Health Insurance - Global Practices 1. 2 Health WHO definition of Health Health is a state of...

Health Insurance - Global Practices

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Health

WHO definition of Health Health is a state of complete physical, mental

and social well-being and not merely the absence of disease or infirmity.


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Impression

Insurance has never been a simple matter People make claims, become furious and sue the

company Unfortunately, without really understanding the

terms why insurance companies are resisting the coverage

Policy holders feel that the terms are negotiable, but not

But interpreted differently at various levels


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contd

o Wording of Terms vary with the insurers elsewhere in the countries and also insurers in India

o Health Insurance is more complex with huge terminologies

o In India peculiarly, the dissonance in Health Insurance is high compared to Life Insurance despite limited penetration.

o The dissonance is generated amongst customers, insurers, health care providers.


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contd

Many controversial or touchy issues on the definition of terms and their applicability have been raised in litigation before consumer courts and ombudsman

Shrinkage in selling the Health Insurance Products, by Agents, for various restrictions and market forces

The industry treats the personal lines more like a financial services commodity


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contd

In the wake of these trends, consumers have to do more of their own analysis.

To look to the terms and conditions that best meet their needs.

Disputes What is covered and what is not

covered?


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Need

Comparative provisions in Indian Health Insurance

Alternative Benefits to fit into the needs of the individuals and groups not appearing in Indian contracts

To introduce designing the products in clear terms

Self bearing for price advantage/focus on certain categories

Advantages of comparable products


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Terms referred-

“Subject to the terms, limitations, exceptions, provisions, conditions, memos, warranties, endorsements contained herein, or endorsed hereon,( herein after collectively referred to as the “Terms” of this Policy)

Study is restricted to Terms


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Variance of Wordings of Terms

Hospital /Nursing Home Hospitalization Pre admission authorization Domiciliary Hospitalization Any One Illness Pre-Hospitalization Expenses Post Hospitalization Expenses Medical Practitioner Qualified Nurse


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Contd-

Pre-existing illness/disease/injury Disease contracted during first 30 days from

the commencement of date of insurance cover

Excluded Treatments for the first 12 months of the operation of insurance cover

Maternity Benefit Naturopathy treatment


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Hospital

Any Institution in IndiaFor indoor care and treatment of

sickness, injuriesEither been registered as a Hospital or

Nursing Home with Local AuthoritiesUnder the supervision of a Registered

Qualified Medical Practitioner


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contd

Alternatively At least 15 in patient beds/ C Class 10 beds Fully equipped operation theatre of its own wherever

surgical operations are carried out Fully qualified Nursing Staff under its employment round the

clock Fully qualified Doctor(s) should be in-charge round the clock

Boundary– Shall not include a place of rest, a place for the aged, a place

for drug addicts or place of alcoholics, a hotel or a similar place


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Other definition (excerpts)

Exclusively to an institution providing treatment in the system of western medicine (allopathy)

Pursuant to the law for the care and treatment Maintain proper medical and patient records to the

standards as required under prevailing laws and regulations

Maintains appropriate quality for delivery of health care to the standards as required under the prevailing law


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Canada

A hospital duly authorized by Government Authorities which has twenty four hours a day nursing services by registered graduate nurses and organized facilities for diagnosis and major surgery and is not other than incidentally, a mental institution, a place for rest, a place for the aged, a place for drug addicts, a place for alcoholics or a nursing home


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Hospitalization

Minimum period of 24 hours, not applicable to specific treatments

Stay in the hospital exceeds 48 hours 24 hours hospitalization, covers 130 minor surgeries

needs less than 24 hours as “ Day Care Procedure” Canada

– Incurred by the insured person as an in patient for a period of at least 6 hours in any recognized hospital


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Pre-Admission Authorization

Absolutely necessary to avail Cashless facility. It is necessary that the insured obtains pre admission authorization 72 hours before admission and 48 hours in case of emergency

US– An authorization for hospital admission given by a

health care provider to a group member prior to their hospitalization. Failure to obtain a pre admission certificate in non-emergency situations reduces or eliminates the health care provider’s obligation to pay for service rendered


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Pre-Hospitalization & Post Hospitalization

Relevant medical expenses incurred during the period up to 30 days before hospitalization for diseases etc sustained

Covers relevant medical expenses incurred 60 days prior to and 90 days after hospitalization

Canada– Follow up treatment by the same physician

reimbursable up to a period of ninety calendar days immediately after the discharge from the hospital


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Any one illness

Relapse within 45 days from date of last consultation with the Hospital

After 45 days considered as a separate illness If two or more confinements are due to the same or

related injury/illness or to any complications arising there from, such confinement if each of them is not separated by more than 90 days from the paid or payable. This rule shall be observed to determine the limit of benefits (Same Confinement)

