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Health Insurance

Health Insurance

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Health Insurance

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  1. Health Insurance Terms Health Insurance - Global Practices

  2. 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. Health Insurance - Global Practices

  3. Look before U leap Health Insurance - Global Practices

  4. 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 Health Insurance - Global Practices

  5. contd • 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

  6. 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 Health Insurance - Global Practices

  7. 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? Health Insurance - Global Practices

  8. 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 Health Insurance - Global Practices

  9. 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 Health Insurance - Global Practices

  10. 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 Health Insurance - Global Practices

  11. 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 Health Insurance - Global Practices

  12. 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 Health Insurance - Global Practices

  13. 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 Health Insurance - Global Practices

  14. 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 Health Insurance - Global Practices

  15. 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 Health Insurance - Global Practices

  16. 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 Health Insurance - Global Practices

  17. 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 Health Insurance - Global Practices

  18. 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 Health Insurance - Global Practices

  19. 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 Health Insurance - Global Practices

  20. 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 Health Insurance - Global Practices

  21. 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 Health Insurance - Global Practices

  22. 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 Health Insurance - Global Practices

  23. 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 Health Insurance - Global Practices

  24. 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 Health Insurance - Global Practices

  25. 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 Health Insurance - Global Practices

  26. 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 Health Insurance - Global Practices

  27. 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) Health Insurance - Global Practices

  28. 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 Health Insurance - Global Practices

  29. 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 Health Insurance - Global Practices

  30. 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? Health Insurance - Global Practices

  31. Special Products Health Insurance - Global Practices

  32. Family Policy • Insures both the policyholder & dependents • Spouse • Children Health Insurance - Global Practices

  33. Senior Citizen Policy • Persons 65 years of age and above • Supplementary to Medicare program Health Insurance - Global Practices

  34. 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 Health Insurance - Global Practices

  35. Contributory Plan • Contribution by the employer and employee • At least 75% employees to be insured Health Insurance - Global Practices

  36. Non-Contributory Plan • Employer bears the full cost • All eligible employees to be covered Health Insurance - Global Practices

  37. Cafeteria Plan • Allows the participating employees • To select among the displayed benefits using predetermined amounts of the employer Health Insurance - Global Practices

  38. 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 Health Insurance - Global Practices

  39. 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 Health Insurance - Global Practices

  40. 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. Health Insurance - Global Practices

  41. 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 Health Insurance - Global Practices

  42. Non-Cancelable • 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

  43. 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 Health Insurance - Global Practices

  44. 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 Health Insurance - Global Practices

  45. Qualified impairment insurance • Sub-standard insurance • Restricts the benefits for the insured person’s particular condition Health Insurance - Global Practices

  46. Evidence of Insurability • Statement or proof of a person’s physical conditions • Underwriting factor Health Insurance - Global Practices

  47. Additional Purchase Option • Permission to an insured to buy additional insurance • Need not provide evidence of insurability Health Insurance - Global Practices

  48. 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 Health Insurance - Global Practices

  49. Benefits Health Insurance - Global Practices

  50. Allocated Benefits • Itemize the specific services • Limit the maximum amount for the benefits Health Insurance - Global Practices