08 - Health insurance products Flashcards
What are the main types of health and employee benefits provided by the state and private sector on both a group and individual basis?
Private Medical Insurance (PMI), Critical Illness Insurance (CI), Long-term care insurance (LTCI), and Major Medical Care.
What is Private Medical Insurance (PMI) designed to cover?
PMI is an indemnity-based product that provides compensation for the cost of private medical treatment, which would otherwise be an out-of-pocket expense for individuals or employers. It can be offered on a profit or non-profit basis.
How can PMI be characterized in the UK, considering the coexistence of public and private benefits?
In the UK, voluntary PMI cover is provided by insurers, and includes both comprehensive and less expensive options designed to complement benefits provided by the NHS.
What are some common exclusions in PMI policies?
Alcohol, drug abuse, and other self-inflicted injuries, cosmetic surgery not for health purposes, wilful and material violation of the law, frail care (which may be covered by LTCI), injuries associated with war or terrorism, non-medical costs associated with search and rescue, experimental treatments, and costs for which a third party is responsible.
What is a ‘provider network’ in the context of PMI?
A provider network refers to a list of approved medical facilities or practitioners where treatment costs will be covered by PMI. Treatment at facilities outside of this network may only be partially covered.
What is the difference between in-patient and out-patient treatment in PMI?
In-patient treatment involves staying overnight in a hospital, often during major surgical procedures. Out-patient treatment involves same-day treatments not requiring an overnight stay, such as dressing changes or physiotherapy. Out-patient cover is often restricted by monetary limits, number of treatments, or time limitations.
What are Prescribed Minimum Benefits (PMBs) in the South African context, and how do they relate to medical schemes?
PMBs are a set of medical treatments that every medical scheme in South Africa is required to cover. These include emergency medical treatment, the diagnosis and treatment of 25 chronic conditions, and 270 listed medical conditions and their treatments.
What is a Medical Savings Account (MSA)?
An MSA is an arrangement where policyholders can self-fund day-to-day medical expenses, and is generally offered as part of PMI cover. A claim is only made against the insurance once the MSA balance has been depleted.
Explain the concept of “excess” or “co-payment” in PMI.
An excess is a fixed amount the policyholder pays before the insurance covers the remaining costs. A co-payment is where the insured is responsible for a certain percentage of the claim.
What is a “waiting list plan” in PMI?
A lower-cost PMI option where benefits are provided in circumstances where the public health system cannot offer treatment within a specified period. The policy will not reimburse private healthcare expenses if treatment is available in a reasonable period via the public system.
What is a Health Cash Plan and what benefits does it typically include?
A health cash plan is a low-cost product with premiums that make specified payouts dependent on certain healthcare-related events. The plan gives a defined cash benefit instead of indemnifying the cost of a claim. Benefits can include hospitalization, dental, optical, physiotherapy, maternity, recuperation, hearing aids, and consultation. These plans do not fully transfer risk from the policyholder to the insurer.
What is “moratorium underwriting” in the context of health cash plans?
This means that detailed information related to the insured’s health, including Pre-Existing Conditions (PECs), is only gathered at the claims stage. A waiting period often applies before benefits are eligible.
What is “Medical Gap Cover” designed to cover?
Medical gap cover is designed to cover the difference between the cost of medical treatment and the amount covered by conventional PMI products. It focuses on in-hospital medical and surgical treatment and out-patient treatment for chemotherapy, radiotherapy, or renal dialysis. It also covers the difference in costs where healthcare providers charge higher fees than are covered by PMI.
What does MME (Major Medical Expense) cover?
MME provides a lump sum to the policyholder when they undergo surgery. The size of the lump sum is based on the procedure’s class, severity, and estimated in-patient costs.
What are the main benefits covered by a Personal Accident Policy?
The main consequences covered are: death, Total Permanent Disability (TPD), Temporary and permanent disability, and loss of a limb, body part, or sense.
