Medicare Expands List of ‘No-Pay’ Hospital Conditions

The list of hospital treatments that Medicare won’t pay for is growing, but not by as much as the feds initially suggested it might.

The Centers for Medicare and Medicaid Services said last year it would stop paying to treat certain complications it said were preventable with good care. (We described the initial list in this post.) Earlier this year, CMS said it could add nine more complications to the list.

CMS said yesterday that after considering public comments, it was adding three conditions:

Blood clots in patients after surgery for knee and hip replacements
Surgical site infections after certain elective procedures, including some orthopedic surgeries and bariatric surgery
Certain major problems that result from failing to control blood sugar levels after a patient is hospitalized
It’s pretty easy to agree that Medicare shouldn’t be paying for preventable errors, such as leaving items inside patients during surgery (one of the conditions on the initial no-pay list). But there are arguments from some quarters that the new items on the list aren’t always preventable, and therefore don’t belong on the no-pay list.

For example, even with the best treatment, blood clots remain relatively common in patients after knee and hip replacements, according to the Society of Hospital Medicine, a national group of hospital-based docs. What’s more, the new rules could add incentives for hospitals to over-use blood thinners in an effort to drive rates down, Patrcick Torcson, who chairs the society’s performance and standards committee, told the Health Blog today.

On the other hand, the blood sugar-related conditions are appropriate for the no-pay list because “complications from uncontrolled blood sugars in diabetics can be reasonably prevented” in hospitalized patients, Torcson said.

Source: Health Blog(The Wall Street Journal)

Max India in JV with UK health insurance major

NEW DELHI: Healthcare and insurance company, Max India, has forayed into health insurance through a joint venture with UK health insurance major, British United Provident Association (BUPA). Max India will hold 50% in the JV, promoter and chairman Analjit Singh and his family will hold 24%, and BUPA will hold the remaining 26%, reports Our Bureau.

BUPA has the option of raising its stake in the JV to 50% when the sector opens up. The JV, Max Bupa Health Insurance, will initially invest Rs 100 crore, a Max India release said. This is Max India’s second venture in the insurance sector. It already has a 26:74 general insurance JV with US-based New York Life Insurance.

“We have been interested in the health insurance sector for a long time, but were waiting for some regulatory reforms to take place. Our decision to partner with BUPA was based on the synergies and unique strengths that BUPA brings to this venture,” said Max India chairman, Analjit Singh.

. BUPA has the expertise in creating and delivering differentiated health-insurance products and a proven ability to operate in and adapt to international health care markets. Through Max India, we will capitalise on our knowledge and experience in the health and life insurance sectors,”

Mr Singh told ET that BUPA was the market leader in the health insurance sector in most of the market it operates. ‘It has a 45% market share in the UK health insurance market. It is the market leader in Spain, in Europe and in emerging markets,’’ he said.

BUPA group chief executive, Ray King, said, “The Indian health insurance market has massive potential, with a growing, young, population. We believe that many of its citizens will be looking for the high quality of care and customer service that Max BUPA will be well placed to offer.”

Health Insurance is a under penetrated market in India, a country where about 70% of the healthcare spend is in the private sector. According to industry estimates, the country’s healthcare spend is expected to touch Rs 3,33,480 crore by 2012 from Rs 1,53,330 in 2006. But less than 2% of the country’s population have any private health related insurance covering.

Source: Economic Times

HEALTH IS WEALTH FOR INSURANCE GIANTS

New Delhi: Post de-tariffing, if fire and engineering are making holes in the balance sheets of non-life insurance companies, it is the retail business — health and motor — that is raking in the moolah. The two sectors account for almost two-third of the Rs 28,126.4 crore general insurance industry.

While the health insurance premium for non-life insurers shot up 55 per cent to Rs 4,969 crore in 2007-08, motor insurance posted a more modest 20 per cent growth during the year. The industry as a whole grew just 12.5 per cent during the year compared with Rs 24, 998.4 crore in 2006-07.

According to an IRDA report card, Reliance General Insurance — with nearly 7 per cent market share — has booked the highest jump in health insurance premium. It collected Rs 257.62 crore, up 307 per cent as against Rs 67.69 crore in 2006-07. The biggest non-life insurer, state-owned New India Assurance, collected nearly Rs 114 crore, 58 per cent more than the previous year. For other major players such as National Insurance, United India and Bajaj Allainz too, the health business premia rose by 105 per cent, 60 per cent and 53 per cent, respectively.

"With the fall in the prices of engineering and fire premia, insurance companies are now focusing more on the retail lines – motor and health," says T Ramalingam, head (underwriting), Bajaj Allianz General Insurance. "Before de-tariffing, group health insurance was bundled with property insurance and offered at a subsidised rate. With de-tariff kicking in, insurance premium for property has come down and medical insurance costs has risen. This has further led to a rise in premium collection for health insurance."

