WorldWideScience

Sample records for insurance claim reporting

  1. Do Insurers Have to Pay for Bad Behaviour in Settling Claims? Legal Aspects of Insurers' Wrongful Claims Handling

    NARCIS (Netherlands)

    W.H. van Boom (Willem)

    2011-01-01

    textabstractAbstract: This article presents a comparative legal analysis of wrongful claims handling by insurance companies in indemnity and liability insurance. From the outset, it is clear that it may be difficult to draw the line between legitimate claims denial and refusal to pay, on the one

  2. Do Insurers Have to Pay for Bad Behaviour in Settling Claims? Legal Aspects of Insurers' Wrongful Claims Handling

    OpenAIRE

    Boom, Willem

    2011-01-01

    textabstractAbstract: This article presents a comparative legal analysis of wrongful claims handling by insurance companies in indemnity and liability insurance. From the outset, it is clear that it may be difficult to draw the line between legitimate claims denial and refusal to pay, on the one hand, and malicious protraction, procrastination and rejection of valid claims, on the other hand. Therefore, it is interesting to find that European legal systems diverge considerably in their stance...

  3. The claims handling process of liability insurance in South Africa

    Directory of Open Access Journals (Sweden)

    Jacoline van Jaarsveld

    2015-04-01

    Full Text Available Liabilities play a very important financial role in business operations, professional service providers as well as in the personal lives of people. It is possible that a single claim may even lead to the bankruptcy of the defendant. The claims handling process of liability insurance by short-term insurers is therefore very important to these parties as it should be clear that liability claims may have enormous and far-reaching financial implications for them. The objective of this research paper embodies the improvement of financial decision-making by short-term insurers with regard to the claims handling process of liability insurance. Secondary data was initially studied which provided the basis to compile a questionnaire for the empirical survey. The leaders of liability insurance in the South African short-term insurance market that represented 69.5% of the annual gross written premiums received for liability insurance in South Africa were the respondents of the empirical study. The perceptions of these short-term insurers provided the primary data for the vital conclusions of this research. This paper pays special attention to the importance of the claims handling factors of liability insurance, how often the stipulations of liability insurance policies are adjusted by the short-term insurers to take the claims handling factors into consideration, as well as the problem areas which short-term insurers may experience during the claims handling process. Feasible solutions to address the problem areas are also discussed.

  4. The claims handling process of engineering insurance in South Africa

    Directory of Open Access Journals (Sweden)

    I.C. de Beer

    2015-05-01

    Full Text Available Due to technological developments, the complicated world of engineering and its associated products are continuously becoming more specialized. Short-term insurers provide engineering insurance to enable the owners and operators of engineering assets to combat the negative impact of the associated risks. It is, however, a huge challenge to the insurers of engineering insurance to manage the particular risks against the background of technological enhancement. The skills gap in the short-term insurance market and the engineering environment may be the main factor which inhibits the growth of the engineering insurance market. The objective of this research embodies the improvement of financial decision-making concerning the claims handling process of engineering insurance. Secondary as well as primary data were necessary to achieve the stated objective. The secondary data provided the background of the research and enabled the researchers to compile a questionnaire for the empirical survey. The questionnaire and a cover letter were sent to the top 10 short-term insurers in South Africa that are providing engineering insurance. Their perceptions should provide guidelines to other short-term insurers who are engaged in engineering insurance, as they are regarded as the market leaders of engineering insurance in South Africa. The empirical results of this research focus on the importance of various claims handling factors when assessing the claims handling process of engineering insurance, the problem areas in the claims handling process concerned, as well as how often the stipulations of engineering insurance policies are adjusted to take the claims handling factors into account.

  5. Understanding Reporting Delay in General Insurance

    Directory of Open Access Journals (Sweden)

    Richard J. Verrall

    2016-07-01

    Full Text Available The aim of this paper is to understand and to model claims arrival and reporting delay in general insurance. We calibrate two real individual claims data sets to the statistical model of Jewell and Norberg. One data set considers property insurance and the other one casualty insurance. For our analysis we slightly relax the model assumptions of Jewell allowing for non-stationarity so that the model is able to cope with trends and with seasonal patterns. The performance of our individual claims data prediction is compared to the prediction based on aggregate data using the Poisson chain-ladder method.

  6. A logistic regression model for Ghana National Health Insurance claims

    Directory of Open Access Journals (Sweden)

    Samuel Antwi

    2013-07-01

    Full Text Available In August 2003, the Ghanaian Government made history by implementing the first National Health Insurance System (NHIS in Sub-Saharan Africa. Within three years, over half of the country’s population had voluntarily enrolled into the National Health Insurance Scheme. This study had three objectives: 1 To estimate the risk factors that influences the Ghana national health insurance claims. 2 To estimate the magnitude of each of the risk factors in relation to the Ghana national health insurance claims. In this work, data was collected from the policyholders of the Ghana National Health Insurance Scheme with the help of the National Health Insurance database and the patients’ attendance register of the Koforidua Regional Hospital, from 1st January to 31st December 2011. Quantitative analysis was done using the generalized linear regression (GLR models. The results indicate that risk factors such as sex, age, marital status, distance and length of stay at the hospital were important predictors of health insurance claims. However, it was found that the risk factors; health status, billed charges and income level are not good predictors of national health insurance claim. The outcome of the study shows that sex, age, marital status, distance and length of stay at the hospital are statistically significant in the determination of the Ghana National health insurance premiums since they considerably influence claims. We recommended, among other things that, the National Health Insurance Authority should facilitate the institutionalization of the collection of appropriate data on a continuous basis to help in the determination of future premiums.

