Health Insurance- Updated Jan 2014 ..Ksn.

HEALTH INSURANCE

An overview of Health Policies and

New issues in

Heath portfolio 2014.

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NATIONAL INSURANCE WELCOMES U

2TRAINING PROGRAM FOR

OFFICERS PROMOTION EXAM 2014 BATCH.

HEALTH INSURANCE 2014

● IRDA ‘s Health Insurance Regulations came into force in 2013.

● Consequently All Health Insurance (Mediclaim) Policies not in line with above new regulations are withdrawn and new Mediclaim Policies (both Group and Individual) are introduced from 1st Oct 2013.

● National Insurance introduced its own new Mediclaim Policy named “NATIONAL MEDICLAIM POLICY” * W E F 1.9.2013 compliant with new IRDA Health Insurance Regulations 2013.

● IRDA standardised many Health Terminology definitions and Claim procedures and TPA Role and duties.

* may vary from each Company. 3

HEALTH INSURANCE 2014 New Features : Grace Period is now 30 Days in case of Renewal

with gap for all Mediclaim policies. Free Look Period (FLP)is introduced. All policies

contain 15 days FLP. If policy is not as per Insured’s requirements he can return the Policy in FLP and if no Claim is made, refund of Premium is given pro-rata but if risk not commenced then refund allowed after deduction of Pre- Acceptance Medical Exam Exp and Stamp duty etc only.

A big and Comprehensive List of 199 Expenses Generally Excluded in the Policy are given in the Policy as Annexure. These are detailed very clearly as Not Payable or Payable subject to limits spelt out for each item of Exp.

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HEALTH INSURANCE 2014 New Features : Major Health Terminology Definitions are put in policy as

per IRDA Definitions, such as Cashless Facility, OPD, Network Provider, Pre-Existing Diseases, Portability, Grace Period, Day Care Treatments, and PPN etc.

Inclusion of Cover for Ayurveda and Homeopathy Treatment up to 20% of SI.*

Time Limits for submission of Claim Documents and Documents required for settlement of Claims are spelt out in Policy Condition clearly. Time Limits for Settlement or Repudiation of Claim and Provision for Payment of interest (@ 2% above Bank rate) for delayed Payments etc are now included in a Policy Condition.

Policy cancellation/Renewal of Policy not to be denied except for FRAUD, MORAL HAZARD OR NON-COOPERATION/ MISREPRESENTATION.

* may vary from each Company.5

HEALTH INSURANCE 2014 New Features :

50% Cost of Pre-Acceptance Medical Examination Exp is to be reimbursed by the Insurer(NIC), as per new health regulations.

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Different policies in Health Insurance- ---- Class rated

●Class rated health policies are of two types- Internal tariff rated and packaged / customized policies.

Internal tariff rated health policies are the standard policies sold by by any of our offices with rates, terms and conditions of cover as set out in the internal guidelines. These are rule based and underwriting offices have no authority for deviation. Mediclaim policy, UHIS, Jana Arogya policy, Parivar Mediclaim, Vidyarthi Mediclaim policy, Varishta Mediclaim Policy are examples.*

Packaged/ customized health policies are policies specially designed for individual client or class of clients in terms of scope of cover, basis of insurance, deductibles, rates, terms and conditions of cover.

Co branded health policies like Baroda Health , BOI National Swasthya Bima, V Arogya, SBBJ Medikavach are examples.

The acceptance of these policies are vested with the OOs.*


Different policies in Health Insurance----Individual rated

Individual rated health policies are experience / merit rated. Here the rates, terms and conditions of cover are determined by reference to the requirement of and the actual claim experience of the insured concerned. This represent insurances with a high frequency but low intensity. Group Mediclaim, tailor-made group mediclaim policies are examples.

Pricing for future with past experience8

Parivar policy**Family floater Health Insurance policy *No pre acceptance medical checkup.*Parents cannot be covered.*Age from 3mths to 60 years.*Can be renewed up to 65 years with loading.* SI from Rs.2 lakhs minimum to Rs.5 lakhs

maximum in multiples of Rs.50,000/-*sub limits for room rent applicable.*sublimit of 50% for any one illness.


