Team Member – Market Conduct Full Time

Business

Health Insurance

Unit

Aditya Birla Health Insurance Company Ltd

Location

North Zone

Poornata Position Number of the job

Reports to: Poornata Position Number

Amit Pokar (HI436027)

Poornata Position Title of the job

Senior Manager

Reports to: Poornata Position Title

Lead – Market Conduct

Function

Legal, Risk & Compliance, Sec

Reports to: Function

Legal, Risk & Compliance, Sec

Department

Legal, Risk & Compliance, Sec

Reports to: Department

Legal, Risk & Compliance, Sec

Designation of the Employee

RLC – 10

Senior Manager- Market Conduct

Designation of the Manager

RLC-8

Lead – Market Conduct

Date of writing/updation of JD

Feb 24, 2026

• Job Purpose: Write the purpose for which the job exists (in 2-3 lines)

The purpose of the role is to carry out overall activity of Prevention, Detection and Monitoring of sales and business practices and strengthen the processes & controls concerning Market Conduct. The role is also required to create awareness on Market Conduct good practices, ethics & compliance, as well as on the company code of conduct/policies. Drive the culture of Zero Tolerance to fraud and misconduct in the Zone.

• Dimensions: Mention quantitative or qualitative parameters that are relevant for the job and provide a better understanding of the scope and scale of the job.

Case investigation received from various stakeholder

~200 cases

Proactive Analysis & investigation

7000-8000

Anti-Fraud Awareness Program

All employees of North Zone (All channel)

Branch Visits

12-15 High Risk Branches

Meeting with Sales

Regular meeting with ZSM/RSM

Mystery Shopping (DC & Hospital)

80-100

Fraud Awareness Week

He will drive various engagement activities for creating awareness in the zone.

• Job Context & Major Challenges: Write the specific aspects of the job that provide a challenge (internal and external) to the jobholder in the context of the Business/Unit/Function/Department/Section

About The Health Insurance Industry –

While the current market sees more than 15 non-life players in the private space and 5 exclusive private players in the health insurance space trying to capture a sizable market share, the nationalized service provider (6) remains a strong competitor. In addition to this the business dynamics are such that the overall market on an annual basis which is to the tune of roughly 10,000 Crs sees close to 85 % of the business renewing with the existing service provider itself. This narrows down the opportunity of the fresh business actually being seriously fought in the market to approximately 1500 odd Crs. With the SME and the start-ups being the driving force of Indian economy, the opportunity to cater to these segments is immense and is increasing manifold year on year. The challenge here therefore remains as to how we capture a larger share of the opportunity by developing specific solutions to cater each segment of the business. Also by creating an inexpensive and standardized solution to increase the reach into the pockets of channel partners across the country to harness on their captive business and explore new opportunities with them.

Market Opportunities – With the advent of medical advancements, lifestyle changes, change in Indian socio-economic scenario and Indian healthcare space, and the insurers are facing challenges to cater to the needs of this diverse clientele. Increasingly Indian customers have started considering health insurance partners as extensions of health advisers. In this scenario it becomes extremely important to understand their psyche and then provide tailored solutions with wellness benefits which would help them meet their end objectives and bring in profitable revenue source for the company.

About The Aditya Birla Health Insurance –

Aditya Birla Health Insurance Co. Limited (ABHICL) was incorporated in 2015 as a 51:49 joint venture between Aditya Birla Capital Limited (ABCL) and MMI Strategic Investments (Pty) Ltd. ABHICL commenced its operations in October 2016.

ABHICL has entered the competitive health insurance market with an aim to expand the category to wider customer segments, beyond the ones that health insurance companies traditionally have marketed to. As the 6 th entrant in a category with well-established players, ABHICL is creating differentiation and equity for itself though the unique business proposition of “Health Insurance for All”, a one of a kind proposition in India at the moment. This is a philosophy that is being built through every single consumer touch point and into every single backend process of the company to ensure a customer’s experience of our proposition is continuous and seamless.

ABHI’s unique offering to market includes proposition includes –

• A Comprehensive Incentivized Wellness Program that will attract the young and health conscious and will motivate, guide and reward them to stay healthy
• A Chronic Care Management Program to cater to the unmet needs of a growing Indian population of those suffering from chronic lifestyle conditions like Diabetes, Asthma, High Cholesterol and Hypertension from Day 1
• ABHICL serves as an enabler and influencer of health and healthcare choices that customers make, in addition to being a payer of healthcare expenses. Thus, ABHICL would act like a much needed catalyst to grow the prevalent health insurance landscape in India through product innovations and a wider choice of consumer relevant products.
• ABHICL’s vision has always been digital. The company has been successful in adopting paper-less approach right from identifying to on-boarding to delivering seamless experience of its customers & employees.

