The Malaysian Insurance Institute

Transcription

1 The Malaysian Insurance Institute (35445-H) 103 Private Medical Insurance Objectives: To develop in the candidate: A knowledge and understanding of the principles and practices of transacting private medical insurance business; A knowledge and understanding of the provision and operation of PMI within the wider healthcare sector; The ability to apply knowledge and skills to practical situations; The ability to synthesise different aspects of the syllabus and apply them to given scenarios. Learning Outcomes: At the end of the course, student should be able to: 1. Demonstrate the knowledge and understanding of the operation of the private medical insurance market. 2. Explain the underwriting procedures and claim management in private medical insurance; 3. Discuss the tax and legislative issues and its implication on private medical insurance; 4. Outline the marketing strategies of private medical insurance. Notes: The syllabus will be based on Malaysian law & practice. Reference is made to UK law & practice where applicable. Syllabus: 1. STRUCTURE OF HEALTHCARE PROVISION 1.1 The National Health Service explain the aims, purpose and scope of the NHS; discuss the main methods of delivery of NHS service; discuss changes in the delivery of NHS services, including: Malaysian s governments efforts in setting up national healthcare; Government efforts in providing same form National Healthcare. 1.2 Primary, secondary and tertiary The difference between primary, secondary and tertiary care; Name of organizations providing healthcare: Haspice etc. 1.3 Private and public services The extent of the services offered by private and public: hospitals; clinics; treatment centers. identify the private and public: Hospital GH;

2 Clinics government clinics; Treatment center. The extent of facilities offered at the private public Hospital, clinic etc. The range of price variation, room rates, ratio of doctor s to patients etc. 1.4 Healthcare professionals The roles of the main professionals involved in the delivery of healthcare services, including: General Practitioners; Consultants; Other healthcare practitioners. Comparing and contrasting how the roles played by GPs, consultants, specialist, etc differ between Malaysia and UK environment. 1.5 NHS and private healthcare provision the relationship between the NHS and private healthcare providers; the economic group, ethnic group, seeking government and private sectors. The reasons why there is a variation relate to major and minor surgeries 2. PRIVATE MEDICAL INSURANCE PRODUCTS AND PRINCIPLES 2.1 PMI policies the main types of private medical insurance policy available within: the individual market; the voluntary group market; the company and corporate group market; the core and additional benefits associated with PMI policies; Malaysian PMI products available in the: individual; voluntary group market; company and corporate products. 2.2 Group schemes the differences in the operation, philosophy and administration of experience-rated and community-rated group schemes; Malaysian operation, philosophy and administration of experience rated and community rated group schemes; difference between UK and Malaysian practice; Malaysian s response to Group PMI schemes compared to other group products. 2.3 International policies the scope of overseas cover and how it differs from UK specific policies; The extent of such covers offered ex SOS benefit etc; the limitation of such covers offered by the Malaysian insurers. Difference between Malaysian Insurers and UK insurers and the reasons behind these differences. 2.4 Funding methods funding methods in relation to individual and group schemes: fully insured; risk sharing; cost plans; self-funding;

3 co-funding related to Malaysian products. Differences and similarities. 2.5 Healthcare Trusts the use, structure, nature and application of Healthcare Trusts and their use as a method of tax mitigation; Malaysian employees and how they go about tax mitigation. How Malaysian employers are taxed by Income Tax Dept on group Healthcare products. 3. RISK ASSESSMENT AND MANAGEMENT 3.1 Assessment and underwriting the principles of assessment and underwriting affecting private medical insurance and group risks; how premiums are calculated, including the use of: post-code pricing; occupation as a rating factor; hospital scales; age-related (banding and age specific) rating; experience rated; other financial underwriting principles. how Medical underwriting differs from life underwriting; healthcare insurance in Malaysia insures underwriting differs ex Moratoria Underwriting. 3.2 Cost containment the main methods of cost containment, including: the operation of no and low claim discount schemes; loyalty discount; payment method discount; the use of excess; profit share; co-insurance; benefit limits; exclusions; the use of provider networks. methods used in the Malaysian market with regards to cost containment; the guideline on cost containment in Malaysia. 4. MEDICAL UNDERWRITING 4.1 How pre-existing condition is handled in the Malaysian environmental. 4.2 The absence of Moratoria underwriting by the Malaysian authorities. 4.3 The views on Moratoria underwriting by the Malaysian authorities. 4.4 Considerations the underwriting considerations of pre-existing conditions; the underwriting consideration of chronic medical conditions. 4.5 Underwriting medical history the application of medical underwriting in private medical insurance business. 4.6 Moratoria the types and uses of moratoria and excesses in private medical insurance policies.