  7. Claims expenses and limits of liability in third party liability insurances

    International Nuclear Information System (INIS)

    Rehmann, J.

    1992-01-01

    After the Chernobyl accident, more than 300,000 individual claims totalling DM 440 million were settled in Germany, even though the level of radiation was relatively low. This has alerted insurers to the potential level of expenses connected with the handling and settlement of claims following a major nuclear accident which, it is estimated, could amount to DM 50 million per 100,000 claims. The Paris Convention (PC) states the principle of congruence between liability and coverage for nuclear installations. The minimum amounts of liability and coverage must be exclusively reserved for the compensation of accident victims. This paper will show that in PC countries, the majority of claims expenses - both internal and external -are borne by the insurers in addition to the sums insured for the compensation of third parties, with limited extensions of coverage in some cases. The situation is different in non-PC countries, and particularly in the United States of America, where expenses are included in the total sum insured together with compensation payments to third parties. This situation would not pose a problem if the minimum amounts of liability and coverage as stated in the PC were still applicable. In practice, most countries have since increased these amounts substantially, thus reducing the insurers' ability to make the maximum possible capacity available for indemnities to victims. Thus, before further increasing the statutory limits of liability, governments should, when conducting the Nuclear Energy Agency revision of the PC, consider allowing insurers to include claims handling expenses in their total sums insured; with a finite amount of risk, insurers would then be able to commit their full capacity instead of withholding a safety buffer for an open-ended commitment. (author)

  8. Primary care closed claims experience of Massachusetts malpractice insurers.

    Science.gov (United States)

    Schiff, Gordon D; Puopolo, Ann Louise; Huben-Kearney, Anne; Yu, Winnie; Keohane, Carol; McDonough, Peggy; Ellis, Bonnie R; Bates, David W; Biondolillo, Madeleine

    Despite prior focus on high-impact inpatient cases, there are increasing data and awareness that malpractice in the outpatient setting, particularly in primary care, is a leading contributor to malpractice risk and claims. To study patterns of primary care malpractice types, causes, and outcomes as part of a Massachusetts ambulatory malpractice risk and safety improvement project. Retrospective review of pooled closed claims data of 2 malpractice carriers covering most Massachusetts physicians during a 5-year period (January 1, 2005, through December 31, 2009). Data were harmonized between the 2 insurers using a standardized taxonomy. Primary care practices in Massachusetts. All malpractice claims that involved primary care practices insured by the 2 largest insurers in the state were screened. A total of 551 claims from primary care practices were identified for the analysis. Numbers and types of claims, including whether claims involved primary care physicians or practices; classification of alleged malpractice (eg, misdiagnosis or medication error); patient diagnosis; breakdown in care process; and claim outcome (dismissed, settled, verdict for plaintiff, or verdict for defendant). During a 5-year period there were 7224 malpractice claims of which 551 (7.7%) were from primary care practices. Allegations were related to diagnosis in 397 (72.1%), medications in 68 (12.3%), other medical treatment in 41 (7.4%), communication in 15 (2.7%), patient rights in 11 (2.0%), and patient safety or security in 8 (1.5%). Leading diagnoses were cancer (n = 190), heart diseases (n = 43), blood vessel diseases (n = 27), infections (n = 22), and stroke (n = 16). Primary care cases were significantly more likely to be settled (35.2% vs 20.5%) or result in a verdict for the plaintiff (1.6% vs 0.9%) compared with non-general medical malpractice claims (P < .001). In Massachusetts, most primary care claims filed are related to alleged misdiagnosis. Compared with malpractice

  9. 24 CFR 207.258 - Insurance claim requirements.

    Science.gov (United States)

    2010-04-01

    ... in 24 CFR part 200, subpart B, of its intention to file an insurance claim and of its election either..., ledger cards, documents, books, papers, and accounts relating to the mortgage transaction. (iv) All...

  10. Simulation Of Premi Calculation Claims Insurance Base On Web; Case Study PT. Sinarmas Insurance Padang

    OpenAIRE

    Rohendi, Keukeu; Putra, Ilham Eka

    2016-01-01

    Sinarmas currently has several insurance services featured. To perform its function as a good insurance company is need for reform in terms of services in the process of calculating insurance premiums of insurance carried by marketing to use a calculator which interferes with the activities of marketing activities, slow printing insurance policies, automobile claims process that requires the customer to come to the office ASM, slow printing of Work Order (SPK) and the difficulty recap custome...

  11. Medical insurance claims associated with international business travel.

    Science.gov (United States)

    Liese, B; Mundt, K A; Dell, L D; Nagy, L; Demure, B

    1997-07-01

    Preliminary investigations of whether 10,884 staff and consultants of the World Bank experience disease due to work related travel. Medical insurance claims filed by 4738 travellers during 1993 were compared with claims of non-travellers. Specific diagnoses obtained from claims were analysed overall (one or more v no missions) and by frequency of international mission (1, 2-3, or > or = 4). Standardised rate of claims ratios (SSRs) for each diagnostic category were obtained by dividing the age adjusted rate of claims for travellers by the age adjusted rate of claims for non-travellers, and were calculated for men and women travellers separately. Overall, rates of insurance claims were 80% higher for men and 18% higher for women travellers than their non-travelling counterparts. Several associations with frequency of travel were found. SRRs for infectious disease were 1.28, 1.54, and 1.97 among men who had completed one, two or three, and four or more missions, and 1.16, 1.28, and 1.61, respectively, among women. The greatest excess related to travel was found for psychological disorders. For men SRRs were 2.11, 3.13, and 3.06 and for women, SRRs were 1.47, 1.96, and 2.59. International business travel may pose health risks beyond exposure to infectious diseases. Because travellers file medical claims at a greater rate than non-travellers, and for many categories of disease, the rate of claims increases with frequency of travel. The reasons for higher rates of claims among travellers are not well understood. Additional research on psychosocial factors, health practices, time zones crossed, and temporal relation between travel and onset of disease is planned.

