Medical Insurance

Presented by:

Kanika Bagaria

BPT08 - 008

1
Introduction
Preventive
Treatment

Rehabilitation Prophylactic

HealthCare

Curative Early
Treatment Diagnosis

Awareness
&
Education

2
Health Sector Challenges

 Increase in health care costs

 High financial burden on the poor

 Need for long term and nursing care for senior citizens

 Increasing burden of new diseases and health risks

 Due to under funding, preventive and primary care and

public health functions are yet to meet their objectives.

3
Pre – Existing Disease

 Any condition, ailment or injury or related conditions for which

policy holder had signs or symptoms or was diagnosed or have
received treatment within 48 months prior to policy holder’s first
policy with the insurer.
 Benefits will not be available for any condition as defined in the
policy, until 48 months of continuous coverage have been passed.
 For some disease, pre existing diseases are cover after 4 yrs of
continuous renewal with the company.

4
 The policy holder usually benefits from cashless facility at
registered hospitals across the geography

 The policy holder can opt for hospitals besides the empanelled
ones
 In this the expenses incurred by him will be reimbursed
usually within 14 working days from the submission of all
documents.

5
 Pre hospitalization expenses cover relevant medical expenses
incurred usually 60 days prior to hospitalization
 Post hospitalization expenses cover relevant medical expenses
incurred usually 90 days after hospitalization
 For every claim free year, a cumulative bonus of defined percentage
is added to policy holder’ s sum assured.
 5% increase in Sum Insured every claim free year, subject to a
maximum accumulation of 10 claim free years i.e. maximum 50%
C.B
 Family discount of some percentage is also applicable

6
 No tests are required upto 45 years of age for a moderate sum
assured.

 Co – payment is applicable if treatment is taken at non

networked hospitals.

 Waiver of co – payment is often available on payment of

additional premium.

 Free health check-ups for some maximum amount paid at the

end of continuous multiple claim free years.

7
Reimbursement of expenses under
following heads is applicable:
 Room & boarding expenses as provided by the hospital /
nursing home.
 Nursing expenses
 Fees of surgeon, anesthetist, medical practitioner, consultant
& specialist
 Expenses on account of anesthesia, blood, oxygen, operation
theatre charges, surgical appliances, medicines & drugs,
diagnostic material, X-ray, dialysis, chemotherapy,
radiotherapy, cost of pacemaker, artificial limbs, and cost of
organs and similar expenses.

8
 Sub Limits applicable on the Expenses Covered.
 Room & boarding expenses as provided by the hospital / nursing home:
 Room rent limit : 1% of sum insured per day subject to a maximum amount of
defined amount (Rs. 5000 in 2008).
 ICU Expenses: 2% of sum insured per day subject to a maximum amount of
defined amount
 Overall limit under this head: 25% of sum insured per illness
 Fees of surgeon, anesthetist, medical practitioner, consultant & specialist:
 maximum limit per illness: 25% of sum insured
 Expenses on account of anesthesia, blood, oxygen, operation theatre charges, surgical
appliances, medicines & drugs, diagnostic material, X-ray, dialysis, chemotherapy,
radiotherapy, cost of pacemaker, artificial limbs :
 maximum limit per illness: 25% of sum insured
 Ambulance services: 1% of sum insured subject to a maximum of a defined amount
( Rs. 1000 in 2008)
 Hospitalization expenses of person donating an organ during the course of organ
transplant will also be payable subject to sub limits.

9
Business Policy-Medical Underwriting

The underwriting department is responsible for:

 Accepting or declining proposals pertaining to insurance of all

medical covers for individuals & groups

 The main objective is to maintain strong underwriting

profitability

10
Medical Underwriting:
Individual customers

11
 START Study the received request Rates & deductibles are to be
from the customer and per age, family/size
process the request based on guidelines of the treaty
chosen plan by the customer underwriter

A network of designated Price the applied medical

providers/in-house team insurance facility based on
administers the medical plan chosen by the customer
scheme

The company shall pre

The renewal of claims
approved the medical service
experience under this class is
providers and a separate
done on a fortnightly basis for
Service level agreement to be STOP
readjustment of rates & terms
signed with each provider for
smooth administration

12
Medical Underwriting – Group
Medical Insurance

13
 Underwrite all proposals for Any amendments or add on
group health insurance as per covers are to be authorized
START the guidelines of the treaty by the head of underwriting
underwriter

On renewal,
Depending on the group size,
the claim
A network of designated cover for pre existing
experience is
providers/in-house team conditions and chronic
conditions for group medical to be reviewed
administers the medical for
shall be decided by the head
scheme readjustment
of underwriting

