Page 70 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

whereby premiums may not be adequately priced, it is recommended to

set a limit for the following stated benefits:

a) Implants

b) Prescribed medicines

c) Medically necessary diagnostic tests

Another way to curtail abuse and ensure that only medically necessary

surgeries are done is to impose the benefit of second surgical opinion. This

is for non-emergency surgery and the Insured has to obtain a confirming
second opinion before undergoing the surgery in order for the expenses to

be reimbursable. A selection of non-emergency surgeries can be identified,

for example, tonsillectomy. This will form part of the product features to
weed out abuse or fraudulent intent cases and allow only genuine,

medically necessary treatment to be covered.

3.2.8 EXCLUSIONS

Apart from the standard policy exclusion, additional exclusions are

generally applied after full medical underwriting has been done for certain

disabilities not within the risk acceptance level of the insurer. These

exclusions will assist in eliminating the risk that has a high probability of

occurrence or which may expose the insurer to a significant loss. This is
usually done for individual and small group PMI policies, wherein medical

underwriting is conducted. In this way, the insurer can also provide a

standard rate for proposers who would otherwise be charged a loading
because of known health problems that may increase the morbidity risk.

Exclusions can also be applied for hazardous occupation risks or hazardous

sports activities that may increase the incidence rate of injury.

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