Parivar policy*

*Any one illness means occurrence of same illness within 45 days from date of last consultation.

* Pre existing diseases Diabetes or/and Hypertension can be covered at applicable extra premium loading.

• For such claims : 10% co-payment, if suffering from diabetes or hypertension or 25% co-payment if suffering from both diabetes and hypertension.

• * may vary from each Company.

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Varista* Medical cover to Senior citizens above the age group

of 60-80 yrs Renewal up to 90 years. Section I : Hospitalization and Dom hospitalisation-Rs.

1 lakh Section II: Critical illness cover as a benefit policy- Rs.

2 lakh Insured has to bear 10% of each claim payable . CB available / alternatively discount can be given. Pre-existing diseases will be covered after one claim

free year of the policy Diabetes and Hypertension excluding any ailment

already manifested due to the same can be covered from inception at addl premium

Cost of health checkup available is available after 3 Claims-free years @ 2% of SI.


National(Individual) Mediclaim

Mediclaim Policy covers insured persons for their Hospitalisation Medical expenses as in- patient for major ailments/diseases ,accidental injuries treatment , including surgical interventions.

Ayurveda and Homeopathy Treatments are admissible up to 20% of S I . No Sub Limits for these 2 Streams of Medicine.

No Sub Limits for Treatment in PPN Hospitals. Domiciliary (outpatient)Treatment is not

covered under Mediclaim policies.

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Pre existing diseases are covered only after 4 continuous renewals

Entry Age group : 18 years to 65years * Renewals up to 85+ years Children above 3 months can be covered if

parents are covered same time.




Maternity Benefits are not covered in individual mediclaim policy, but can be covered for entire Group in GMP.

Family Discount of 10% on total premium is allowable if, spouse , dependent children, or dependent parents are covered in same policy.

Cumulative Bonus @5% for each claims- free year of policy. Maximum accumulation of 50%. For claims 10% reduction in CB.

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Cost of Health Check-up -1% of average SI without CB, for a block of 4 policy-years with our company.

Delay in renewals – grace period of 30 days allowed now, only for pre-existing ailments continuity cover and for CB. But no cover for gap period.

Excl: 4.2,,30 days waiting period for non accidental claims(Disease claims) if policy is new or additional limits opted.

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National(Individual) MediclaimWhat is covered

Medical expenses for 24 hrs or more hospitalization for Non-pre existing ailments or accidental injuries.

Less than 24 hrs hospitalization if advanced treatment packages are involved.

No Dental /Cosmetic treatment Sub limits apply. Ayurveda and Homeopathy treatments upto

20% of S I. * Ambulance Charges admissible: up to 1%of SI

Max Rs 2,000 in a Policy Period.*



What is covered *

A. Room Rent Boarding Nursing expenses: Room rent limits: 1% of Sum Insured per day subject to

maximum of Rs.5000/-. If admitted in IC unit 2% of sum insured per day subject to maximum of Rs.10,000/-.

Over all limit under this Head: 25% of SI per illness. B. Surgeon Anesthetist Medical practitioner,

consultants special fees. Maximum limit per illness -25% of SI

C. Anesthesia, Blood, Oxygen, OT charges, Surgical appliances, medicines, drugs, Diagnostic material &

X-ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs and cost of stent and implant. Maximum limit per illness- 50% of SI.

Any one illness : continuous period of illness and includes relapse within 45 days from the date of discharge from date of discharge from the hospital/nursing home. * may vary from each Company. 17

Other Important Features

Sum Insured : Rs.50,000 to Rs.5,00,000 in slabs of Rs.25000/- per head *

No floater cover /first loss policy under individual Mediclaim.

TPA services are Mandatory Definition of Hospital , surgical operation ,

post-hospitalization(60 days), pre- hospitalization(30 days).

