Liang Seng POH 傅良胜 - Founder of Personal Finance M.A.P’s Post

This is chilling. KFF did a survey of how people view their health insurance company. The two things that disturb (but not surprise me) most are these. "Looking at responses by health status, two-thirds (67%) of adults in fair or poor health experienced problems with their insurance, compared to 56% of adults who say they are in at least “good” physical health." Think about that. The people that need insurance the most have the most problem with it. Can you imagine a company where two thirds of their customers have a problem with the product? Then there is this one. "Nearly half of insured adults who had insurance problems were unable to satisfactorily resolve them, with some reporting serious consequences." So two thirds of the people that need health insurance the most report having a problem using it and almost half of them report not having their problem resolved with some reporting serious consequences. There in lies the problem. Why does this happen with health insurance and not other products? Because with any other product this kind of performance would put you out of business but with health insurance it makes you record profits. https://lnkd.in/eYkdCm5d.

The latest guideline of IRDA is actually a fertile ground for disputes. The intention of the regulator seems to be to exclude only fraudulent claims ie claims which are fabricated. Probably, the intent of the regulator is not to exclude claims emanating out of policies which have been obtained through deception. Because, the onus of proof is on the insurer to prove the element of subterfuge and hence it becomes almost impossible for the insurer to prove that the insured had a fraudulent intention and it was not an element of negligence which led to the non-disclosure. So, the intent of the regulator seems to be that all claims have to be paid even if there was deliberate misrepresentation on the part of the insured. I would presume so because there is no cogent effort to address the concerns of the insurers. If the insurer has no access to medical records there is no way he can prove the malafide intent of thre insured. However, the government and IRDAI are creating a nation wide data base of the Health records of individuals. A separate Ayushman Bharat Account Number (acronym ABHA) is going to be given to the voluntary participants. I feel that rhe benefit of moratorium of 5 years should be given only to those who have ABHA

New insurance product regulations: I spoke to Money Control on the recent changes by IRDA in the health insurance regulation space. There is a lot of chatter on reduction of maximum waiting period for pre-existing diseases from 48 months to 36 months and moratorium period from 96 months to 60 months respectively. But the IRDA Insurance Product Regulations 2024 also says, the previous health insurance regulations of 2016 stands repealed. Under the Master Circular on Standardization of Health Insurance Products issued in July 2020 as part of the previous health insurance regulations, there were a considerable amount of standardisations that were carried out, some of which are as under: 👉Standard Definitions of terminology to be used in Health Insurance Policies 👉Standard Nomenclature and Procedure for Critical Illnesses 👉Standards and benchmarks for hospitals in the provider network 👉Exclusions not allowed in Health Insurance Policies 👉Standard Wordings for exclusions in Health Insurance Policies 👉Existing Diseases allowed to be permanently excluded 👉Modern Treatment Methods and Advancement in Technologies 👉Standard list of consumable items 👉List of the Items for which optional cover may be offered by Insurers 👉List of the Items that are to be subsumed into Room Charges 👉List of the Items that are to be subsumed into Procedure Charges 👉List of the Items that are to be subsumed into costs of treatment So with the repealing of health insurance regulations of 2016, what happens to the master circular and the above standardization? Has that also been repealed since the guidelines were issued on the strength of the regulations? If so, it will leave a huge vacuum and the insurers are free to introduce their own definitions and practices. I’m afraid the deregulation is ending up being one step forward and two steps backwards. Hope this gets addressed. https://lnkd.in/gMaPW__m

Waiting Period (WP) vs Moratorium Period (MP) in health insurance - the perverse incentive. As per the new product regulations, effective 1.4.2024, WP for any pre-existing disease (PED) and WP for any specified diseases has both been reduced from 48 months to 36 months. The MP has been reduced to 60 months from 96 months. WP refers to the period that an insured must wait for the specific condition or disease to be covered under the policy. So if you have declared diabetes as PDE, you have to wait for 36 months. The coverage for any illness or disease arising out of diabetes would be available from the fourth continuous renewal of the policy only. MP is the number of continuous months of coverage (including portability and migration) in health insurance policy, after which the policy and claim shall not be contestable by the insurer on grounds of non-disclosure, misrepresentation, except on grounds of established fraud. So if someone inadvertently fails to declare diabetes, then upon the seventh continuous renewal, any illness or disease related to diabetes would be automatically covered under the policy. In my opinion, the above situation creates a PERVERSE INCENTIVE for the proposers with PDE(s) to avoid declaring them and get insurance. If they faithfully declare the PDE(s), the following things can happen: 👉The insurer may decline the proposal 👉The insurer may put a permanent exclusion for the PDE 👉The insurer may impose waiting period of 36 months or lesser, depending on his judgment However, all of the above can be avoided if the proposer chooses not to declare the PDE and bypass the medical underwriting by the insurer. Since MP is now brought down to 60 months, he needs to wait for only 24 months more than the normal WP (36 months), after which the insurer would be forced to cover the undeclared PDE. Practically, the insurer has little choice. If he has to refuse coverage, then he has to establish fraud by bringing evidence. The burden of proof is on the insurer. This is a high bar for the insurer to cross. He has to prove intent on the part of the insured to deceive, which in the absence of documentary evidence, would require a court trial to establish - something not possible or practical. A proposer who is a substandard risk for health insurance may decide that the odds of not declaring PDE and getting health insurance is better than declaring and being denied health insurance. So ladies and gentlemen, the ground is now fertile for more frauds and disputes.