The health insurance sector in the country has witnessed rapid growth since insurance liberalisation in 2001. The premium has grown from Rs 774 crore in 2001, to Rs 3,300 crore in 2006-07. The sector is expected to maintain momentum and grow at a CAGR of 40 per cent in future.

"De-tariffing has led to hectic competition and at present market-driven rates prevail. Owing to this, everybody is slowly shifting to the more stable segments, i.e., the retail segment — motor and health. Health segment is growing fast at the rate of more than 30 per cent. This 30-35 per cent growth rate is expected to continue for the next two-three years," says M Ramadoss, chairman and managing director Oriental Insurance.

Motor insurance is further classified into own damage and third-party. While premium for own damage motor insurance saw a sluggish growth at 8 per cent, it is the third party motor insurance that booked a 50 per cent rise in premium collection. “The spurt in the premium collection for third party motor insurance is primarily due to the creation of pool from April 1, 2007,” says Rahul Aggarwal, CEO of Optima Insurance Brokers. “The move has encouraged a lot of small companies for third party underwriting.”

Source: Suneeti Ahuja
The Indian Express

FEATURES OF NEW HEALTH INSURANCE SCHEME EXPLAINED

Tuticorin: The district administration conducted an awareness programme at the Treasury here on Wednesday to highlight the salient features of the ‘New Health Insurance Scheme’ (NHIS) introduced by the State Government last month.

The scheme is being implemented under the control of Director of Treasuries and Accounts. Addressing government officials, D. Ganesan, District Treasury Officer, said that the scheme, which replaced the Tamil Nadu Government Employees’ Health Fund Scheme, offers wider coverage extending health insurance to employees of all departments, local bodies, public sector undertakings, statutory boards and state universities, and their families.

“About 21,000 employees and their families in the district are being benefited by the scheme,” he added. The family members of the employees entitled to the coverage include spouse, children till they got employed, married or attained 25 years, whichever was the earliest, and parents if the employee was unmarried.

“The new package provides cashless assistance at an affordable premium of Rs.25 a month, which is being deducted from the employees’ salary, instead of the reimbursement model followed under the earlier scheme,” Mr. Ganesan said.

The insurance company identified to provide the coverage (Star Health and Allied Insurance Company) would reimburse the medical expenses up to Rs.2 lakh for a family for a block of four years, directly to the ‘approved hospitals’ identified for the scheme.

In the district, Sundaram Arulraj Hospital, K. J. Nursing Home, Rajam Nursing Home (all in Tuticorin town), and Aarthy Hospital, Venkateswara Hospital (both in Kovilpatti), would provide medical assistance.

The insurance company would issue identity cards to all the employees carrying details about them and their family members before August 31, to help them display their identification while availing treatment at the said hospitals.

Mr. Ganesan said that cost of medicines of laparoscopic, cardiac and emergency life saving surgeries, doctor fees, room charges, diagnostic charges and dietary charges, incurred at the ‘approved hospitals’, would be reimbursed. The District Public Relations Officer, S.R. Sarathy, was present.

Source: The Hindu

Anil Ambani co plans to roll out home-based health venture

The World Health Organisation (WHO) projects that by 2015, India will face an estimated annual loss in national income of $54 billion on account of chronic diseases

Mumbai: The Anil Ambani-controlled Reliance Health Venture Ltd plans to roll out India’s first home-based disease management service through a wholly owned company, Medybiz.
Disease management, a concept popular in developed countries where medical insurance plays a vital role in health care, is a subscription-based business involving a panel of doctors, paramedical staff, diagnostics laboratories and drug supply chains to help patients control the pace of disease progression and enable faster recovery.
Medybiz executives will approach patients at their homes, offering comprehensive packages for disease management, including medical advice, diagnostics, follow-up treatment and medicine supplies. The home-based services will be based on an annual subscription.
Medybiz, which will also offer lifestyle health management services, says it has already appointed 120 executives to sign up subscribers and expects to add 280 more in the next two months, according to a person familiar with the development.
“Our teams of medical specialists are currently finalising the home-based disease management services to address various chronic ailments,” a Medybiz spokesman said. “These home-based programmes have been designed to help people change unhealthy lifestyles that lead to chronic diseases, improve self-care skills during an illness and make cost-effective healthcare decisions.”
The disease management service is in addition to Reliance’s ambitious plans for its health care business. It already runs medical insurance and hospital businesses.
The World Health Organisation (WHO) projects that by 2015, India will face an estimated annual loss in national income of $54 billion on account of chronic diseases. This will rank India as the second-fastest growing health risk economy after China.
Medybiz is finalising its home-based disease management programmes to address chronic ailments such as cancer and diabetes, orthopaedic disorders such as rheumatoid arthritis and osteoarthritis, neurological disorders including Alzheimer’s disease and Parkinson’s disease, and respiratory disorders such as asthma, the same person familiar with the development said.
Reeni Edward Kennedy, a housewife in a northern suburb in Mumbai, who has subscribed to the Medybiz service, said proper and strict administration of health care services in the comfort of a patient’s home facilitates quicker rehabilitation and recovery.
“Though we want quality service and continuous monitoring, we are price-sensitive. Therefore, it will purely depends on what Medybiz is going to charge us,” she said.

