National Health Protection Mission: For claim ratio below 85%, insurer can pocket 15%, give rest to govt

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Mains Paper 2: Governance | Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

From UPSC perspective, the following things are important:

Prelims level: Ayushman bharat scheme(read the attached story)

Mains level: The new framework.


News

Framework for the insurers: Under the National Health Protection Mission (NHPM)

  1. The government has told insurers that they will be under obligation to return part of the premium collected if they fall short of the 85-per cent claim ratio
  2. For any claim ratio below 85 per cent, the insurers can keep a maximum of 15 per cent of the unclaimed premium and return the rest to the government

Explanation

  1. For example, if only 50 per cent is consumed in medical claims of the total annual premium paid to an insurance company, the insurer cannot take the entire remaining sum
  2. It will have to return 35 per cent of the premium amount to the government at the end of the year, and take the remaining 15 per cent

What is the claim ratio?

  1. Claim ratio is calculated as the total value of all claims paid by the company divided by the total amount of premium collected in a financial year
  2. A claim ratio of 75-90 is usually thought to be an indicator of a robust claim settlement system by an insurer

Concern related to reverse bidding

  1. One of the concerns insurance companies raised at the meeting was that the reverse bidding(in which the top three bidders are allowed to revise their bids) should not be done for this programme,
    Another concern related to eligibility condition
  2. the eligibility conditions be relaxed so that new entrants in the insurance sector with less than three years experience can bid as well
Health Sector – UHC, National Health Policy, Family Planning, Health Insurance, etc.
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