Health interview questions for insurance roles
89 questions from core to advanced: concepts, calculations, whiteboard diagrams, SQL, scenarios and behavioural. Answer out loud first, then reveal the model answer and example. Mark each one practised when you can answer it without looking.
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Individual vs family floater: when would you recommend each?
- Floater: one shared SI, cheaper for young families.
- Individual: each member has own SI; better when ages differ widely or a member has PED.
- Floater premium is driven by the eldest member.
What factors drive a health premium?
- Age, sum insured, zone, medical history, lifestyle, BMI.
- Deductible and co-pay reduce it; multi-year tenure gets a discount.
- Add-ons (room rent waiver, maternity, CI) increase it.
STP vs NSTP in health. What can the underwriter decide?
- STP: under 45, SI up to ₹10 lakh, no PED, BMI in range.
- NSTP: pre-policy medical check-up and underwriter review.
- Decisions: accept, accept with loading, special conditions, counter offer, reject.
What are the current IRDAI timelines for cashless claims?
- Pre-authorisation decided within 1 hour.
- Final discharge authorisation within 3 hours of the request.
- System need: timers, auto-escalation, TAT reporting.
What is the moratorium period and why was it cut to 5 years?
- After 5 continuous years, claims cannot be contested for non-disclosure except fraud (was 8).
- Protects long-standing customers; insurers must underwrite properly at entry.
- BA impact: continuous-coverage tracking, including ported years.
Explain waiting periods.
- Initial 30 days (accidents excluded).
- Specific illnesses (cataract, hernia, joint replacement) usually 2 years, capped at 3.
- PED at most 3 years (was 4).
- Maternity often 2–4 years. Portability carries served waiting periods.
What is NHCX and how would you approach an integration?
- National Health Claims Exchange under ABDM; FHIR-based eligibility, pre-auth, claim and payment messages.
- Advised by IRDAI, not legally mandated.
- Approach: map internal claim fields to FHIR profiles, handle async status, reconcile with TPA systems, test with sandbox.
What changed for senior citizens and entry age?
- No upper entry-age limit for buying health insurance.
- Senior renewal increases capped at 10% a year without IRDAI approval.
- Insurers must offer products for seniors.
Why are health claims rejected, and how would you reduce wrongful rejections?
- Waiting period, non-disclosure, exclusions, documentation gaps, room-rent proportionate deduction.
- Fixes: clear CIS at sale, rule transparency in claim decisions, checklist-driven document upload, second-level review before rejection.
A customer ported after 2 years on ₹5 lakh to a ₹15 lakh policy. In year 2 of the new policy they claim ₹8 lakh for a declared pre-existing disease (3-year wait). What is paid?
- Waiting periods served carry over only up to the previous sum insured.
- On the first ₹5 lakh: 2 + 2 = 4 years served, so the PED wait is over.
- On the extra ₹10 lakh: only 2 years served, so the PED is still excluded.
- Pay ₹5 lakh; the remaining ₹3 lakh is not covered this year.
ExampleNext year (year 3 on the new policy) the extra ₹10 lakh has served 3 years, so the full ₹8 lakh would be payable.The business wants a 25% renewal increase for senior citizens. What do you say?
- Increases above 10% a year for senior citizens need IRDAI approval first.
- Ask for the claims data that justifies it and the filing plan.
- Plan customer communication, portability options and the system change for renewal notices.
- Model the impact on retention and complaints.