Life Insurance Council Committee on Standard Guidelines with respect to underwriting, claims,etc for
people living with HIV or vulnerable to HIV/AIDS.
The Committee members comprised of the following members:
1.
Ms. T. T. Mathew (Chairperson) – Executive Director – Underwriting and Reinsurance, LIC
2.
Mr. P. R. Shanbhag – Secretary – Underwriting, LIC
3.
Mr. P. K. Arora – Dy Secretary – (Product Development), LIC
4.
Ms. Anasuya Ghosh – SVP – Underwriting, New Business, & EB Operations, Reliance Life
5.
Ms. Vanitha Subramanian – VP – Underwriting, Birla Sun life
6.
Mr. Frederick D’Souza – SVP – Underwriting, Claims & HUB Operations, HDFC Life
7.
Mr. Nazir Damji – EVP – Chief Underwriter, Max New York Life
8.
Mr. Mahaveer Chandiwala – Head Underwriting and Claims – Munich Re Services
9.
Dr. Himanshu Bhatia – Asia Chief Medical Officer – Swiss Re Services
10. Mr. N. Srinivasan – Advisor Actuary – GIC Re Services
11. Dr. Dhiraj Goud – Associate Director – RGA Services
Introduction
This Committee constituted by the Life Council met on 15 March 2012 and discussed the exposure draft in
detail to get a clarity on the expectations of the Authority. The members agreed that the draft warranted a
holistic and collaborative outlook towards the technical aspects of insurance business and at the same time be
inclusive to the extent viable for the growing HIV/AIDS population.
At the pre-work stage itself, the members were provided with information regarding mortality and morbidity
trends for People Living with HIV/AIDS (PLHA) as well as update on various products across the world.
It was noted that in almost all countries, majority of the products for PLHA were dealing with life insurance
benefits given that much more reliable data is available for mortality than morbidity. On the other hand,
majority of the health insurance products were offered as a fixed basket of benefits (along with other chronic
diseases), priced mainly on community rating basis. After a thorough debate on the above issue, it was agreed
that the current committee would focus only on life insurance benefits for PLHA, while the scope of health
insurance benefits would be left to the General Insurance Council to consider(as majority of health business is
administered by General Insurance/Stand Alone Health companies).
The Committee has listed some of the reasons why they recommend that health products offered by Life
insurance companies are not a suitable option for PLHA:
a) Health products offered by Life Companies are long term in nature unlike health products offered
by Non-Life Insurers which are yearly renewable.
b) There is limited data available on healthcare utilization and cost for PLHA, which makes it
difficult to appropriately price a benefit package inclusive of HIV/AIDS related services.
c) Extremely high utilization rates and claims ratios for co-morbidities associated with HIV/AIDS
(e.g. increase in prevalence rates of HIV/AIDS – TB, co-infections).
The Committee then divided themselves into work groups that would deliberate over different aspects of the
exposure draft.
Working group deliberations
The Product Development Group comprising of Mr. Nazir Damji, Mr. Fredrick D’souza & Mr. Arora debated
over whether PLHA should be offered existing products or niche products catering exclusively to PLHA. They
delved over aspects like the target segment, type of product to be offered, i.e. savings, term, etc. and the cost and
feasibility of developing and maintaining such a product on the technology platform used by various life
insurance players. The members had to ponder over whether such an exclusive niche product will end up being
elusive to the customer in need of the product on account of its pricing and the customer’s affordability.
The Underwriting Group comprising of Mr. Shanbhag, Ms. Anasuya Ghosh, Mr. Mahaveer Chandiwala and
Dr. Himanshu Bhatia had to set out the underwriting guidelines for such a product. The group agreed that the
underwriting approach had to be standardized across all the companies to ensure equity for all affected
customers and at the same time act as a progressive and inclusive underwriting community. The team looked at
the underwriting practices that are being followed in other parts of the world and discussed the practicality of
acquiring all the suggested diagnostic tests in various parts of the country since a large chunk of the insured and
insurable population is in the semi-rural and rural belt of India. The progression of the condition, expected
longevity and the possible disorders that may arise due to the said condition had to be given serious thought as
there are limited actuarial studies for Indian population in this regard.
The Actuarial Group comprising of Mr. Srinivasan & Ms. Meenakshi shared with the Committee members
some of the regional and state specific studies on Indian population, e.g. Pune Study Models. The working
group gave some indicative standardized rating models that insurers have to apply for such lives. The lack of
statistical data for the Indian HIV/AIDS population is a deterrent in terms of pricing since most studies related
to HIV/AIDS treatment costs etc. are from South Africa and Europe which cannot be directly applied to the
Indian context.
The Claims Group comprising of Ms. T. T. Mathew, Ms. Vanitha Subramanian & Dr. Dhiraj Goud had to
deliberate over the Claims handling for such lives. This working group concluded that if the initial screening at
the underwriting stage was being done as per the guidelines laid down by the Committee, the handling of Claims
should be simple, quick and hassle free in conformance to the existing Claims procedure. A common database
for PLHA Claims to be set up in addition to the central repository of all PLHA applications and policies issued
to be administered under the flagship of IRDA.
Experience sharing & Assumptions
On 22nd March 2012, a special meeting was held at Yogakshema where the Committee members sought
guidance from the Maharashtra State AIDS Society that has set up the Green Book initiative and has spread its
arms deep into the villages of the state. Dr. Dilip Kadam, Joint Director – Basic Services who is a subject matter
expert represented the Mumbai District AIDs Control Society giving an overview of the progress made by the
health ministry of the Central Government in early detection and efforts to improve the quality of life of affected
patients. He also confirmed that the cost of anti-retroviral therapy (ART) from the government / government
sponsored centres is free. He also spoke of the associated conditions and possible risks of such HIV/AIDS
patients. The Committee members invited Mr. Sarabjot Singh from Marsh Broking to get some insight on the
various products sold in the global market for HIV/AIDS affected persons.
On the 12th April, the Committee intensely deliberated and finalized the draft underwriting guidelines and the
eligibility criteria. Mr. Srinivasan provided the indicative extra mortality charges which were debated by the
Committee members. The reinsurers were in principle agreeable to the suggested flat extra mortality charges. It
was decided to finalize the report on April 26th, 2012. After an intensive full day's discussion, the document was
forwarded for legal vetting and the final report was presented to the Committee on May 2 nd, 2012.
Conclusion
a)
PLHA will be offered existing life insurance products subject to satisfying the recommended
Underwriting guidelines and extra mortality charges
b) The Committee recommends to proceed with existing products and not to formulate a niche
product for PLHA.
c) Riders / Health products may not be viable for PLHA for reasons mentioned earlier (ref:
Introduction Page 1).
d) Reinsurers will participate in risk sharing as mutually agreed between the reinsurer and the direct
insurer.
Please find enclosed the following annexure:
1.
2.
3.
4.
Underwriting guidelines for PLHA
Extra Mortality Charges recommendations for PLHA
Comments on the exposure draft PLHA
ART Registration Form
Annexure: 1
Underwriting guidelines for PLHA
a)
LIFE Insurance plan only.
b) No niche Product will be developed. Base pricing of the insurance company can vary (as with
current products), but the extra mortality charges and underwriting guidelines for PLHA
across the companies will remain the same.
c)
Product Guidelines:
 Plan: Life Insurance Plans including Term Plans (Satisfying below product criteria).