Source: Livemint

Corporates pruning health insurance cover for staff

Mumbai: Many corporates, particularly top IT companies and BPOs, are pruning the health insurance coverage for their staff, following sharp increase in premium rates. Some corporates have even taken away parents of employees from their group insurance scheme, restricting the benefit only to the staff.

IT companies, which have traditionally offered substantial health covers for their staff as a human resource incentive, are now choosing to cut costs either by introducing a co-payment structure (where an employee has to partly bear the cost) or by doing away with the cover altogether, they said.

“IT companies are reacting to the twin but unrelated threats of business recession and increase in health insurance premium rates by tweaking benefits and coverage. BPOs, for instance, where traditionally attrition has been high, are cutting down on coverage for parents,” said Mr V.G. Dhanasekaran, Vice-President and Regional Head – South, India Insure Risk Management & Insurance Broking Services P Ltd. India Insure handles several group health insurance accounts.

“Some have either reduced the overall limits or brought in sub-limits within the overall floater limit for parents. Co-payment has been introduced in several policies,” he said.

The insurance restrictions come in the wake of high claims from parents.

“The overall claims ratio in the corporate group health portfolio is high — up to 150 per cent. Around 60 per cent of the claims in this segment come from parents of employees. So, the cover is either being spun out of the scope of coverage or co-payment has been put in,” said Mr Girish Rao, Managing Director, Swiss Re Healthcare Services.

“Covers for employees have also been restricted. So, junior employees may have access only to twin sharing rooms in hospitals, employees in the middle rung may be given a single room and senior officials may have air conditioned rooms, he added.

Owing to their high staff strength, IT, ITeS and BPO companies are the biggest buyers of group policies, followed by other services companies, manufacturers and media houses.

Since the beginning of the free pricing regime, insurance companies have raised rates on their group health policies since they no longer require to cross-subsidise it against the more profitable corporate property insurance policies.

In the last 6 months, premium rates have gone up by 25-40 per cent on group health covers but the claims still far outweigh the premium. Insurers still want to have big corporate names as their clients, even at a cost.

An insurer accepted renewal of the health cover by a leading IT company for Rs 25 crore in spite of it suffering claims of around Rs 35 crore in the previous year.

Likewise, a leading BPO which had reported claims of over Rs 9 crore in the previous year, renewed its policy for just Rs 6 crore.

Some experts argue that the individual customers are paying higher premium and end up subsidising for the corporates.

“While premium for individuals has gone by an average of 10-50 per cent, the increase has not been in the same proportion for corporates,” said Dr Sandeep Dadia, Director, Enam Insurance Brokers.

The health insurance market currently stands at Rs 4,000 crore in terms of premium of which 40 per cent comes from corporate health insurance.

Source: Business Line

Centre-sponsored health insurance scheme for BPL families soon

TIRUNELVELI: Getting advanced medical assistance with government aid from a well-equipped private hospital for the below poverty line families of the district is no longer a dream as the recently introduced Rashtriya Swasthya Bima Yojana will come into force here within next 30 days.
The objective of this health insurance scheme is protecting BPL households with unorganised sector workers without any age limit from 700-odd ailments that involve even hospitalisation with a cost of up to Rs.30,000 per annum for a nominal registration fee of Rs.30. The coverage extends to the head of households, spouse and up to three dependent children or parents.
An annual premium of Rs.700 to be paid by the beneficiaries would be shared by the Centre (75 per cent) and State (25 per cent) governments and hence the beneficiary families would have to bear only the nominal registration charges.
Since the district administration has already completed the exercise of preparing the electronic list of eligible BPL households to be provided to the insurer, United India Insurance, according to a pre-specified format, it would be soon posted in each village prior to the enrolment and the date and location for enrolment would be publicised in advance.
Mobile stations equipped with the hardware required to collect biometric information (fingerprints) of the members of the household would be set up in public places like schools.
Based on the information collected from the BPL families smart cards with a photo of the family head will be printed.
Smart card
The smart card along with an information pamphlet describing the scheme and the list of hospitals would be issued on the spot once the beneficiary pays the registration charge of Rs.30.
On showing the smart card in the select hospitals the patients could avail themselves of the medical assistance.
In Tirunelveli district, one of the two districts in the entire State (the other district is Kancheepuram) selected for this programme, distribution of smart cards was expected to commence within 30 days, informed District Collector (In-Charge), G. Srinivasan, who explained the salient features of this Centre-sponsored health insurance scheme in the district planning committee meeting here on Wednesday.