ID Cards & Cash-less Hosp. treatments Reimbursement claims-Non-network

Hospitals. * may vary from each Company.

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National(Individual) Mediclaim Other Important Features

Claims intimation – 3 days of hospitalisation/injury/death.

Final claims submission -15 days of discharge from Hospital /completion of PHC.

We have an Obligation to renew the policy in time.

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Exclusions: 4.1 : Pre-existing diseases : means Any condition,

ailment, injury or related condition(s) for which Insured had signs or symptoms and/or were diagnosed and/or received medical advice/treatment within 48 months prior to your first policy with us.

Benefits for pre existing diseases will not be available for any condition(s) as defined in the policy until 48 months of continuous coverage have elapsed since inception of the first policy with us.

4.2 : First 30 Days waiting Period for Non-Accidental Claims

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National(Individual) Mediclaim Other Important Features

Exclusion 4.3: During the first one year : Benign ENT disorders

& surgeries like tonsillectomy adenoidectomy /mastoidectomy/ tympanoplasty.

During the first two years of policy: cataract, hysterectomy, hernia,piles,sinusitis,congenital internal diseases, diabetes, hypertension, calculus diseases etc

During the first four years of policy: Treatment for joint replacement due to degenerative conditions, age related osteoarthritis and osteoporosis

If these diseases are pre-existing at the time of proposal, will be covered only after four continuous claim free policy years.

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Other Important exclusions:

Injuries or diseases caused by war and war like operations.

Circumcision, vaccination, inoculation, cosmetic treatment, plastic surgery

Spectacles, contact lenses, hearing aids Dental treatment without hospitalisation Convalescence, general weakness, congenital, venereal

disease, sterility, self injury or alcohol use AIDS Diagnostic expenses without any disease Vitamins and tonics unrelated to treatment Diseases by nuclear weapons Naturopathy treatment

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Policies does have regulatory provisions for a grace period of 30 days for renewal.

Enhancement of sum insured S.I. can not be increased mid-term. On renewal if a

request is received, enhancement can be allowed provided

(I) S.I. up to Rs.5,00,000 Maximum at discretion of Company, subject to satisfactory Medical check up.

(II) Continuing or recurrent nature of diseases/ complaints

will be excluded from the scope of cover for enhanced S.I.

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National(Individual) MediclaimPre-acceptance health check up

Pre-acceptance health check up is mandatory. for proposers 50 years and above seeking insurance for the first

time as an individual or as a member of family.- Where there is break in insurance. - In case of enhancement of SI on renewal. Pre-acceptance health check up is not mandatory- if the policy holder submits satisfactory evidence/documents of

having held a health policy of other Insurers without break - Where the proposer is below 50 years of age. - For proposers above 50 years of age covered under any Health

Insurance Policy - Proposers other than above have to undergo pre acceptance

medical check up at their own cost. NIC will reimburse 50% Exp only. The reports to be submitted are

Physical examination Blood test, Urine sugar, Blood pressure, ECG, Eye check up

including retinoscopy, Lipid Profile and Serum Creatinine.*


Group and Tailor-made Policies.

Groups include- employer employee group and non employer employee groups like employee welfare association, holders of credit cards issued by a specific company, customers of a particular business where insurance is offered as an add on benefit, borrowers of bank, professional associations or societies where the president/secretary/manager/group organizer in his capacity as organizer of the group has an authority from majority of the members to arrange on their behalf.

In case of non-clarity about a group falling under is to be referred to IRDA.

A person negotiating group rates and then going around finding members to insure is considered an illegitimate group.

Entry or exit of members permitted from well defined date- anniversary of policy or first of following month.

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Group health policies provide: Large numbers and volume Lower administrative costs Experience rating Tailoring of benefits Group policy or tailor-made policies for group < than

1000 not allowed: (a) To help guard against adverse selection (b) Limited scope for risk pooling affecting sustainability

of the policy. © Probability of high variance by actual claims vis a vis

expected claims.