Recurrence Clause


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Medical Practitioner

A person who holds a degree/diploma of a recognized institution and is registered by Medical Council of respective State of India. The terms includes Physician, Specialist and Surgeon

Elsewhere– A physician, other than the Insured, Insured Person, or their

Close Relative, qualified by degree in Western Medicine who is legally licensed and duly qualified to practice medicine and surgery authorized in the geographical area of his/her practice


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Qualified Nurse

A person who holds a certificate of a recognized Nursing Council and who is employed on recommendations of the attending Medical Practitioner

Elsewhere– Graduate in Nursing


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Pre-Existing Condition

To exclude claims arising out of the conditions for which treatment, care or advice is obtained before the commencement of the policy period

Where treatment, care or advice was not taken and not known to the insured, are excluded


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contd

Pre-existing conditions means a medical condition which exists on the effective Date and during the past five years

– caused to receive medical advice or treatment or

– caused symptoms for which an ordinary prudent persons would seek medical advice or treatment


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contd

“Sickness for which the insured or to the best of his knowledge and belief, was aware existed (or) symptoms for which an ordinary prudent person would seek medical advice or treatment”

Difficult to establish medically and also legally controversial and debatable


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Maternity Exclusion

Treatment arising from or traceable to pregnancy, child birth, miscarriage, abortion or complications of any of these, including caesarian section, infertility

Pregnancy, miscarriage or child-birth including caesarean section, abortion, voluntary termination of pregnancy


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contd

US– Sickness – disease or illness which

manifests itself while this policy is in force. Sickness includes the complications of pregnancy.

– Normal pregnancy is not a sickness but complications of pregnancy are treated as sickness


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Treatment (Exclusion)

Naturopathy Other company

– Ayurvedic, homeopathy, unani, naturopathy, reflexology, acupuncture, acupressure, bone setting, herbalist treatment, hypnotism, rolfing, massage therapy, aroma therapy or any treatments other than allopathy/western medicine

Western Medicine (Allopathy)


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Specific limits

Room Rent Hospital Accommodation up to the costs of a

single bedded air conditioned room Just in hotel, private hospitals normally offer

different types of accommodation, known as banding, categorized as Band A to D


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Look Free Clause

Please read this policy carefully to ensure that it meets your requirements. If it does not, please return it to us immediately. We would remind you that you must advise us fully and faithfully all the relevant facts you know or ought to know any changes in the information you have given to us otherwise you may not receive any benefit under this policy

Meeting to the needs and Confirm within 10 days. Return the policy if not meeting the needs and refund is allowed. Benefit offered by insurers


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Overseas Mediclaim

Mediclaim Policy would stand suspended for the said period.

The validity of period of insurance for Mediclaim protection shall extended for the same period beyond the scheduled expiry date.

No adjustment or refund of premium shall be involved

Does it appear as a condition?


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Family Policy

Insures both the policyholder & dependents Spouse Children


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Senior Citizen Policy

Persons 65 years of age and above Supplementary to Medicare program


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Group

Group Contract Master Contract/Master Policy

– Employer or other entity– Relationship identified to the entity– Certificates to individuals– Economy under group approach

Master contract is a detailed document– Flexibility– Experience Rating


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Contributory Plan

Contribution by the employer and employee At least 75% employees to be insured


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Non-Contributory Plan

Employer bears the full cost All eligible employees to be covered


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Cafeteria Plan

Allows the participating employees– To select among the displayed benefits using

predetermined amounts of the employer


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Conversion Privilege

COBRA Consolidated Omnibus Budget Reconciliation

1985 Employers with 20 or more employees

– To extend the insurance benefit to the terminated employee, spouse, dependents, children

– Cover for 18 months to 36 months


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Other Qualifying Events

Death of an employee and cover to the dependents

Child ceases to be an eligible employee Reduction in employees coverage Reduction in the employee’s working hours Employee becomes eligible for Medicare


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Conversion privilege – Group Policy

Right given to an insured person To change coverage, without evidence of

medical insurability, to an individual policy upon termination of the group coverage

The conditions under which conversion can be made are defined in the master policy.


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HIPAA – A protection

Health Insurance Portability and Accountability Act 1996

Primary purpose of which was to help ensure that individuals would not lose their medical coverage or be subject to new pre-existing condition periods whey they changed or lost their jobs


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Non-Cancelable

Guaranteed Renewal Right to continue the policy until specified

age Insurer can not cancel nor make any

changes in any provisions


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Optionally renewable

Insurer reserve the right to terminate the coverage at any anniversary (or)

At any premium due date but not in the middle of the due dates


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Non-Occupational Policy

Covers off the job accidents and illness Group accident and health insurance policies

often fall in the category Non-Job Related accidents or sicknesses not

covered under WC Insurance


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Qualified impairment insurance