  12. Index for Predicting Insurance Claims from Wind Storms with an Application in France.

    Science.gov (United States)

    Mornet, Alexandre; Opitz, Thomas; Luzi, Michel; Loisel, Stéphane

    2015-11-01

    For insurance companies, wind storms represent a main source of volatility, leading to potentially huge aggregated claim amounts. In this article, we compare different constructions of a storm index allowing us to assess the economic impact of storms on an insurance portfolio by exploiting information from historical wind speed data. Contrary to historical insurance portfolio data, meteorological variables show fewer nonstationarities between years and are easily available with long observation records; hence, they represent a valuable source of additional information for insurers if the relation between observations of claims and wind speeds can be revealed. Since standard correlation measures between raw wind speeds and insurance claims are weak, a storm index focusing on high wind speeds can afford better information. A storm index approach has been applied to yearly aggregated claim amounts in Germany with promising results. Using historical meteorological and insurance data, we assess the consistency of the proposed index constructions with respect to various parameters and weights. Moreover, we are able to place the major insurance events since 1998 on a broader horizon beyond 40 years. Our approach provides a meteorological justification for calculating the return periods of extreme-storm-related insurance events whose magnitude has rarely been reached. © 2015 Society for Risk Analysis.

  13. Model estimation of claim risk and premium for motor vehicle insurance by using Bayesian method

    Science.gov (United States)

    Sukono; Riaman; Lesmana, E.; Wulandari, R.; Napitupulu, H.; Supian, S.

    2018-01-01

    Risk models need to be estimated by the insurance company in order to predict the magnitude of the claim and determine the premiums charged to the insured. This is intended to prevent losses in the future. In this paper, we discuss the estimation of risk model claims and motor vehicle insurance premiums using Bayesian methods approach. It is assumed that the frequency of claims follow a Poisson distribution, while a number of claims assumed to follow a Gamma distribution. The estimation of parameters of the distribution of the frequency and amount of claims are made by using Bayesian methods. Furthermore, the estimator distribution of frequency and amount of claims are used to estimate the aggregate risk models as well as the value of the mean and variance. The mean and variance estimator that aggregate risk, was used to predict the premium eligible to be charged to the insured. Based on the analysis results, it is shown that the frequency of claims follow a Poisson distribution with parameter values λ is 5.827. While a number of claims follow the Gamma distribution with parameter values p is 7.922 and θ is 1.414. Therefore, the obtained values of the mean and variance of the aggregate claims respectively are IDR 32,667,489.88 and IDR 38,453,900,000,000.00. In this paper the prediction of the pure premium eligible charged to the insured is obtained, which amounting to IDR 2,722,290.82. The prediction of the claims and premiums aggregate can be used as a reference for the insurance company’s decision-making in management of reserves and premiums of motor vehicle insurance.

  14. Brief biopsychosocially informed education can improve insurance workers' back pain beliefs: Implications for improving claims management behaviours.

    Science.gov (United States)

    Beales, Darren; Mitchell, Tim; Pole, Naomi; Weir, James

    2016-11-22

    Biopsychosocially informed education is associated with improved back pain beliefs and positive changes in health care practitioners' practice behaviours. Assess the effect of this type of education for insurance workers who are important non-clinical stakeholders in the rehabilitation of injured workers. Insurance workers operating in the Western Australian workers' compensation system underwent two, 1.5 hour sessions of biopsychosocially informed education focusing on understanding and identifying barriers to recovery of injured workers with musculoskeletal conditions. Back pain beliefs were assessed pre-education, immediately post-education and at three-month follow-up (n = 32). Self-reported and Injury Management Advisor-reported assessment of change in claims management behaviours were collected at the three-month follow-up. There were positive changes in the Health Care Providers' Pain and Impairment Relationship Scale (p = 0.009) and Back Beliefs Questionnaire (p = 0.049) immediately following the education that were sustained at three-month follow-up. Positive changes in claims management behaviours were supported by self-reported and Injury Management Advisor-reported data. This study provides preliminary support that a brief biopsychosocially informed education program can positively influence insurance workers' beliefs regarding back pain, with concurrent positive changes in claims management behaviours. Further research is required to ascertain if these changes result in improved claims management outcomes.

  15. Joint Asymptotic Distributions of Smallest and Largest Insurance Claims

    Directory of Open Access Journals (Sweden)

    Hansjörg Albrecher

    2014-07-01

    Full Text Available Assume that claims in a portfolio of insurance contracts are described by independent and identically distributed random variables with regularly varying tails and occur according to a near mixed Poisson process. We provide a collection of results pertaining to the joint asymptotic Laplace transforms of the normalised sums of the smallest and largest claims, when the length of the considered time interval tends to infinity. The results crucially depend on the value of the tail index of the claim distribution, as well as on the number of largest claims under consideration.

