PMI Flashcards
What is PMI
annually renewable policy
Dos not cover chronic conditions
like Asthma
Acute Condition v Chronic Condition
a disease, illness or injury likely to respond to treatment
chronic needs long term monitoring incurable
PMI Benefits
1 access to medical and surgical treatment
2 get private hospital of your choice
3 convenience
4 avoids waiting for treatment
5 Access to a Private Room
6 Ability choose consultant of your choice
7 Peace of mind - access to medical attention
8 speed
Types of Cover
Personal or
Corporate
Personal Products
Can be single, married or family
Can be paid annual, quarterly or monthly
Some insurer offer total healthcare packages
Some policies are age restricted
Range - Comp, Std, Budget, Senior and International
Corporate
May have different categories of cover
Large Group Schemes
Cover 50+ members
Usually include pre existing conditions
premiums calc to group claim history
Small Group Schemes
less than 50 members
underwritten and administered as individual plans
Discount will be given on size of group and claim history
Pre existing conditions excluded
Less Flexible to large schemes
Core Benefits
Care benefits as follows:
Hospital Charges - benefit prov for paying hospital charges in respect of in patient and day case. Includes accommodation, theatre fees, diagnotics (x rays etc), drugs and dressings and prostheses
Most products do not cover non medical costs eg meals, tel calls
Most providers Band Hospitals
Within one hospital
Surgeon and Anaesthetist for surgical procs
some insurers classify complexities Minor removal of a skin Lesion Intermediate - removal an impacted tooth major hysterectomy Major plus total hip replacement Complex major eg heart surgury
Other benefits
Physicians fees
Outpatient Charges eg consulations, MRI, Physio
Cancer not usually a core benefit
Flexible Benefit Packages
Allow customise benefits
eg nomination of hospitals, overseas cover, employee assistance programmes
Flex Schems
include PMI, Life Assuranc, IRP, Health Cash Plans
taxation of PMI schemes
Personal Schemes - no tax relief and premiums subject to IPT (10% from 1/10/16), benefits tax free
Corporate Group Schemes - If cost met by employer treated as P11d, benefits tax free
Underwriting
Principles
1 use standard exclusions
2 Moratoria underwriting
3 declared medical history
Standard Exclusions
generally include pre existing conditions Pregnancy or child birth HIV, AIDS Alcohol or solvent abuse cosmetic war, invasion private GP treatment
Moratoria Underwriting
often referred to as point of claim underwriting
Underwriting for Corporate Business
Normally all employees of categorised by age, employee status and length of service.
Small Schemes
risk in managed by price according to claim history of all employees. Additional factors: No of eligible employees type of industry geography occupations
May offer no worse terms Before offering term underwriters will investigate: size of scheme when last underwritten loss ratio with existing insurer cover has changed Category of employees
Premium Loading
products so pre existing conditions are incorporated. Maybe necessary to get more info from GP. Calcs include smoking occupation weight and height alcohol consumption exercise plan
Claims
Before claim procedure
1 Most insist check before claiming
2 Normally Gp or specialist complete claim form
3 member will be advised how claim will be paid
Managed Care
Insurer intervenes in decision surrounding care, maybe in differ ways
Pre Authorisation - prior to admission
Case Management - high cost of complex treatments
Concurrent Review check the on-going need
