up with much of the $5,000 being disputed.

Now, if we take the same fire that destroys the property and the dispute between the policyholder and the insurance company is $40,000, appraisal should be considered. The policyholder now has a chance to recover substantially more money than originally offered.

Also, the Appraisal Clause is only applicable if a dispute arises from a covered loss. If the insurance company denied the claim as something not covered then this is not a dispute on the amount to repair, but rather a dispute on coverage. For example; homeowners and business policies due not cover floods. Flood policies are purchased separately. So, if there is no coverage for the flood damages then the Appraisal Process is not an option.

Simply put, the Insurance Appraisal Process is to determine the "amount of loss," to property only. The Appraisal Panel is not to determine coverage, policy provisions, deductibles, how much was previously paid on the claim, etc. Let's say there was an appraisal for a grand piano that fell off a delivery truck on the highway. The Appraisal Panel's job is not to determine who's at fault, the policy coverage limit, if the truck had a registration, or anything other than "How Much is the Piano Worth."

As with our example earlier, if the insurance company offers a settlement of $10,000 to repair a roof and the policyholder has contractor bids for $15,000, then the Appraisal Process may not be the best option. The Appraisal Process may cost more than the $5,000 that's being disputed. Unfortunately, the differences in repair/replacement costs are usually much greater. When an insurance company generates an estimate for a claim of $75,000 and the policyholder has acquired professional bids several contractors of $200,000 or more, its time to invoke the appraisal clause.

Beginning The Appraisal Process

Either party associated with the policy can invoke the Appraisal Process. However, such a request must be made in writing. Each policy will have a time limit of when this can take place. Even if a claim has been closed for many years, either party can still dispute the claim and reopen for review. It's recommended that the request to invoke appraisal be sent via certified mail. Once the request to invoke the Appraisal Clause has been initiated, as explained earlier, each party, the insurance company and policyholder, appoints an Independent Appraiser. (If you wish to invoke the appraisal clause in your policy you need to submit a letter to your insurance company. Find more information at http://www.insurance-appraisal-services.com/invoke-appraisal.html )

Choosing An Independent Appraiser

It's important to select an Independent Appraiser that has experience with the damages being disputed in the claim. A person with expert knowledge of insurance claims handling and firsthand knowledge of the damaged property and its replacement cost. For example; a person with expert knowledge of insurance claims handling and with expert knowledge of the Appraisal Process, with little experience on the costs to replace an antique grand piano may not be the best choice. In the case of a home or building fire; a good Appraiser is someone who can generate their own line-item detailed estimate to repair or replace the damaged property, can secure multiple bids from reputable contractors to back up their findings, knows building codes, and can articulate unforeseen costs of repairs. If a building has historic features with materials like, solid Adler doors, large detailed moldings, and custom cabinets, a great amount of research with a salvager may be needed. The Appraiser should have experience with building procedures, materials and the cost of such terms to create an accurate "amount of loss," to return the property to the same condition it was prior to the loss. See, the policy provides coverage to replace the damaged property with those of like kind and quality. An Independent Appraiser that is not familiar with, or that does not have experienced contractors, engineers, and other experts to consult with about mold, demolition, cost associated with contents, and in some cases, additional living expenses, does not sound like a good candidate. You should choose your Independent Appraiser wisely. Look and interview someone with experience of the type of damage you have and with the type of property damaged, as well as a specialist when it comes to the Insurance Appraisal Process and also Insurance Claims Handling.

Many people confuse the words Independent Appraiser with that of a real estate appraiser. As you can see, a real estate appraiser is far from what is needed for an Insurance Appraisal. An Independent "Insurance," Appraiser is an insurance claims expert on costs and processes to repair or replace damaged property. The next question is, "Who will have such knowledge?" People requesting assistance in the past have asked if the following experts with the following backgrounds are good choices ;



Structural Engineers: This person may be a structural expert and could probably provide a good estimate to replace a building, but what about the contents (furniture, food, etc.) damage? Do they know anything about the insurance policy, the claims process, the software used by insurance companies, the Appraisal Process?  