  16. Using Self-reports or Claims to Assess Disease Prevalence: It's Complicated.

    Science.gov (United States)

    St Clair, Patricia; Gaudette, Étienne; Zhao, Henu; Tysinger, Bryan; Seyedin, Roxanna; Goldman, Dana P

    2017-08-01

    Two common ways of measuring disease prevalence include: (1) using self-reported disease diagnosis from survey responses; and (2) using disease-specific diagnosis codes found in administrative data. Because they do not suffer from self-report biases, claims are often assumed to be more objective. However, it is not clear that claims always produce better prevalence estimates. Conduct an assessment of discrepancies between self-report and claims-based measures for 2 diseases in the US elderly to investigate definition, selection, and measurement error issues which may help explain divergence between claims and self-report estimates of prevalence. Self-reported data from 3 sources are included: the Health and Retirement Study, the Medicare Current Beneficiary Survey, and the National Health and Nutrition Examination Survey. Claims-based disease measurements are provided from Medicare claims linked to Health and Retirement Study and Medicare Current Beneficiary Survey participants, comprehensive claims data from a 20% random sample of Medicare enrollees, and private health insurance claims from Humana Inc. Prevalence of diagnosed disease in the US elderly are computed and compared across sources. Two medical conditions are considered: diabetes and heart attack. Comparisons of diagnosed diabetes and heart attack prevalence show similar trends by source, but claims differ from self-reports with regard to levels. Selection into insurance plans, disease definitions, and the reference period used by algorithms are identified as sources contributing to differences. Claims and self-reports both have strengths and weaknesses, which researchers need to consider when interpreting estimates of prevalence from these 2 sources.

  17. Reducing medical claims cost to Ghana?s National Health Insurance scheme: a cross-sectional comparative assessment of the paper- and electronic-based claims reviews

    OpenAIRE

    Nsiah-Boateng, Eric; Asenso-Boadi, Francis; Dsane-Selby, Lydia; Andoh-Adjei, Francis-Xavier; Otoo, Nathaniel; Akweongo, Patricia; Aikins, Moses

    2017-01-01

    Background A robust medical claims review system is crucial for addressing fraud and abuse and ensuring financial viability of health insurance organisations. This paper assesses claims adjustment rate of the paper- and electronic-based claims reviews of the National Health Insurance Scheme (NHIS) in Ghana. Methods The study was a cross-sectional comparative assessment of paper- and electronic-based claims reviews of the NHIS. Medical claims of subscribers for the year, 2014 were requested fr...

  18. Organized investigation expedites insurance claims following a blowout

    International Nuclear Information System (INIS)

    Armstreet, R.

    1996-01-01

    Various types of insurance policies cover blowouts to different degrees, and a proper understanding of the incident and the coverage can expedite the adjustment process. Every well control incident, and the claim arising therefrom, has a unique set of circumstances which must be analyzed thoroughly. A blowout incident, no matter what size or how severe, can have an emotional impact on all who become involved. Bodily injuries or death of friends and coworkers can result in additional stress following a blowout. Thus, it is important that all parties involved remain mindful of sensitive matters when investigating a blowout. This paper reviews the definition of a blowout based on insurance procedures and claims. It reviews blowout expenses and contractor cost and accepted well control policies. Finally, it reviews the investigation procedures normally followed by an agent and the types of information requested from the operator

  19. Data analytics for insurance loss modelling, telematics pricing and claims reserving.:Data analytics for insurance loss modelling, telematics pricing and claims reserving.

    OpenAIRE

    Verbelen, Roel

    2017-01-01

    Today's society generates data more rapidly than ever before, creating many opportunities as well as challenges for statisticians. Many industries become increasingly dependent on high-quality data, and the demand for sound statistical analysis of these data is rising accordingly. In the insurance sector, data have always played a major role. When selling a contract to a client, the insurance company is liable for the claims arising from this contract and will hold capital aside to meet th...

  20. Pricing the property claim service (PCS) catastrophe insurance options using gamma distribution

    Science.gov (United States)

    Noviyanti, Lienda; Soleh, Achmad Zanbar; Setyanto, Gatot R.

    2017-03-01

    The catastrophic events like earthquakes, hurricanes or flooding are characteristics for some areas, a properly calculated annual premium would be closely as high as the loss insured. From an actuarial perspective, such events constitute the risk that are not insurable. On the other hand people living in such areas need protection. In order to securitize the catastrophe risk, futures or options based on a loss index could be considered. Chicago Board of Trade launched a new class of catastrophe insurance options based on new indices provided by Property Claim Services (PCS). The PCS-option is based on the Property Claim Service Index (PCS-Index). The index are used to determine and payout in writing index-based insurance derivatives. The objective of this paper is to price PCS Catastrophe Insurance Option based on PCS Catastrophe index. Gamma Distribution is used to estimate PCS Catastrophe index distribution.

  1. 76 FR 44491 - Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals...

    Science.gov (United States)

    2011-07-26

    ... 37208) entitled, ``Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims..., ``Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and... external review processes for group health plans and health insurance issuers offering coverage in the...

  2. The Impact of Changes to the Unemployment Rate on Australian Disability Income Insurance Claim Incidence

    Directory of Open Access Journals (Sweden)

    Gaurav Khemka

    2017-03-01

    Full Text Available We explore the extent to which claim incidence in Disability Income Insurance (DII is affected by changes in the unemployment rate in Australia. Using data from 1986 to 2001, we fit a hurdle model to explore the presence and magnitude of the effect of changes in unemployment rate on the incidence of DII claims, controlling for policy holder characteristics and seasonality. We find a clear positive association between unemployment and claim incidence, and we explore this further by gender, age, deferment period, and occupation. A multinomial logistic regression model is fitted to cause of claim data in order to explore the relationship further, and it is shown that the proportion of claims due to accident increases markedly with rising unemployment. The results suggest that during periods of rising unemployment, insurers may face increased claims from policy holders with shorter deferment periods for white-collar workers and for medium and heavy manual workers. Our findings indicate that moral hazard may have a material impact on DII claim incidence and insurer business in periods of declining economic conditions.

