Pioneering a Safer Tomorrow
Welcome to the maiden issue of InCHES Risk Insights.
This launch marks a double milestone for us. As we celebrate 26 years of empowering the insurance ecosystem, we are proud to introduce this bi-monthly window into the future of risk management.
When I founded InCHES, my vision was simple yet disruptive: to bridge the gap between complex medical realities and insurance intelligence. Over the last two and a half decades, that vision has matured into an institutional legacy. We have evolved from a pioneering concept into India's trusted authority on risk mitigation, consistently delivering fit-for-purpose solutions across life, health, and accident ecosystems.
However, legacy is not just about looking back; it is about steering forward. The modern insurance landscape faces unprecedented complexity, demanding a shift from reactive processing to proactive risk engineering. This newsletter is born out of that imperative. It is designed to share our deep domain expertise, proprietary insights and specialised risk mitigation frameworks directly with you.
As we embark on our next chapter, InCHES remains steadfast in its commitment to collaborative innovation and scientific rigour. Thank you for your enduring trust.
Together, let us redefine the benchmarks of risk mitigation.
An opportunity to ask a question directly to Team InCHES. Every issue we address a real question submitted by practitioners from the field — answered by our expert panel.
Read Full Interview ↗
Three case studies revealing the intersection of clinical judgement, underwriting scrutiny and audit intelligence. Each article presents a real-world scenario with key takeaways for practitioners.
Product: Pure Term Plan | Sum Assured: ₹1 Crore | Life Assured: Age 54, Business Profile
A 54-year-old male applicant for a ₹1 Crore pure term plan was issued at standard rate — despite significant red flags that should have triggered a decline.
| Area | Observation | Action Taken | Correct Action |
|---|---|---|---|
| Photo Verification | LA appears significantly older than 54 in photo | Not flagged | Request alternate age proof |
| Age Discrepancy | Son (nominee) is 40 — only 14-year gap with LA | Not flagged | Investigate; highly suspicious |
| Financial Underwriting | P&L net profit ≠ income declared in ITRs (AY24/25: ₹4.5L, AY25/26: ₹6L) | Not verified | Reconcile financials; seek explanation |
| Final Decision | Issued at standard, full cover | Issued | DECLINE |
Applicant: 45-year-old male, non-smoker | BMI: 27 | No diabetes or hypertension
Initial labs showed elevated Total Cholesterol (260 mg/dL), high LDL-C (170 mg/dL), critically low HDL-C (19 mg/dL) and borderline high Triglycerides (220 mg/dL). Case was postponed for 6 months or until lipids normalised.
One month later the applicant reapplied with a dramatically improved profile: Total Cholesterol 190, LDL-C 121, HDL-C 48, Triglycerides 164. He stated he had started Statin-Fenofibrate combination therapy.
Patient: 24-year-old male | Admission: 3.1.24–6.1.24 | Procedure: ORIF of left radius shaft fracture
A patient admitted with a displaced left radius shaft fracture underwent ORIF. However, operative records — including anaesthetist notes, OT report and nursing notes — consistently stated the procedure was performed under spinal anaesthesia.
Spinal anaesthesia blocks nerve transmission below the injection level (typically T4–L5) and is conventionally used for lower abdomen, pelvis and lower limb surgeries. Its use for isolated forearm surgery is anatomically and clinically implausible — it would not provide anaesthesia to the upper limb.
Strengthening Insurance Contracts Through Compliance, Clinical Reasoning and Judicial Awareness. Health insurance contracts in India are increasingly being interpreted through a wider lens — medical necessity, policyholder fairness and regulatory compliance are no longer separate considerations.
The Court held that an insurer cannot reject a genuine reimbursement claim merely because of delayed filing. If the hospitalisation, treatment, expenses and medical records are genuine, delay alone may not be sufficient ground for repudiation. Insurers must demonstrate that the delay caused material prejudice to their ability to verify the claim.
Recent regulatory directions focus on: continuity of coverage, renewal rights, portability, moratorium periods, faster claim processing, wider product accessibility and clearer policyholder communication. Compliance now extends to how exclusions are applied, how medical necessity is evaluated and how decisions are documented.
As regulatory scrutiny and judicial intervention increase, insurers must strengthen the medical intelligence layer within claims management. Protocol-based reviews, evidence-backed claim notes and clinically reasoned decisions will help reduce disputes, improve compliance and build greater trust in health insurance contracts. The strongest claims process is one where medical experts, legal teams and claims teams work together — not in silos.
In life and health insurance, claim patterns often reveal risk signals much before they become visible in portfolio-level profitability/ loss. One such signal that deserves closer attention is the rising share of dubious critical illness claims linked to first heart attack.
Traditionally, cardiovascular claims were viewed as concentrated among older policyholders or those with visible lifestyle risks and although terminal coronary events are occurring in younger age patients with multiple co-morbidities i.e. hypertension, diabetes mellitus, dyslipidaemia, obesity or smoker. However, recent claim observations across the industry suggest a gradual shift: first-time cardiac events are increasingly appearing in late 20s/ early 30s without a single risk factor and with critical illness policies of up to 50 lakhs to 1 crore.
At InCHES, this trend is important not merely a claims statistic, but as a broader underwriting and portfolio risk indicator. Based on internal medical review work across life and health insurance claims, InCHES has observed that fraudulent first heart attack-related critical illness claims accounted for 45%+ of reviewed critical illness cases during last two Financial Years.
To identify these dubious claims, medical adjudication must remain medically precise – scrutinizing all available ECGs, collating ECG tracings with Echo findings and Coronary Angiography findings helps identify such claims.
For insurers, the key message is clear: the first heart attack is no longer only a claims event. It is a portfolio signal.
As critical illness portfolios mature, so will fraudulent claims – largely because there is no underwriting.
At InCHES, our focus is to help insurers interpret these medical signals with greater precision. Rising first heart attack claims should not only be tracked as numbers on a dashboard. They should be understood as early warnings for claims vigilance.
Continuous upskilling is the bedrock of a resilient insurance workforce. InCHES Academy brings structured learning pathways for underwriting, claims, compliance and leadership — aligned with CII, IRDAI and international standards.