Source: The Hindu

VIOLATION OF NORMS FAILED INSURANCE SCHEME

Thiruvananthapuram: A new health insurance scheme covering below poverty line (BPL) and above poverty line (APL) sections may not have materialised yet in the State, but a health and accident insurance scheme for BPL families proposed by the previous United Democratic Front government failed to take off since it was drawn up in violation of norms.

Before striking an agreement, the then government is learnt to have invested substantial sums with a private insurance company in the name of the scheme. The premium envisaged was Rs.399 for a family. It was largely based on a subsidy of Rs.300 for a family from the Universal Health Insurance Scheme (UHIS). The rest was to be shared equally by the beneficiaries, State government and local self-government institutions.
Official sources told The Hindu that the proposal to sign the agreement on January 3, 2006, did not work out, but a sum of Rs.7,098,0265 was invested with the company in February 2006.

The scheme turned out to be a non-starter since it was against the norms of the Insurance Regulatory Development Authority (IRDA) and the UHIS. The Centre is understood to have told the State government that the norms did not permit the government to associate with a private company. Still, the government proceeded with the proposal and deposited the funds, the sources said.

Moreover, during the initial negotiations, the company offered to get the subsidy from the Centre. Once the implementation schedule went awry, the then executive director of Kudumabsree wrote a letter to the company on February 22, 2006 saying that the agreement could be signed on March 2, 2006, to which there was no response.

The scheme could not be commenced owing to the delay in getting Rs.300 per family from the Centre. The company retracted from its commitment to securing the subsidy.
It was after a protracted correspondence that the government managed to secure the amount from the company. Now, refunding a sum of Rs.72,70,288 collected by the local bodies has become a difficult proposition for the government and it has been decided to use the funds for the new scheme proposed to be launched soon, the sources said.

Source: N.J. Nair
The Hindu

GROUP INSURANCE IS A GOOD BET

Mumbai: You may have faced hardships while procuring a mediclaim policy for your ageing parents. Even the agents must have quoted exorbitant premium rates for a policy to cover pre-existing diseases, if any.

The group insurance policy may be the right choice for you. Insurance companies, which deny taking patients altogether or bloat the premium figures for a person whose health profile is not good, easily agree to the same when you go for a group insurance cover.
Group insurance policies have easy norms as the insurance companies have to spend less to clinch one policyholder.

Insurers consider that the chances of claims in a group insurance policy are less. A policyholder can get additional cover and can even negotiate for the premium rate, depending on the group profile.

Also, as Ajit Singh Dhingra, managing director of Prudent Insurance Brokers said, “The same type of cover is cheaper when taken under group.” The premium on a group policy depends on the number of members, the age profile they all come under, the area in which they stay and the number of claims that the company has experienced for a similar group.

The most common group policy which the salaried employees come across is the ‘Employees Group Mediclaim’. These days, most of the companies are using this insurance tool to either retain employees by including insurance benefit in the package or as a gesture towards employee welfare. However, many other groups too can be insured.

Even all the residents of a building, any social club, school students or a union can be insured. But, one cannot create a group just to get insurance, says Dhingra. “That is unfair. Insurance is not the intention of a group. The employees, club or building members have something in common and hence they form a group, which in turn is insurable,” he says.

The age of a group member is not a matter of concern for issuing a group insurance. Dhingra said, “We have also insured a group where one of its members was 101 years old.”

Most of these policies are family floaters, wherein the entire family of the group member, i.e. spouse, children and often parents, are covered. If one goes hunting for a family floater cover as an individual, the chances are bleak.

The best part is that none of the group members will undergo medical tests or give any declaration for good health. One reason for dropping the medical test may be, unlike individual health policy, all the pre-existing diseases are covered under a group policy.

In addition, the exclusion period of 90 days to one year that applies in individual policies is absent in group mediclaim. So, all the hospital expenses made since day one of the policy coming into effect can be claimed. “Under individual policy, claims for operations linked to cataract, hernia, fistula, etc cannot be made if done within a year of taking a policy. But, under group policy, they are immediately covered,” Dhingra says.

Maternity expenses can be claimed under group scheme. “Another unique feature is that employees and their spouses are covered for maternity expenses upto Rs 50,000 per delivery from the date of the employee joining the company, thus waiving the nine-month waiting period,” states a group policy from United India Insurance.

