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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