Construction Attorney: A Construction Attorney most likely has knowledge of construction contracts and issues that building contractors have. Do they know anything about the insurance policy, the claims process, the software used by insurance companies, the Appraisal Process, the contents damaged? (NOTE: If you retain an attorney as Appraiser, remember, there is NO attorney/client privilege because the attorney is being hired as an Appraiser, not as an attorney.)  

Construction Superintendent or General Contractor: Again, excellent choice for generating a structural estimate, but is most likely not familiar with insurance claims... and even more importantly, the Insurance Appraisal Process.  

Insurance Claim Attorney / Lawyer: Keep in mind that the process was designed to keep these types of disputes out of court. You can surely use an attorney as your appraiser; however, the fees can exhaust your reward. Attorney's fees range between 30% and 40% of the amount collected. This will dig deep into the net amount you receive. An Insurance Attorney will also have expert knowledge of the policy. However, the Appraisal Provision clearly notes that no policy provisions will apply. Has the attorney represented their clients in many appraisals or mostly in court cases? How familiar are they with the Appraisal Process, building costs, construction practices, the contents damaged? Does the attorney know anything about the software used by insurance companies? (NOTE: If you retain an attorney as Appraiser, remember, there is NO attorney/client privilege because the attorney is being hired as an Appraiser, not as an attorney.)  

Independent Insurance Appraiser: Doesn't it make sense to hire an individual who is an expert of the process in which you are about to engage? You've heard the expression, "Would you go to your auto mechanic if you needed brain surgery?" It is highly recommended to use a qualified, professional, Insurance Appraiser. This professional will already know the Insurance Appraisal Process. They will also have qualified professionals (engineers, contractors, inspectors, etc.) at there disposal to back up their analysis.

Regardless of background, an Independent Appraiser will also require good communication skills and agree with the position they are defending. They should know about the insurance policy, the claims process, the software used by insurance companies, the Appraisal Process, contents damage, structural damages, building costs and processes, as well as materials and building codes. Makes sense, right?

Advantages to the Insurance Appraisal Process

There are several advantages to the Insurance Appraisal Process. The most obvious is costs. Insurance Attorney's will usually charge 30% to 45% of the total award. On a $200,000 claim, the attorney's fee would be in the range of Sixty to Ninety-thousand dollars ($60,000 to $90,000). That can hurt a policyholder trying to rebuild their life. Remember, the Insurance Appraisal Process was designed to keep these disputes out of the courtroom.

The advantage of invoking appraisal allows for a less formal or non-legal proceeding. An Independent Appraiser usually charges in the range of $125 to $200 per hour. Using the same example above with an award of $200,000; if the dispute took 25 to 50 hours, the cost would be in the range of Five Thousand to Ten Thousand dollars ($5,000 to $10,000). This can be a significant difference.

Another advantage is time. The courtroom can delay an insurance claim dispute for years, where the Appraisal Process usually only takes a few months. Sometimes it can last longer depending on the complexity of the claim. However, the courtroom will most certainly be longer. The result of less time and less cost becomes a less of a burden for both sides of the dispute.

Once an award is signed the insurance company has 30 to 60-days (depending on state) to settle the award.

Should I Invoke the Appraisal Clause For My Claim?

When the dispute is real and the damages are real, the policyholder usually see's a greater return at the end of the appraisal. If the policyholder's claim is supported by an Insurance Claims Expert, building or repair contractors, or an engineer - and the amount of money between the two estimates is large, the Appraisal Process is a no-brainer. However, if a contractor or Public Adjuster is trying to beef-up the damages for their own benefit, then it's the policyholder that pays dearly for it. If you're considering invoking appraisal on your claim you should consult an insurance claim expert to see if it's worth your time and effort.

Being that the Appraisal Award is binding the policyholder should be sure before they cost themselves unwanted anguish. If the outcome of your Appraisal Award is not what was to be expected, both parties must live with the result. As stated, the Appraisal Award is binding on "both parties."

