Medical Insurance Concept's
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Transcript of Medical Insurance Concept's
Going Ahead
Current Regulatory Requirement
A progressive employer is expected to provide health facilities to the 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.
System in place 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 insuranceFor 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
Present & Future AheadHealth 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 channelIncurred Claim ration 96.43 - a bit improvementFuture is promising as there is a growing
concern for the health careGovt. too is thinking of providing some universal
health care on the line of RSBY
Stake holders EmployeesEmployerGovt. Regulations / RegulatorsIntermediaries (Agents/ Brokers)Insurance Companies (Reinsurance Co.)TPAs / Internal Claim settlement Medical Service Providers IT network
Insurance vs. Cost ManagementUnlike other forms of insurance Medical
insurance is more of cost management natureThe 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.
Market Realities There is a very cut-throat competition in marketGroup Medical is a big bargaining point for
clients to place other lines of businessCompanies are looking for the lowest possible
rates irrespective of their claims experienceNormally claim experiences are not favourable This has resulted into frequent shifting of the
portfolio from one Company to another.
Essentials for successUnderstanding of the basic needs of the
customerSimple product features with least deviation
from the universal and standard norms.Having least possible feature having 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
Important Product Features Annual Max. Limit (Flexibility)Provision of Pre-Existing ConditionWide option of Geographical coverage (Abroad/USA
)Tie –up in other counties In-patient / Out-patient Discount for limiting outpatient limit as a % of AMLWide & attractive options of deductible Improved Group / favorable loss ratio discount Gate-keeper / Preventive schemes
Standard Exclusions….Aids/HIVInfertility, In-vitro fertilization, SurrogacyPsychiatric, mental retardation, Alzheimer and
similar degenerative diseasesCongenital disease, malformations or
malfunctionsOncology, Kidney dialysis, Hormone replacement,
Bone densitometory, Tumours, Development problems, Physical aids
Organ donationExpenses for homecare, sanatoriums, long term
care facilities and similar institutionsEpidemics declared by Government/WHO
Standard ExclusionsRegular/Preventive health check upsExpenses for work related injuries/accident as these are
covered under WC policy – mandatory in OmanElective Treatment received outside area of coverHealth Spas/Nature Cure Clinics etcPlastic and cosmetic surgery and beauty related skin
treatmentVitamins and supplements, medicated shampoos, mouth
washAny 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
Claim SettlementThe 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.
Medical CardsThe Medical Card contains the following
information & provides the bearer medical services within the scope of the Medical Policy.
Name of MemberDate of Birth , Unique identity no Name of the companyValidity period of the cardBroad Coverage details , restrictionsDeductible , 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 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.
Pre - ApprovalsAll non emergency cases that need
hospitalization for medical or surgical treatment.
Chronic medications for more than 1 monthMedical tests etc. beyond a normal
/prescribed limit Endoscopies, EEG, ECGMRI Scans and CT ScansFacilities having sub-limitsHowever in case of emergency hospitalization
no such approval is required. Intimation with in 24 hours.
Claim Process – Important aspects Tie up reputed TPA having high volume of
business / IT infrastructure Network availability in promised locations24*7 customer helpline by TPAsAvailability of Ins. Co official for TPA support Claim processing by experienced professionalsPossibility of Expert / Second opinion Cost reduction – better discount from
providers