1 Health Insurance - Global Practices
Health l l 2 WHO definition of Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Health Insurance - Global Practices
3 Health Insurance - Global Practices
Impression l l l 4 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 Health Insurance - Global Practices
contd o o 5 Wording of Terms vary with the insurers elsewhere in the countries and also insurers in India Health Insurance is more complex with huge terminologies In India peculiarly, the dissonance in Health Insurance is high compared to Life Insurance despite limited penetration. The dissonance is generated amongst customers, insurers, health care providers. Health Insurance - Global Practices
contd § § § 6 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 Health Insurance - Global Practices
contd § § § 7 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? Health Insurance - Global Practices
Need l l l 8 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 Health Insurance - Global Practices
Terms referredl l 9 “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 Health Insurance - Global Practices
Variance of Wordings of Terms l l l l l 10 Hospital /Nursing Home Hospitalization Pre admission authorization Domiciliary Hospitalization Any One Illness Pre-Hospitalization Expenses Post Hospitalization Expenses Medical Practitioner Qualified Nurse Health Insurance - Global Practices
Contdl l l 11 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 Health Insurance - Global Practices
Hospital l Any Institution in India l For indoor care and treatment of sickness, injuries l Either been registered as a Hospital or Nursing Home with Local Authorities l Under the supervision of a Registered Qualified Medical Practitioner 12 Health Insurance - Global Practices
contd l l 13 Alternatively l At least 15 in patient beds/ C Class 10 beds l Fully equipped operation theatre of its own wherever surgical operations are carried out l Fully qualified Nursing Staff under its employment round the clock l 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 Health Insurance - Global Practices
Other definition (excerpts) l l 14 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 Health Insurance - Global Practices
Canada l 15 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 Health Insurance - Global Practices
Hospitalization l l 16 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 Health Insurance - Global Practices
Pre-Admission Authorization l l 17 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 Health obligation to pay for service rendered Insurance - Global Practices
Pre-Hospitalization & Post Hospitalization l l l 18 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 Health Insurance - Global Practices
Any one illness l l 19 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 Health Insurance - Global Practices
Medical Practitioner l l 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 – 20 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 Health Insurance - Global Practices
Qualified Nurse l l 21 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 Health Insurance - Global Practices
Pre-Existing Condition l l 22 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 Health Insurance - Global Practices
contd l 23 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 Health Insurance - Global Practices
contd l l 24 “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 Health Insurance - Global Practices
Maternity Exclusion l l 25 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 Health Insurance - Global Practices
contd l 26 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 Health Insurance - Global Practices
Treatment (Exclusion) l l Naturopathy Other company – l 27 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) Health Insurance - Global Practices
Specific limits l l l 28 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 Health Insurance - Global Practices
Look Free Clause l l 29 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 Health Insurance - Global Practices
Overseas Mediclaim l l 30 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? Health Insurance - Global Practices
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Family Policy l l l 32 Insures both the policyholder & dependents Spouse Children Health Insurance - Global Practices
Senior Citizen Policy l l 33 Persons 65 years of age and above Supplementary to Medicare program Health Insurance - Global Practices
Group l l l 34 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 Health Insurance - Global Practices
Contributory Plan l l 35 Contribution by the employer and employee At least 75% employees to be insured Health Insurance - Global Practices
Non-Contributory Plan l l 36 Employer bears the full cost All eligible employees to be covered Health Insurance - Global Practices
Cafeteria Plan l 37 Allows the participating employees – To select among the displayed benefits using predetermined amounts of the employer Health Insurance - Global Practices
Conversion Privilege l l l 38 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 Health Insurance - Global Practices
Other Qualifying Events l l l 39 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 Health Insurance - Global Practices
Conversion privilege – Group Policy l l l 40 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. Health Insurance - Global Practices
HIPAA – A protection l l 41 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 Health Insurance - Global Practices
