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