Upload
maxjt7
View
134
Download
0
Tags:
Embed Size (px)
DESCRIPTION
MBA, Healthcare management, Health Insurance, Legal framework & documentation (health insurance)
Citation preview
LEGAL FRAMEWORK
& DOCUMENTATIO
N
Dr. Mark J Anthony (069)
( BA, BHMS, MBA)
Symbiosis institute of health sciences
INSURANCE CONTRACT
CONTRACT
“It is defined as an arrangement enforceable by
law, made between two or more person, by
which rights are acquired by one or more, to act
on the part of the other.”
OFFER & ACCEPTANCE
Conditions of making an offer
Lapse of the offer
Conditions for acceptance
CONSIDERATION
Kinds of consideration
Rules for consideration
Exceptions
CAPACITY
Minor
Persons of unsound mind
Persons disqualified by law
FREE CONSENT
Coercion
Undue influence
Misrepresentation
Fraud
Mistake• law• Fact
• Unilateral mistake• Bilateral mistakes
LEGAL PURPOSE
Not be forbidden by Law
Should not defeat the provisions of
Law
Should not be fraudulent
Should not be immoral under the Law
SPECIAL ASPECTS OF INSURANCE CONTRACTS
Principles of utmost good faith
Principle of insurability
Principle of indemnity
Actual cash value
Subrogation
HEALTH CARE AND MORAL HAZARD
To ove rcome the eff ec ts o f mora l haza rds i t i s necessa ry to f o rmu la te some o f the documents p rope r ly so
tha t the re i s no doub t to the i n su red and the insu re r regard ing the po l i cy regu la t i ons , cond i t i ons and benefi ts
g iven under the po l i cy.
Provisions under health care coverage are designed
not only to provide financial incentives but also to
control the problem of moral hazards, which is
strongly prevalent in health insurance.
I M P O RTA N T P O L I CY D O C U M E N T S T H AT A R E L I K E LY T O R E S U LT I N “ M O RA L
H A Z A R D”
Prospectus
Proposal forms and other related documents
Non-medical insurance
Age proof
Duty of Disclosure
DISCLOSURE
Disclosure means the giving out of
information, either voluntarily or to be
in compliance with legal regulations or
workplace rules.
THE LEGAL DOCTR INES OF D ISCLOSURE
Breach of Warranty
Misrepresentation
Concealment
WARRANTY
A statement that becomes part of the
contract and is guaranteed by the maker to
be true in all respects
Affirmative warranty : specifies a condition to
exist only on the date, the statement is made
Promissory warranty: states a condition that
exists throughout a part or whole of the policy
period
BREACH OF WARRANTY
If the court interprets a statement as warranty
then it may allow the insurer to deny coverage
The insurer only needs to show that the
warranty had been breached, even if it was
unintentional and not related to the loss, the
court allows him to deny coverage to the insured
MISREPRESENTATION
An inaccurate or untrue statement which is made
by the insured in response to a question from the
insurer
If an insurer can prove that the factual information
provided to him by the insured was: incorrect and
material
The insurer just needs to prove that but for the
misrepresented information, he would not have
offered the coverage
CONCEALMENT
Failure to reveal information which is not so such
common knowledge that the insurer would be
expected to be aware of.
The insurer has to prove that the insured
intentionally concealed some facts which he or she
knew to be material and that they would not be
apparent from an inspection of the exposure
STATUTORY MODIFICATIONS
All statements by the insured shall, in the
absence of fraud, be deemed representations
and not warranties
Statutes permit the insured to recover, unless1. There is breach of warranty2. The facts misrepresented increased the risk or materially effected the hazard assumed by the insurer
Waiver: • Relinquishment of a known right voluntarily
Estopple: • Prevents a person from asserting a right
because he or she acted previously in such a way to deny any interest in preserving that right
PROPOSAL
A Proposal form is an application
filled up by the applicant who
requires insurance in which he
mentions his name, address, age
and occupation.
THE PROCESS
Verification
Agent Report
Medical Report
VERIFICATION
The application is scrutinized by the agent or
the insurance company with the help of the
other documents provided by the applicants as
proof. It maybe a license or certificate,
mentioning his name, age, sex and address.