Minimum Entry: 25 years

Maximum Entry: 45 Years

Minimum term: 5 years

Maximum term: 15 years subject to below outlined criteria

Maximum maturity age: 55 years

Maximum Sum assured (from all companies)
o Regular Premium: INR 1,000,000
o Single Premium : INR 2,000,000
d) Underwriting Guidelines:
 Life insured should be EITHER registered with government approved ART nodal agency for a
consecutive period of preceding 2 years from the date of application OR if the treatment is
taken from a Private hospital, detailed records of treatment and medical history for a
consecutive period of preceding 2 yrs to be sent directly by the treating hospital/physician to
the insurance company CMO.

Duration of Cover:
o If on ART Treatment (copy of treatment record to be submitted (attached below)):
 < 2 yrs on ART: defer risk till end of Year 2 of treatment
 Treatment into Year 3 to end of Year 5: Maximum term 15 years
 Treatment into Year 6 to end of Year 8: Maximum term 10 years
 Treatment into Year 9 to end of Year 10: Maximum term 5 years
No major systemic (e.g. renal/hepatic/cardiac) side effects of treatment should be
present
o If no ART treatment is required, and the applicant is asymptomatic for:

< 1 year since date of diagnosis of HIV/AIDS: defer risk
 > 1 year since diagnosis of HIV/AIDS: maximum term 10 years subject to
CD4 count/viral load over 1 year period

