To make Mediclaim logical, practical & efficient

At present less than 15% of Indian population having health insurance, means more than 85% people have not health insurance cover. They pay for health from their pockets.
In insurance sector, health insurance (mediclaim) also plays an important role.
However, for all general insurance companies health insurance (mediclaim) is loss-making segment.
In spite of increasing premium, every year insurance company’s loss of that particular (health) segment is also increasing.
Disputes between insurer and company are increasing day by day.
Private and corporate hospitals are charging tremendously for ordinary illnesses, which can be treated in clinic on OPD basis at nominal cost.
As medical personals, I observed the pattern of mediclaim functioning & claim settlement.
(1) Only indoor cases considered for claim.
(2) More than 50% of claims are from patients suffering from infectious diseases like malaria, typhoid, pneumonia, diarrhea, fever etc.
(3) All these type of cases are treated by family physician (called family doctor) routinely at an average cost of Rs.300 to Rs.3000 per case including investigations, medicines, and injections with intravenous therapy.
(4) But as per terms and conditions of mediclaim policy patient has to admit as indoor patient for at least 24 hour for reimbursement from mediclaim. So, patient who suffers from simple illness (like malaria, diarrhea, uti etc.), which can be treated as OPD basis at maximum 3000 Rs(inclusive of all) will be admitted in hospital for the same and insurance company are paying minimum Rs.15, 000 to maximum up to Rs.40, 000.
Due to existing terms and conditions of mediclaim policy, all hospitals are charging excessively.
Ultimately, insurers have to bear all financial burdens.
Irony is that an insurer, who never claim for single rupee from company and pays his premium regularly, suffered in the form of more premium payment without any fault.
Now, questions come that how insurance company and insurer both will be benefited and make health insurance sector profitable?
How leakages of mediclaim policy will be minimized at the same time insurer will get various options at an affordable price?
How dispute between company and insurer can be minimized?
Today only one or two plans of mediclaim policies are available.
MY SUGGESTIONS ARE:
(A) Keeping existing policy plans continue, few measures will help both company and insurer.
(1) Some percentage (say 10%) of claim amount must be paid by insurer (It already exists in USA).
(2) Excluding accidental cases prior to indoor admission insurer must be examined by family physician and reference (recommendation) letter for indoor treatment should be mandatory. It can be tie up with above (1) condition.(i.e. if person admit directly without family physician’s reference note he/she has to bear 10 % of total bill.
(3) Reimbursement for OPD treatment for infectious disease by registered medical practitioner should be considered in mediclaim policy.
(4) New policy, which covers hospitalization excluding infectious diseases (that treated medically), should be introduced. I.e. mediclaim covers cardiac, renal, neurological, cancers, liver diseases etc, infectious disease treated surgically and accident cases. These are the diseases, which should be really taken care of as indoor patient. (Gujarat branch of Indian medical Association is running such type of scheme in which two members are getting cover of 3.5 lacs at an annual premium of only 1050 Rs. per person.) Company can offer this type of mediclaim at very cheaper rate.
(5)Policy that covers only accident case should introduce.
(B) Premium calculation should make logical and scientific by following measures.
(1) Instead of considering mediclaim as a whole throughout the country, mediclaim policy should be categorize according to plan wise and city wise .i.e. city under category A (Delhi, Mumbai, Kolkata, Chennai i.e. more than 1crore of population), category B(Ahmedabad, Bengaluru, Kanpur, Bhopal, Jaipur etc.i.e. 50 lacs to 1 crore of population) category C( Noida, Nagpur, Baroda, Surat, Rajkot, Kochi, Lacknow etc.( i.e. between 10 to 50 lacs of population) and category D (less than 10 lacs of population) like that. During Profit/ Loss and Claim ratio and premium calculation, plan & city category should be considered.
(2) Instead of hiking premium of all mediclaim policy equally throughout country and all policyholder to cover high claim ratio, premium to claim ratio of each compartment should considered separately at the time of premium calculation. It will prevent leakages and only those policy holders will be affected who are in that particular compartment.
(3) During deciding the premium amount, total claim amount of company for that particular plan and city category should be considered and loss due to higher claim ratio, amount should be passed on (in a form of premium hike) to only that particular compartment of policy.
By editing in existing online software, company will get all above types of data and reports at fingertip. This will help company to make whole mediclaim policy very logical, effective, transparent, efficient and leakage proof.
(C) Instead of TPA, insurance company appoints qualified medical professionals in their
office to verify claims.
After TPA era, disputes in consumer court have increased.
Advantages of mediclaim excluding infectious diseases are
(1) People can have various options to choose.
(2) It will reduce the claim ratio drastically and workload of company too.
(3) It will prevent unnecessary hospital admissions (for malaria, diarrhea etc) when our country has too high patient to hospital bed ratio.
(4) Company can provide policy at cheaper premium. Therefore, large section of society who still not covered under mediclaim can be covered.
(5) Problem of fake (bogus) claims will reduced.
(6) By mediclaim policy, which covers only accident, lives of truck drivers can saved who haven’t have any medical policy now. more  

