1. Health Insurance

2. HISTORY OF HEALTH INSURANCE
Hamurabi Managed Care Circa 1700 BC
 Health Insurance rules carved on a
stone Codex Hammurabi
 Rates set for general surgery
 Fees set on ability to pay
 Owners to pay for slaves
 Consumers & Patient’s rights to be
advertised

3. Modern Health Insurance
 Blue Shield & Blue Cross (1st half 20th century )
 Medicare (1960)
 Medicaid (1960)
 NHS (1946)
 Prime Minister Health Ins Scheme

4. Jubilee life , 1570
Adamjee , 1272
Allianz EFU , 994
Jubilee General, 801
IGI Life , 411
AsiaCare, 340
Alfalah, 286
Others, 806
Gross Premium (Million)

5. Jubilee life
24%
Adamjee
20%
Allianz EFU
15%
Jubilee General
12%
IGI Life
6%
AsiaCare
5%
Alfalah
5%
Others
13%
Market size in (%)

6. Jubilee life Adamjee Allianz EFU Jubilee General IGI Life AsiaCare Alfalah IGI General
87%
104%
94%
114%
102%
122%
92%
131%
75%
90%
74%
83%
81% 80% 79%
106%
Loss Ratio of Top 8 Companies
With Admin Exp Without Admin Exp

7. Heath Insurance Underwriting
• Hospitalization Premium
• Maternity
• OPD

8. H Hospitalization Premium
On average per year 10 % of Insured shall be
hospitalized
10% of the insured Average hospital Bill

9. Premium
0
2000
4000
6000
8000
10000
12000
14000
16000
0-17
18-25
26-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
Rise of premium with age
Premium

10. Age Premium % Loading or discount
0 - 17 1287 44 %
18 - 25 1543 _ 33 %
26 - 29 1794 _ 22 %
30 - 34 2048 _ 11 %
35 - 39 2297
40 - 44 2608 + 14 %
45 - 49 3054 + 33 %
50 - 59 4758 + 106 %
60 - 64 5956 + 160 %
65 - 69 7146 + 210 %
70 - 74 14294 + 520 %

11. Maternity Premium
 On average 30% of Total Fertile ( below 45)
shall avail maternity benefit
 30 % of fertile female Average Maternity
bill

12. OPD Premium
70 -- 90 % of the OPD Limit

13. Coverage
• Inpatient Hospitalization / Surgery
• Maternity
• D & C / Missed abortion
• Daycare procedures under local anesthesia
• Cataract
• Biopsy
• MRI/ CT Scan
• Endoscopy
• Angioplasty / CABG
• Chemotherapy
• ICU

14. Exclusions
• Dental
• Cosmetic
• Emergency / short stay
• Hormonal therapy
• External devices / Implants
• Experimental treatment
• Out of country planned treatment
• Self inflicted / suicide
• Sports injury
• Psychiatric Treatment

15. Percentage of medical cost shared by the
insured patient as agreed upon at the time of
policy inception, with or without a cap limit
e.g 10% copayment means for a medical claim
of Rs 10,000 insured shall pay Rs 1000 whilst
insurance company shall pay Rs 9000

16. Deductible
A fixed amount ( regardless of cost of medical
claim ) to be paid by the insured patient at the
time of medical claim, as agreed at the time of
policy inception
e.g Rs 2000 deductible means for a medical
claim of Rs 20,000 insured shall pay Rs 2000
whilst insurance company shall pay Rs 18,000

17. Pre existing conditions
Any disease ,condition or symptom for which
the insured sought treatment , consultation or
was aware of , before the inception of policy

18. Congenital disease
Any disease or condition present at the time of
birth of new born

19. Panel Hospital Network

20. Reimbursement
• Policy of Reasonable & customary
reimbursement
• REASONABLY AND CUSTOMARY (Bench Marking )
• Hospitalization expenses for a particular surgical
procedure / conservative management by a panel
hospital of similar standard in the vicinity

22. Case Management

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Health Insurance professionals