  3. Gender Disparities in Ghana National Health Insurance Claims: An Econometric Analysis

    Directory of Open Access Journals (Sweden)

    Samuel Antwi

    2014-01-01

    Full Text Available The objective of this study was to find out the gender disparities in Ghana national health insurance claims. In this work, data was collected from the policyholders of the Ghana National Health Insurance Scheme with the help of the National Health Insurance database and the patients’ attendance register of the Koforidua Regional Hospital, from 1st January to 31st December 2011. The generalized linear regression (GLR models and the SPSS version 17.0 were used for the analysis. Among men, the younger people prefer attending hospital for treatment as compared to their adult counterparts. In contrast to women, younger women favor attending hospital for treatment as compared to their adult counterparts. Among men, various levels of income impact greatly on their propensity to make an insurance claim, whereas among women only the highest income level did as compared to lowest income level.Men, who completed senior high school education, were less likely to make an insurance claim as compared to their counterparts with basic or no education. However it was women who had basic education that preferred using the hospital as compared to their more educated counterparts. It is suggested that the government should consider building more health centers, clinics and cheap-compounds in at least every community, to help reduce the travel time in accessing health care.  The ministry of health and the Ghana health service should engage older citizens by encouraging them to use hospitals when they are sick instead of other alternative care providers.

  4. Claims Handling Co-operation between Nuclear Insurance Pools in a Case of Transboundary Damage - Multilateral and Bilateral Agreements in Progress

    International Nuclear Information System (INIS)

    Zaruba, P.

    2008-01-01

    The paper is a short progress report on matters concerning the core reason for insurance of nuclear third party liability - registration, handling, organizing and settling of claims in case of a major nuclear incident, underlining claims handling co-operation between national nuclear insurance pools when damage to health or property becomes international. The contents of this paper is in close relation to information provided on this subject during the 6th International Conference in 2006. Commercial insurance companies have gained extensive experience with handling large scale claims (e.g. after floods and other natural disasters) and are capable in gathering and organizing a high number of professional loss surveyors and adjusters in a very short period of time. In case of nuclear insurance pools co-operation between members (commercial insurance companies) is an added value and can be used practically all over the country bringing into action the network of branches and offices of all the pool members. This advantage is also used in case of cross border claims when it is necessary to gather information and claims advises from a large number of subjects and from many countries, sometimes very far apart. The international network of nuclear insurance pools is an ideal tool for this task and can be mobilized practically at once. Operators of nuclear installations, especially nuclear power plants, do not have the possibility to put aside hundreds of workers to handle claims and are also usually not sufficiently equipped with the necessary know-how. The same goes for governments and government agencies which in many countries guarantee the payments of claims to victims. National nuclear insurance pools are on the other hand well equipped for this task which usually has to be in place for many years after a nuclear incident. Multilateral and bilateral agreements between national nuclear insurance pools and other institutions should be prepared and signed before any

  5. Registry and health insurance claims data in vascular research and quality improvement.

    Science.gov (United States)

    Behrendt, Christian-Alexander; Heidemann, Franziska; Rieß, Henrik Christian; Stoberock, Konstanze; Debus, Sebastian Eike

    2017-01-01

    The expansion of procedures in multidisciplinary vascular medicine has sparked a controversy regarding measures of quality improvement. In addition to primary registries, the use of health insurance claims data is becoming of increasing importance. However, due to the fact that health insurance claims data are not collected for scientific evaluation but rather for reimbursement purposes, meticulous validation is necessary before and during usage in research and quality improvement matters. This review highlights the advantages and disadvantages of such data sources. A recent comprehensive expert opinion panel examined the use of health insurance claims data and other administrative data sources in medicine. Results from several studies concerning the validity of administrative data varied significantly. Validity of these data sources depends on the clinical relevance of the diagnoses considered. The rate of implausible information was 0.04 %, while the validity of the considered diagnoses varied between 80 and 97 % across multiple validation studies. A matching study between health insurance claims data of the third-largest German health insurance provider, DAK-Gesundheit, and a prospective primary registry of the German Society for Vascular Surgery demonstrated a good level of validity regarding the mortality of endovascular and open surgical treatment of abdominal aortic aneurysm in German hospitals. In addition, a large-scale international comparison of administrative data for the same disorder presented important results in treatment reality, which differed from those from earlier randomized controlled trials. The importance of administrative data for research and quality improvement will continue to increase in the future. When discussing the internal and external validity of this data source, one has to distinguish not only between its intended usage (research vs. quality improvement), but also between the included diseases and/or treatment procedures

  6. Modeling the Malaysian motor insurance claim using artificial neural network and adaptive NeuroFuzzy inference system

    Science.gov (United States)

    Mohd Yunos, Zuriahati; Shamsuddin, Siti Mariyam; Ismail, Noriszura; Sallehuddin, Roselina

    2013-04-01

    Artificial neural network (ANN) with back propagation algorithm (BP) and ANFIS was chosen as an alternative technique in modeling motor insurance claims. In particular, an ANN and ANFIS technique is applied to model and forecast the Malaysian motor insurance data which is categorized into four claim types; third party property damage (TPPD), third party bodily injury (TPBI), own damage (OD) and theft. This study is to determine whether an ANN and ANFIS model is capable of accurately predicting motor insurance claim. There were changes made to the network structure as the number of input nodes, number of hidden nodes and pre-processing techniques are also examined and a cross-validation technique is used to improve the generalization ability of ANN and ANFIS models. Based on the empirical studies, the prediction performance of the ANN and ANFIS model is improved by using different number of input nodes and hidden nodes; and also various sizes of data. The experimental results reveal that the ANFIS model has outperformed the ANN model. Both models are capable of producing a reliable prediction for the Malaysian motor insurance claims and hence, the proposed method can be applied as an alternative to predict claim frequency and claim severity.