At the end of the day nothing is risk free. There are no promises or guarantees with the outcome of any Appraisal. However, if you have a dispute over $20,000 you're more than likely to have a result you can live with. Do your homework and remember to choose an Independent Appraiser that is educated and experienced with the type of damages you have, what caused the damage, and the type of property damaged. Keep in mind that this is "YOUR," property and "YOUR," insurance policy. Your policy protects you with the Insurance Appraisal Process, so that...

The Playing Field Remains Level, and The Process Works Fairly

For Both Parties... Not Just The Insurance Companies! 

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Piccoli affari di assicurazione - la miglior politica è un grande agente

I have been a health insurance broker for over a decade and every day I read more and more "horror" stories that are posted on the Internet regarding health insurance companies not paying claims, refusing to cover specific illnesses and physicians not getting reimbursed for medical services. Unfortunately, insurance companies are driven by profits, not people (albeit they need people to make profits). If the insurance company can find a legal reason not to pay a claim, chances are they will find it, and you the consumer will suffer. However, what most people fail to realize is that there are very few "loopholes" in an insurance policy that give the insurance company an unfair advantage over the consumer. In fact, insurance companies go to great lengths to detail the limitations of their coverage by giving the policy holders 10-days (a 10-day free look period) to review their policy. Unfortunately, most people put their insurance cards in their wallet and place their policy in a drawer or filing cabinet during their 10-day free look and it usually isn't until they receive a "denial" letter from the insurance company that they take their policy out to really read through it.

The majority of people, who buy their own health insurance, rely heavily on the insurance agent selling the policy to explain the plan's coverage and benefits. This being the case, many individuals who purchase their own health insurance plan can tell you very little about their plan, other than, what they pay in premiums and how much they have to pay to satisfy their deductible.

For many consumers, purchasing a health insurance policy on their own can be an enormous undertaking. Purchasing a health insurance policy is not like buying a car, in that, the buyer knows that the engine and transmission are standard, and that power windows are optional. A health insurance plan is much more ambiguous, and it is often very difficult for the consumer to determine what type of coverage is standard and what other benefits are optional. In my opinion, this is the primary reason that most policy holders don't realize that they do not have coverage for a specific medical treatment until they receive a large bill from the hospital stating that "benefits were denied."

Sure, we all complain about insurance companies, but we do know that they serve a "necessary evil." And, even though purchasing health insurance may be a frustrating, daunting and time consuming task, there are certain things that you can do as a consumer to ensure that you are purchasing the type of health insurance coverage you really need at a fair price.

Dealing with small business owners and the self-employed market, I have come to the realization that it is extremely difficult for people to distinguish between the type of health insurance coverage that they "want" and the benefits they really "need." Recently, I have read various comments on different Blogs advocating health plans that offer 100% coverage (no deductible and no-coinsurance) and, although I agree that those types of plans have a great "curb appeal," I can tell you from personal experience that these plans are not for everyone. Do 100% health plans offer the policy holder greater peace of mind? Probably. But is a 100% health insurance plan something that most consumers really need? Probably not! In my professional opinion, when you purchase a health insurance plan, you must achieve a balance between four important variables; wants, needs, risk and price. Just like you would do if you were purchasing options for a new car, you have to weigh all these variables before you spend your money. If you are healthy, take no medications and rarely go to the doctor, do you really need a 100% plan with a $5 co-payment for prescription drugs if it costs you $300 dollars more a month?

Is it worth $200 more a month to have a $250 deductible and a $20 brand name/$10 generic Rx co-pay versus an 80/20 plan with a $2,500 deductible that also offers a $20 brand name/$10generic co-pay after you pay a once a year $100 Rx deductible? Wouldn't the 80/20 plan still offer you adequate coverage? Don't you think it would be better to put that extra $200 ($2,400 per year) in your bank account, just in case you may have to pay your $2,500 deductible or buy a $12 Amoxicillin prescription? Isn't it wiser to keep your hard-earned money rather than pay higher premiums to an insurance company?