Not just for health insurance, but group covers are available for accident as well as term life insurance policies. Anybody who sells individual health insurance policy — an agent, broker or an insurance company sales person — can also sell group policies.

Source:
Daily News & Analysis
Khyati Dharamsi

NATIONAL HEALTH INSURANCE SCHEME

Chennai: Nearly 4.7 lakh families living below the poverty line in two districts in the State will be covered by the national health insurance scheme for unorganised workers in the next couple of months.

Inaugurating a State workshop on the Rashtriya Swasthya Bima Yojana (RSBY), Labour Minister T. M. Anbarasan said about Rs.5.5 crore would be spent by the State on the pilot scheme in Kancheepuram and Tirunelveli districts. The premium has been fixed at Rs.512 for a family of five with the State government’s share amounting to Rs.113.

Source: The Hindu

RISING HEALTH INSURANCE TO BOOST TPA BUSINESS

Mumbai: The ongoing focus on health insurance business is expected to provide the much needed boost to the third party administrator (TPA) business. TPAs provide the much needed linkage services to the customers and insurance Companies by managing the claims.

However they are not allowed to market health insurance products.
The business of health insurance which is offered by both life and general insurers are growing at 50% and is being encouraged by the Insurance Regulatory & Development Authority.

By 2012, the Indian TPA industry is expected to grow exponentially to Rs 15,000 crore in size in terms of value of premiums managed. With around 30 players, the current size of the TPA is estimated at Rs 4,400 crore and the business growing at 40%. The top five players have a market share of 60%.

Among the top ranking TPA players are TTK manages around premiums worth Rs 560 crore followed by MediAssist (premiums worth Rs 450 crore approx),and Paramount (with premiums worth Rs 400 crore approx), Raksha (premiums worth Rs 430 crore approx), Family Health Plan (premiums worth Rs 250 crore approx), MD India (premiums worth Rs 350 crore approx).

The life insurance behemoth Life Insurance Corporation(LIC) has now entered the health insurance market and has mobilised premium income of Rs 100 crores in last two months of 2007-08.

Observers say some Third Party Administrators (TPAs) in the Indian health insurance sector are spinning-off separate insurance brokerage firms or looking at strategic alliances with insurance brokers with a focus to improve overall business margins
Also some insurance brokers are looking at diversifying into TPA services or being strategically aligned to TPA service providers. Also some players in the TPA industry do not find the volumes and the fees economically lucrative proposition.

Source: The Financial Express

How to make the best use of cashless mediclaims

MUMBAI: Cashless hospitalisation is in today. If cashless were to be efficiently used, you can simply walk into a network hospital, flash your card and undertake treatment without paying a penny. But these “hassle-free” plans can actually end up being more painful for you. Here is a checklist which could come in handy at stressful times. If it’s a planned hospitalisation, talk to your third-party administrator (TPA). Get an estimate of the medical cost for your treatment and choose the hospital from the mentioned network accordingly. n Keep your mediclaim cards handy. Also, keep the contact details of your TPA. Check the list of network hospitals covered under your mediclaim policy along with the room specifications. Check the room details, as some mediclaim policies accommodate only simple air-conditioned rooms as against deluxe rooms, because of rising medical costs. Some policies also have imposed sub-limits. The most common sub-limits imposed by insurers are room rents, doctors’ fees and diagnostics. So, when you sign up for a policy, check if the insurer has assigned a maximum amount for a specific expense. If you have a sum insured of Rs 1 lakh and the insurer has capped your room rent at 1-1.5% of the sum insured, then your room rent cannot exceed Rs 1,000. Similarly, insurers cap the doctor’s fee at 25-30% of the bill amount. If the actual bill amount exceeds any of these sub-limits, then you will have to pay the balance from your pocket. Stay within the sum assured of your mediclaim. If you hail from a small or mid-sized town, you should look at a cover of Rs 2-3 lakh. If you reside in a metro, you should not look at covers less than Rs 4-5 lakh. Finally, cashless mediclaim does not cover OPD consultation/procedure done in pre-hospitalisation period. The recent budget has given an additional deduction of Rs 15,000 year under Section 80 D if you pay medical premiums for your parents. Earlier, you could avail of deduction up to Rs 15,000 per annum on the premium payment for dependent parents, spouse or children. The money should be on its way. Although there are administrative hassles in a cashless product, you can’t rule it out. It’s a must have in your financial kitty today.
ET

