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Presentation on Health Insurance

By S. Nanda

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What is Health Insurance

Insurance Cover for reimbursement orcashless services for hospitalizationexpenses incurred due to

Disease

Illness

Accident

Popularly known as MEDICLAIM INSURANCE

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What is Health Insurance

Personal Accident Insurance is alsoclubbed with Health Insurance

Accidents resulting in

Death

Disablement Loss of income earning capacity

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Types of Cover

Standard Mediclaim Insurance (Individual &Group)

Tailor-made Covers

Floater Covers (for the entire family) Overseas Mediclaim Insurance

Micro Health Insurance Cover

Combi-Products (Health + Life Insurance) Rastriya Swastya Bima Insurance (RSBY)

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What is Covered

Doctors Fees Medicine / Drugs

OT Charges

Hospital Room Charges

Cost of Artificial Limbs

Transplantation of organs

Blood / Oxygen

Other such expenses

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Mediclaim InsuranceSalient Features

THE POLICY COVERS REIMBURSEMENT OFHOSPITALISATION / DOMICILIARYHOSPITALISATION EXPENSES FOR ILLNESS /INJURY SUSTAINED.

EXPENSES REASONABLY ANDNECESSARILY INCURRED ON ROOM RENT,NURSING EXPENSES, DOCTORS FEES, O.T.CHARGES, ANAESTHESIA, BLOOD, OXYGEN,

MEDICINES, DIAGNOSTIC MATERIAL & X-RAY, DIALYSIS, CHEMOTHERAPY,RADIOTHERAPY, PACE MAKER, ARIFICIALLIMBS & COST OF ORGANS ETC. AREREIMBURSED.

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SUM INSURED PER PERSON IS THE MAXIMUMLIABILITY OF THE COMPANY DURING ANYPERIOD OF INSURANCE.

HOSPITAL/NURSING HOME - REGISTEREDWITH LOCAL AUTHORITIES & SUPERVISED BYA REGISTERED & QUALIFIED MEDICALPRACTITIONER OR SHOULD HAVE AT LEAST

15 IN-PATIENT BEDS, OPERATION THEATREAND QUALIFIED DOCTOR(S) & NURSING STAFFROUND THE CLOCK.

NORMALLY HOSPITALISATION SHOULD BEFOR A MINIMUM PERIOD OF 24 HOURS.

THIS TIME LIMIT DOES NOT APPLY FOR FORSPECIFIC TREATMENTS, I.E., DIALYSIS,CHEMOTHERAPY, RADIOTHERAPY, EYESURGERY, DENTAL SURGERY, LITHOTRIPSY,TONSILLECTOMY.

SALIENT FEATURES Contd.

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SALIENT FEATURESContd

POST HOSPITALISATION - MEDICALEXPENSES INCURRED DURING THE PERIODUPTO 60 DAYS AFTER HOSPITALISATION.

PRE-HOSPITALISATION EXPENSES -MEDICAL EXPENSES INCURRED DURING THE

PERIOD UPTO 30 DAYS BEFOREHOSPITALISATION.

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MAJOR EXCLUSIONS UNDERMEDICLAIM INSURANCE

ALL PRE-EXISTING DISEASESWHEN THE COVER INCEPTS FORTHE FIRST TIME.

ANY DISEASE OTHER THAN THOSESTATED BELOW CONTRACTED BYTHE INSURED PERSON DURINGTHE FIRST 30 DAYS FROM THE

COMMENCEMENT DATE OF THEPOLICY IN CASE OF FRESHINSURANCE.

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MAJOR EXCLUSIONS UNDERMEDICLAIM INSURANCE

THE ABOVE EXCLUSIONS WILL NOTAPPLY IF IT IS ESTABLISHED THAT THEINSURED PERSON COULD NOT HAVE

KNOWN OF THE EXISTENCE OF THEDISEASE OR ANY SYMPTOM THEREOFAND HAD NOT TAKEN ANYCONSULTATION/TREATMENT PRIOR TOTAKING THE INSURANCE.

DURING THE FIRST YEAR OF POLICY -CONGENITAL INTERNAL DISEASES,CATARACT, HERNIA, PILES, SINUSITIS.....

