No. OF MEMBERS INSURED IN GROUP INSURANCE COVERAGE UNDER
H & A SCHEME OF AMC
IS 1976 ( AS ON 19/01/ 2001 )
IS HEALTH INSURANCE NECESSARY FOR A DOCTOR ?
Dr. P.N. RAO
H & A PROJECT OF AMC
Would you be surprised to note that hardly 10% of the entire medical community has health insurance in India. If it makes you feel any better, take confidence in knowing that in the consultant community in India nearly 15% are health insured and YES 25% of the members of our Association of Medical Consultants have thought it necessary to cover their health ! “Shocking to know how little we consider our own health needs!”
It is undeniable that medical expenses are getting costlier by the day. Expenses towards sophisticated investigations can perhaps ruin your peace more than actual illness could.
Are we surprised any longer to hear of major medical catastrophe, life threatening illness and major expenses involving accidents that over-run any individual’s life? and, what gives us the cocky feeling that we are immune to these possibilities?
A CABG could cost an individual 3-4 lakhs. Joint replacements and transplants can cost a bomb. Angio nearly takes away 35,000 – 50,000. And, if any, but the absolute exceptions in the medical fraternity feel that these charges are just out of pocket expenses, they need immediate counselling !
HEALTH INSURANCE SCHEME OF AMC.
Tailor made group insurance product for members and their families.
- No premedical check up needed to join the scheme.
- Pre-existing Diseases and illness are excluded in the first year, but are covered later with specific restriction.
- Costly investigation like MRI, Thallium test can be done as an OPD procedure. No hospitalization needed for such OPD procedure
- Likewise day care surgery and procedure do not require hospitalization.
- Congenital diseases having a functional disability will be considered after 1 year of insurance to the extent of CSI on that year.
- The scrutiny of all claim is by the H & A Committee of AMC, whose decision is final and binding on the New India Assurance Co. Ltd.
- Family members are permitted to join the scheme.
- In the unfortunate event of death of the main member (consultants) in the scheme, those family members who have already enrolled, will be permitted to continue in the health Insurance of the AMC.
- All the restrictive clause of last year will be continued.
This year the premium payable has been pegged down at the last year’s premium; however an increase in Govt. tax 10.2% will increase the premium by an unavoidable circumstances.
Since TPA has been made compulsory for cashless service will have to pay the Rs. 200/- per person over and above the increase in the premium payable.
SPECIAL TERMS IN THE H & A POLICY FROM 1.10.05 TO 30.09.06
Sophisticated medical treatment is getting costlier by the hour.
Even routine standard treatment is often beyond the reach of many an individual. Our H & A policy was tailor made to meet the demands of the medical community, the chief difference being the inclusion with certain restrictions of pre-medical illness of all types.
The salient features of our H & A policy is being tabled below along with our latest premium table. 1.) Domiciliary Hospitalization, and Domiciliary Physiotherapy etc is not reimbursable. Nursing charges are only payable when a fully qualified registered nurse is specially called to do nursing services, exclusively for the patients. A stamped receipt of the qualified nurse of such payment must be sent separately with the bills for reimbursement.
2.) All claimants will pay a 15% compulsory deductible of their reimbursable claim and remaining 85% of the claim will be paid by insurance. For treatment and investigation of Cataract, Heart ailment, Joint replacement, hysterectomy payment, will be 50% in the 2nd year of renewal and full reimbursement in the 3rd year of renewal (first 12 months of joining insurance scheme and for enhancement of CSI, no payment is done for ANY pre-existing disease / ailments). Please note that the 10% compulsory deductible applies to ALL REIMBURSABLE CLAIMS.
3.) Health premium chart for Rs. 1 lac of Capital Sum Insured (CSI) (in Rupees). All rates for CSI to 5 lacs to be calculated in multiples of 1 lac.
|Premium Table for CSI of 1 Lac.|
PREMIUM FOR PERSONAL ACCIDENT COVER
Premium with weekly benefit cover incl. S.tax
Premium without weekly benefit cover incl. S.tax
|N.B.: ALL PREMIUM RATES FOR CSI UPTO 5 LACS TO BE CALCULATED IN MULTIPLE OF 1 LAC|
Minimum CSI for all NEW ENTRANTS above 18 years of age is 1 lac. Only below 18 years of age one can take CSI of minimum Rs. 50,000/- or above.
Previous insurance year implies1.10.03 to 30.09.04
Current insurance period implies1.10.04 to 30.09.05
xt (Renewal insurance period implies)1.10.05 to 30.09.06
4.) Loading of premium will apply to all those who have made a reimbursable claim in the current year. Formula of loading % as follows: If CSI (current) 1.10.04 – 30.09.2005 is 1 lac and claim reimbursed is 10000.
|Claim Reimbursed 10000|
|————————– X 200 ————— x 200 = 20%|
If CSI (current) 1.10.04 – 30.09.2005 is 1 lac and claim reimbursed is 10000. e.g. If your earlier loadings amounted to say Rs. X.
Your claim in the current year necessitates a fresh loading of 10% because you have availed of a reimbursable claim of 10% of CSI.
Then total premium payable at renewal is current premium + 10% loading on the premium for every 1 lac of CSI + past loading of x Rs.
