Health Insurance CA 2

Submitted By: ARCHIT BABEL

ROLL:03
ARTICLE 1

How Covid is changing the Indian Life

Insurance industry?

ARTICLE IN STUDY:
https://finshots.in/archive/how-covid-is-changing-the-
indian-life-insurance-industry/

THE STORY:
Before we get to the heart of the story, a brief introduction on “term life insurance.”

Now, most people think of these as investment products that just happen to extend
the benefits of insurance as well — Like ULIPs and Endowment policies. They’ll hope
to invest some money over a period of 5 or 10 years, and get the invested corpus
back when the policy matures — obviously with some extra money on top. They’ll
also expect a large lump sum to be paid to their nominees in the event they die
during this period.

So in summary, there’s a common misconception that all life insurance policies

extend the benefits of investment alongside life protection.

WHERE COVID STRIKES:

And this brings us to the story today. Since Covid made landfall, demand for term
insurance products has been on the rise. However, elsewhere, Covid has also
changed the risk landscape. With so many claims cropping up over such a short
period of time, life insurers are evaluating if they need to rethink their pricing
strategy. And they’re having to expedite this process because there’s added
pressure from their insurers or otherwise called as reinsurers.
The thing is — Life insurance companies in India and elsewhere have to set aside a
small sum every time they insure an individual. After all, you wouldn’t want to run out
of funds in the event of mass casualties. But if insurers don’t have the financial
muscle power to set aside large sums of money, they could transfer some of this risk
to reinsurers — who will bear a part of the downside for a small cut in the premium.
And unlike insurance companies that can rely on reinsurers, reinsurers can’t rely on
anybody else if things went wrong. They are the last line of defence and they have to
have sufficient funds at all times. However, with Covid wreaking havoc across the
world, some of them are seeking a higher cut from insurance companies — especially
their Indian clients.

Because prices in India have remained relatively low despite the fact that we don’t
have the most sophisticated industry out here. Insurance companies have little
information on prospective customers and they lack the data needed to adequately
gauge risk. Ideally, our premiums should have been way higher considering most
insurers are walking blind. But that hasn’t always been the case and this anomaly
has persisted for a while. However, now that reinsurance companies are finally
tightening the screws (and they've been doing it for a while now), the anomaly might
disappear.

And that means term insurance prices in India may also rise considerably (10-30%)
over the next few weeks once again. Sad!

The 4 major transformations in the post-pandemic life insurance

sector:

1. Life Insurance is deemed as an ‘Essential Commodity’

The financial impact of the pandemic has led to people valuing the protection

and fallback offered by life insurance products in tough times. The second

half of the 2020-21 financial year saw a 16% YoY business premium growth,

with more people preferring to buy single premium policies (as a protection

against future loss of incomes).

 2. Change of Perception for life insurance as a pure risk insurance cover:

This can be attributed to the psychological impact of the COVID-19

pandemic, but people are veering towards pure protection plans like term life

insurance rather than insurance-based plans like ULIPs. As more and more

people look to buy life insurance, the affordability and simplicity of term plans

have led to its rising popularity.

3. Customers are looking for better customization and targeted products:

After the pandemic, consumers are looking for better life insurance products, along

with personalized options. The need for flexibility in payments, innovative products,

online modes of transactions (contactless purchase and renewal and added benefits

of COVID-19 insurance in existing plans are some of the primary expectations from a

post-pandemic insurance sector.

4. Rise in digital modes of transactions by customers:

With the increasing focus on social distancing and contactless transactions, more and

more consumers are turning to online modes of buying and renewing life insurance.

This has prompted insurance companies to offer digitally enabled omnichannel

systems and better online functionalities.

As a buyer, you need to avoid ‘panic-buying’ and focus on buying the right product.

Research, compare and find the best term insurance plan that suits your needs
What can the industry do?[3][4]

Both the health and the life insurance industries are currently already in
a good position. As the economy gets back on track, the insurance
industry is also likely to continue with its good performance. That said,
there are several challenges in front of the industry that it needs to
address. Here’s a quick look at what the industry can do –

1. Increase focus on digitization

Due to strict social distancing norms and the general preference of

people to stay away from physical branches, the industry should direct
its focus towards providing all of its services through the digital mode.
2. Provide proactive customer support

The insurance industry must step up its efforts to connect with their
customers in a more proactive manner digitally.

3. Introduce innovative customer-focused products

The industry should work towards providing its customers with products
that can be tailor-made according to their needs and requirements.

4. Ensure faster claim settlements

With the transition to digital, the industry should also focus on enhancing
the claim settlement process and make it as easy as possible. This
would not only ensure increased efficiency, but also provide customers
with faster pay-outs.

Conclusion

The impact of Covid-19 on the insurance industry is clear. Although it initially

derailed the industry progress, it has also led to a spur in demand for insurance
products. And though there are no specific COVID insurance plans, life insurance
plans in general cover COVID-19 related deaths too. This has resulted in more
people becoming interested in life insurance. Buoyed by the positive sentiment
towards insurance, the industry is likely to further intensify its efforts in the near
future to increase insurance penetration in India.