This scrutiny is very important to the company.
AGENT REPORT
The agent works as an intermediary between
the applicant and the company by providing
information to the applicant about various
policies. Similarly he also provides information
about the applicant to the company. Both the
Insurance Company and the Applicant depend
on the agent.
MEDICAL REPORT
The insurance company then scrutinizes
the health of the applicant in such a way
that he fits the various criteria laid down by
the insurance company. This medical report
is then Verified and then submitted to the
company.
CONTRACTUAL PROVISIONS
CONTRACTUAL PROVISIONS
Contractual provisions for medical
expense reimbursement includes: 1. Coordination of benefits2. Policy limits3. Coinsurance 4. Deductibles 5. Co- payment
CO-ORDINATION OF BENEFITS
Prevent s duplicate coverage for the same set of
medical expenses.
The co-ordination of benefits provision stipulates that
any plan without COB is Primary plan
And with COB is a Secondary plan.
Duplicate coverage arises under: • An employee has two jobs• If the children are covered under both parents
and stepparents.• When husband and wife both work for employers
which provide health coverage.
POLICY LIMITS
Specify a specific maximum amount that can be
recovered for medical and health expenses for
specific time period.
May extend as long as an individual lifetime.
In case of a lifetime limit, separate clause for
annual restoration.
EXAMPLE
Annual restoration : 5,000/-
Life time limit : 1,00,000/ -
Medical expenses : 40,000
lifetime limit reduced to :
Rs.60,000
Limit increased to:
Rs. 65,000 (after annual rest.)
DEDUCTIBLES
Provisions designed to reduce morale hazard among the
insured.
A deductible is the initial amount of covered medical
expenses that an individual has to pay so as to receive
benefits under the major medical plans.
The policy document should specify the type and the
amount of deductibles that is being used under the health
insurance policy.
TYPES OF DEDUCTIBLES
1.Initial Deductible:
• Most simplest and convenient mode of deductible.
• Mostly under the comprehensive plans.
• Here the insured has to meet the deductible
expenses purchased under the policy, so as to
claim the benefits under the policy.
2. Corridor Deductible:
Mostly under the supplementary medical expense
plan
Here, insured first pay the prescribed deductible
from the covered expenses above those paid under
basic coverage
example
Covered expenses : 8000/-
Expense under protection : 4000/ -
4000
Less deductible : 2000
2000
Amt. payable under theMajor medical plan
=Rs.2000
CO-INSURANCE
Major medical plans contains a provision for co-insurance.
It requires insured to share certain percentage of medical
expenses after meeting the deductibles from his own sources.
Different co-insurance percentages for various categories of
medical expenses.
Like, in case it is a catastrophic medical expense, the
individual may be required to pay a large share in the co-
insurance arrangement.
EXAMPLE
Covered expenses :
2000
Less deductible :
400
1600
Less 80% to be insured by the insurer :
1280
The amount to be borne by the insured :
Rs. 320
presume that under the co-insurance of 80/20
Represents a cost sharing arrangements in the
form of deductibles or co-insurance
In simple words: • It is the fees paid by the insured, which entitles
him to• receive medical benefits and other services.
Are designed so as to provide financial incentives
to the customer availing medical services.
example
Co- Payment
A fee of Rs. 50 will be imposed
For routine visit to physicians
CONTENTS OF POLICY DOCUMENTS
Policy document should be signed and
stamped as per the stamp duty
Special terms and conditions are
printed on the document.
Policy preamble
Provise
Schedule
Attestation
Conditions & Privileges
Declarations
Warranties
GRIEVANCES REDRESSAL MECHANISM
INTERNAL CONTROL SYSTEM
Sound Control system
Factors that influence control system• Technological Innovations• Quantum Growth in Business• Competition• Globalization of Business
OMBUDSMAN
Powers of an Ombudsman
Functions of an Ombudsman
CONSUMER PROTECTION ACT
THE CONSUMER’S RIGHTS AVAILABLE UNDER THE ACT
Right to safe consumer environment
Right to information
Right to choice
Right to be heard
Right to seek redressal
Right to consumer education
THE HIERARCHY ESTABLISHED BY THE ACT
District forum at district level
State commission at state level
National commission at national level
THANK YOU!