Insurance companies should pay for Cataract check up/ surgery with a view to reduce Orthopedic Fracture Claims being submitted by senior citizens.

Insurance companies should pay for Cataract check up/ surgery with a view to reduce Orthopedic Fracture Claims being submitted by senior citizens.

Everyone knows that older people undergo eye surgery to remove cataract andconsequently they improve their vision. A large sample study undertaken in USA has revealed that there is correlation between poor eye sight and hip fractures among senior citizens. It is noticed that for senior citizens, there is significant reduction of their risk of breaking a hip in a fall in case they have undergone cataract surgery. This study also revealed that those in their early 80s experienced nearly 30% fewer Hip Fractures in comparison to those who had not underwent cataract surgery. 

According to Dr. Anne L Coleman, the study�s lead author and a professor of Ophthalmology at the Jules Stein Eye Institute at the University of California �it is desirable that senior citizens should go in for Cataract Surgery as and when required as:

• It is safe and low cost surgery in comparison to complex orthopedic hip fracture surgery.
• It reduces Orthopedic Fracture rate among senior citizens significantly and reduces monetary expenses as well as painful surgery/ physiotherapy exercises which the senior citizen has to undergo.
•  An orthopedic Fracture rate is 30% lower in case of those who have gone Cataract surgery.

We know that orthopedic fracture surgery costs Rs 1.20lakh to Rs 2.00lakhs against Cataract surgery which costs Rs. 20000 to Rs 30000.

This leads us to the thinking that Insurance Companies in India should encourage senior citizens to go in for eye check up at 60 years + at interval of 2 years and also encourage them to go in for Cataract Surgery, if required. This will save large amount of claims which are filed/going to be filed in future (population of senior citizens is going to increase in the country in the coming years) under the head of Orthopedic Fracture Claims.

I am 32 years old and was suffering from cholesterol a few months back but now it is normal. I have decided to take a health policy. If I mention about the high cholesterol, what are the chances for the policy getting rejected. What all should I check when taking a policy.

I am 32 years old and was suffering from cholesterol a few months back but now it is normal. I have decided to take a health policy. If I mention about the high cholesterol, what are the chances for the policy getting rejected. What all should I check when taking a policy.

The fact is that if you are having high cholesterol and you are taking medicine then cholesterol level should be coming normal whenever blood test is conducted.

The proposal form of insurance companies is having question.

For example in Oriental Insurance proposal form it is:-

1. Have you suffered from any of these following?


• High blood pressure
• Palpitation
• Heart Diseases including ischemic heart disease. Yes No
       

In Apollo Munich Health Insurance proposal form it is:-

• Hypertension
• Chest pain
• Ischemic heart disease  
• or any other cardiac disorder. Yes No      

You have to mention Yes or No against every question. Assuming you have replied yes then it will be for Insurance company to decide whether they should ask for medical examination to decide whether to 

• Issue the policy
• Refuse the policy
• Issue the policy with loading

Assuming you have replied No, then there is near to 100% chance that policy will be issued without medical examination. In the event of lodging of claim of high amount the Insurance Company may call for investigation and if it is proved that at the time of filling up of proposal form you were taking the medicine to bring down cholesterol level then they may say that heart ailment was preexisting disease and refuse to pay the claim.

It is up to you to decide which option you want to take.

Let us welcome Religare Health Insurance

Let us welcome Religare Health Insurance                                                                          

It is always good to have entry of a new Insurance company. There is a challenge for the new company to come out with new/innovative /attractive product.

Religare Health Insurance has become operational and has started doing business in July, 2012

Salient points of their policy are:

• Maximum sum Assured � Rs 60 Lakhs (highest in India)
• Yearly check up on free of cost basis.
• Overseas treatment permitted for those who have sum assured of Rs 50 Lakhs/ Rs 60 Lakhs.
• No age limit for entry
• Life long renewals
• In house claim settlement
• Restoration of sum assured after lodging/settlement  of claim

You will be interested to know the premium to be paid by someone for sum assured of Rs 50 Lakhs:

Family Floater for 2 adults of age group 61-65 years it is Rs 2, 58,360.

The good point is that insured is permitted to undergo treatment in foreign countries for critical/serious ailments/surgeries. This is to make clear that till now all health insurance policies were having the condition that insured can have treatment within India only.
 

Religare has taken a welcome step by permitting overseas treatment (for sum assured Rs 50 lakhs & Rs.60 lakhs).

You being a well informed person are aware of that Overseas Travel Policy does not permit you to travel abroad and get hospitalized for treatment of existing diseases.

For the same family -Family Floater for 2 adults of age group 61-65 years for sum assured of Rs 25 Lakhs the premium is Rs 47,958. But it permits treatment within India only.

The premium for Rs 50 Lakhs is not 2 times of the premium for Rs 25 Lakhs but it is 5.39 times or 439% higher.

Any Comment?

Health Insurance Portfolio � An Analysis

Few years back we were very enthusiastic about the growth of Health Insurance portfolio. This was especially true during 2007-08, when this portfolio grew from Rs 3210 Cr to Rs 5110 Cr. i.e by 59.20%. Let us look at the growth figures from 2006 to 2012:

% Growth of Health Insurance over the Years

We have drawn graph showing the % growth YOY and, it shows that figure is fluctuating and is becoming less and less attractive as years have passed by.

Graph Showing % Growth Year  Over Year

Let us try to make projections for next 6 years.
We have done this with growth rate of 12%, 20%, 30% & 60%.

Projections for Health Insurance Portfolio

If we achieve figure of 30% then the portfolio will be Rs 64414 Cr. in 2017-2018.