Yes, there are many ways you can keep more of the money that you would normally give to an insurance company in the form of higher monthly premiums. For example, the federal government encourages consumers to purchase H.S.A. (Health Savings Account) qualified H.D.H.P.'s (High Deductible Health Plans) so they have more control over how their health care dollars are spent. Consumers who purchase an HSA Qualified H.D.H.P. can put extra money aside each year in an interest bearing account so they can use that money to pay for out-of-pocket medical expenses. Even procedures that are not normally covered by insurance companies, like Lasik eye surgery, orthodontics, and alternative medicines become 100% tax deductible. If there are no claims that year the money that was deposited into the tax deferred H.S.A can be rolled over to the next year earning an even higher rate of interest. If there are no significant claims for several years (as is often the case) the insured ends up building a sizeable account that enjoys similar tax benefits as a traditional I.R.A. Most H.S.A. administrators now offer thousands of no load mutual funds to transfer your H.S.A. funds into so you can potentially earn an even higher rate of interest.

In my experience, I believe that individuals who purchase their health plan based on wants rather than needs feel the most defrauded or "ripped-off" by their insurance company and/or insurance agent. In fact, I hear almost identical comments from almost every business owner that I speak to. Comments, such as, "I have to run my business, I don't have time to be sick! "I think I have gone to the doctor 2 times in the last 5 years" and "My insurance company keeps raising my rates and I don't even use my insurance!" As a business owner myself, I can understand their frustration. So, is there a simple formula that everyone can follow to make health insurance buying easier? Yes! Become an INFORMED consumer.

Every time I contact a prospective client or call one of my client referrals, I ask a handful of specific questions that directly relate to the policy that particular individual currently has in their filing cabinet or dresser drawer. You know the policy that they bought to protect them from having to file bankruptcy due to medical debt. That policy they purchased to cover that $500,000 life-saving organ transplant or those 40 chemotherapy treatments that they may have to undergo if they are diagnosed with cancer.

So what do you think happens almost 100% of the time when I ask these individuals "BASIC" questions about their health insurance policy? They do not know the answers! The following is a list of 10 questions that I frequently ask a prospective health insurance client. Let's see how many YOU can answer without looking at your policy.

1. What Insurance Company are you insured with and what is the name of your health insurance plan? (e.g. Blue Cross Blue Shield-"Basic Blue")

2. What is your calendar year deductible and would you have to pay a separate deductible for each family member if everyone in your family became ill at the same time? (e.g. The majority of health plans have a per person yearly deductible, for example, $250, $500, $1,000, or $2,500. However, some plans will only require you to pay a 2 person maximum deductible each year, even if everyone in your family needed extensive medical care.)

3. What is your coinsurance percentage and what dollar amount (stop loss) it is based on? (e.g. A good plan with 80/20 coverage means you pay 20% of some dollar amount. This dollar amount is also known as a stop loss and can vary based on the type of policy you purchase. Stop losses can be as little as $5,000 or $10,000 or as much as $20,000 or there are some policies on the market that have NO stop loss dollar amount.)

4. What is your maximum out of pocket expense per year? (e.g. All deductibles plus all coinsurance percentages plus all applicable access fees or other fees)

5. What is the Lifetime maximum benefit the insurance company will pay if you become seriously ill and does your plan have any "per illness" maximums or caps? (e.g. Some plans may have a $5 million lifetime maximum, but may have a maximum benefit cap of $100,000 per illness. This means that you would have to develop many separate and unrelated life-threatening illnesses costing $100,000 or less to qualify for $5 million of lifetime coverage.)

6. Is your plan a schedule plan, in that it only pays a certain amount for a specific list of procedures? (e.g., Mega Life & Health & Midwest National Life, endorsed by the National Association of the Self-Employed, N.A.S.E. is known for endorsing schedule plans) 7. Does your plan have doctor co-pays and are you limited to a certain number of doctor co-pay visits per year? (e.g. Many plans have a limit of how many times you go to the doctor per year for a co-pay and, quite often the limit is 2-4 visits.)