Some health insurance providers offer just one policy. In contrast, others offer multiple options to suit different family health needs. But as you can tell, they aren’t Kenya’s only health insurance providers. There are many others, but we can’t cover them all. We had to settle on the best in terms of affordability, reliability, and service scope. This guide will help you understand why health insurance is essential, how to find the best health insurance provider, and the types of coverage, among other things. Here’s what we plan to cover:  Why do you need health insurance in Kenya? What are the various types of health insurance covers? How do you choose the best health insurance in Kenya? How much does health insurance cost in Kenya? Which is the best health insurance in Kenya? Let’s jump into it! https://lnkd.in/dm2A383k

## **Exciting News for Your Health Insurance: A New Regulator Might Be Coming Sooner Than Expected!** A recent article on LiveMint suggests that a new health insurance regulator could be on its way sooner than we originally thought. So, what does this mean for you and your health insurance coverage? Well, having a dedicated regulator specifically for health insurance could lead to some positive changes for all of us. This new regulator would work to make sure that health insurance companies are following the rules, providing affordable plans, and offering better services to customers like us. The idea behind this new regulator is to create a smoother and more efficient system for regulating health insurance. By focusing solely on health insurance, the regulator can tailor its rules to better meet the needs of the industry. This could mean clearer guidelines, better protection for us as policyholders, and more innovative insurance options. The goal of this new regulator is to improve the quality and accessibility of healthcare services for everyone. By keeping a close eye on how health insurance companies operate and making sure they meet certain standards, the regulator aims to ensure that we get the support we need when we face health challenges. As working professionals, it's important for us to stay informed about changes in the health insurance sector. Being aware of new regulations and opportunities can help us make better decisions about our health coverage and financial security. You can read the full article on LiveMint to get a deeper understanding of what this new health insurance regulator could mean for us. Let's see this news as a chance to bring positive changes to the world of health insurance and make sure we all have access to the care we need. *Stay informed. Stay prepared. Stay healthy.* #HealthInsurance #Regulator #AffordableCoverage #WorkingProfessionals #StayInformed

In the absence of any public insurance a citizen is forced into a situation of being left without coverage. If insurers clearly specify the expected decision if PED is declared and probable additional loading I am sure people will declare the actual condition. People buying retail products have been forced into this situation so that top line of insurers can be improved by cross subsidizing group polices with day one coverage and copay for dependents. Work towards creating a level playing field for all.

While reading the interesting post on changes in Health Insurance rules, a simple question came to my mind. What is the current data on the number of claims being made and rejected on account of the "Pre-Existing diseases" exclusion ? What is the current data on the number of claims being made and rejected (Policy year wise) on account of misrepresentation of material facts ? Can someone guide or direct me to the source of such data in the Indian Health Insurance? It will be further interesting to look at it segregated by Group Health Insurance and Individual retail Health Insurance products. I am just plainly curious to understand what are the underlying data patterns which are driving these changes in waiting periods ?

The new health insurance rules for senior citizens are a step in the right direction, aiming to provide better health coverage and make insurance more accessible and affordable for the elderly #2050healthcare #eldercare

https://lnkd.in/dywsSdwS While the removal of age limitations and the introduction of policies tailored to the needs of different demographic groups are positive steps toward inclusivity in health insurance, they may not fully address the specific challenges faced by the elderly. One concern is that despite the ability to purchase health insurance at an advanced age, premiums for older individuals may be prohibitively high, making coverage unaffordable for many. Additionally, there may still be gaps in coverage related to long-term care, chronic conditions, and age-related health issues that are not adequately addressed by standard insurance products. Furthermore, while the reduction in waiting periods for pre-existing conditions is beneficial, there may still be limitations on coverage for certain medical conditions or treatments that are more prevalent among older adults. The transition to benefit-based policies may also result in limitations on reimbursement for healthcare expenses, which could impact the financial security of elderly policyholders. In summary, a good start made by making health insurance more inclusive but a long way to go before these measures start to move the needle!