HIV/AIDS Caused due to Intravenous Drug Use: Decline

HIV/AIDS Stages to be covered:
o Offer cover up to Stage II only (as defined by WHO in the current guidelines)
Primary HIV Infection

Asymptomatic

Acute retroviral syndrome
Clinical Stage 1

Asymptomatic

Persistent generalized lymphadenopathy
Clinical Stage 2
1.
2.
3.
4.
5.
6.
7.
8.
Moderate unexplained weight loss (<10% of presumed or measured body weight)
Recurrent respiratory infections (sinusitis, tonsillitis, otitis media, and pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulceration
Papular pruritic eruptions
Seborrheic dermatitis
Fungal nail infections

All Reports are to be provided for minimum period of 2 consecutive preceding years from the
application date. Reports must include:
o A Medical Questionnaire to be completed by the Treating Physician if treatment is
taken from a Private hospital or "Green book" to be provided if treatment is taken
from an ART centre.
o All the reports must include following details:
 Date of diagnosis of HIV/AIDS
 Details of Drug Therapy (Drugs used, dosage prescribed & duration
suggested / administered)
 6 monthly CD4 & Viral Load count as a reflection of quality of care
 Details of any past / current complications or a negative confirmation
 Any co-morbidities associated or a negative confirmation

CD4 counts and Viral Load:
o 6 monthly CD4 counts of historical records post 6 months of starting ART should
always be above 350 cells per micro liter
o Latest CD4 count (not older than last 3 months from the date of application)
submitted to the Insurance Company should be above 350 cells per micro liter.
o Viral Load (not older than 6 months from the date of application) should be nearly
undetectable (< 50 copies/ml)
o Costs for latest CD4 count and Viral Load to be borne by client
o CD4 and Viral Load count should be done from fixed and approved empanelled
centers only

o
No other co-morbidities
Hepatitis B and Hepatitis C should be –ve in the medicals done for the insurance cover and no
other co-morbidities. (maximum EMR upto +50 accepted for non related risk factors like
LFT/CVS risk factors)
o No drug abuse should be present
o No history of DM, Heart Disease, Cancer, Stroke, TB and other respiratory disorders,
Organ failure, etc, should be present

All Cases applied for; need to be monitored by central data base like CIBIL
o All companies to share data of such cases with CIBIL / similar agency
o
o
For periodical portfolio analysis, data should be shared by all companies with the
Life Council
The data formats, analysis formats and frequency for such portfolio analysis will be
decided subsequently

Revival:
o Revival guidelines would be based on entry level guidelines and would be subject to
individual company’s product specific revival guidelines

Claims:
o As per existing Claims procedures of individual company.

Riders for those who are HIV negative at inception:
o Existing Products: HIV Exclusion to remain as the companies cannot change the
pricing at this stage
o New Products: There is an option to remove HIV from the list of exclusions by
adjusting the premium at new product development stage. However, this would
require HIV testing for all applicants at underwriting stage (this was not considered
to be a practical or viable option by the committee) and will also result in increase in
premiums for all applicants. It is therefore recommended that HIV exclusion is
maintained even in new products.
o New Riders filed in future may include Occupationally acquired HIV/AIDS &
HIV/AIDS due to Blood transfusion under CI products
Annexure: 2
Extra Mortality Charges recommendations for PLHA – Regular Premium
Please Note:

The recommendations are for Regular Premium only. Single Premium Extra Mortality
Charges are to be derived from the recommendations for Regular Premium below.