If some one asks me- What should be the growth with which you will be happy?- I will say it should not be 30% gross but it should be 30% net (as we have to discount for inflation of 10% per annum in normal costs and 20% per annum in health care costs). Let us not be satisfied with meager growth of 16%- let us aim for 60%.
It means we should have growth of 60% year over year and then the figure will reach Rs 223892 crores.

Is compulsory Co Payment of 20% in Group Health Insurance Policy a solution?

We understand that for controlling the losses of Health Insurance portfolio a circular has been issued by Ministry Of Finance to 4 PSU�s namely

• New
• National
• Oriental
• United

This circular has many guidelines out of which few guidelines are such, which are to be strictly followed:-

(i)     Co-payment (20%) shall be made compulsory in every Group Health Policy.

Let us see the implication

Employer- Should it pay this Co payment as and when any member of Group Health Insurance Policy undergoes hospitalization and lodges claims to the insurance company.

Employee- Should it be borne by him/her.

Employer is ready to pay higher premium (but without Co Payment clause) in the beginning so that it does not have uncertainly with respect to

• Payment under Co Payment clause.
• Funds planning.
• Avoid unnecessary paper work in accounts/ administration department of the company in dealing with copies of bills etc. In case employer pays this- taxation aspect also is to be taken care of as payment beyond Rs 15000 may have implication of TDS.

Is it that with this move an effort is being made to?

-          decelerate the growth of health insurance portfolio

-          Move business to Private sector companies?

What will be the repercussions of this?

Only Time will tell- let us wait.

Our suggestion is that insurance companies should be asked /instructed to give 2 quotations:-

Option 1- Premium with Co-payment 0% (as at present). We know it will be higher.

Option 2- Premium with Co-payment 20%. Let customers choose this option if budget is the constraint at their end.

Let the Market and the customer decide whether they need Option 1 or Option 2?

Your comments are invited by IRDA on draft Health Insurance Regulations 2012

Health Insurance emerged as an important segment of Indian Insurance Industry as a result of that various initiatives were taken by the following:

IRDA Regulations Health Companies with a view to consolidate various guidelines circulars/ instructions the reputation has released.

IRDA�s exposure draft on Insurance Regulatory and Development Authority (Health Insurance) Regulations 2012

This is a serious attempt to put various points in one document. Selected Points are:

� The IRDA (Policyholder Protection of Interest) Regulations, 2002 (hereinafter referred as �2002 Regulations� shall be applicable mutatis mutandis to all health insurance policies, wherever relevant.

� Entry and Exit Age:

? All health insurance policies shall provide for entry age at least up to 65 years, except for those referred in regulation. In health insurance policies, where the covers offered are specific to a particular age groups like maternity covers, children covered under a family floater policies, cover offered to students etc, insurers shall offer an option to migrate to a suitable health insurance policy, at the renewal of the policy or at the end of the specified exit age, by providing suitable credits for all the previous policy years, provided the policy has been maintained without break.

? All health insurance policies shall not have an exit age for renewal of the policies, once the proposal is accepted, provided policy is continuously renewed without break.

� Settlement of Claim: On receipt of complete documents, an insurer shall within a period of 30 days offer a settlement of the claim to the insured. If the insurer, for any reasons to be recording in writing and communicated to the insured, decides to reject a claim under the policy, it shall do so within a period of 30 days from the receipt of complete documents.

� Timeline for Submission of claims documents:

I. Insurer may stipulate a time limit latest by which the claims documents should be furnished by the policyholder/ insured to make a claim.

II. In case of non submission of timely submission of claims documents, insurers shall not repudiate such claims unless and until the reasons of delay are categorically enquired about, reasons recorded and the insurers sufficiently satisfy that the delayed claims could have otherwise been rejected if reported in time.

III. All insurers shall develop a sound mechanism of their own to handle such claims with utmost care and caution. The insurers shall incorporate additional wordings in the policy documents, suitably providing insurer�s decision to condone delay on merit for claims which are not submitted in time, but if substantiated by the insured that the delay is beyond his/her control and due to exceptional/ unavoidable circumstances.

You as a customer are the most important link- It is suggested that you should go into details of this 44 pages document and make suggestions to IRDA by June 30, 2012. Feel free to send comments to us.

Health care costs can definitely be reduced by using Generic Medicines Vs Branded Medicines

Various People have been discussing about inflation as well as increase in Health care costs in the country and how it is resulting in more and more families getting into debt trap. The statement of our Health Minister Mr. Ghulam Nabi Azad that every year more than 3.50 crores families get into below the poverty line is an eye opener.

Aamir Khan also realized this as a major social and economic problem of Indian society and has covered this in his TV show �Satyamev Jayate� on May 27, 2012. I was also highly impressed and pleased to read his informative article in HT- May 28, 2012.
An interesting point raised by Aamir is by giving facts & figures of some diseases, medicines, price and difference in the price of branded vs. generic medicines.

Question before us is: - Can hospitalization costs be reduced by using generic medicines?

Yes, we feel definitely the cost can be reduced. The general impression in the market is that quality of branded medicines and that too of reputed companies is much better. Is it correct or is it the impression of common man. Test labs of Government/ Non Government/ even NGO�s can play a significant role in the country by bringing out results- publicize them through print/ electronic/ internet/ Social Media.

There seems to be potential of reducing health insurance claims (paid by insurance companies) by 10% and this can be 10% of Rs 19000 crores- straight Rs 1900 crores. It is a significant figure. Let us try to achieve it for betterment of our society.