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Tailor-making of policies is done to meet with the specific requirement of claims and for covers not available in a standard group health policy.

Floater –purpose is to increase the number of persons under coverage of a family- spouse and children. Floater SI not to be less than Rs 2 lac.

Floater loading not to be less than 15% for spouse and 10% for each child.

If Parents covered in floater amount loading may be 25% minimum for each parent.

Maternity: Sum insured may be restricted to 20 to 25% of overall SI and not to exceed Rs 50,000/-.Load 15% on premium.

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Baby day one cover excluding pre birth disabilities- 5% loading.

Waiver of 9 months waiting period: 5% loading Waiver pre-existing disease: 10% Waiver of I month waiting and 1/2/4 years waiting:

25% loading for fresh policies. OPD treatment: 100% loading on sum insured opted. Addition of domiciliary hospitalization: Corporate Buffer: 10% on sum insured opted. Claims loading : as if 70% basis or rating on outgo

basis+TPA+Procurement costs+ Management expenses+ profit

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New Issues in Health Portfolio.

TPA Services are by and large compulsory. New SLAs (Service Level Agreements) are

entered into by NIC with TPAs effective from Aug 2012. These contain Performance based Fees payment replacing Fee payment as a % of Premium charged under Policies.

Claim Intimation Time Limits are imposed. Delayed Intimations can not be accepted by TPAs without Company waiver approval.

New TAT (Turn Around Timelines) are prescribed.

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PPN System (Preferred Provider Network of Hospitals)has come into operation in Mumbai, Delhi, Chennai, Bangalore, Hyderabad, Pune and Ahmedabad.

In PPN Hospitals, Cashless Treatment is rendered at Pre-Agreed Tariff rates for most of the Treatment Procedures. Hospitals are classified based on infrastructure and scale.

Where Treatment is taken in PPN Hospitals, for such Claims, Policy Head-wise Sub-Limits are not applicable.

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New Covers of TOP-UP and Super TOP-UP are now in use.

Top-Up Cover is cheaper and works above the Standard Mediclaim Policy as additional Cover. Any Single Claim exceeding (per Treatment) Mediclaim Policy SI Limits will be covered by TOP-UP policy.

Super Top-Up Cover is little costlier but cheaper than regular Mediclaim policy. It covers all treatments above Std Mediclaim policy, not per Treatment but for all Claims together.

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Mortality and Morbidity Studies are being done to improve the Premium rates for future.

Morbidity.. Disease-wise Data collection, age wise Morbidity rates and Epidemic and Endemic Disease spread are being analysed to draw insights on Morbidity rating patterns.

HIV and AIDS Coverage, in limited way, is contemplated by IRDA as a new measure in better coverage provisions with Medical advancements in the research field.

Non-Allopathy streams of Medical treatments are now being considered for reimbursements.

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Portability is now introduced. At renewal time Insured can switch-over to a New Health Insurer with similar benefits and Coverage.

45 days Prior Notice in Writing by Insured has to be given to Existing Insurer for such Switch-over and New Insurer can give benefit of Continuing Covers and Benefits only upon receiving Outgoing Insurer’s Confirmation and approval for Portability request received in time.

Portability is subject New Insurer’s Entry age and SI limits etc. for each policy request.

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Portability is applicable to Individual Mediclaim policies and Floater Policies other than Group Policies. At Renewal only this Option can be exercised.

Individuals under Group Policies can switch over to Individual policies and One Year there after can use Portability Option.

Portability is a right given to Insured to have the Benefit of Number of Years Policy is taken for Waiver of PED Cover Exclusions. And also entitlement for Cumulative Bonus and up to outgoing Policy S I.

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Thanks

K Sankara NarayanaManager NIC HRO

Hyderabad.Jan 2014

6 th Jan 2014.

Health Insurance- Updated Jan 2014 ..Ksn.

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Transcript of Health Insurance- Updated Jan 2014 ..Ksn.