Health Insurance - Global Practic Es

1 Health Insurance - Global Practic
es
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.

es
es
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

es
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.

es
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
es
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?

es
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

es
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

es
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

es
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

es
Hospital
 Any Institution in India

 For indoor care and treatment of
sickness, injuries
 Either been registered as a Hospital or
Nursing Home with Local Authorities
 Under the supervision of a Registered
Qualified Medical Practitioner

es
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

es
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

es
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

es
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

es
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

es
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

es
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

es
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

es
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

es
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

es
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
es
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

es
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

es
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
es
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)

es
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

es
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

es
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?

es
es
Family Policy
 Insures both the policyholder & dependents

 Spouse
 Children

es
Senior Citizen Policy
 Persons 65 years of age and above

 Supplementary to Medicare program

es
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

es
Contributory Plan
 Contribution by the employer and employee

 At least 75% employees to be insured

es
Non-Contributory Plan
 Employer bears the full cost

 All eligible employees to be covered

es
Cafeteria Plan
 Allows the participating employees

– To select among the displayed benefits using
predetermined amounts of the employer

es
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

es
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

es
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.

es
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

es
Non-Cancelable
 Guaranteed Renewal
 Right to continue the policy until specified
age
 Insurer can not cancel nor make any
changes in any provisions

es
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

es
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

es
Qualified impairment insurance
 Sub-standard insurance
 Restricts the benefits for the insured person’s
particular condition

es
Evidence of Insurability
 Statement or proof of a person’s physical

conditions
– Underwriting factor

es
Additional Purchase Option
 Permission to an insured to buy additional

insurance
– Need not provide evidence of insurability

es
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

es
es
Allocated Benefits
 Itemize the specific services

 Limit the maximum amount for the benefits

es
Unallocated Benefit
 Reimbursement of Maximum limit

 All extra miscellaneous hospital services
 Does not specify amount for each service

es
Waiver of Premium Benefit
 Policy holder is exempted to pay the future

premiums
 Totally disabled during the life of the contract

es
Ancillary Benefits
 Secondary Benefits
 Added to the basic medical care
 Lab, X-ray, ECG and other services

es
Duplication of Benefits
 Overlapping of identical cover in various

plans
 Known as “Multiple Coverage”

es
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

es
Rider
 Increase or decrease or waiver of benefits

 Alter the base contract

es
es
Insuring Clause
 Refers the parties to the contract

 Coverage of type of loss

es
Recurring Clause
 Recurrence of a condition
 Continuation of a prior period of
hospitalization
 India
– Any One Illness
– Same confinement

es
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

es
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

es
Self Bearing
 Benefit Period  Deductible

 Cat Limit (Out of  Flat Deductible
Pocket Maximum)  Elimination Period
 Co-Insurance  Waiting Period
 Co-Payment  Family Deductible
 Corridor Deductible Provision

es
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

es
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

es
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

es
Co-Payment
 One shall pay a fixed dollar amount for a

service or benefit provided by a plan

es
Corridor Deductible
 A deductible between the benefits paid by

the basic plan and beginning of supplemental
major medical plan

es
Deductible
 Pay before the plan pays benefits

– Calendar year deductible
 Individual
 Family
– Inpatient hospital deductible

 Flat Deductible
 Percentage Deductible

es
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

es
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

es
es
 Pure administrative services of programs
designed by some one
 Billing and Enrolment
 ID Card Generation
 Claims Processing
 Management of Basic Net Work
 Reporting

es
Expectations
 Operational Effectiveness and Efficiency

 Turnaround time and quality standard in
claims processing

es
es
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.

es
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.
es
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.
es
es
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

es
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

es

Health Insurance - Global Practic Es

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Health Insurance - Global Practic Es

Caricato da

Copyright:

Formati disponibili

1 Health Insurance - Global Practic

 WHO definition of Health

2 Health Insurance - Global Practic

 Insurance has never been a simple matter

4 Health Insurance - Global Practic

o Wording of Terms vary with the insurers elsewhere

5 Health Insurance - Global Practic

 Many controversial or touchy issues on the

 In the wake of these trends, consumers

7 Health Insurance - Global Practic

8 Health Insurance - Global Practic

 “Subject to the terms, limitations, exceptions,

9 Health Insurance - Global Practic

 Hospital /Nursing Home

10 Health Insurance - Global Practic

11 Health Insurance - Global Practic

 Any Institution in India

12 Health Insurance - Global Practic

13 Health Insurance - Global Practic

 Exclusively to an institution providing treatment in the

14 Health Insurance - Global Practic

 A hospital duly authorized by Government

15 Health Insurance - Global Practic

 Minimum period of 24 hours, not applicable to

16 Health Insurance - Global Practic

 Absolutely necessary to avail Cashless facility. It is

17 Health Insurance - Global Practic

 Relevant medical expenses incurred during the period

18 Health Insurance - Global Practic

 Relapse within 45 days from date of last consultation

19 Health Insurance - Global Practic

 A person who holds a degree/diploma of a

20 Health Insurance - Global Practic

 A person who holds a certificate of a

21 Health Insurance - Global Practic

 To exclude claims arising out of the

22 Health Insurance - Global Practic

 Pre-existing conditions means a medical

 “Sickness for which the insured or to the

24 Health Insurance - Global Practic

 Treatment arising from or traceable to

25 Health Insurance - Global Practic

27 Health Insurance - Global Practic

28 Health Insurance - Global Practic

 Please read this policy carefully to ensure that it

29 Health Insurance - Global Practic

 Mediclaim Policy would stand suspended for the said

30 Health Insurance - Global Practic

 Insures both the policyholder & dependents

32 Health Insurance - Global Practic

 Persons 65 years of age and above

33 Health Insurance - Global Practic

34 Health Insurance - Global Practic

 Contribution by the employer and employee

35 Health Insurance - Global Practic

 Employer bears the full cost

36 Health Insurance - Global Practic

 Allows the participating employees

37 Health Insurance - Global Practic

38 Health Insurance - Global Practic

 Death of an employee and cover to the

39 Health Insurance - Global Practic

 Right given to an insured person