The document discusses health insurance and medical benefits for employees in India. It notes that while not legally required, many employers provide some level of healthcare for workers. Group medical insurance is presented as a comprehensive solution that outsources this non-core activity while providing benefits to both employers and employees. The future of health insurance in India is promising as awareness and demand are growing, though more widespread coverage is still needed as most people currently pay medical costs out-of-pocket.

2. 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.

3. 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 .

4. 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

5. 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

6. Stake holders
Employees
Employer
Govt. Regulations / Regulators
Intermediaries (Agents/ Brokers)
Insurance Companies (Reinsurance Co.)
TPAs / Internal Claim settlement
 Medical Service Providers
IT network

7. 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.

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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.

15. 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.

16. 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.

17. 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