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Health Insurance - Global
Practices
Health
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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
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Health Insurance - Global
Practices
Impression
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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
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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
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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
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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
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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 referred
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“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
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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
Contd
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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
 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
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Health Insurance - Global
Practices
contd
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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
Other definition (excerpts)
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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
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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
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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
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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 Insurance - Global
obligation to pay for service rendered
Practices
Pre-Hospitalization & Post
Hospitalization
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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
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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
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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
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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
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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
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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
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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
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“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
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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
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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)
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Naturopathy
Other company
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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
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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
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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
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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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Health Insurance - Global
Practices
Family Policy
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Insures both the policyholder & dependents
Spouse
Children
Health Insurance - Global
Practices
Senior Citizen Policy
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Persons 65 years of age and above
Supplementary to Medicare program
Health Insurance - Global
Practices
Group
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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
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Contribution by the employer and employee
At least 75% employees to be insured
Health Insurance - Global
Practices
Non-Contributory Plan
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Employer bears the full cost
All eligible employees to be covered
Health Insurance - Global
Practices
Cafeteria Plan
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Allows the participating employees
– To select among the displayed benefits using
predetermined amounts of the employer
Health Insurance - Global
Practices
Conversion Privilege
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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
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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
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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
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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
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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
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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
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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
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Sub-standard insurance
Restricts the benefits for the insured person’s
particular condition
Health Insurance - Global
Practices
Evidence of Insurability
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Statement or proof of a person’s physical
conditions
– Underwriting factor
Health Insurance - Global
Practices
Additional Purchase Option
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Permission to an insured to buy additional
insurance
– Need not provide evidence of insurability
Health Insurance - Global
Practices
Minimum Premium Plan
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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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Health Insurance - Global
Practices
Allocated Benefits
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Itemize the specific services
Limit the maximum amount for the benefits
Health Insurance - Global
Practices
Unallocated Benefit
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Reimbursement of Maximum limit
All extra miscellaneous hospital services
Does not specify amount for each service
Health Insurance - Global
Practices
Waiver of Premium Benefit
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Policy holder is exempted to pay the future
premiums
Totally disabled during the life of the contract
Health Insurance - Global
Practices
Ancillary Benefits
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Secondary Benefits
Added to the basic medical care
Lab, X-ray, ECG and other services
Health Insurance - Global
Practices
Duplication of Benefits
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Overlapping of identical cover in various
plans
Known as “Multiple Coverage”
Health Insurance - Global
Practices
Co-Ordination of Benefits
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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
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Increase or decrease or waiver of benefits
Alter the base contract
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Health Insurance - Global
Practices
Insuring Clause
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Refers the parties to the contract
Coverage of type of loss
Health Insurance - Global
Practices
Recurring Clause
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Recurrence of a condition
Continuation of a prior period of
hospitalization
India
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Any One Illness
Same confinement
Health Insurance - Global
Practices
Incontestable Clause
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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
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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
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Benefit Period
Cat Limit (Out of
Pocket Maximum)
Co-Insurance
Co-Payment
Corridor Deductible
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Deductible
Flat Deductible
Elimination Period
Waiting Period
Family Deductible
Provision
Health Insurance - Global
Practices
Benefit Period
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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
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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
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A fixed percentage of covered charges after
applying the deductible
80% covered charges means
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Deductible and 20% to be borne by the insured
Health Insurance - Global
Practices
Co-Payment
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One shall pay a fixed dollar amount for a
service or benefit provided by a plan
Health Insurance - Global
Practices
Corridor Deductible
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A deductible between the benefits paid by
the basic plan and beginning of supplemental
major medical plan
Health Insurance - Global
Practices
Deductible
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Pay before the plan pays benefits
– Calendar year deductible
 Individual
 Family
Inpatient hospital deductible
Flat Deductible
Percentage Deductible
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Health Insurance - Global
Practices
Contd
All Cause deductible
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Per Cause deductible
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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
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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
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Health Insurance - Global
Practices
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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
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Operational Effectiveness and Efficiency
Turnaround time and quality standard in
claims processing
Health Insurance - Global
Practices
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Health Insurance - Global
Practices
Health Maintenance Organization
(HMO)
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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)
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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)
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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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Health Insurance - Global
Practices
Levels of Nursing Care
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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
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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