Current Regulatory RequirementThough not mandatory by law but a progressive

employer is expected to provide health facilities to their employees.

There are some mandatory provisions such as workmen compensation / ESI but they have limited coverage.

In some of the countries providing healthcare for employees is a must

In such cases , maternity , dental and optical treatment and the expenses thereon are normally not given.

There are many ways of extending medical facilities to the employees.

Medical insurance is one such step.

Systems in use – Health Management

Depending up on the size / decision of management ,we find different solutions of health management

The Small and Medium size organizations have the system of reimbursement of the actual expenses.

Some of them even have the system of medical allowance on monthly basis.

Few big organizations have their own medical facility set up and in a way it is self managed

Group Medical insurance is getting accepted as a wholesome solution .

Need for health insurance

For Employers it gives an opportunity to outsource this non-core activity.

It provides a cover against unexpected health related expenses – helps in financial planning & cost saving.

For employees – it provides a wider range of medical facilities.

Depending up on the coverage – specialized treatment abroad / special care can be arranged.

Control on leakages – Managed by professionals Provides far wide options for the employees –

Geographical sense

Present & Future Ahead

At present < 15% population in india has some sort of health insurance . Out of pocket health expense is around 86%

No wonder - Health Insurance is the fasted growing segment in insurance business.

Premium income has gone up from Rs. 2221 Cr in 2005-06 to Rs. 13975 Cr. In 2012-13 – CAGR 30%

Commission pay out was Rs. 876 Cr. In 2012-13 – means bulk of the business is thru direct channel

Incurred Claim ration 96.43 - a bit improvementFuture is promising as there is a growing concern for the

health care and empoloyee are becoming more & more demanding.

Govt. too is thinking of providing some universal health care on the lines of RSBY

Stake holders

EmployeesEmployerGovt. Regulations / RegulatorsIntermediaries (Agents/ Brokers)Insurance Companies (Reinsurance Co.)TPAs / Internal Claim settlement Medical Service Providers IT network

Insurance vs. Cost Management

Unlike other forms of insurance Medical insurance is more of cost management nature

The frequency of claim and related costs are more or less similar and consistent over the period.

The pricing is more dependent on the past claims history than the technical parameters.

The success of Medical Schemes depends much on the approach of the Management and the co-ordination of all involved.

Market Realities

There is a very cut-throat competition in market

Group Medical is a big bargaining point for clients to place other lines of business

Companies are looking for the lowest possible rates irrespective of their claims experience

Normally claim experiences are not favourable This has resulted into frequent shifting of the

portfolio from one Company to another.

Essentials for success

Understanding of the basic needs of the customer

Simple product features with least deviation from the universal and standard norms.

Having least possible feature and sub-limits.Regular communication between all concerned Limiting the number of Service Outlets.Emphasis on quality delivery which need not

be the costliest.Optimum pricing Continuous feedback / corrective measures

Important Product Features Annual Max. Limit (Flexibility)Sub-limits Provision of Pre-Existing ConditionWide option of Geographical coverage

(Abroad/USA )Tie –up in other counties In-patient / Out-patient Discount for limiting outpatient limit as a % of

AMLWide & attractive options of deductible Improved Group / favorable loss ratio discount Gate-keeper / Preventive schemes

Standard Exclusions….

Aids/HIVInfertility, In-vitro fertilization, SurrogacyPsychiatric, mental retardation, Alzheimer and

similar degenerative diseasesCongenital disease, malformations or

malfunctionsOncology, Kidney dialysis, Hormone replacement,

Bone densitometory, Tumours, Development problems, Physical aids

Organ donationExpenses for homecare, sanatoriums, long term

care facilities and similar institutionsEpidemics declared by Government/WHO

Standard Exclusions

Regular/Preventive health check upsExpenses for work related injuries/accident as these are

covered under WC policy – mandatory in OmanElective Treatment received outside area of coverHealth Spas/Nature Cure Clinics etcPlastic and cosmetic surgery and beauty related skin

treatmentVitamins and supplements, medicated shampoos, mouth

washAny treatment which only offers temporary relief of

symptoms rather than dealing with the underlying medical conditions

Treatment following drugs or substance abuse Injuries from playing professional sport or from any

dangerous sport and activity

Claim Settlement

The enrolled members are provided individual medical card & that takes care of all expenses at network clinics with in the permissible limits.

Almost 90-95% of the billing is thru cards only.

For non-network clinics and the facilities having sub-limits , the customer need to pay the bill him/herself to the service provider and take reimbursement subsequently.

Medical Cards

The Medical Card contains the following information & provides the bearer medical services within the scope of the Medical Policy.

Name of MemberDate of Birth , Unique identity no Name of the companyValidity period of the cardBroad Coverage details , restrictionsDeductible , if any and Hotline / Contact no for assistance and

clarifications in case of difficulties.

Reimbursement of Cash Claims

Medical expenses incurred at non designated Medical Service Providers are covered subject to customary costs of network hospital or as per the policy provisions.

Claims papers are to be submitted to the insurance company on monthly basis.

The claim must be supported by # Cash Claim Form duly filled in and signed by the

Doctor # Prescriptions # Original Bills – clear break up of amounts in case of

multi prescriptions, # Original diagnostic reports The bills are scrutinized and payment is made to the Client.

The average turn around time would be around 15 days.

Pre - ApprovalsAll non emergency cases that need

hospitalization for medical or surgical treatment.

Chronic medications for more than 1 monthMedical tests etc. beyond a normal

/prescribed limit Endoscopies, EEG, ECGMRI Scans and CT ScansFacilities having sub-limitsHowever in case of emergency hospitalization

no such approval is required. Intimation with in 24 hours.

Claim Process – essentials

Tie up reputed TPA having high volume of business / IT infrastructure

Network availability in promised locations24*7 customer helpline by TPAsAvailability of Ins. Co official for TPA support Claim processing by experienced

professionalsPossibility of Expert / Second opinion Cost reduction – better discount from

providers