Should you NOT have any claims in current year 1.10.02 – 30.09.03 BUT you have loading collected at last renewal, your premium amount is Renewal premium / lac + 75% of past loading (25% reduction in old loaded amount for no claim in current year.
Should you want to increase your CSI at renewal loading will only apply to your last CSI on which you made a claim.
Should you wish to decrease your CSI this year for any reason (especially those who may opt for additional Long Term Policies) the loading %age (calculated on your current year CSI) will apply only for the reduced CSI.
i.e. If current year (1.10.04 – 30.09.05 you had CSI of 5 lacs, and you made a reimbursable claim of 50 thousand then your loading will be 10 %.
Now this year you decrease you CSI to 2 lacs, 10 % loading will apply to renewal premium on CSI of 2 lacs only. Loading does not apply to
- New Entrants
- Enhancement of CSI
N.B. : Since the premium WILL BE COLLECTED by the 15th September 05 (15.9.05) it is likely that some insured may institute a claim for the remaining period of the current insurance (till 30.09.05). If such an insured has availed of a) bonus and b) reduction of loading for the next renewal, this amount will have to be refunded to the AMC, along with the actual increase in the newly loaded premium.
This refund + actual excess premium to be paid must be sent to AMC office within 15 days of receipt of such a fresh notice seeking payment.
Those claimants who have claimed AN AVERAGE of between 90-100% of CSI over the last 3 years, will be allowed only 50% of the average CSI of last 3 years.
3 lacs on CSI of 3 lacs in 2000-2001
3 lacs on CSI of 3 lacs in 2001-2002
3 lacs on CSI of 3 lacs in 2002-2003
Total Claims in 3 years is Rs.9 lacs and Total CSI in 3 years is Rs 9 lacs i.e. average claim is 100%
If the following year claims are again between 90-100% of CSI, this amount will be reduced by a further 50% and so on.
For those having claims between 50-90% average over 3 years CSI will be permitted to the extent of 75% of average of those last 3 years
By this system, we are reducing the claim ratio in future years, while at the same time not totally excluding the need for health insurance.
N.B. : This above average of claims and CSI will only be relevant for a maximum of the last 3 continuous years of the H & A policy.
Most claims are settled without dispute. However some claims which are considered excessive, unreasonable or out of range by the H & A Committee, will be called in for scrutiny, the claimant would have to justify the fairness of the claim and abide by the decision of the professional colleagues in the H & A Cell.
When an insured or his dependents are treated for any illness or disease in one’s OWN FAMILY INSTITUTION OR SETUP, the medical bills of hospitalization, will not be reimbursed. Visiting charges, operation charges towards dependents bills raised by the insured members when he is himself looking after them, will also not be reimbursed; however any other physician or surgeon who attends can give them their bills which will be reimbursed as applicable. Similarly also investigations & pathology labs tests carried out in one’s own family institution, will only be reimbursed to the extent of 50% of the standard charges in that institution.
All Pre-existing diseases and ailments and their investigation will be covered except.
- in the first year of insurance.
- On any enhanced CSI where the enhanced value will be available after 1 year.
- Conditions involving the
- Heart ailments,
- Those requiring joint replacement surgery and
- Cataract are also covered except
1) No payments in the first year,
2) 50% will be reimbursed in the IInd year
3) Fully reimbursed from the third year onwards.
- 10% Compulsory deductible on the reimbursable part of all claims, will however continue to be collected.
Dependents that can avail of our scheme include children, grand children, and parents of spouse, son-in-law and daughter-in-law.
N.B. : CSI of any dependent cannot exceed the CSI of main member of group.CSI of parents of Non member spouse can be equal to or less than the CSI of the concerned spouse.
Deposits payable at hospitals where Paramount Healthcare Management becomes applicable.
Since the new IRDA rules have been introduced, this service will be only available on payment of 5.5% pf the actual premium (not bonus or loaded premium) to the TPA (PHM).
Partly Cashless Service of Paramount Healthcare Management, who is our TPA (Third Party Agents).
15% of the amount (which has been estimated by the claimant) will be payable as initial deposit e.g. if the CSI is Rs. 1 lac, a doctor requests Paramount Healthcare Management for Authority letter for a planned surgery which would according to his estimate be Rs. 30000/- ; the doctor would be required to deposit
15% or Rs. 4500/- out of whatever deposit is asked for by the hospital concerned. The claimant would immediately fax this receipt of 15% to Paramount Healthcare Management who will then fax Authority letter to the hospital concerned informing them about the willingness to pay the remaining amount of Rs. 26500/-. Any amount over Rs. 26500/- will be borne entirely by the claimant and later reimbursed by the New India Assurance Co Ltd. It would be prudent that members are better off making a bigger estimate than anticipated for any claim so that they would then have to pay only 15 % of that amount on which they require a cover.
In emergency situations or unusual situations when the amount of cover needed is unknown the insured would have to pay a deposit of 15 % of the CSI or 15% of the probable bill estimated by him. The onus of the probable bill will be entirely on the insured; if he is not sure it is advisable to put higher probability of the bill for safety. The remaining amount will then be borne by Paramount Healthcare Management where applicable.