Professional Documents
Culture Documents
Health Insurance N TPA by Poonam N Neha Bhaker
Health Insurance N TPA by Poonam N Neha Bhaker
&
THIRD PARTY
ADMINISTRATION
Customer
NGOs / SHGs /
MFIs Health Insurance
Industry Government
Insurance
TPAs companies
IRDA -
regulator
Introduction to Health
Insurance Policy
Provided by both private and public Cos.
Voluntary medical insurance program that provides
for reimbursement of hospitalization/domiciliary
hospitalization expenses/disease suffered/
accidental injuries sustained during policy period.
Includes :
Family floater (for families) mediclaim.
Health insurance or mediclaim for individuals and for senior
citizens.
Overseas travel insurance.
Mediclaim Policy
Instituted in 1986.
Eligibilty criteria - 5 to 80 years of age.
Premium – depends on age and sum insured.
Benefits – hospitalization benefits from Rs.15000 to
a maximum of Rs. 5,00,000.
Providers – any hospital with 15 beds or more
Exclusions – any pre-existing disease
Payment mode – reimbursement of bill by Co. or by
TPA is also possible. (premium – 6%)
Need For H.I Policy
According to Money Digest 2003:
and easily.
99% of Indians will face financial crunch in case of
critical illness.
Hence the need for Health Insurance.
Who does not need H.I???
One who is covered by his employer.
Community Based /
Private Social Micro Insurance
Existing Schemes Can Be
Categorized As:
(1) Voluntary health insurance schemes or
private-for-profit schemes;
Insurance
TPAs are BPO of company
insurance companies and
are responsible for premium reimbursement
Reimbursement
Enhancement
Claim settlement
CASHLESS You require hospitalization
HOSP.
Network hospital Non-Network hospital
Planned Emergency
Claim disapproval or
denial
PROBLEMS :
FACED BY TPAs :
Lack of proper communication
FACED BY HOSPITALS :
Lack of awareness of the procedure
limit
Claim reimbursement is also unnecessarily delayed in some
cases.
Health Insurance – Focus
Areas
Health Insurance - potential to
become a Rs.25000 crores industry
by 2012.
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Insurance
Company
COST DRIVERS IN HEALTH
INSURANCE
Technology / Specialization
Prescription Drugs
Medical Inflation
Moral Hazard / Adverse Selection
New treatments
Unnecessary treatments
PROBLEMS FROM INSURERS
Policy condition problems
Customer Ignorance
Pre-Existing Condition Issues
Disputes with hospitals / insured
Delays
PROBLEMS FROM TPAs
Lack of Infrastructure
“There are no holidays in Health care” yet
offices not open on holidays, telephone
access unavailable, etc
No qualified doctor / staff
Delay in claim-settlement
Deduction in bills without basis
Increased paperwork
SOLUTION :
Insurer
Designing a less complex products
Clarity in policy terms, conditions & exclusions
Efficient system for claims processing
Need for quicker services. E.g.: Toll free no's, cashless,
quick response
Expense analysis on a regular basis
Product innovation
Efficient training of sales force
SOLUTION :
Policyholder
Pay attention to policy conditions
very carefully
Compare premium costs, deductibles,
co-payments
Take an informed decision
SOLUTION :
Proper infrastructure
Speedy claim settlement process
Efficient staff.
SOLUTION :
Regulator/Government
Come out with health insurance regulations
Centralized data base for health insurance
experience statistics
Provider rating
Ensure that a decent portfolio of health
coverage represent the rural sector
Guard against ill effects of privatization
Further tax incentives
Compulsory savings towards health care
Recent Initiatives Of IRDA
Committee to formulate regulations
Pure health insurance products
Allowing the formation of an stand alone
health insurance company
Renewability/policy renovation
Senior citizens
Data management/data pool
Third party administrators.
Recent Concepts in H.I
Day care surgeries/
treatment covered
insurance.
Co-payment concept
Health insurance through
credit card.
Micro insurance.
Challenges in Health Insurance
Medical advance, both a challenge & also
impediment
Increase in health care cost
Ageing population
Acute shortage of trained personnel ranging
from doctors to health care administrators
New emergence and resurgence of old
diseases
CONCLUSION
Creating awareness & meeting the
demand for health care & financing
Creating modules for aligning the
services of all concerned
Focusing on enhancing affordability &
reducing costs
Rapid coverage and health benefit to all
WANT TO KNOW MORE???
www.healthinsuranceindia.org
www.expresshealthcare.in
www.google.com
Bussiness world
“While buying health insurance one is
also buying peace of mind, when one
may need hospitalization”
Thank You