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MAJOR EXCLUSIONS UNDERMEDICLAIM INSURANCE

DENTAL TREATMENT OR SURGERYOF ANY KIND UNLESS REQUIRING

HOSPITALISATION. CONGENITAL EXTERNAL DISEASES

OR DEFECTS.

ALL EXPENSES CONNECTED WITHAIDS.

NATUROPATHY TREATMENT.

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AGE LIMIT

05 YEARS TO 80 YEARS.CHILDREN BETWEEN THE

AGE OF 3 MONTHS TO 5YEARS CAN BE COVEREDPROVIDED ONE OR BOTH

THE PARENTS ARECOVEREDCONCURRENTLY.

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CLAIMS PROCEDURE -DOCUMENTS REQUIRED

PRELIMINARY NOTICE OFCLAIM - WITHIN 7 DAYS

DULY COMPLETED CLAIM FORM

- WITHIN 30 DAYS BILLS, RECEIPTS AND

DISCHARGE CERTIFICATE

FROM THE HOSPITAL CASH MEMO FROM THE

HOSPITAL

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CLAIMS PROCEDURE -DOCUMENTS REQUIRED

BILLS FROM CHEMIST SUPPORTEDBY PROPER PRESCRIPTION

RECEIPTS AND PATHOLOGICALTEST REPORTS SUPPORTED BYDOCTORS REPORT PRESCRIBINGTHE PATHOLOGICAL TESTS

SURGEONS BILL AND RECEIPTS

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IN CASE OF DEATH OF THE

INSURED PERSON AFTER HAVINGINCURRED MEDICAL EXPENSES,THE ADMISSIBLE CLAIM AMOUNTCAN BE PAID TO THE LEGALREPRESENTATIVE OF THEDECEASED OR ANY OTHERFAMILY MEMBER.

CLAIMS PROCEDURE -

DOCUMENTS REQUIRED

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CASHLESS SETTLEMENT

Cashless hospitalization means as aMediclaim policyholder one will not have torun around paying off the hospital bills andgetting a reimbursement later. On thecontrary the policyholder will be able to availof medical services at designated hospitalsand his bills will be settled through TPAs(third party administrators) who will

additionally offer a 24 hours toll free help line,access to physicians, specialties, diagnosticcenters.

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4/9/2012 17

NOTICE OF CLAIM:

Immediate notice of claim with particularsrelating to policy number, ID Card No., Nameof the insured person in respect of whomclaim is made, Nature of disease / illness /

injury and Name and Address of theattending medical practitioner / Hospital /Nursing Home etc.should be given to theCompany / TPA while taking treatment in the

Hospital / Nursing Home by Fax, E mail.Such notice should be given within 48 hoursof admission or before discharge fromHospital /Nursing Home.

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4/9/2012 18

PROCEDURE FOR AVAILING CASHLESS ACCESS SERVICES IN

NETWORK HOSPITAL / NURSING HOME:

Claim in respect of Cashless Access

Services will be through the TPAprovided admission is in a listedhospital in the agreed list of the

Networked Hospitals / Nursing Homesand is subject to pre admissionauthorization.

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4/9/2012 19

The TPA shall, upon getting the relatedmedical details / relevant information fromthe Insured Person / Network Hospital /

Nursing Home, verify that the person iseligible to claim under the policy and aftersatisfying itself will issue a pre-authorizationletter / guarantee of payment letter to the

Hospital / Nursing Home mentioning the sumguaranteed as payable, also the ailment forwhich the person is seeking to be admittedas in-patient.

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4/9/2012 20

The TPA reserves the right to deny pre-authorisation in case the Hospital /Insured Person is unable to provide the

relevant information / medical details asrequired by the TPA.In suchcircumstances denial of cashless accessshould in no way be construed as denial

of claim.

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4/9/2012 21

The insured person may obtain thetreatment as per his / her treating doctorsadvice and later on submit the full claim

papers to the TPA for reimbursementwithin 7 days of the discharge fromHospital / Nursing Home.

