Case Management & Review Systems

This write-up comes to you in the backdrop of recently concluded 3-day seminar on "Health insurance training - Audit and Medical Management" under aegis of Insurance Institute of India.
Health Insurance is based on a novel concept of pooling individual premia to cover health risk of a large base of subscribers.
Health Assurance on the other hand is protection provided by either an employer or a Government body. The scenario in India is not very encouraging as increasing the base of subscribers is actually leading to still larger number of claims with a negative impact on the bottom line.
Nearly a decade of rigid processes, systems and risk mitigation activities have not been able to contain fraud. It's time a new dimension is given to review systems


Medical Management

50-60% of death claims and 100% of health claims need prudent review of the clinical data for a well-informed decision.
Unfortunately Claims management is discussed in the context of administrative overheads. Currently Risk Management is only capping non-medical damages and claims experience only for vulnerability and trends.