8. Does your plan offer prescription drug coverage and if it does, do you pay a co-pay for your prescriptions or do you have to meet a separate drug deductible before you receive any benefits and/or do you just have a discount prescription card only? (e.g. Some plans offer you prescription benefits right away, other plans require that you pay a separate drug deductible before you can receive prescription medication for a co-pay. Today, many plans offer no co-pay options and only provide you with a discount prescription card that gives you a 10-20% discount on all prescription medications).

9. Does your plan have any reduction in benefits for organ transplants and if so, what is the maximum your plan will pay if you need an organ transplant? (e.g. Some plans only pay a $100,000 maximum benefit for organ transplants for a procedure that actually costs $350-$500K and this $100,000 maximum may also include reimbursement for expensive anti-rejection medications that must be taken after a transplant. If this is the case, you will often have to pay for all anti-rejection medications out of pocket).

10. Do you have to pay a separate deductible or "access fee" for each hospital admission or for each emergency room visit? (e.g. Some plans, like the Assurant Health's "CoreMed" plan have a separate $750 hospital admission fee that you pay for the first 3 days you are in the hospital. This fee is in addition to your plan deductible. Also, many plans have benefit "caps" or "access fees" for out-patient services, such as, physical therapy, speech therapy, chemotherapy, radiation therapy, etc. Benefit "caps" could be as little as $500 for each out-patient treatment, leaving you a bill for the remaining balance. Access fees are additional fees that you pay per treatment. For example, for each outpatient chemotherapy treatment, you may be required to pay a $250 "access fee" per treatment. So for 40 chemotherapy treatments, you would have to pay 40 x $250 = $10,000. Again, these fees would be charged in addition to your plan deductible).

Now that you've read through the list of questions that I ask a prospective health insurance client, ask yourself how many questions you were able to answer. If you couldn't answer all ten questions don't be discouraged. That doesn't mean that you are not a smart consumer. It may just mean that you dealt with a "bad" insurance agent. So how could you tell if you dealt with a "bad" insurance agent? Because a "great" insurance agent would have taken the time to help you really understand your insurance benefits. A "great" agent spends time asking YOU questions so s/he can understand your insurance needs. A "great" agent recommends health plans based on all four variables; wants, needs, risk and price. A "great" agent gives you enough information to weigh all of your options so you can make an informed purchasing decision. And lastly, a "great" agent looks out for YOUR best interest and NOT the best interest of the insurance company.

So how do you know if you have a "great" agent? Easy, if you were able to answer all 10 questions without looking at your health insurance policy, you have a "great" agent. If you were able to answer the majority of questions, you may have a "good" agent. However, if you were only able to answer a few questions, chances are you have a "bad" agent. Insurance agents are no different than any other professional. There are some insurance agents that really care about the clients they work with, and there are other agents that avoid answering questions and duck client phone calls when a message is left about unpaid claims or skyrocketing health insurance rates.

Remember, your health insurance purchase is just as important as purchasing a house or a car, if not more important. So don't be afraid to ask your insurance agent a lot of questions to make sure that you understand what your health plan does and does not cover. If you don't feel comfortable with the type of coverage that your agent suggests or if you think the price is too high, ask your agent if s/he can select a comparable plan so you can make a side by side comparison before you purchase. And, most importantly, read all of the "fine print" in your health plan brochure and when you receive your policy, take the time to read through your policy during your 10-day free look period.

If you can't understand something, or aren't quite sure what the asterisk (*) next to the benefit description really means in terms of your coverage, call your agent or contact the insurance company to ask for further clarification.

Furthermore, take the time to perform your own due diligence. For example, if you research MEGA Life and Health or the Midwest National Life insurance company, endorsed by the National Association for the Self Employed (NASE), you will find that there have been 14 class action lawsuits brought against these companies since 1995. So ask yourself, "Is this a company that I would trust to pay my health insurance claims?

Additionally, find out if your agent is a "captive" agent or an insurance "broker." "Captive" agents can only offer ONE insurance company's products." Independent" agents or insurance "brokers" can offer you a variety of different insurance plans from many different insurance companies. A "captive" agent may recommend a health plan that doesn't exactly meet your needs because that is the only plan s/he can sell. An "independent" agent or insurance "broker" can usually offer you a variety of different insurance products from many quality carriers and can often customize a plan to meet your specific insurance needs and budget.

