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“รบประกนภยอยางไร จงจะชวยลดปญหาในการจายสนไหม” Suthon Chutiniyomkarn, M.D.
Executive Director
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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