Wading through the dense jargon of health insurance

Have you ever tried to decipher an insurance policy? The words in the policy document might put you in a plight similar to that of Eeshan Awasthi, the little boy in Taare Zameen Par — where the teacher in the classroom is desperately trying to impart her ‘knowledge’ and the little boy is off in another world of his own!
Similarly, an insurance policy goes on and on, with most of the text going above the head of the policy holder. There’s a dazzling assortment of the preamble, clauses, sub-limits, coinsurance, definitions, notifications, fees, penalties, exclusions and warranties, to be read, re-read and understood. Despite this, one may not fully understand the document.Jargon! How we love it!
The insurance industry has its share of dense jargon that causes ambiguity and results in innumerable disputes. In this article, we try to simplify a few terms used in the health insurance policies, so that it will be easier for the reader to wade through it, the next time he reads.
Floater Policy: In a floater policy, there will be a single limit for the entire family. Any member of your family or all put together can claim up to this limit for which the policy has been taken. For example: Let us assume that you have a mediclaim floater policy for Rs 2 lakh for your entire family consisting of self, spouse and 2 children. The benefit of a floater policy is that if any member of your family gets hospitalised, he/she can claim up to Rs 2 lakh. The only condition being that the total amount which can be claimed during the year by the entire family irrespective of who claims it stands capped at Rs 2 lakh.
The floater policy is generally not given to individuals but is taken by corporates for their employees and their families.
Non floater policy or the standard policy: In case of a non floater policy, or a standard policy, there is a cap on the individual limit for each member of the family. Say self and spouse have a limit of Rs 75,000 each and 2 children for Rs 25,000 each. In this case, in case of hospitalisation of one of the children, for a bill amounting to Rs 40,000, the maximum reimbursement that can be made is Rs 25,000 only. Whereas had it been a floater policy, the full claim of Rs 40,000 can be made, subject to availability of this limit by not having claimed over Rs 1.60 lakh earlier during the year.
Waiting period
It’s the period of time specified in a health insurance policy, which must pass before your health insurance coverage pertaining to certain ailments can begin. For example: If one has a waiting period of one year for covering cataract, and one has been operated for cataract around 9 months after the policy commenced, the claim will not be payable.
Pre-existing diseases: A pre-existing medical condition is one wherein the ailment has been diagnosed (or medically treated by a doctor) before the policy commencement date.
Suppose a person had an angioplasty done before the date of the policy, then his cardiac condition would be considered a ‘pre-existing condition’. If he subsequently suffers a heart attack, the insurer would be entitled to refuse payment.
The claim is repudiated when the prior existing medical condition has a direct bearing upon the ailment for which the hospitalisation has now taken place.
This exclusion applies normally to all individual policies, whereas groups can negotiate for waiver.
TPA (Third Party Administrator): A TPA is an authorised agency, appointed by the insurance company, to take care of claim settlements in health insurance.
The claim settling function is outsourced by the insurer, in order to improve the efficiency of claim settlement.
Cashless Claim Settlement: When you opt for a cashless facility, you can avail medical treatment as an inpatient (only at an empanelled hospital — known as ‘network’) without paying the treatment costs upfront to the hospital. The insurer / TPA will directly settle the bill with the hospital. When you avail cashless facility, personal expenses like telephone charges, toiletries, health drinks etc will have to be borne by you.
Reimbursement Claim Settlement: When you opt for a reimbursement facility, all the bills related to the hospitalisation will have to be paid by you directly to the hospital.
After discharge, all the reports, bills and receipts must be submitted by you, along with the claim form to the insurer or TPA. After scrutiny of the same, the insurer/TPA will settle the claim and reimburse you the claimed amount.
Network hospital (empanelled): A hospital which has entered into an agreement with an insurer or a TPA to extend cashless facility.
Non-network hospitals: Those hospitals which do not have a tie-up with your insurer / TPA are called non-network hospitals and you cannot avail cashless facility at these hospitals. You have to pay first and claim later.
One of the most important things you can do as a policy-holder to avoid hassles during a claim is to review and understand the terms and conditions of the insurance policy.
If you have any questions, contact your agent/ broker/ insurer for an explanation. This helps you to avoid any misunderstanding.