  7. The relationship between insurance claim closure and recovery after traffic injuries for individuals with whiplash associated disorders

    DEFF Research Database (Denmark)

    Boyle, Eleanor; Cassidy, J David; Côté, Pierre

    2017-01-01

    PURPOSE: The purpose of this study was to determine if time to claim closure was similar to time to self-reported recovery in a no fault motor vehicle collision insurance system. METHOD: A prospective cohort of traffic injured adults with a whiplash-associated disorder (WAD) was assembled. We...... Time to claim closure as an outcome measure for whiplash-associated disorders has been criticized in the literature because it is thought that closure is not reflective of the health status of the individual. We found that claim closure was associated with lower levels of disability, but the time...

  8. The effectiveness of insurer-supported safety and health engineering controls in reducing workers' compensation claims and costs.

    Science.gov (United States)

    Wurzelbacher, Steven J; Bertke, Stephen J; Lampl, Michael P; Bushnell, P Timothy; Meyers, Alysha R; Robins, David C; Al-Tarawneh, Ibraheem S

    2014-12-01

    This study evaluated the effectiveness of a program in which a workers' compensation (WC) insurer provided matching funds to insured employers to implement safety/health engineering controls. Pre- and post-intervention WC metrics were compiled for the employees designated as affected by the interventions within 468 employers for interventions occurring from 2003 to 2009. Poisson, two-part, and linear regression models with repeated measures were used to evaluate differences in pre- and post-data, controlling for time trends independent of the interventions. For affected employees, total WC claim frequency rates (both medical-only and lost-time claims) decreased 66%, lost-time WC claim frequency rates decreased 78%, WC paid cost per employee decreased 81%, and WC geometric mean paid claim cost decreased 30% post-intervention. Reductions varied by employer size, specific industry, and intervention type. The insurer-supported safety/health engineering control program was effective in reducing WC claims and costs for affected employees. © 2014 Wiley Periodicals, Inc.

  9. Analysis of the Romanian Insurance Market Based on Ensuring and Exercising Consumers` Right to Claim

    Directory of Open Access Journals (Sweden)

    Dan Armeanu

    2014-05-01

    Full Text Available In the financial market of insurance, consumer protection represents an important component contributing to the stability, discipline and efficiency of the market. In this respect, the activity of educating and informing insurance consumers on ensuring and exercising their right to claim plays a leading role in the mechanism of consumer protection. This study aims to improve the decision-making capacity of the financial services consumers from the Romanian insurance market through better information on ensuring and exercising their right to claim under the legislation. Thus, by applying three data analysis techniques – principal components analysis, cluster analysis and discriminant analysis – to the data regarding the petitions that were registered by the 41 insurance companies which operated in the Romanian market in 2012, a classification that assesses the insurance market transparency is achieved, resulting in a better information for consumers and, hence, the improvement of their protection through reducing the level of transactions that are harmful to consumers

  10. 76 FR 37037 - Requirements for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and...

    Science.gov (United States)

    2011-06-24

    ... Requirements for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and... interim final regulations published July 23, 2010 with respect to group health plans and health insurance..., group health plans, and health insurance issuers providing group health insurance coverage. The text of...

  11. Nonparametric Fine Tuning of Mixtures: Application to Non-Life Insurance Claims Distribution Estimation

    Science.gov (United States)

    Sardet, Laure; Patilea, Valentin

    When pricing a specific insurance premium, actuary needs to evaluate the claims cost distribution for the warranty. Traditional actuarial methods use parametric specifications to model claims distribution, like lognormal, Weibull and Pareto laws. Mixtures of such distributions allow to improve the flexibility of the parametric approach and seem to be quite well-adapted to capture the skewness, the long tails as well as the unobserved heterogeneity among the claims. In this paper, instead of looking for a finely tuned mixture with many components, we choose a parsimonious mixture modeling, typically a two or three-component mixture. Next, we use the mixture cumulative distribution function (CDF) to transform data into the unit interval where we apply a beta-kernel smoothing procedure. A bandwidth rule adapted to our methodology is proposed. Finally, the beta-kernel density estimate is back-transformed to recover an estimate of the original claims density. The beta-kernel smoothing provides an automatic fine-tuning of the parsimonious mixture and thus avoids inference in more complex mixture models with many parameters. We investigate the empirical performance of the new method in the estimation of the quantiles with simulated nonnegative data and the quantiles of the individual claims distribution in a non-life insurance application.

  12. Perspectives on medical malpractice self-insurance financial reporting.

    Science.gov (United States)

    Frese, Richard C; Kitchen, Patrick J

    2012-11-01

    Financial reporting of medical malpractice self-insurance is evolving. The Financial Accounting Standards Board Accounting Standards Codification Section 954-450-25 provides guidance for accounting and financial reporting for medical malpractice. Discounting of medical malpractice liabilities has been reassessed in recent years. Malpractice litigation reform efforts continue in several states. Accountable care organizations could increase the frequency of medical malpractice claims because of patients' heightened expectations regarding quality of care.