Acceptance of The renewal of

The company shall pre stand-alone claims experience
STOP
approved the medical service business shall be under this class is
providers and a separate at the sole done on a quarterly
Service level agreement to be discretion and basis for monitoring
signed with each provider for approval of the and intimating the
smooth administration top management insured

14
Medical Underwriting:
Medical Claim

15

START Advice the customers to
obtain pre-authorized
approval prior to treatment
incase of inpatient treatments
For all claims subjected to
reimbursement, advice
customer to submit the
request within 45 days from
the date of treatment

Process all claims within the

period of 30 days from the Receive claim notification
date of submission of based on the plan either on
documents reimbursement basis/ direct
billing basis through the
network of hospitals

A network of designated
providers/in-house team are
appointed who administers
the medical scheme STOP

16
Medical Claims
 Depending on the plan, claims shall be submitted either on
reimbursement basis or direct billing basis through the network of
hospitals & pharmacies
 All claims are to be processed within a time frame of 30 days from
the date of submission of all documents
 All claims for inpatient treatment shall be preauthorized prior to the
treatment
 All claims for reimbursement should be submitted within 45 days
from the date of treatment
 Claims are to settled either by in house team or TPA

17
Claim Documents
1.Claim Form properly filled and signed by the claimant
2. Discharge Certificate from the hospital 
3. All documents pertaining to the illness starting from the date it was first
detected
 Bills, Receipts
 Cash Memos from hospital supported by proper prescription 
 Receipt and diagnostic test report supported by a note from the attending
medical practitioner/surgeon justifying
such diagnostics. Surgeon's certificate stating the nature of the operation
performed and surgeon's bill and receipt 
 Attending doctor's / consultant's / specialist's / anesthetist's bill and
receipt, and certificate regarding diagnosis
 Certificate from the attending medical practitioner / surgeon that the
patient is fully cured 
  

18
 Cashless Claim
 Cash Less facility is available only in network hospitals. In case the patient wants to be
referred to a network hospital the TPA needs to obtain the following documents from
the patient before issuing a preadmission authorization for cash less facility: 
 Original first prescription of the doctor referring the hospitalization, complete with
details of symptoms and diagnosis on his/her prescription letter head. 
 Hospitalization Form in the given format 
 Details of previous policies: if the details are not already available with TPA except
in case of accidents.
 In case information is not complete in the hospitalization form or if the history of the
disease is not confirmed, a preadmission authorization cannot be issued for cash less
facility. In such a case, if the patient is admitted in a network hospital, treatment will be
same as in the case of a non-network hospital. 
 The doctor must mention in the history sheet - the record of history of the disease,
relation to preexisting diseases like hypertension, diabetes etc if any and history of the
same.   

19
Important exclusions under mediclaim
policy
1 . Pre-existing diseases i.e. Any condition, ailment or injury or related condition(s)
for which insured person had signs or symptoms and/or was diagnosed and/or
received medical advice/treatment within 48 months prior to his/her health
policy with the company. Pre existing diseases will be covered after a maximum of
four years since the inception of the policy 
2. Any disease contracted during the first 30 days of inception of policy except in case
of injury arising out of accident 
3. Certain diseases such as cataract, piles, hernia, and sinusitis etc. are excluded for
specified periods if contracted or manifested during the currency of the policy. 
4. Injury or Diseases directly or indirectly attributable to War, Invasion, Act of
Foreign Enemy, War like operations.
5. Cosmetic, aesthetic treatment unless arising out of accident. 
6. Cost of spectacles, contact lenses and hearing aids

20
Important exclusions under mediclaim
policy
7. Charges incurred at Hospital or Nursing Home primarily for diagnostic,
x-ray or laboratory examinations, without any treatment. 
8. Naturopathy or other forms of local medication 
9. Pregnancy & childbirth related diseases 
10. Intentional self-injury / injury under influence of alcohol, drugs 
11. Diseases such as HIV or AIDS 
12. Expenses on vitamins and tonics unless forming part of treatment for
disease or injury as certified by the attending physician. 
13. Convalescence, general debility, run-down condition or test cure,
congenital external diseases or defects or anomalies, sterility, venereal
disease.

21
22
Thank you

23
Family Floater Policy
 Family Floater is a policy wherein the entire family of the insured,
comprising of insured, spouse and two dependent children, is covered under
single sum insured. 

The advantages of such a policy are: 

1. All members of the family (as defined above) can be covered under one
policy.

2.Single Premium is payable for the entire family.

3. The amount of Sum Insured floats over the entire family i.e. the limit can
be used by any member of the family and for any number of times. 

4. One does not have to keep a track of renewals for different members; a
single renewal date is to be remembered.   

24