Amit Bhandari, head- Health & Agricultural Insurance, Underwriting & Claims, at ICICI Lombard, said while awareness among employees was low, in several cases the company-provided health cover was not sufficient to meet their expenses.
The survey showed the sum insured was often breached and the choice of hospitals was the main reason for that, he added. Survey data showed that in 2013-14, for such sum-insured breach cases, there were 1,033 secondary cases and 2,084 tertiary cases. According to norms, there was no restriction on the choice of hospital for treatment of any ailment. Hence, even for viral fever, nothing stops a patient from visiting a high-end hospital for treatment. This increases expenses for the insurer when ordinarily the treatment could have been done otherwise at a secondary care hospital at a lower cost.
With respect to the top 10 cases for sum insured breach, neoplasms or cancer-related diseases occupy the top spot followed by heart ailments and genito-urinary diseases. Metro and tier-1 cities had seen higher quantum of breaches, especially with medical costs being higher in these regions.
Difficulties were also faced by employees when a hospital they go to falls out of the network provided by the respective insurer. The survey showed 35 per cent of employers end up spending time on coordination in case of a non-network hospital. Bhandari said some customisations could be offered within the network of providers.
With respect to value-added benefits, wellness benefits was a big area on which corporates were working on. The report said 68 per cent of corporates provided wellness benefits while only 55 per cent employees were aware of such initiatives. Some of them included annual health check-ups, yoga sessions and health talks, among others.
Money being spent on outpatient department (q) was also gradually on the rise. The survey showed 37 per cent of employees incur an expense in the range of Rs 10,000-25,000 annually and 14 per cent employees incur expenses greater than Rs 50,000. Of them, about 48 per cent of the total spend was on pharmacy, followed by 24 per cent on diagnostics.
Going forward, Bhandari said, there could be health care assistance models which would come up in the industry. “Lots of employees surveyed said they do not understand the costs involved. Assistance services would be able to help them here,” he said. Staying with an insurer for group health scheme for a longer duration would enable more accountability and better services, Bhandari added.