Dr. Arvind L. Patel M.B.B.S, F.C.G.P, C.M.T.P, L.P.H.M CONSULTANT MEDSAVE T.P.

A(PANINDIA)
ATTACHMENTS : ESIS, LIC OF INDIA, STATE BANK OF INDIA FACILITY : EX. AKI COLLEGE, MUMBAI PRIVATE CLINICS : MUMBAI CENTRAL G.T.B NAGAR, SION

HOW TO REDUCE ICR

ICR is increasing both in individual and group health insurance. There is substantial underwriting loss in group health insurance. 50% of the companies has claim ratio between 100% to 150%. According to towers and watson global consultancy :Companies with claim ratio between 125% to 150% will have to pay 25% to 50% more premium.
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or Claim for parental sickness constitutes 60%. Therefore some companies have started excluding parents or they ask higher premium from the employee on case to case basis.

Infectious, 3.18

Digestive, 2.44

Number of claims in lacs in 2009-2010

Urology, 2.2 Eye, 1.94 Circulatory, 1.7

Infectious disease e.g. Malaria, Septicemia, Fever, Meningitis has highest number of claims. The total amount paid for 3.18lacs claim is 397.91cr i.e. Rs. 12,333 per claim. Claim amount is less because hospital stay is short. Cost of treatment and investigations less expensive, no surgery is required.
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Circulatory, 758.04

Total amount paid in INR crores

Digestive, 501.94 Urology, 458.71 Infectious, 393.41 Eye, 368.12

50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 Circulatory Urology Digestive Eye Infectious
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Reasons Hospital stay is more. Surgery is involved. Implants are used. Drugs and investigation are expensive.
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Urology and digestive diseases the total amount paid INR 458.71cr and INR 501. 94cr. The average claim amount is almost same Rs. 20,827- Urology Rs. 20,584- Digestive disease The average claim amount is more because implants are used and surgery is involved
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800

700
600 500

400
300 200

100
0 Circulatory Arthropathy

Total claim paid INR crores.

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45,000 44,500 44,000 43,500 43,000 42,500 42,000 41,500 Circulatory Average claim amount paid INR Arthropathy

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Circulatory Total number of claim

Arthropathy

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If the number of claim in arthropathy increases then the claim amount will increase substantially.

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To reduce ICR Cost of implant/ stents must be found from govt.agencies/ hospitals. Implants/ stents sticker must be asked. The manufacturer name and code number to be matched with Bills/ Invoice/ Receipts. Capping on surgeon fees. Capping on total package. Chr. Disease e.g. IHD, HT, DM, OA to be made payable after 4 years Close reduction of # not payable
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To reduce ICR GI surgeries to be made payable after 3 complete claim free years Hernia ,hydrocele after 4 years Capping on laparoscopic surgeries Implants/stents stickers must be asked. The batch number/ code number and manufacturers name should be matched with Bills/ Invoice/ Receipts To find the cost of Implants/ stents from independent sources/ govt.agencies/ govt.hospitals/ municipal hospitals.
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Reasons for high number of claims Because of health policy the insured gets admitted in hospital on day 1 of sickness If admitted in hospital the insured is sure of sick leave and also extended sick leave.

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To reduce ICR Referral note of family physician and/ or treatment taken before admission . Patho. / Radio reports done before admission must be asked. Justification for admission by the treating consultant. Capping on PUO/ Fever. Curbing repeated pathological and other investigations. Maximum 2 referral opinions is payable. Restricted number of visits of 2nd and 3rd opinion doctor.
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Measures to decrease ICR Capping on all laparoscopic surgeries, lithotripsy and other such procedures. Implants/stents stickers must be asked. The batch number/ code number and manufacturer name to be matched with bills/ invoice/ receipts. Find the cost of implants/stents from independent sources/ govt.agencies/ govt.hospitals/ municipal hospitals.

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Measures to decrease ICR OPD procedures should be clearly specified e.g. strabismus (squint), Keratoplasty, Yag Laser, Capsulotomy, Pterygium, stye, chalazion , ,Ing.Avastin, Keratoconus. Development of membrane over IOL after cataract surgery i.e. after 60 days. Implants stickers must be asked. The batch number/ code number and manufacturer name to be attached with bills/ invoice/ receipts. To find cost of implants from independent agencies, govt. agencies/ govt.hospitals/ minicipal hospitals
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Most

of the staff in corporate particularly private corporate are young. Therefore, following diseases mist require second look: -Migraine, sinusitis, pancreatitis, ALD, APD, PSY, PID, backache, cervical spondylosis (because of wrong sitting postures while working on the computers) Therefore capping or excluded for 1st 2 years.
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Diseases not disclosed and cannot be detected during routine health check before recruitment: Epilepsy, young diabetes, young hypertensive, DUB, renal calculi, congenital or acquired infective disease e.g. Mild MS, valvular disease, PCOD, RHD. They all require capping or exclusion for two years.

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Pregnancy D & C for DUB Hysterectomy

Payable after 2 years and/ or capping.

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Corporate policies must have stop loss and the policies should be reviewed every six months. Claim payable from day I should be removed because senior staff very likely to have IHD, DM, HT, OA, cataract. Young staff join with inherent problems

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General measures to reduce ICR Capping on all implants/ stents. Capping on surgeon charges. Assistant surgeon only one allowed. Assistant surgeon charges 1/10 of main surgeon charges. Assistant surgeon charges not to be paid in surgery like cataract, biopsy, nasal surgery, etc. Anesthetist charges is 1/3rd of main surgeon charges . No assistant anesthetist charges. RMO charges not payable. Nursing charges must be fixed and includes IV drip, IV injection, IM injection, general nursing.
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Contd..
No charges for fixed reusable instruments e.g. microscope, laparoscope, boyels apparatus, etc. Capping on OT charges. Plug all loopholes in policies. Educate agents, DO, policy makers. Monitor the progress and implement all good measures of competitor. Shed lethargy. Educate and monitor agents/DO. Clarify on policy terms and condition Reduce response time Black listed
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