I found the solution for the mediclaim on the infectious diseases very helpful, private hospitals, clinics charge exuberantly, there should also be regulatory for charging in all hospitals and private clinics and they have to abide by it. Also the solution mentioned for drivers is very life saving. more  
Irrespective of an organization being public or private, every organization should provide basic medical insurance to all its employees, all cashless, that would generate money to insurance companies, all hospitals will be forced to have uniform rate, though the costs increase for the company, it may be supplemented through tax breaks to organization this way can help the employees and avoid fictitious bills and all these to be through electronic e-digitization. This system is mandatory in all gulf countries and works very successfully. The insurance coverage is graded to the importance or position of the person in an organization. However, to ensure that people do not misuse, for every visit made to the doctor, the person has to make some amount from his own pocket and this brings in transparency. Ensure the women population gets benefits in the scheme for they are the true voters and are loyal to the party that brings benefit to them. more  
The extraordinary unclaimed / unpaid [ due to legalities at illiteracy ] bumper values of L I C , made many for opting Insurance and Assurance Fields though some policy holders are well benefited with minimum period participation . Healthcare / Mediclaim Insurance really increased the costs of Hospitalization , Operation etc., etc., even at the adds of N R I hospitals & Multipurpose Hospitals , and even Super Specialty Hospitals . If really the Indian Medical Authority inspects the so so Hospitals , in deed they will demand Many of the hospitals to rename and correct their Boards . This is the real status . more  
Post a Comment

Related Posts

    • Price Disclosure Transparency by Dentists

      I wrote about this issue in one of the circles in 2015-16 when a Dentist in Banaras charged my father 18000 for a treatment which at best was 7000. I am glad it has been taken up by Localcircles. W...

      By Aditi Gupta
      /
    • Unemployment for graduates at 29.1%

      As a country we may miss the demographic dividend bus as we can't find employment for the young. Please note the following: Unemployment for 19-29 with a graduate degree, at 29.1% &...

      By RN Chopra
      /
    • Home Loans too expensive need action

      ‘From soaring interest rates to lengthy tenures. HomeLoans, have become very expensive lately. • Home Loan: ₹50 Lakh - Tenure: 180 months - Interest Rate: 7% -...

      By Darshan Rao
      /
    • Railways services in India

      The railways minister in India is trying to seek feedback. However given that what his staff must have done to prep or place people plus minister coming himself puts people in awkward position to n...

      By Ajay Dutta
      /
    • Robo and Pesky Calls

      The robo and pesky calls situation is fast crossing all limits https://www.localcircles.co...

      By Vijaya Nair
      /
    • Covid concerns rising again

      New XBB.1.16 or Arcturus variant has now been detected in at least 12 countries. Highest cases in India followed by the US, Brunei, Singapore and the UK. In India, there is ...

      By Nikita Goyal
      /
    • Cash Transaction cases that likely generate income tax notice

      Income Tax Notice is likely to come to you on these 5 Cash Transactions. So avoid them. 1. Bank Fixed Deposit: Cash deposit in bank FD should not exceed Rs 10 lakh. The Centr...

      By Aditi Jain
      /
    • Banking Crisis and India

      The silicon valley bank and 2 other banks in the US failed yesterday and shares of most regional banks fell 15-50%. Today credit suisse declared there is a problem with their 2021 and 20...

      By Rajesh Suri
      /
    • Giving farmers their due

      Onion Wholesale price (Feb 28) ~Delhi Rs 11/Kg ~Chandigarh Rs 14.50/Kg ~Nashik Rs 7.65/Kg ~Patna Rs 15/Kg Retail price (Feb 28) ~New Delhi Rs 27/Kg ...

      By Sarbvir Singh
      /
    • Children at risk of co-infection of H3N2 and Covid

      Many doctors in India are suspecting co-infection of H3N2 & Covid, so they’re testing all H3N2 +ve people for Covid Adenovirus is causing ARDS in young children & more than...

      By Vikram Gupta
      /
    • Lots of Cyberfrauds through matrimonial websites/apps

      Lots of Cyber frauds are happening through matrimonial websites. Such cases reported almost every month. 2) Both men & women are victims in matrimonial fraud cases. In 2022, DCW issued notice...

      By Sudesh Rai
      /
Share
Enter your email and mobile number and we will send you the instructions

Note - The email can sometime gets delivered to the spam folder, so the instruction will be send to your mobile as well

All My Circles
Invite to
(Maximum 500 email ids allowed.)