Over the years, I have developed strong, trusting relationships with my clients because of my insurance expertise and the level of personal service that I provide. This is one of the primary reasons that I do not recommend buying health insurance on the Internet. In my opinion, there are too many variables that Internet insurance buyers do not often take into consideration. I am a firm believer that a health insurance purchase requires the level of expertise and personal attention that only an insurance professional can provide. And, since it does not cost a penny more to purchase your health insurance through an agent or broker, my advice would be to use eBay and Amazon for your less important purchases and to use a knowledgeable, ethical and reputable independent agent or broker for one of the most important purchases you will ever make....your health insurance policy.

Lastly, if you have any concerns about an insurance company, contact your state's Department of Insurance BEFORE you buy your policy. Your state's Department of Insurance can tell you if the insurance company is registered in your state and can also tell you if there have been any complaints against that company that have been filed by policy holders. If you suspect that your agent is trying to sell you a fraudulent insurance policy, (e.g. you have to become a member of a union to qualify for coverage) or isn't being honest with you, your state's Department of Insurance can also check to see if your agent is licensed and whether or not there has ever been any disciplinary action previously taken against that agent.

In closing, I hope I have given you enough information so you can become an INFORMED insurance consumer. However, I remain convinced that the following words of wisdom still go along way: "If it sounds too good to be true, it probably is!" and "If you only buy on price, you get what you pay for!"

©2007 Small Business Insurance Services, Inc. http://www.smallbusinessinsuranceservices.com

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Insurance Agents Name Choices - Insurance Specialist, Financial Planner, or Life Advisor?

Are you one of the plain insurance agents? Agents often prefer to upgrade their title as an insurance specialist or financial advisor on their business card. Names like life advisor reflect positive experience and knowledge. Which of these different terms distinguishes you from being just one of the insurance agents? Here are 101 top choices to pick from.

There is a lot more to a name then may realize. Calling yourself an agent or sales agent makes you sound run of the mill. It also projects the sound of a salesman trying to sell you something. Few people enjoy feeling a person is selling them anything, it stinks of pressure. This is why in this list of different terms you will see how high words like specialist, expert, and professional rank. The prospect gets a completely new perspective, just by the title you give yourself! Prospects closely take notice when an agent jointly works with them in reaching a decision on what is the best plan of action. Prospective clients want to feel like they are part of the decision process.

Important internet search tip: to get an accurate count use quote marks around your term, "insurance specialist" will only give you that term in that exact order. Without the quotes you would also get all instances of people searching terms such as specialist insurance, specialist in writing insurance claims, specialist in automobile insurance sales, etc.

To give this article value, in front of each of the insurance agents distinctions is the number of current Google listings. This way you can easily see how often internet views "insurance agent " look-up terms like specialist, planner, representative, and. advisor. Please remember the Google count figures often change daily.