Non-Cancelable l l l 42 Guaranteed Renewal Right to continue the policy until specified age Insurer can not cancel nor make any changes in any provisions Health Insurance - Global Practices
Optionally renewable l l 43 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 Health Insurance - Global Practices
Non-Occupational Policy l l l 44 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 Health Insurance - Global Practices
Qualified impairment insurance l l 45 Sub-standard insurance Restricts the benefits for the insured person’s particular condition Health Insurance - Global Practices
Evidence of Insurability l 46 Statement or proof of a person’s physical conditions – Underwriting factor Health Insurance - Global Practices
Additional Purchase Option l 47 Permission to an insured to buy additional insurance – Need not provide evidence of insurability Health Insurance - Global Practices
Minimum Premium Plan l l 48 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 Health Insurance - Global Practices
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Allocated Benefits l l 50 Itemize the specific services Limit the maximum amount for the benefits Health Insurance - Global Practices
Unallocated Benefit l l l 51 Reimbursement of Maximum limit All extra miscellaneous hospital services Does not specify amount for each service Health Insurance - Global Practices
Waiver of Premium Benefit l l 52 Policy holder is exempted to pay the future premiums Totally disabled during the life of the contract Health Insurance - Global Practices
Ancillary Benefits l l l 53 Secondary Benefits Added to the basic medical care Lab, X-ray, ECG and other services Health Insurance - Global Practices
Duplication of Benefits l l 54 Overlapping of identical cover in various plans Known as “Multiple Coverage” Health Insurance - Global Practices
Co-Ordination of Benefits l l 55 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 Health Insurance - Global Practices
Rider l l 56 Increase or decrease or waiver of benefits Alter the base contract Health Insurance - Global Practices
57 Health Insurance - Global Practices
Insuring Clause l l 58 Refers the parties to the contract Coverage of type of loss Health Insurance - Global Practices
Recurring Clause l l l Recurrence of a condition Continuation of a prior period of hospitalization India – – 59 Any One Illness Same confinement Health Insurance - Global Practices
Incontestable Clause l l 60 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 Health Insurance - Global Practices
Look Free Clause l l 61 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 Health Insurance - Global Practices
Self Bearing l l l 62 Benefit Period Cat Limit (Out of Pocket Maximum) Co-Insurance Co-Payment Corridor Deductible l l l Deductible Flat Deductible Elimination Period Waiting Period Family Deductible Provision Health Insurance - Global Practices
Benefit Period l l 63 Choice of Elimination/Waiting Period Ranges from ‘ 0’ to ‘ 365’days Longer the waiting period, lower the premium Daily Benefit and Length of Benefit Health Insurance - Global Practices
Cat Limit/Out of Pocket Limit l l l 64 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 Health Insurance - Global Practices
Co-Insurance l l A fixed percentage of covered charges after applying the deductible 80% covered charges means – 65 Deductible and 20% to be borne by the insured Health Insurance - Global Practices
Co-Payment l 66 One shall pay a fixed dollar amount for a service or benefit provided by a plan Health Insurance - Global Practices
Corridor Deductible l 67 A deductible between the benefits paid by the basic plan and beginning of supplemental major medical plan Health Insurance - Global Practices
Deductible l Pay before the plan pays benefits – Calendar year deductible l Individual l Family Inpatient hospital deductible Flat Deductible Percentage Deductible – l l 68 Health Insurance - Global Practices
Contdl All Cause deductible – l Per Cause deductible – 69 All expenses are accumulated irrespective of number of illnesses or accidents All expenses incurred because of the same or related causes are accumulated to satisfy the deductible, for the expenses incurred during the benefit period Health Insurance - Global Practices
Family Deductible Provision l 70 Waives the deductible for all family members after any two or three of them individually have satisfied their deductible in the same year Health Insurance - Global Practices
71 Health Insurance - Global Practices
l l l 72 Pure administrative services of programs designed by some one Billing and Enrolment ID Card Generation Claims Processing Management of Basic Net Work Reporting Health Insurance - Global Practices
Expectations l l 73 Operational Effectiveness and Efficiency Turnaround time and quality standard in claims processing Health Insurance - Global Practices
74 Health Insurance - Global Practices
Health Maintenance Organization (HMO) l l l 75 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. Health Insurance - Global Practices
Preferred Provider Organization (PPO) l l 76 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. Health Insurance - Global Practices
Exclusive Provider Organization (EPO) l l l 77 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. Health Insurance - Global Practices
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Levels of Nursing Care l l l 79 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 Health Insurance - Global Practices
Community Care l l l 80 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 Health Insurance - Global Practices persons diagnosed with terminal illnesses
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