Sub-standard insurance Restricts the benefits for the insured person’s

particular condition


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Evidence of Insurability

Statement or proof of a person’s physical conditions– Underwriting factor


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Additional Purchase Option

Permission to an insured to buy additional insurance– Need not provide evidence of insurability


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Minimum Premium Plan

Insurance company administers claims for a fee

Insure against large claims for self insured group

The employer self-funds a fixed percentage of the estimated monthly claims

The insurer covers the remainder


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Allocated Benefits

Itemize the specific services Limit the maximum amount for the benefits


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Unallocated Benefit

Reimbursement of Maximum limit All extra miscellaneous hospital services Does not specify amount for each service


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Waiver of Premium Benefit

Policy holder is exempted to pay the future premiums

Totally disabled during the life of the contract


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Ancillary Benefits

Secondary Benefits Added to the basic medical care Lab, X-ray, ECG and other services


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Duplication of Benefits

Overlapping of identical cover in various plans

Known as “Multiple Coverage”


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Co-Ordination of Benefits

To avoid duplication of benefits To cover 100% of health expenses To make out the order of payment the

multiple insurer would pay India

– Doctrine of contribution


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Rider

Increase or decrease or waiver of benefits Alter the base contract


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Insuring Clause

Refers the parties to the contract Coverage of type of loss


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Recurring Clause

Recurrence of a condition Continuation of a prior period of

hospitalization India

– Any One Illness– Same confinement


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Incontestable Clause

Not to contest the validity of the contract after it has been in force for two/three consecutive years

Non-cancelable/Guaranteed renewable health insurance contracts


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Look Free Clause

Free look to the policy Most companies provide at least 10 days to

look at the policy from day of receipt. One is uncomfortable with the cover or

terms, return and have your premium refunded

Is not required by law but a benefit offered


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Self Bearing

Benefit Period Cat Limit (Out of

Pocket Maximum) Co-Insurance Co-Payment Corridor Deductible

Deductible Flat Deductible Elimination Period Waiting Period Family Deductible

Provision


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Benefit Period

Choice of Elimination/Waiting Period Ranges from ‘0’ to ‘365’days Longer the waiting period, lower the premium Daily Benefit and Length of Benefit


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Cat Limit/Out of Pocket Limit

Limit the maximum benefit of large and unusual medical bill of the insured and family

Maximum amount of covered expenses Separate limits for surgical expenses Separate limits for mental conditions Stop loss provision


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Co-Insurance

A fixed percentage of covered charges after applying the deductible

80% covered charges means– Deductible and 20% to be borne by the insured


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Co-Payment

One shall pay a fixed dollar amount for a service or benefit provided by a plan


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Corridor Deductible

A deductible between the benefits paid by the basic plan and beginning of supplemental major medical plan


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Deductible

Pay before the plan pays benefits– Calendar year deductible

IndividualFamily

– Inpatient hospital deductible Flat Deductible Percentage Deductible


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Contd-

All Cause deductible– All expenses are accumulated irrespective of

number of illnesses or accidents

Per Cause deductible– All expenses incurred because of the same or

related causes are accumulated to satisfy the deductible, for the expenses incurred during the benefit period


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Family Deductible Provision

Waives the deductible for all family members after any two or three of them individually have satisfied their deductible in the same year


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Pure administrative services of programs designed by some one

Billing and Enrolment ID Card Generation Claims Processing Management of Basic Net Work Reporting


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Expectations

Operational Effectiveness and Efficiency Turnaround time and quality standard in

claims processing


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Health Maintenance Organization (HMO)

A health care system Assumes insurance and service risk The responsibility for health care delivery in a

particular geographic area to HMO members, in return for a fixed, prepaid fee.


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Preferred Provider Organization (PPO)

An indemnity plan Coverage is provided to participants through

a network of selected health care providers (such as hospitals and physicians)

The enrollees may go outside the network Incur larger costs in the form of higher

deductibles, higher coinsurance rates, or non discounted charges from the providers.


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Exclusive Provider Organization (EPO)

A more restrictive type of preferred provider organization plan

Employees must use providers from the specified network of physicians and hospitals to receive coverage

There is no coverage for care received from a non-network provider except in an emergency situation.


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Levels of Nursing Care

Skilled Nursing Care– Highest level of nursing care– 24 hour care ordered by physician– Registered/licensed nurse/therapist

Intermediary nursing care– 24 hours nursing not necessary– Effective non-continuous care

Custodial Care– Basic level of nursing care– Non-medical personnel– Ordered by a physician and supervised by a

nurse


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Community Care

Needs assistance and able to stay in the home or community

Home health care – Part time nursing care Adult care Respite Care

– Care in individual’s home in a long term care facility temporarily

Hospice Care – Special care and emotional support for the persons

diagnosed with terminal illnesses

Health Insurance - Global Practices 1. 2 Health WHO definition of Health Health is a state of...

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