Current Regulatory Requirement
Though not mandatory by law but a progressive employer
is expected to provide health facilities to their employees.
There are some mandatory provisions such as workmen
compensation / ESI but they have limited coverage.
In some of the countries providing healthcare for employees is a must
In such cases , maternity , dental and optical treatment
and the expenses thereon are normally not given.
There are many ways of extending medical facilities to the
Medical insurance is one such step.
Systems in use – Health Management
Depending up on the size / decision of management ,we
find different solutions of health management
The Small and Medium size organizations have the
system of reimbursement of the actual expenses.
Some of them even have the system of medical allowance
on monthly basis.
Few big organizations have their own medical facility set
up and in a way it is self managed
Group Medical insurance is getting accepted as a
wholesome solution .
Need for health insurance
For Employers it gives an opportunity to outsource this
It provides a cover against unexpected health related
expenses – helps in financial planning & cost saving.
For employees – it provides a wider range of medical
Depending up on the coverage – specialized treatment
abroad / special care can be arranged.
Control on leakages – Managed by professionals
Provides far wide options for the employees –
Present & Future Ahead
At present < 15% population in india has some sort of health
insurance . Out of pocket health expense is around 86%
No wonder - Health Insurance is the fasted growing segment in
Premium income has gone up from Rs. 2221 Cr in 2005-06 to Rs.
13975 Cr. In 2012-13 – CAGR 30%
Commission pay out was Rs. 876 Cr. In 2012-13 – means bulk of
the business is thru direct channel
Incurred Claim ration 96.43 - a bit improvement
Future is promising as there is a growing concern for the health
care and empoloyee are becoming more & more demanding.
Govt. too is thinking of providing some universal health care on
the lines of RSBY
Insurance vs. Cost Management
Unlike other forms of insurance Medical
insurance is more of cost management nature
The frequency of claim and related costs are more
or less similar and consistent over the period.
The pricing is more dependent on the past claims
history than the technical parameters.
The success of Medical Schemes depends much
on the approach of the Management and the co-
ordination of all involved.
There is a very cut-throat competition in market
Group Medical is a big bargaining point for clients to
place other lines of business
Companies are looking for the lowest possible rates
irrespective of their claims experience
Normally claim experiences are not favourable
This has resulted into frequent shifting of the
portfolio from one Company to another.
Essentials for success
Understanding of the basic needs of the customer
Simple product features with least deviation from the
universal and standard norms.
Having least possible feature and sub-limits.
Regular communication between all concerned
Limiting the number of Service Outlets.
Emphasis on quality delivery which need not be the
Continuous feedback / corrective measures
Important Product Features
Annual Max. Limit (Flexibility)
Provision of Pre-Existing Condition
Wide option of Geographical coverage (Abroad/USA )
Tie –up in other counties
In-patient / Out-patient
Discount for limiting outpatient limit as a % of AML
Wide & attractive options of deductible
Improved Group / favorable loss ratio discount
Gate-keeper / Preventive schemes
Infertility, In-vitro fertilization, Surrogacy
Psychiatric, mental retardation, Alzheimer and similar
Congenital disease, malformations or malfunctions
Oncology, Kidney dialysis, Hormone replacement, Bone
densitometory, Tumours, Development problems, Physical
Expenses for homecare, sanatoriums, long term care
facilities and similar institutions
Epidemics declared by Government/WHO
Regular/Preventive health check ups
Expenses for work related injuries/accident as these are covered
under WC policy – mandatory in Oman
Elective Treatment received outside area of cover
Health Spas/Nature Cure Clinics etc
Plastic and cosmetic surgery and beauty related skin treatment
Vitamins and supplements, medicated shampoos, mouth wash
Any treatment which only offers temporary relief of symptoms
rather than dealing with the underlying medical conditions
Treatment following drugs or substance abuse
Injuries from playing professional sport or from any dangerous
sport and activity
The enrolled members are provided individual
medical card & that takes care of all expenses at
network clinics with in the permissible limits.
Almost 90-95% of the billing is thru cards only.
For non-network clinics and the facilities having sub-
limits , the customer need to pay the bill him/herself
to the service provider and take reimbursement
The Medical Card contains the following
information & provides the bearer medical
services within the scope of the Medical Policy.
Name of Member
Date of Birth , Unique identity no
Name of the company
Validity period of the card
Broad Coverage details , restrictions
Deductible , if any and
Hotline / Contact no for assistance and
clarifications in case of difficulties.
Reimbursement of Cash Claims
Medical expenses incurred at non designated Medical Service
Providers are covered subject to customary costs of network hospital
or as per the policy provisions.
Claims papers are to be submitted to the insurance company on
The claim must be supported by
# Cash Claim Form duly filled in and signed by the Doctor
# Original Bills – clear break up of amounts in case of multi
# Original diagnostic reports
The bills are scrutinized and payment is made to the Client. The
average turn around time would be around 15 days.
Pre - Approvals
All non emergency cases that need
hospitalization for medical or surgical treatment.
Chronic medications for more than 1 month
Medical tests etc. beyond a normal /prescribed
Endoscopies, EEG, ECG
MRI Scans and CT Scans
Facilities having sub-limits
However in case of emergency hospitalization no
such approval is required. Intimation with in 24
Claim Process – essentials
Tie up reputed TPA having high volume of business /
Network availability in promised locations
24*7 customer helpline by TPAs
Availability of Ins. Co official for TPA support
Claim processing by experienced professionals
Possibility of Expert / Second opinion
Cost reduction – better discount from providers
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