Health Insurance

HISTORY OF HEALTH INSURANCE

Hamurabi Managed Care Circa 1700 BC

Health Insurance rules carved on a stone Codex Hammurabi Rates set for general surgery Fees set on ability to pay Owners to pay for slaves Consumers & Patient’s rights to be advertised

Modern Health Insurance

Blue Shield & Blue Cross (1st half 20th century )

Medicare (1960)

Medicaid (1960)

NHS (1946)

Prime Minister Health Ins Scheme

Jubilee life ; 1570

Adamjee ; 1272

Allianz EFU ; 994

Jubilee General; 801

IGI Life ; 411

AsiaCare; 340

Al-falah; 286

Others; 806

Gross Premium (Million)

Jubilee life 24%

Adamjee 20%

Allianz EFU 15%

Jubilee General12%

IGI Life 6%

AsiaCare5%

Alfalah4%

Others12%

Market size in (%)

Jubilee life Adamjee Allianz EFU Jubilee General IGI Life AsiaCare Alfalah IGI General

87%104%

94%

114%

102%

122%

92%

131%

75%

90%74%

83%81% 80% 79%

106%

Loss Ratio of Top 8 CompaniesWith Admin Exp Without Admin Exp

Heath Insurance Underwriting

• Hospitalization Premium

• Maternity

• OPD

H Hospitalization Premium

On average per year 10 % of Insured shall be hospitalized

10% of the insured Average hospital Bill

0-17 18-25 26-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74

0

2000

4000

6000

8000

10000

12000

14000

16000 Rise of premium with age

Premium

Age Premium % Loading or discount

0 - 17 1287 44 %

18 - 25 1543 _ 33 %

26 - 29 1794 _ 22 %

30 - 34 2048 _ 11 %

35 - 39 2297

40 - 44 2608 + 14 %

45 - 49 3054 + 33 %

50 - 59 4758 + 106 %

60 - 64 5956 + 160 %

65 - 69 7146 + 210 %

70 - 74 14294 + 520 %

Maternity Premium

On average 30% of Total Fertile ( below 45) shall avail maternity benefit

30 % of fertile female Average Maternity bill

OPD Premium

70 -- 90 % of the OPD Limit

Coverage• Inpatient Hospitalization / Surgery • Maternity• D & C / Missed abortion• Daycare procedures under local anesthesia• Cataract• Biopsy• MRI/ CT Scan• Endoscopy• Angioplasty / CABG• Chemotherapy• ICU

Exclusions• Dental• Cosmetic• Emergency / short stay• Hormonal therapy• External devices / Implants• Experimental treatment• Out of country planned treatment• Self inflicted / suicide • Sports injury• Psychiatric Treatment

Percentage of medical cost shared by the insured patient as agreed upon at the time of policy inception, with or without a cap limit

e.g 10% copayment means for a medical claim of Rs 10,000 insured shall pay Rs 1000 whilst insurance company shall pay Rs 9000

Deductible

A fixed amount ( regardless of cost of medical claim ) to be paid by the insured patient at the time of medical claim, as agreed at the time of policy inceptione.g Rs 2000 deductible means for a medical claim of Rs 20,000 insured shall pay Rs 2000whilst insurance company shall pay Rs 18,000

Pre existing conditions

Any disease ,condition or symptom for which the insured sought treatment , consultation or was aware of , before the inception of policy

Congenital disease

Any disease or condition present at the time of birth of new born

Panel Hospital Network

Reimbursement

• Policy of Reasonable & customary reimbursement

• REASONABLY AND CUSTOMARY (Bench Marking )• Hospitalization expenses for a particular surgical

procedure / conservative management by a panel hospital of similar standard in the vicinity

Case Management

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