Order in the matter of M/s Universal Sompo General Insurance Co. Ltd.

Violation of Regulation 27 of IRDAI (Health Insurance) Regulations, 2016 and Para 4(b) & 5 of IRDAI Circular on Data Submission for onsite inspections.

The regulations require insurers to settle or reject claims within the prescribed timelines and ensure that necessary documents are collected properly without causing inconvenience to policyholders.

The Authority observed that:

• The Insurer closed Health Insurance Claims where requirements were pending from Claimants/Insured.
• The Insurer closed claims and subsequently reopened them for settlement, causing unnecessary financial and emotional strain to policyholders.
• The Insurer failed to effectively manage records and retrieve documents during COVID-19, indicating weaknesses in business continuity planning.
• 9980 claims were intimated but not registered by the Insurer.
• 5180 admitted claims were closed due to missing essential documents and were later paid after obtaining required information.

Caution and Advisory:

• Insurer was cautioned against closing claims without a final decision.
• Any recurrence of similar lapses shall invite stringent regulatory action.
• All intimated claims must be registered in the system.
• Claims must be concluded through payment or repudiation with appropriate reasons.
• Review all claims closed from April 01, 2018 onwards that were neither paid nor repudiated.

Violation of Regulation 8(6) and 8(7) of IRDAI (Protection of Policyholders Interest) Regulation, 2017
relating to processing of proposals and refund of proposal deposits.

The Authority observed that:

• 76 out of 1337 rejected proposals during FY 2019-20 and FY 2020-21 were not refunded within 15 days.
• Obtaining customer account details and cancelled cheques before refund indicated operational gaps.
• Delays occurred due to an inefficient email-based refund process.
• Operational weaknesses affected policyholder servicing.

The Authority cautioned the Insurer and advised ensuring that such lapses are not repeated.
Future similar lapses shall invite strict regulatory action.

Violation of Regulation 3(a) of IRDA (Manner of Receipt of Premium) Regulation, 2002.

• The Insurer was not accepting cash payments towards premium from policyholders/prospects.
• Customers should have the choice to select their preferred mode of premium payment.

Charge Not Pressed

The Insurer submitted evidence through policies issued confirming that cash payments were being accepted.

Violation of Regulation 15(8) and 15(10) of IRDAI (Protection of Policyholders Interest) Regulation relating to claim settlement timelines and payment of penal interest.

The Authority observed that:

• There were delays in claim settlements beyond 30 days from receipt of survey reports or additional documents.
• The Insurer failed to pay penal interest for delayed settlements during FY 2018-19 to FY 2023-24.
• Similar observations were made during earlier inspections.

Warning:

• The Authority warned the Insurer to strictly comply with Regulation 15(8) and 15(10).
• Failure to comply may result in stringent regulatory action.

Directions:

• Place the Order before the Board of the Insurer in the upcoming Board Meeting.
• Submit a copy of the Board meeting minutes to the Authority.
• Submit an Action Taken Report within 90 days from the date of Order.