Internal

Challenges:

• Turnaround times in delivery of investigations and closure of cases.

External

• Quality of investigation report and evidences provided by vendors
• Key Result Areas: Write the key results expected from the job and the supporting actions for each of these key result areas (For a majority of jobs typically there could be 4- 7 key result areas)

Key Result Areas

Supporting Actions

Training and Awareness .

• Carry out Anti-Fraud Awareness Training Program for all employees of North Zone (incl. non-sales) on a regular basis. Create an environment of voluntary compliance in the zone.
• Carry out branch visits in the zone as well as conduct awareness trainings.
• Regular meeting with the BM/FLS/Advisor and educate them to create a culture of Zero Tolerance to fraud/Misconduct. Also focus on Reduction in Business Leakage & LR.
• Conduct Thematic sessions for branches where certain adverse trend / areas of improvement are observed.
• Active participation in conducting Fraud Awareness Week (Annually) and drive multiple agenda during the week on various subject for creating a culture of voluntary compliance. Educating the employee to stay vigilant & alert for protecting the organization from any fraud.
• Conduct yearly Compliance certification of all employees of North Zone on adherence to the code of conduct policy and other org. policies and processes.
• Conduct monthly governance meeting with North Zone Leadership Team (sales/non-sales) and discuss on critical cases, trend along with areas of improvement.

Prevention and Detection Activities

• Conduct detailed investigations of cases referred from various stakeholder such as Sales, Finance, New Business, Grievance, Underwriting, Claims, FWA, Branch/Central Operations, Persistency, Accounts, etc.
• Review and investigate all suspicious and fraud matters pertaining to the Zone.
• Monitoring of financial fraud such as employee and claims reimbursement transactions, Misappropriation of premium & churning of policy renewal premiums.
• Recovery of employee reimbursement & fraudulent claim amount paid to fraudster.
• Proactive and continuous control monitoring on business leakage parameters like cheque dishonour, non-deposition of cheque, EMI Bounce (Fibe/Finsall) freelook, loss ratio, financial frauds (employee reimbursement).
• While investigating any case, focus should be to unearth fraud/misconduct in the case, take corrective action in the form of disciplinary action and process improvement and/or save cost.
• Carry out Root Cause and Trend Analysis on business leakage areas, financial fraud, other misconduct and suggest appropriate action / process improvement to the Management.
• Reinvestigate high value claim cases.
• Investigate employee reimbursement fraud cases & recovery of amount; if any.
• Carry out recovery from employees/agents/partners/vendors on embezzlement of fraud cases
• Investigate whistle blower cases assigned.
• Assist Team Members / Supervisors / Legal / HR Team wherever necessary.
• Work on special project basis high risk areas and observation of financial fraud trend.
• Carry out benchmarking at regular intervals to ensure industry best practices are implemented in the organisation.
• Drive process improvement basis learnings from the investigation.
• All investigations to be completed as per the defined TAT.

Corrective Actions / Consequence Management

• Take actions on all proven cases against employees, advisors, distribution channels, provider network hospitals, Diagnostic centres, other intermediaries, vendors as per the malpractice matrix.
• Corrective actions to be taken both in the form of disciplinary actions and driving process improvement in the organisation.
• On all proven cases, prepare the show cause notice to be issued to the employees/agents (as applicable) and seek their responses.
• Take help of HR/DOPS Team wherever applicable.
• Post investigation is completed and SCN response received, need to prepare an Alert Report (Investigation Report) of the case along with disciplinary action recommendation (as per the action matrix) and share with reporting manager for his review.
• Drive Police Actions: Liaising with advocates and law enforcement authorities to file police complaints/FIRs in critical matters.

Reporting

• Regularly update the investigation tracker with complete case details
• Prepare monthly Sales Compliance meeting Deck.
• Assist in Quarterly Fraud Monitoring Report for submission to RMC/Board.
• Assist in Quarterly Whistleblower Report for submission to RMC/Board.
• Assist in Fraud Monitoring Report for submission to IRDAI (Annual)
• Job Purpose of Direct Reports: Describe the job purpose of the direct report/s to the job (in 2-3 lines for each report)

Nil

• Relationships: Describe the nature and purpose of most important contacts or relationship (except superior/team members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives

Relationship Type Frequency Nature

Internal

All Functions

Regular

To discuss matter pertaining to Market conduct and execution of activities pertaining to the function

External

Investigators & Vendors

Need Based

To plan and discuss investigations on case to case basis

• Organizational Relationships: Provide the structure for a level above and below the position for which this job description is written. Use position titles in the structured and indicate all the reports of the position.

SIGN-OFF: Provide the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record.

Job Holder

Reports to – Manager

Name

Signature (needed for the hard copy)