4 5. LEGISLATION AND REGULATION 5.1 PMI claims procedures the main principles and practice for dealing with claims arising under PMI policies; the principles and practice of managed care and other claims management techniques, settlement methods, administration and coding. Malaysian practices in dealing with claims. 5.2 Pre-authorisation the impact of pre-authorisation of claims. the extent to which pre-authorisation of claims is used in the Malaysian Market 5.3 Scheme management the basic principles of scheme management and administration. 5.4 Transferring business the considerations in respect of business transferring between insurers. continuation of risk takeover from another insurers. How is handled in the Malaysian environment. 5.5 Customer service the role of the customer service function and the benefits of claims helpline facilities. 5.6 Insurer / provider relations the impact on claims management of insurer / provider relations. the relationship between Malaysian Health providers and healthcare insurers. 5.7 Contribution and recoveries the impact of contribution and third party recoveries on PMI claims management. 5.8 Third party administrators the role of third party administration in the claims management function. The role of 3rd party administration in Malaysia. the active 3rd party administrators. the success and failures involved in 3rd party administrators in the Malaysian Market. 6. LEGISLATION AND REGULATION 6.1 Legislation the application to PMI business of the following pieces of legislation; 6.2 Regulation Insurance Act 1996; Disability discrimination Act. the Access to Medical reports Act 1988; (UK) the Data Protection Act 1998; (UK) the Disability Discrimination Act (UK) the impact of the Confidentiality Guidelines contained in the ABI Code of Practice on genetic testing; the key components of the Financial Services authority rulebook as applicable to PMI business. the guidelines put forward by LIAM, PIAM and Bank Negara with regards to healthcare insurance. 6.3 The Financial Ombudsman Service the role of the FOS as applicable to PMI business. Malaysian insurance - Mediation Bureau role; guidelines.

5 7. MARKETING AND SALES 7.1 Guidelines on marketing and sales by various Malaysian authorities. 7.2 FSA rule book 7.3 Buyers the main provisions of the FSA rule book as applicable to the sales and promotion of PMI business. Evaluation of the needs of buyers of private medical insurance, within: the individual market; the voluntary group market; corporate / company group markets. 7.4 Marketing techniques the techniques employed in marketing private medical insurance business. 7.5 Distribution channels the direct and indirect distribution channels used in insurance business. 7.6 Product marketing the role of the insurer / provider relationship and the link with product marketing. the extent of the role played by health providers in the insurance Market in Malaysia and how this differs from UK market. 7.7 Market size and growth the importance of market size, growth and predicted growth to a PMI provider s marketing strategy and direction. 7.8 Private medical insurance providers 8. RELATED ISSUES the types of organization that underwrite and administer PMI. 8.1 Initiatives carried out in the Malaysia Market on: Healthcare; Control of escalating prices by health providers. And the short comings of these initiatives. 8.2 Industry bodies and cross industry initiatives the reasons for, results of and impact of industry bodies and cross-industry initiatives with the PMI market, including: 8.3 Reinsurance Association of Medical Expenses Insurers; ABI PMI panel; Healthcode; The Relative Values review. the need for reinsurance, and methods of, insuring private medical insurance business. how reinsurance differs from life reinsurance. 8.4 Taxation the taxation of benefits and benefits-in-kind to individuals in relation to private medical insurance. the rules governing taxation of PMI.

6 Primary Texts 1. Coursebook 790 Medical Insurance. London: The CII. 2. Pre-Contract Examination for Insurance Agents - MII Periodicals 1. Insurance Annual Report, Bank Negara Malaysia 2. Asia Insurance Review. 3. The Journal, The CII. 4. Post Magazine. 5. The Edge Daily. 6. BNM Annual Report. 7. BNM Takaful Annual Report.