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4/9/2012 22

Should any information be available tothe TPA which makes the claiminadmissible or doubtful requiring

investigations, the authorisation ofcashless facility may be withdrawn.However this shall be done by the TPAbefore the patient is discharged from the

Hospital.

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GROUP MEDICLAIM INSURANCE ALL THEMEMBERS OF A GROUP ARE COVERED UNDERONE INSURANCE POLICY.

FAMILY FLOATER INSURANCE COVER

ALL THE MEMBERS OF THE FAMILY ARECOVERED UNDER ONE SUM INSURED.

THE CHOSEN SUM INSURED FOR THE FAMILYWILL BE AVAILABLE FOR ONE OR MORE

MEMBERS OF THE FAMILY. MAXIMUM LIABILITY OF THE INSURANCECOMPANY WILL BE LIMITED TO THE CHOSEN SUMINSURED FOR THE FAMILY.

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Health Insurance - Present Position

Fastest growing sector in Non-life

Insurance Sector

2010-11

Health Insurance PremiumRs 10,932 crore

(40% growth rate)

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Health Insurance - Present Position

Share of Health Insurance Premium inTotal Premium About 30%

Next only to Motor Insurance

Due to price competition in othersectors (Fire, Motor, Engineering

Insurance) the growth rate has come

down Health Insuranceoffers tremendous

opportunities for Insurance Companies

to grow

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Health Insurance - Present Position

During 2010-11 : Only 5.25 crore peoplecovered Out of 1.20 billion population

Rastriya Swastya Bima Yojana inprogress in various States includingOrissa

RSBY : Objective is to reach out to therural poor BPL families

Total Premium Total Claim Paid and Claim

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Period Premium(` in Crs.)

Claims paid(` in Crs.)

Claims PaidRatio %

2003-2004 944 785 83%

2004-2005 987 948 96%

2005-2006 1,947 1,777 91%

2006-2007 2,820 2,198 78%

2007-2008 2,758 2,904 105%

2008-2009 3,976 4,087 103%

2009-2010 7,803 7,456 96%

2010-2011 10,932 10,797 99%

Total Premium, Total Claim Paid and ClaimRatio

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Impediment

Very High Claims Experience

The Claims Ratio in 2009-10 was 96%,More than 100% in the previous twoyears

Relatively Low Premium Base Reasonfor high Claims ratio?

Or.

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Impediment

Fraud Claims? Inflated Claims?

High billing by Hospitals?

Inappropriate handling by TPAs? Urban-centric Approach by Insurance

Companies?

Dissatisfaction among customers fordenial of claims?

May be Combination of all these factors

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Need of the hourHealth insurance is a need, that requires to

be addressed. This is where there is a roleto

develop more innovative products

to address needs of specific target groups

to build awareness regarding health insuranceand its potential to protect from suchunforeseen health expenditure

A lot more needs to be done by the StakeHolders - trade chambers, insurance industry,health service providers, NGO/MFI,Government

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The Future

Health insurance is likely to grow rapidly

Cover 20% of the population

Constitute 12% of the total health market

of the country, or over Rs 30,000 croresby 2015

A six-fold increase over the next 5 years.

No doubt that there is tremendouspotential for development of healthinsurance.

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Sustainability

Prices of health insurance products shouldcontinue to be affordable to ensure wideracceptance and increased reach to poor

At the same time the insurance industryrequires that this line of business remainscommercially viable.

Learn from the unpleasant experience in

certain other countries where spiralingcosts, high premium have resulted in a verycomplicated and perhaps unsustainablehealth insurance system.

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Role of TPAsTowards bettermanagement of Health Insurance

Error free preparation and distribution ofHealth Cards

Turn Around Time (TAT) must bereduced

Quick Response for Cashless Facilities

Include more health providers (hospitals)

Fair settlement of claims

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Role of Insuring Public

Understanding the Health InsuranceCover

It is only a cover against unforeseen

contingencies Tendencies to enforce a wrong claim or

enlarge the scope of a genuine claim

must be curbed Understanding the exclusions

(pre-existing diseases are not covered)

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The Supreme GoalA healthy

Health Insurance Industry

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Thank You