1. 10,600,000 = financial advisor

2. 6,690,000 = insurance agent

3. 4,280,000 = financial planner

4. 2,120,000 = investment advisor

5. 1,780,000 = insurance agents brokers

6. 1,600,000 = investment adviser

7. 999,000 = insurance guide

8. 735,000 = insurance specialist

9. 638,000 = financial expert

10. 604,000 = financial professional

11. 590,000 = financial specialist

12. 513,000 = life pro

13. 433,000 = insurance professional

14. 431,000 = health insurance agent

15. 322,000 = insurance expert

16. 271,500 = insurance salesman

17. 269,000 = life professional

18. 268,000 = life insurance agent

19. 253,000 = insurance consultant

20. 252,000 = insurance advisor

21. 244,000 = insurance sales representative

22. 219,000 = insurance manager

23. 218,000 = estate advisor

24. 217,000 = insurance executive

25. 189,000 = estate planner

26. 186,000 = independent insurance sale

27. 179,000 = insurance sales agent

28. 155,000 = insurance seller

29. 130,000 = insurance producer

30. 126,000 = investment representative

29. 120,000 = insurance authority

30. 119,000 = insurance representative

31. 112,000 = life agent

32. 107,000 = life insurance specialist

32. 104,000 = life specialist

33. 102,000 = insurance adviser

34. 89,900 = insurance sales manager

35. 86,200 = licensed insurance agent

36. 85,200 = insurance manager

37. 71,000 = health agent

38. 66,600 = insurance pro

39. 65,100 = insurance sales rep

40. 60,000 = insurance designer

41. 59,400 = insurance sales person

42. 55,600 = life consultant

43. 54,500 = group agent

44. 52,200 = ins agent

45. 50,100 = estate adviser

46. 50,000 = insurance pros

47. 46,800 = insurance counselor

48. 43,800 = financial pro

49. 43,400 = insurance salesperson

50. 40,200 = insurance sales specialist

51. 37,700 = life producer

52. 37,000 = insurance sales executive

53. 35,400 = independent insurance brokers

54. 34,700 = long term care professional

55. 34,500 = financial planning advisor

56. 33,900 = medical insurance specialist

57. 31,300 = health insurance professional

58. 29,300 = life insurance expert

59. 29,000 = insurance rep

60. 28,900 = financial planning advisor

61. 27,500 = health insurance specialist

62. 26,000 = health insurance advisor

63. 25,500 = independent insurance professional

64. 24,700 = employee benefits specialist

65. 24,000 = life advisor

66. 22,900 = life insurance advisor

67. 21,800 = life insurance sales specialist

68. 19,900 = life insurance professional

69. 19,300 = insurance producer

70. 19,200 = licensed financial planner

71. 16,200 = health insurance producer

72. 14,900 = insurance sales consultant

73. 14,000 = term life insurance broker

74. 12,800 = long term care specialist

75. 12,700 = annuity specialist

76. 12,500 = estate planning specialist

77. 12,200 = insurance marketer

78. 11,950 = life insurance representative

79. 11,900 = insurance planner

80. 10,600 = insurance sales professional

81. 10,400 = life insurance advisor

82. 10,200 = insurance writer

83. 9,650 = insurance recruiter

84. 9,480 = financial planning advisor

85. 9,030 = estate planning advisor

86. 8,570 = annuity broker

87. 7,520 = insurance general manager

88. 7,070 = insurance trainee

89. 6,800 = long term care insurance specialist

90. 6,670 = term life insurance agent

91. 6,440 = long term care insurance agent

92. 5,870 = licensed life agent

93. 5,300 = financial insurance agent

94. 5,270 = annuity agent

95. 5,080 = ins professional

96. 5,030 = medical insurance professional

97. 5,010 = disability insurance agent

98. 4,990 = employee benefits professional

99. 4,430 = mortgage insurance agent

100. 4,200 = disability insurance specialist

101. 3,900 = long term care agent

For your own sake, never tell prospective clients that you are one of 1,500,000 insurance agents licensed to sell life, health, annuities, and financial policies. The term insurance specialist or insurance professional immediately makes your prospect more confident of your abilities. However, please do not use the overused and abused terms of financial planner or estate planner unless you actually are qualified to be one.

If case, you are interested, here are more titles with over 1,000 Google entry occurrences that did not make the top 101 list. They include group health professional, ins specialist, insurance marketing representative, health insurance adviser, ins representative, term life insurance specialist, mortgage life insurance agent, insurance marketing specialist, disability insurance broker, life ins agent, term life agent, senior market specialist, life investment adviser, MDRT insurance agent, and insurance saleswoman.

Should you want to get more attention on major search engines like Google, Yahoo, and Ask, here are some tips. On the front of your website entry page, use the title and first line to put a more descriptive term about the services you provide. Rather than announcing "insurance agent for many products", try this, "medical insurance professional and disability insurance specialist." Both these titles only have about 5,000 competing entries, which could include 3,500 to 4,000 weak ones each. Now it depends on following the advice given, and internet search engine skills you possess. An internet searcher might now find you in the top 100 listings for each of the terms! On an "insurance agent" search, with well over 6,000,000 listings, it might take a 24/7 week to find you listed toward the end of the heap.

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