  13. Recursive estimation of the claim rates and sizes in an insurance model

    Directory of Open Access Journals (Sweden)

    Lakhdar Aggoun

    2004-01-01

    Full Text Available It is a common fact that for most classes of general insurance, many possible sources of heterogeneity of risk exist. Premium rates based on information from a heterogeneous portfolio might be quite inadequate. One way of reducing this danger is by grouping policies according to the different levels of the various risk factors involved. Using measure change techniques, we derive recursive filters and predictors for the claim rates and claim sizes for the different groups.

  14. 75 FR 43109 - Requirements for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and...

    Science.gov (United States)

    2010-07-23

    ... Requirements for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and... the Office of Consumer Information and Insurance Oversight of the U.S. Department of Health and Human... health insurance coverage offered in connection with a group health plan under the Employee Retirement...

  15. Premium analysis for copula model: A case study for Malaysian motor insurance claims

    Science.gov (United States)

    Resti, Yulia; Ismail, Noriszura; Jaaman, Saiful Hafizah

    2014-06-01

    This study performs premium analysis for copula models with regression marginals. For illustration purpose, the copula models are fitted to the Malaysian motor insurance claims data. In this study, we consider copula models from Archimedean and Elliptical families, and marginal distributions of Gamma and Inverse Gaussian regression models. The simulated results from independent model, which is obtained from fitting regression models separately to each claim category, and dependent model, which is obtained from fitting copula models to all claim categories, are compared. The results show that the dependent model using Frank copula is the best model since the risk premiums estimated under this model are closely approximate to the actual claims experience relative to the other copula models.

  16. The relationship between insurance claim closure and recovery after traffic injuries for individuals with whiplash associated disorders.

    Science.gov (United States)

    Boyle, Eleanor; Cassidy, J David; Côté, Pierre; Carroll, Linda J

    2017-05-01

    The purpose of this study was to determine if time to claim closure was similar to time to self-reported recovery in a no fault motor vehicle collision insurance system. A prospective cohort of traffic injured adults with a whiplash-associated disorder (WAD) was assembled. We excluded participants who applied for benefits after 42 days of the collision, who were in hospital for more than two days and participants who were not followed up at least once after their injury. Questionnaires were completed at baseline, six weeks, three-, six-, nine- and 12-months after the collision. The mean age of the cohort was 39 years and 66% were female. The mean number of days until claim closure and for self-reported recovery was 291days and 134 days, respectively. We found those who had their claim closed at each follow-up period had lower levels of disability and were more likely to report they were recovered than participants with open claims. We conclude that time to claim closure could be used as an outcome measure in traffic collision; however, this measure should be used with caution since it over-estimates the true time to recovery. Implications for Rehabilitation Time to claim closure as an outcome measure for whiplash-associated disorders has been criticized in the literature because it is thought that closure is not reflective of the health status of the individual. We found that claim closure was associated with lower levels of disability, but the time to claim closure was significantly longer than the time to self-reported recovery. Time to claim closure may be used with caution as a "proxy" measure of recovery from an injury; however, it must be noted that it over-estimates the true time of recovery.

  17. Pluvial, urban flood mechanisms and characteristics - Assessment based on insurance claims

    Science.gov (United States)

    Sörensen, Johanna; Mobini, Shifteh

    2017-12-01

    Pluvial flooding is a problem in many cities and for city planning purpose the mechanisms behind pluvial flooding are of interest. Previous studies seldom use insurance claim data to analyse city scale characteristics that lead to flooding. In the present study, two long time series (∼20 years) of flood claims from property owners have been collected and analysed in detail to investigate the mechanisms and characteristics leading to urban flooding. The flood claim data come from the municipal water utility company and property owners with insurance that covers property loss from overland flooding, groundwater intrusion through basement walls and flooding from the drainage system. These data are used as a proxy for flood severity for several events in the Swedish city of Malmö. It is discussed which rainfall characteristics give most flooding and why some rainfall events do not lead to severe flooding, how city scale topography and sewerage system type influence spatial distribution of flood claims, and which impact high sea level has on flooding in Malmö. Three severe flood events are described in detail and compared with a number of smaller flood events. It was found that the main mechanisms and characteristics of flood extent and its spatial distribution in Malmö are intensity and spatial distribution of rainfall, distance to the main sewer system as well as overland flow paths, and type of drainage system, while high sea level has little impact on the flood extent. Finally, measures that could be taken to lower the flood risk in Malmö, and other cities with similar characteristics, are discussed.

  18. 24 CFR 266.626 - Notice of default and filing an insurance claim.

    Science.gov (United States)

    2010-04-01

    ... 24 Housing and Urban Development 2 2010-04-01 2010-04-01 false Notice of default and filing an... AND OTHER AUTHORITIES HOUSING FINANCE AGENCY RISK-SHARING PROGRAM FOR INSURED AFFORDABLE MULTIFAMILY PROJECT LOANS Contract Rights and Obligations Claim Procedures § 266.626 Notice of default and filing an...

  19. Estimating Total Claim Size in the Auto Insurance Industry: a Comparison between Tweedie and Zero-Adjusted Inverse Gaussian Distribution

    Directory of Open Access Journals (Sweden)

    Adriana Bruscato Bortoluzzo

    2011-01-01

    Full Text Available The objective of this article is to estimate insurance claims from an auto dataset using the Tweedie and zero-adjusted inverse Gaussian (ZAIG methods. We identify factors that influence claim size and probability, and compare the results of these methods which both forecast outcomes accurately. Vehicle characteristics like territory, age, origin and type distinctly influence claim size and probability. This distinct impact is not always present in the Tweedie estimated model. Auto insurers should consider estimating total claim size using both the Tweedie and ZAIG methods. This allows for an estimation of confidence interval based on empirical quantiles using bootstrap simulation. Furthermore, the fitted models may be useful in developing a strategy to obtain premium pricing.

