Medical insurance concept


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Basics of health insurance

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Medical insurance concept

  1. 1. 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 employees. Medical insurance is one such step.
  2. 2. 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 .
  3. 3. Need for health insurance For Employers it gives an opportunity to outsource this non-core activity. It provides a cover against unexpected health related expenses – helps in financial planning & cost saving. For employees – it provides a wider range of medical facilities. 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 – Geographical sense
  4. 4. 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 insurance business. 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
  5. 5. Stake holders Employees Employer Govt. Regulations / Regulators Intermediaries (Agents/ Brokers) Insurance Companies (Reinsurance Co.) TPAs / Internal Claim settlement  Medical Service Providers IT network
  6. 6. 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.
  7. 7. Market Realities 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.
  8. 8. 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 costliest. Optimum pricing Continuous feedback / corrective measures
  9. 9. Important Product Features Annual Max. Limit (Flexibility) Sub-limits 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
  10. 10. Standard Exclusions…. Aids/HIV Infertility, In-vitro fertilization, Surrogacy Psychiatric, mental retardation, Alzheimer and similar degenerative diseases Congenital disease, malformations or malfunctions Oncology, Kidney dialysis, Hormone replacement, Bone densitometory, Tumours, Development problems, Physical aids Organ donation Expenses for homecare, sanatoriums, long term care facilities and similar institutions Epidemics declared by Government/WHO
  11. 11. Standard Exclusions 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
  12. 12. Claim Settlement 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 subsequently.
  13. 13. Medical Cards 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.
  14. 14. 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 monthly basis. The claim must be supported by # Cash Claim Form duly filled in and signed by the Doctor # Prescriptions # Original Bills – clear break up of amounts in case of multi prescriptions, # Original diagnostic reports The bills are scrutinized and payment is made to the Client. The average turn around time would be around 15 days.
  15. 15. 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 limit 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 hours.
  16. 16. Claim Process – essentials Tie up reputed TPA having high volume of business / IT infrastructure 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