Medical insurance is an agreement between two parties in which the first party bears the expenses incurred in the treatment services provided to the second party (individual or group) in return for a specified amount, to be paid in one payment or in the form of installments
Medical insurance is based mainly on the concept of distributing the expected risk that an individual may face, which leads to alleviating the burdens and costs involved when treating the sick conditions that the insured are exposed to, and it is thus a social system based on cooperation and interdependence between individuals to bear what one of them cannot bear alone, and companies The insurance regulates the benefit from the distribution of risk in return for a known wage ( insurance premium)
The beginnings of medical insurance
The world's first compulsory medical insurance policy was issued in Germany in 1883 and forced employers and workers to pay the costs, and the last stages of insurance development in Europe came after World War II when countries made available to their citizens the same medical services that had previously been provided to those covered by insurance. The United States of America finances the free system followed by private insurance and includes a free choice of the type of coverage and the doctor and provides a high quality of care for those who can afford it only, and in the European Union, the system is related to work, which is financed by compulsory insurance premiums, which involves combining good quality Freedom of choice, fairness and reasonable cost. But this does not mean that health insurance is one of the characteristics of rich countries. Health insurance is no longer a luxury, but rather a necessity and a basis not for the health of individuals but for the whole of society
Private commercial health care insurance provides services for
1- Reducing the burden of treatment expenses and contributing to the cost of health insurance, which enables the state to allocate larger sums for prevention operations (immunizations, vaccinations, etc.)
2- Raising the health level of the insured and its impact on production as a result of reducing the number of days of absence due to illness.
The insured person
1- Psychological safety and reassurance from the dangers of diseases and surgeries.
2- Raising the level of health and productivity of the individual.
3- Protecting individuals' incomes from price fluctuations and high treatment costs.
4- Improving the quality of the medical service in return for what the female insured pays.
Companies are always working to provide the greatest degree of protection to the insured at a reasonable cost commensurate with the risk, which led to these companies providing medical services not only to their customers, but this insurance has become a way to attract other new insurance operations
The experiences of countries in medical insurance
The health care system in the United States of America relies heavily on the private sector to provide medical services to most groups of the population, and the role of the government sector is limited to pensioners, the poor, federal employees and some other groups. At least by contracting with a health care company to provide medical services to employees
The health system in England and Wales was also established by the National Health Service Act in 1946, which stipulated that the provision of medical services be through the National Health Service (NHS) largely and that the role of the private sector is limited to providing complementary services
The authority is the oldest and largest service buyer in the world, making it one of the top 5 business owners in the world after the Chinese army, India Railways, Wal-Mart and the US Department of Defense, with nearly 1.07 million workers, including 150,000 doctors in 2014
The health care system in France relies on the integration between the government and the private sector so that the beneficiary obtains the service from any hospital subject to the private sector contracted with the government and then recovers part of its expenses from the health insurance system, and the system is classified by the World Health Organization as one of the “closest systems to perfection in healthcare delivery” globally and France spends approximately 11.6% of its GDP on healthcare
In Egypt, there are many legislations that cover categories of the population under the umbrella of social health insurance. ” Law No. 10 of 1981 for the supervision and control of insurance in Egypt. There are no articles in the law related to the medical insurance branch, but the law covers all branches of insurance and the law is limited to the separation between the life insurance system and the general insurance system It is worth noting that there is no legislative system regulating the relationship between beneficiaries and HMO health care companies , which puts the beneficiaries at risk in the event of bankruptcy or problems with these companies, especially since there is no regulatory body that supervises and monitors these companies, and there is no legislation regulating the relationship Between insurance companies and TPA health services management companies
Frequently Asked Questions
?What is meant by medical (health) insurance
Medical (Health) Insurance: It is insurance for medical costs, medicines, all medical and treatment services and supplies, and management of medical programs.
?What is meant by the benefit that accrues to the insured in medical (health) insurance
The benefit is the expenses of providing the health service covered by the insurance coverage within the limits set out in the policy schedule.
?What is the basis for direct or debiting the company's account in medical (health) insurance
It is the non-payment facility provided to insured persons with the service provider or providers appointed by the company, whereby all such expenses are charged directly to the company's account.
?What is meant by service provider in medical (health) insurance
It is the person or health facility approved and licensed, in accordance with the applicable regulations, to provide medical services in the Kingdom, for example, a hospital, diagnostic center, clinic, pharmacy, laboratory, physical therapy center or radiation therapy.
?What is meant by network of service providers in medical (health) insurance
It is the group of health service providers approved by the Council of Cooperative Health Insurance and specified by the insurance company to provide the service to the employer / policy holder and to be credited directly to the account of the insurance company when the insured presents a valid insurance card.
?What are the supporting documents for a claim in medical (health) insurance
All documents that prove and support the age, nationality and identity of the insured person, the validity of the insurance coverage, the circumstances of the event arising from that claim, and the payment of costs. It also includes other documents such as: invoices, receipts, medical prescriptions, doctor's report, referral and recommendations, and any other original documents that the company may require.
?What diseases do insurance companies usually exclude from medical (health) insurance
1- Plastic surgery unless the surgery was necessary because of a deformity resulting from an accident and the surgery was performed because of this deformity.
2- Chronic diseases that a person suffers from before the validity of the insurance policy, such as diabetes, for example.
3- Routine medical examinations such as employment or travel examinations.
4- Stimulants and vitamins.
Does the insured bear part of the costs of the treatment, or does the insurance company bear all the costs of the treatment
It depends on the type of the policy, as there are some documents that do not require the insured to participate in paying the costs, and some documents require the payment of a certain percentage of the costs according to the company's agreement with the insured. In general, the value of the insurance policy in which the insured does not participate in paying a proportion of the costs is higher than the value of the policy in which the insured participates in paying a proportion of the costs