Source: The Hindu

Rural India to Reap Benefits of E-health Services

HealthSprint, a healthcare IT company, in collaboration with various microinsurance service providers, is poised to offer e-health services to rural India. The company, through its e-health services offers transfer of healthcare data, appointments with specialists, health insurance coverage, Web-based searches for physicians, and online prescriptions and medical reports. In addition, the company offers customers' connectivity with neighborhood laboratories and pharmacies through technology-based systems. The company is planning to implement the rural Micro Health Insurance Project Network in a couple of months. Initially, it will cover rural areas in the states of AP, North Karnataka, and Gujarat. Through its e-health service, HealthSprint connects rural hospitals to those in metropolitan cities and rural customers with microinsurance companies. The platform is already operational in Bangalore, Mangalore, Pune, Chennai, Hyderabad, Vellore, and Delhi through major hospitals and nearly 10 health insurance companies. "We wish to touch 1 billion lives in the next 5 years and become one of the most credible Indian healthcare data exchange platforms in India to solve people's problems in a convenient and secure manner," said P. Rammohan, co-founder and MD, HealthSprint. The company has initiated an upgraded Web service platform that provides medical and financial information to payers and providers in the healthcare arena. It also offers state-of-the-art content management systems which plug in as a middleware in the portal. "This system enables the transformation of present paper-based claims management into electronic submission system in India", informs Brahmesh D. Jain, co-founder of HealthSprint.
"The idea is to provide a laptop, scanner and printer to rural hospitals that ensures effective communication of healthcare data to insurance companies and tertiary hospitals. We are expected to connect with nearly 1,000 hospitals, 2,000 pharmacies, and 2,500 diagnostic centers", added Jain. The company is setting up a venture with the SKS Microfinance, Hyderabad and Sewa Women's Co-operative Federation in Gujarat for e-health services. HealthSprint operates through a network of nearly 160 hospitals and has a partnership with Yos Technologies for the creation and maintenance of personal health records. The company operates health insurance information exchange system for patients, whose hospitalization expenses are settled directly by the healthcare insurance companies. In addition, it provides a corporate platform that allows firms to manage pre-employment and annual health checkups for employees online. "The company, through its portal, provides pre-policy health services and underwriting support to insurance companies. These platforms are communication-oriented and designed to enable transparency, speed, traceability and accountability across healthcare players," explains Rahul Shukla, co-founder and CEO, HealthSprint.

Source: CXOtoday.com

HealthSprint plans tie-up with microinsurers for rural services

HEALTHCARE IT services company Health-Sprint plans to expand its reach a hundred-fold in two years to five lakh patients a month and take e-health services to rural areas in tie-ups with microinsurance providers. By then, it expects to be connected through its internet portal to 1,000 hospitals, 2,000 pharmacies and 2,500 diagnostic centres, Brahmesh D Jain, one of the three co-founders, said. Among the 150 hospitals it currently has tieups with are the Manipal Group of Hospitals, the Wockhardt Group and St Johns Medical College Hospital. Through its portal, HealthSprint provides services such as the exchange of healthcare data, including health insurance procedures, searches for a specialists, scheduling appointments with doctors, securing medical reports and getting prescriptions online directly from hospitals. It also helps connect customers with labs and pharmacies in the neighbourhood. Its e-health services for rural areas will be launched in Gujarat and Andhra Pradesh by connecting rural hospitals to those in metropolitan cities and rural customers with microinsurance companies. It is in the process of tying up SKS Microfinance and the SEWA women’s cooperative federation in Gujarat for the venture. “The idea is to provide a laptop, a scanner and a printer to rural hospitals, which will help to communicate the healthcare data to microinsurance companies and tertiary hospitals,” Dr Jain said. HealthSprint also has a tie-up with Yos Technologies to collaborate for creation and maintenance of personal health records. The company’s health insurance information exchange platform is for patients whose hospitalisation expenses are settled directly by the insurance company. Its corporate healthcare platform allows firms to manage pre-employment and annual health checkups for employees online. For pre-policy health checkups, insurance companies can schedule appointments online for potential customers with networked labs and secure reports for underwriting policies speedily.

Source: The Economic Times

ORIENTAL GAME FOR $1M HEALTH COVER

Kolkata: Oriental Insurance Co Ltd, the Delhi-based non-life insurance major, is moving out of its public sector mindset and looking at the idea of a health policy with a cover of up to $1 million, which will entitle the insured to go for treatment anywhere in the world. M Ramadoss, chairman and managing director, said public sector insurance Companies like Oriental are usually directed into the low-end and 'Janata' segment, but there is no reason for them not to target high net worth individuals (HNIs), considering that the PSU insurers have the highest financial strength, the government's backing and longest-standing market presence.

"One person came to me recently and said he wants a health insurance product with a coverage of $1 million, and he can go anywhere in the world to receive treatment, but he was skeptical of our ability," Ramadoss said.

Against this cover of $1 million or Rs 4.37 crore, Oriental's highest health cover at present is Rs 5 lakh.

Ramadoss said the policy is at "a very preliminary stage, but nothing has been finalised so far."

"What I am saying is that in health, we should have a low premium, but we can also come up with very premium products, and there is no constraint," Ramadoss said. "People think only private Companies can do it."
Ramadoss pointed out that competition is increasing in the insurance segment, with more players entering the national scene and some even speaking of regional players. So it is imperative for PSU Companies to focus on service.

Source: The Financial Express

Insurers clip TPAs’ wings

Kolkata: Bugged by ‘upfront cash payment’ issues when admitting someone to hospital? Don’t worry, help is at hand.

General insurance companies covering over 85% of mediclaim policies issued in India have decided to make payments of claims directly to health service providers (or hospitals etc) through some private banks instead of routing the money through third-party administrators (TPAs) as is being done now.