ARTICLE 2

Why Your Health Insurance Won't Pay

for Your Health Care
IN STUDY:
https://www.verywellhealth.com/why-your-health-insurance-wont-pay-for-your-health-
care-1738481
INTRODUCTION:

When your healthcare provider recommends a test, medication, or procedure and

your health insurance won’t pay for it, it can be frightening. If there’s an alternate
test, medication, or procedure that will work and that your health plan will cover, then
this situation is just an irritating nuisance. But, if the test, medication, or procedure is
the only thing that will work, the situation can be life-threatening.

When this claim or pre-authorization denial happens to you, it’s common to be angry
and want to fight the denial. However, before you spend your energy on this battle,
first make sure you know exactly what happened and why your health plan won’t
pay.

While investigating the cause for the claim denial or refusal of your pre-authorization
request, you’ll gain valuable insight into the standards of treatment for your particular
medical problem, as well as how your health insurance company “thinks.” You’ll be a
more competent warrior if a fight with your health insurance company becomes
necessary.

Reasons Your Health Insurance Won’t Pay for the Care Your
Healthcare Provider Says You Need

1. What you need isn’t a covered benefit of your health plan.

When your health plan denies your claim or refuses your pre-authorization request
for this reason, it’s basically saying that your policy doesn’t cover that test, treatment,
or drug no matter what the circumstances are.

Your insurer should know exactly what benefits your policy provides and what isn’t
covered, but sometimes your insurer is wrong. Check your policy carefully. If your
health insurance is through your job, check with your employee benefits office to see
if you actually do have coverage for the service your health insurance says isn’t
covered.

If you feel you’re being denied the benefits of coverage your policy says you actually
have, follow the appeals procedure your health plan booklet outlines. Also, enlist the
help of your employee benefits office if your coverage is job-based, or your
state’s insurance commissioner (be aware that if your plan is a self-
insured employer-sponsored plan, the insurance commissioner won't be able to help
you, as self-insured plans are not regulated at the state level).
2. You got the care from an out-of-network provider when your health plan
coverage is limited to in-network providers.

If you have an HMO or EPO, with very few exceptions, your coverage is limited to in-
network providers that your health plan has a contract with. Your health insurance
won’t pay if you use an out-of-network provider.

If you’re asking for pre-authorization and your pre-authorization request was denied
due to your chosen provider, you can simply re-submit the request using an in-
network provider rather than an out-of-network provider.

However, if you’ve already gotten the care and your health plan won't pay your claim
because you went out-of-network, you’re going to have a more difficult fight on your
hands. You may be successful if you can show that no in-network providers were
capable of providing that particular service so you had to go out-of-network. You
might also be successful if you can show that it was an emergency and you went to
the closest provider capable of rendering the care you needed.

3. Your health plan doesn’t think the test, treatment or drug is medically
necessary.

If your claim or pre-authorization request has received a medical necessity denial, it

sounds as though your health insurance won’t pay because it thinks you don’t really
need the care your healthcare provider has recommended. This might be what your
health plan is actually saying, but it might not be.

There are some reasons for a medical necessity denial that don’t really mean your
health plan thinks the care is unnecessary. In order to figure out just what, exactly,
your medical necessity denial means, you’ll have to do some digging. The good
news is this digging may well show you the path to getting your pre-authorization
request approved, or your claim paid, if you just tweak your approach a bit.

If you've received a claim or pre-authorization based on medical necessity, this is a

scenario in which you can and should enlist the help of your practitioner. Your
healthcare provider has recommended the service for a reason, and they'll be able to
communicate that reason to your insurer. In some cases, the insurer might then
approve the procedure, or they might work with your practitioner to approve another
approach that both the insurer and the healthcare provider consider medically
necessary.

4. Your health plan doesn’t recognize you as a benefited member, and other
mix-ups.

This type of scenario is more common than most people would imagine. In today’s
complex healthcare system, information about your coverage must flow correctly
from your employer, insurance broker, or health insurance exchange to your health
plan. If there’s a glitch or delay anywhere along the way, it can appear as though you
don’t have health insurance even though you actually do.

Along these same lines, it’s common for health insurers to outsource to a medical
management company the decision-making about whether or not your test,
treatment, or drug will be covered. In this case, information about your coverage
must flow correctly from your health plan to the medical management contractor.
Likewise, information about your medical situation must flow correctly from your
healthcare provider’s office to the health plan or its medical management contractor.
Any glitch in the flow of this information can result in a claim denial or a refusal of
your request for pre-authorization.

The good news is that these claim denials or pre-authorization refusals can be
relatively easy to overturn once you understand exactly what the problem is. For
more information, see “How Silly Mix-Ups Cause a Health Insurance Claim Denial.”

5. You didn't get the correct referral or prior authorization

Depending on your health plan's rules, you may be required to have a referral from
your primary care provider and/or an approved prior authorization before receiving
various types of medical care. If you didn't do that, you may be facing a claim denial.
For example, maybe you're used to having a PPO that allowed you to self-refer to a
specialist, and you forgot that your new HMO requires a referral from your primary
care doctor.