All ages refer to age attained
Rating groups are based upon HAART (Highly Active ART) year and are split between year attained of treatment
from year 3 to end of year 5, year 6 to end of year 8 and year 9 to end of 10 years.
Separate ratings are provided for those who do not require treatment and are asymptomatic.
1. PLHA on ART
A. HAART year 3-5; CD4 > 350 cells per micro liter
Fixed loading (per Mille)
Age at issue
25-29
30-34
35-39
40-44
45
Term
5
4.0
6.0
6.0
6.0
6.0
10
4.0
6.0
6.0
6.0
6.0
15
4.0
6.0
6.0
6.0
6.0
B. HAART year 6-8; CD4 > 350 cells per micro liter
Fixed loading (per Mille)
Age at issue
25-29
30-34
35-39
40-44
45
Term
5
5.0
5.0
6.0
7.0
7.0
10
5.0
5.0
7.0
8.0
9.0
C. HAART year 9-10; CD4 > 350 cells per
micro liter
Fixed loading (per Mille)
Age at issue
25-29
30-34
35-39
40-44
45
Term
5
6.0
6.0
8.0
8.0
10.0
2. PLHA who do not require ART and are asymptomatic; CD4 > 350 cells per micro liter
Fixed loading (per Mille)
Term
Age at
issue
25-29
30-34
35-39
40-44
45
5
5.0
5.0
6.0
7.0
7.0
10
5.0
5.0
7.0
8.0
9.0
Annexure: 3
Comments on the exposure draft on People Living with HIV/AIDS (PLHA)
Sr.
No.
1
Guideline
No.
1.
Regulatory Provision
Recommendations
All Life Insurers and General Insurers shall
put in place an underwriting policy on
health insurance coverage for persons
suffering from HIV
The committee has formulated underwriting
and extra mortality charges guidelines for
life insurance products.
However the Committee is unable to
suggest a viable health insurance product for
PLHA
2.
2.
The policy shall indicate the eligibility
criteria at the outset to consider proposal for
Health Insurance Cover for PLHA in
accordance with such underwriting policy.
The Underwriting policies amongst others
shall specifically address :
Persons who are not yet showing AIDs
symptoms but are in stage 1 or 2 of HIV
infection;
2.1.
Compliance with the treatment protocols of
the medication and in according to a very
strict timetable;
2.2
The Committee Report has recommended
detailed underwriting criteria and guidelines
for life insurance products.
CD4 count in excess of 350;
CD4% greater than 23%;
2.3
To be p24 antigenemia negative etc.
3
3.0
The health insurance cover for PLHA shall
not be denied if the eligibility criteria as per
the underwriting policy are satisfied.
4
4.0
The underwriting policy shall
provide clear guidelines on PLHA:
all the possible risks that can be considered
for underwriting and all those risks which
4.1
The Committee Report includes criteria for
life insurance cover for PLHA, which if
satisfied, life insurance coverage will not be
denied.
The underwriting guidelines included in the
Committee report provide clear guidelines
on PLHA in conjunction with the existing
medical and financial guidelines of the
Sr.
No.
Guideline
No.
Regulatory Provision
Recommendations
would be denied.
insurer as applicable.
3
5.0
The underwriting policy shall also clearly
indicate the specific loadings for PLHA
with reference to the different stages of the
disease, to provide the health insurance
cover. The specific loadings shall be over
and above the actual premium of a product.
These loadings shall be as filed and
approved by the Authority under File and
Use procedure within a period of three
months from the date of this circular.
Acceptance of risk and specific flat extramortality charges by CD4 count, duration of
treatment has been recommended for life
insurance coverage
5
6.0
The insurer shall also design suitable
proposal form to capture necessary
information to underwrite the proposal in
accordance with the underwriting policy.
6
7.0
With respect to persons who are HIV
negative at outset, and subsequently found
to be HIV positive, the insurers shall not
reject/deny:
No change in the proposal form is required,
however a HIV questionnaire (to be
formulated) to be completed by the
applicant and in some cases by the treating
physician
For those who are HIV negative at inception
and subsequently found to be HIV positive
7.1
any claim, on such grounds;
-Existing guidelines governing
Claims shall be applicable.
7.2
7.
8.0
renewal, however, suitable loading may
be charged, which is filed and approved
under the File and Use Procedure.
Products covering HIV/AIDS for persons
who are HIV negative at inception may
design products such as:
HIV/AIDS as a one of the Critical Illness;
Death
-Claims will not be repudiated for people
who have acquired AIDS/HIV after the
policy issuance and/or revival.
-Revival guidelines will be applicable
immediately after the grace period based on
proposed entry level PLHA underwriting
criteria.
For HIV negative at inception, New Riders
filed in future may include
occupationally acquired HIV & HIV due to
Blood transfusion under CI products
Sr.
No.
Guideline
No.
8.1
8.2
8.3
Regulatory Provision
Covering HIV/AIDs by providing a lump
sum on becoming HIV positive, as a rider
Lump sum amount offered to be paid as
annuity for life in the event of the insured
becoming HIV positive during the term of
the contract;
AIDS Deaths covered as an insured event
under health insurance cover;
Covering HIV/AIDS under group schemes
catering to various segments of population.
Recommendations
The Committee has suggested to currently
start off with individual life insurance cover.
After gaining sufficient experience in due
course, the other product designs may be
considered.
Annexure 4 – ART Registration Form