Insurance companies, TPAs and health service providers have been into a blame-game over payment of claims for quite some time now.

Many hospitals and nursing homes have often refused to admit mediclaim patients through the “cashless” option.

Some hospitals refuse the cashless option even after upfront payments because of the delay in receiving the balance money from TPAs, “in some cases for 9-10 months” said a hospital executive.

G Srinivasan, chairman and managing director, United India, said the company has already initiated making payments through its designated banks instead of TPAs.

V Ramasaamy, chairman and managing director, National Insurance Company, and M Ramadoss, Oriental Insurance chief, are following suit.

TPAs will now process the claims and send it to the bank, which, in turn, will make the payment directly to the health service provider.

Insurance companies have been conducting quarterly reviews of TPAs, which involves auditing and checking of their records and flow of funds.

The potential of the health insurance, which is around Rs 5,500 crore at present is said to be Rs 40,000 crore by 2020 and expected to grow by 35% for the next five years.

Source: DNA Money

ISO CERTIFICATION TO BE MUST FOR ESI HOSPITALS

New Delhi: ESI hospitals providing healthcare facilities to workers covered under the Employees State Insurance Corporation (ESIC) will be soon required to have ISO certification. Minister of state for labour and employment Shri Oscar Fernandes has said that the certification will be made mandatory so that hospitals provide world class medical facilities to workers of both organised as well as unorganised sector.

In the first conference of revenue officers of ESIC, the minister said ESIC revenue officers should dedicate themselves to the cause of healthcare of workers and should aim at increasing the number of beneficiaries to at least 4 crores, same as EPF members.

The minister added that the doctors and staff at these hospitals would be given special training to meet the shortage of medical personnel in the country.

Labour and employment secretary Sudha Pillai said that the government will ensure that the insurance scheme is expanded to new areas. The latest figures show that during 2007-08, the scheme was implemented in 37 new areas covering nearly 98,000 workers. The total number of beneficiaries were 3.94 crore. During the year, contribution income increased to a record high of Rs 3,249 crore against the target of Rs 2,450 crore, thereby registering an increase of Rs 800 crore which is 32.61% higher than the target, Ms Pillai said.

The motive of this conference was to interact with field workers and make them aware about their role in the implementation of policies and programmes of the ESIC and the ministry. Insurance inspectors and other officials were also asked to improve efficiency so that delivery system could be improved.

Source: The Economic Times

United India Insurance launches new health product

United India Insurance Co Ltd unveiled a new health product called "Family Medicare Policy".

The policy covers family members under a single Sum Insured against hospitalisation expenses due to disease or accident and any family member can avail upto the entire sum during the policy period.

The proposer can be aged between 18 and 80 years and the family cover is available for Self, Spouse and dependent children. A wider range of Sum Insured options is also available starting from Rs one lakh to Rs 10 lakh. In addition, the policy also has add-on covers like ambulance charges, hospital daily cash and Section 80-D benefits.

Source: Insuremagic

ICICI Pru prims health to be key growth driver

Having emerged as one of the core areas of ICICI Prudential Life's portfolio in the last couple of years, the company is putting its efforts behind the health vertical to make it one of its major growth drivers.

Among the plans are variants of the flagship products like critical illness, hospital care and a crisis cover plan that includes cancer and diabetes care. The company also plans to explore the health savings and reimbursement category in future.

Binay Agarwala, senior VP and head, health business and corporate strategy, ICICI Prudential Life told DNA Money, "As a strategic initiative, the organisation energy in terms of marketing, actuarial and operation is dedicated to the health insurance space. Although the ticket size is small, the volumes have grown."

At present, over 10% of policies sold by the company are health policies.

What about competition from other private players also getting into health space?

"The idea is to make the bulk of sales beyond the Top 10 cities and this would be the major differentiator," Agarwala said, adding: "For many such customers, this will be the first of any health policy. We've created a comprehensive distribution scale by reaching out to 1,600 locations across India."

The health segment, which is dominated by indemnity plans (mediclaim) from general insurers, has seen the entry of almost all life players and has grown five-fold to Rs 5,000 crore from Rs 1,000 crore five years ago. Last year, health insurance business grew 63%.

"In the current year, there could be improved versions of some of our existing products like Diabetes Care. We will also think of new offerings keeping in mind the market dynamics and also profitability to both the customer and the company," Agarwala said.

Two new areas the company is likely to weigh are the savings-linked insurance plans and the reimbursement category. Both would help increase penetration of health insurance.

Internationally, health insurance with savings is a growing segment. But for this, much would depend whether health insurance plans qualify for tax benefits under Section 80D of the Income Tax Act.

Source: Nandini Goswami / DNA MONEY