Depending on the circumstances, you might be out of luck. But you might be able to
get your insurer to work with you on this if your primary care doctor can provide a
statement to your insurer about the necessity of the services you received.

6. Your hospital stay was incorrectly classified as inpatient vs observation.

If Medicare or your health plan is refusing to pay for a hospital stay, the reason may
have to do with a disagreement about the correct status of your hospitalization rather
than a disagreement about whether or not you actually needed the care. When
patients are placed in the hospital, they’re assigned either observation
status or inpatient status according to a complex set of rules and guidelines.

Sometimes, the hospital and your admitting healthcare provider may believe you
should be admitted to inpatient status, while Medicare or your health plan thinks you
should have been hospitalized in observation status. Here’s the catch: if you’re
admitted to the wrong status, your health plan or Medicare might refuse to pay for
the entire admission even though your insurer agrees that you needed the care the
hospital provided. It’s kind of like a technical foul.

Why would health insurance not pay certain claims, and

what can I do?
1. Human error
It’s possible that your insurance company made an error in processing your claim, or
perhaps they gave you misinformation that led you to make a doctor’s visit or
undergo a treatment that isn’t fully covered. Or maybe your healthcare provider billed
your visit incorrectly. One example is when a well-woman visit that is free, preventive
care is categorized as a specialist visit to the gynecologist. Medical billing is complex
and can be error-prone, so call your healthcare provider and insurance company to
try to rectify these errors first, and then go through your insurance company’s
appeals process if necessary.

It’s also possible that your insurance company required additional information but
either your provider did not provide it or the information got lost during processing,
leaving your claim hanging. While this may not seem like your fault, the burden is on
you to follow up with your insurance company and your healthcare provider to make
sure all the information needed is provided and processed so your claim can be paid.

2. The provider is not in-network

While many people think that a healthcare provider accepting their insurance is the
same as being covered, it’s actually not. To avoid getting an unexpected medical bill
in the mail, you also need to verify that this healthcare provider is in your insurance
plan’s network. If a provider accepts your insurance but is not in-network for your
plan, it means they will bill your insurance company for the service and then charge
the balance of what insurance won’t pay for directly to you. If you have a PPO plan,
this typically means paying higher, out-of-network costs. But if you have an HMO
plan, you may be stuck with the entire cost of the visit. Note that it’s important to
determine whether your healthcare provider is in-network with your specific health
insurance plan, as insurance companies can have several plans with different
provider networks. Make sure to get this confirmation directly from your insurance
company, not via your healthcare provider, as the insurance company has the final
word on what gets covered.

3. Bundling
Another type of misunderstanding that can occur is one between your healthcare
provider and your insurance company, something known in the medical billing
industry as “bundling.” Bundling is when a secondary procedure is considered part of
a primary procedure. For example, if an incision is required before a certain surgery,
your insurance company may “bundle” the two procedures together and only pay out
one claim. However, your surgeon may bill the incision and the surgery separately,
thus leaving you with the bill for the incision claim. Because these bundling cases
are mired in medical billing codes and jargon, it’s worth considering consulting a
medical billing professional to help you dig through it.

4. Lack of pre-approvals/referrals
Some plans require referrals or other pre-approvals to see a specialist, and if you get
your medical care without this pre-approval, it’s possible that your insurer will deny
your claim. If this is the case, make sure to get a referral immediately so your future
visits are covered, and see if your past claims can be reimbursed now that you have
a referral. If not, you can appeal via your insurance company’s official process.

Most plans will also only cover medically necessary care, and your insurer may deny
your claim if they feel the service wasn’t medically necessary. If this is your situation,
you can ask your doctor to submit a “Medical Necessity” form on your behalf (or any
other information requested by your insurance company).

5. Your insurance does not cover the medical service

Lastly, it’s possible that your medical service was simply one that is not covered
under your health insurance policy. There are always exceptions, so speak to a
representative of your insurance company to understand why your care was not
covered and try to appeal it if you feel like an exception should be made.

CONCLUSION:
One way is to learn how to negotiate medical bills with insurance and healthcare
providers. You can work with them to negotiate an interest-free payment plan, a
discount for immediately paying the balance, or another compromise solution that
will help you pay your bills without them being sent to the debt collectors and
damaging your credit. To help you negotiate, you can use tools such as Healthcare
Bluebook to determine the fair price of various treatments in your area. You can also
ask and see if there’s any sort of financial assistance program; many hospitals have
them.

Another option is to work with a medical billing advocate who can reduce your costs
by looking for abusive, fraudulent, and erroneous billing practices. While it may
sound outrageous, industry estimates say approximately 80 percent of medical bills
have errors. Many medical billing advocates will also negotiate with healthcare
providers on your behalf.

Whatever you do, make sure to be persistent but polite, and keep good
documentation of your efforts, including the date and contact info of each person you
speak with. And don’t procrastinate on having these conversations. Once a bill gets
sent to the debt collectors, not only does your credit get damaged, but the bill is also
effectively out of your healthcare provider’s hands, making it much harder to
negotiate.