Basics of health insurance

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