Case Study On Group Health Insurance - CiteHR
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Case Study On Corporate Health Insurance



A large service sector company with around 30,000 employees spread across multiple group businesses and multiple locations was experiencing inconsistent experience on healthcare benefits. The premiums they paid and the benefits they extended to the employees differed across locations as well as the partners that the individual businesses selected, offered them little solace at the time of hospitalization. The brokers that were selected helped the company to place the business with an insurer but had no experience and vision to service the account consistently at the time of claim. The Third Party Administrators servicing the account who were responsible on behalf of the insurance companies to provide claims validation, health insurance identification cards, organizing cashless network arrangement with hospitals etc. were selected arbitrarily and without negotiating service levels and turn around time agreements. Employees often experienced pain points during the cashless treatment with long wait at the hospitals. The respective HR SPOCS were also under pressure often due to slip ups in data gathering and sharing with the insurance company, them selves having no knowledge of the implications of various nuances of health insurance. Many times, the new employees were not enrolled in the policy and their dependants ended up in the hospital but only to find that the benefits cannot be availed due to lack of endorsed data with the insurancecompany and the TPA. HR SPOCS braced themselves against employee ire especially during employee forums and stories of apathy of the organization during trying times for an employee were common.



About a year and a half ago, we visited one of the units of the company and started helping them to manage the healthcare and healthinsurance benefits of a small but senior group of about 600 employees. During this period we took the opportunity to study the organization benefits in insurance as a whole and recommended that the client should consolidate the health insurance portfolio on a pan India basis to extend a seamless and a single experience to the employees and along with centralizing the data collection and information dissemination. Our exercise spread over 3 months resulted in a shared services model for the company and eventually fit in well with client organization structuring since they too shortly moved on the shared services platform.



As a part of the solution, we implemented a single policy in the organization with same benefit structures which incidentally are one of the best in the country including Maternity for Rs. 60,0000 coverage of all pre-existing ailments, waiver of all standard exclusions and a critical illness cover to double the sum insured in case of 10 ailments including cardiac, neurological and severe trauma cases. Other exclusions like cosmetic surgery, OPD treatment exclusion and the spirit of the coverage under health insurance is clearly defined and communicated to all. Dental treatment, though covered last year, has been removed this year, and treatment of AIDS has not been covered (though in the US Embassy policy issued by the same insurer it is covered and therefore it can get covered). The process for reimbursement claims is also clearly defined and a Turn around time of 15 days has been laid down for 90 % of the cases. In case the documents submitted are deficient, the same needs to be communicated to the employees by the TPA within 10 days. What is also covered is 30 days pre hospitlisation expenses on out patient basis and 60 days post discharge expenses, these to be filed separately as reimbursements and cover cost of drugs, investigations and doctor consults.



Interestingly, the employees in the company decide their own sum insured after the organization has negotiated with the insurer and therefore the data collection exercise is done annually with the employees and often there are changes in sum insured, substituting coverage of parents with parents in law etc. We set up centralized collection of employee data through our web based model. Once theemployee logs in to her account, she can see the detailed benefit chart, premium rates, policy terms, FAQs etc and she can fill in her family details. Once she submits the details, an automatic email is sent to her with the same details for her records and as a confirmation of her data being added. This mail also has 3 attachments containing policy terms, Salient features and process flow chart with escalation matrix. The portal is open for new joinees for 15 days every month to add their data.



Clearly well documented systems have been set up, TPA selected and service levels agreed to and communicated. Processes have been set up to track the performance of all parties including the TPA and ourselves. We become the single point of contact for all information and actions whether to do with information sharing, coordinating with the TPA / Hospital and the HR. We have implemented a trouble ticket system with auto escalation upto 4 levels to track internal and external SLA’s. We are hosting a knowledge base on our website to share various issues and implementing a strong feedback system for all intervention to track the quality of service and the experience of customers. All these processes are shared transparently and real time with the client SPOC.



We realized early on, that coordination of health insurance benefits is just a hygiene factor , what is more critical to the employees is not only taking care of their operational issues with compassion during such times but also they require a strong support in terms of Medical assistance. Our medical wing, comprising of full time doctors, has created a huge knowledgebase on ailments and their treatment especially home treatment for minor ailments and the dos and don’ts for critical ones including post hospitalization recovery process, generally an overlooked area even for treating doctors. We understand that healthcare is a low involvement area for most people till there is need to go to a doctor. At such times often individuals rely on word of mouth and unreliable sources for their choice of doctors. We, with our industry experience, under stand the need for such reliable and timely information viz. which gynecologist is better known for more normal deliveries than surgical and which ones may be good for uterine cysts, similarly doctors based on specialty, experience, good peer review etc has been compiled along with their personal contact details. Quite often we provide solicited recommendations on good doctors in the country and go a step ahead to fix appointments and ensure that the employee has an experience of some one on her side during such times. Our doctors interpret clinical findings of the treating doctor translating them in a lay-mans language to explain to the family on what the condition is and what the treatment options are, we at times do specific research in finding the best in class treatment across the world in critical cases, organize 2nd opinion in such cases from other leading doctors across the country. We have classified critical cases internally which get tagged for extra care. These critical cases are of two types – the ailment being critical or theemployee being critical in the organization (Hay’s principle). In such cases we often are present in the hospital at such times as required. This gives employees an amazing experience and also communicates the organizations concerns for their well being and importance for the company.



For our client organization, our in house doctor implant is helping understand the trends in the morbidity pattern within the company during working hours. We are now analyzing data of the past few months and looking at the loss for the client due to sickness and its impact on the company. Regular seminars with defined outcomes are being conducted to proactively manage the welfare of the employees including alternative therapies like yoga, pranic healing etc.



Our various initiatives with this client has earned us the nick name of Munna Bhai and we are happy to be known that way.

The idea behind sharing this case study is to help fellow members select and choose possible structuring to their employee benefits program and get some pointers to how other organisations are doing it. While the above example is that on one of the largest companies in India, the same is true, in a sense much more, for small and medium companies. This so due to the nature of smaller group sizes and therefore greater focus on creating sustainable health insurance policies.
Insurance companies, will, needless to mention, keep raising premiums for every adverse claims history. The employees, quite often remain insulated to the amount of sleepless nights that HR Professionals, Finance Heads and Supply Chain people go through every year at the time of renewal. This doesn't need to be this way. Once benefits design is played around with, it can make all the difference between providing real benefits to employes v/s ensuring that premium increases are kept low.

Will be glad to offer any further information to those who may find this of value.

Regards, Deepak

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