d of care - tlaa.org · suthonc@bumrungrad.com. d of care ... hospital medical inflation ... d of...

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“รบประกนภยอยางไร จงจะชวยลดปญหาในการจายสนไหม” Suthon Chutiniyomkarn, M.D.

Executive Director

suthonc@bumrungrad.com

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Topics for Today

Health Insurance Business Situation

– Business Opportunities & Challenges

Underwriting in Health Insurance

– Goals Of Underwriting

– Individual Underwriting

– Group Underwriting

– Underwriting Decisions

– Example of exclusions

Case Study

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Health Insurance Premium 04-13

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Health Insurance Loss Ratio Yr 04-13

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Challenges in Health Insurance

Insurer

Health Ins. Demand

Product Differentiation

Narrow Margins

Hospital

Medical Inflation

Consumer Driven

New Technology

Consumer

High quality

Need more accessibilities

Portfolio

Viable

Value

Delivering

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Health Care Barrier Accessibility

Geographic

Financial

Cultural

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Sound Underwriting

– Issue the insurance as applied for

– Issue the insurance not as applied for

– Decline or postpone making a decision

Mortality and Morbidity Gain

– *health insurance – Morbidity experience

Persistency

– Acquisition Cost & Financial Risks

Goal of Underwriting

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Individual Underwriting

Risks factors

– Medical Risk Factor

– Financial Risk Factor

– Personal Risk Factor

– *Moral Hazard

Antiselection

Traditional Risk

Classes

– Super-preferred

class *

– Preferred class

– Standard class

– Substandard class

– Declined class

– Tobacco user and

non user

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Underwriting Method

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Group Underwriting

Based on group’s characteristics

– Size, nature of business, occupations

– Average age, sex, turn over rate, location

– Past claims History

Small group – as individual guideline

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Underwriting Individual Health Insurance

3 Basic types of individual health insurance

products

1. Medical Expenses Insurance

2. Disability Income Insurance

3. Long Term Care (LTC) insurance

Sources of information

– Insurance Application

– APS & Specialized Medical Questionnaires

– Medical examination

– Inspection report

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4 Medical Test : Underwriting

EKG

– Resting & Stress Exercise

Urinalysis

– Kidney, DM, HT, Blood cells & certain drugs

Blood Chemistry Profile

Oral Specimen test : Anti HIV

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Making an Underwriting Decision

Underwriting decision

Policy

modification

Higher standard premium rate Exclusions Decline

Deductible

Co insurance

Reduce coverage

Waiting Period

x

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Exclusions

Exclude from coverage any loss that

– 1. arises from a specified disease or physical

impairment

– 2. concerns a specific body part

Long Term Care (LTC) : guideline

– Mental and nervous disorders or diseases

– Alcoholism and drug addiction

– Illness caused by an act of law

– Treatment already paid for by the government

– Attempted suicide or self-inflicted injury

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Underwriting Factors

Age & Sex

Health History and Family History

– Health & Life insurance concerns

– Accident related : Epilepsy, blindness, deafness, sleep apnea,

Existing Insurance coverage

Finances

Occupation

Avocation

Driving History, Alcohol and substance abuse

Foreign Travel and Residence

Foreign Citizenship

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Sleep Apnea

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UW : Source of Information

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ตวอยางการออกขอยกเวน กรมธรรมประกนสขภาพ

กรมธรรมไมคมครองภาวะทเปนมากอนการท าประกนภย

กรมธรรมไมคมครองโรคความดนโลหตสง และ ภาวะแทรกซอน

กรมธรรมไมคมครองโรคความดนโลหตสง ภาวะโรคหลอดเลอดหวใจ ภาวะเสนเลอดสมองผดปกต ภาวะไตวาย และ ภาวะแทรกซอนทเกยวของกบความดนโลหตสง

กรมธรรมไมคมครองอาการปวดหลงทเปนมากอน

กรมธรรมไมคมครองการแกไขการผาตดกอนการท าประกนภย

ไมชดเจน คลมเครอ ซ าซอนขอยกเวนทวไปของกรมธรรม ไมเปนธรรมแกผเอาประกน

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Key skills and Competencies

Underwriting concepts

Analytic Skills

Negotiation Skills

Medical Knowledge

Marketing Mind with cost conscious

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Case Study

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A World of Care