  20. Medical reports on persons claiming compensation for personal injury.

    Science.gov (United States)

    Cornes, P; Aitken, R C

    1992-06-01

    An audit of one insurance company's files on all employer's liability and third party motor claims settled over two years for 5000 pounds or more presented an opportunity to review the medical reports on the patients involved. A stratified random sample of files on 203 patients contained 602 reports prepared by 400 consultants. Content analysis was undertaken to evaluate compliance with published guidance on reports prepared for medico-legal purposes and to ascertain how well reports met recipients' requirements. While clinical topics were well covered, generally to a high standard, other functional, psychosocial and occupational topics, reflecting the wider clinical and non-clinical frame of reference within which lawyers and insurers normally seek information and advice, were covered less frequently, extensively and comprehensively--leaving considerable scope to improve these aspects of assessment and reporting. Further review of this aspect of professional practice should include attention to the appropriateness of existing guidance, postgraduate training requirements and the involvement of other agencies or professions in some aspects of assessment for medico-legal purposes.

  1. Claims settlement in insurance contracts from a consumer protection perspective in Cameroon

    Directory of Open Access Journals (Sweden)

    Comfort Fuah Kwanga

    2017-10-01

    Full Text Available Everyone in the society is faced with the possibility of one or more hazards that are part of life will sooner or later befall him and may occasion some loss. This misfortune is uncertain as to the time and period when it will occur and this amongst others include: fire outbreak, accident, and even death. This necessitates the need for people to go for insurance policies which suit their various needs in order to permit compensation in case of loss. Most consumers of insurance products are “short changed” in the process because very few take the trouble to read through their insurance policies in order to ascertain and understand the terms and conditions. The result is that most often when a claim arises and it is discovered that the loss is not covered by the terms of the insurance contract, there is the tendency of blaming the insurance companies. This paper posits that: there are of course some “bad eggs” in the industry who manipulate consumers. However, the paper holds that this unpleasant quagmire is often due to lack of understanding of the terms of insurance contracts in general and consumer apathy in particular. The essence of this study is to re-iterate the need to communicate the rules of the insurance game, thereby minimizing some of the misunderstanding and problems faced by consumers.

  2. Predicting number of hospitalization days based on health insurance claims data using bagged regression trees.

    Science.gov (United States)

    Xie, Yang; Schreier, Günter; Chang, David C W; Neubauer, Sandra; Redmond, Stephen J; Lovell, Nigel H

    2014-01-01

    Healthcare administrators worldwide are striving to both lower the cost of care whilst improving the quality of care given. Therefore, better clinical and administrative decision making is needed to improve these issues. Anticipating outcomes such as number of hospitalization days could contribute to addressing this problem. In this paper, a method was developed, using large-scale health insurance claims data, to predict the number of hospitalization days in a population. We utilized a regression decision tree algorithm, along with insurance claim data from 300,000 individuals over three years, to provide predictions of number of days in hospital in the third year, based on medical admissions and claims data from the first two years. Our method performs well in the general population. For the population aged 65 years and over, the predictive model significantly improves predictions over a baseline method (predicting a constant number of days for each patient), and achieved a specificity of 70.20% and sensitivity of 75.69% in classifying these subjects into two categories of 'no hospitalization' and 'at least one day in hospital'.

  3. 76 FR 20298 - Insurer Reporting Requirements; List of Insurers; Required To File Reports

    Science.gov (United States)

    2011-04-12

    ... vehicle insurers that are required to file reports on their motor vehicle theft loss experiences. An... the agency. Each insurer's report includes information about thefts and recoveries of motor vehicles... more vehicles not covered by theft insurance policies issued by insurers of motor vehicles, other than...

  4. 75 FR 34966 - Insurer Reporting Requirements; List of Insurers Required To File Reports

    Science.gov (United States)

    2010-06-21

    ... vehicle insurers that are required to file reports on their motor vehicle theft loss experiences. An... the agency. Each insurer's report includes information about thefts and recoveries of motor vehicles... vehicles not covered by theft insurance policies issued by insurers of motor vehicles, other than any...

  5. The use of breast conserving surgery: linking insurance claims with tumor registry data

    International Nuclear Information System (INIS)

    Maskarinec, Gertraud; Dhakal, Sanjaya; Yamashiro, Gladys; Issell, Brian F

    2002-01-01

    The purpose of this study was to use insurance claims and tumor registry data to examine determinants of breast conserving surgery (BCS) in women with early stage breast cancer. Breast cancer cases registered in the Hawaii Tumor Registry (HTR) from 1995 to 1998 were linked with insurance claims from a local health plan. We identified 722 breast cancer cases with stage I and II disease. Surgical treatment patterns and comorbidities were identified using diagnostic and procedural codes in the claims data. The HTR database provided information on demographics and disease characteristics. We used logistic regression to assess determinants of BCS vs. mastectomy. The linked data set represented 32.8% of all early stage breast cancer cases recorded in the HTR during the study period. Due to the nature of the health plan, 79% of the cases were younger than 65 years. Women with early stage breast cancer living on Oahu were 70% more likely to receive BCS than women living on the outer islands. In the univariate analysis, older age at diagnosis, lower tumor stage, smaller tumor size, and well-differentiated tumor grade were related to receiving BCS. Ethnicity, comorbidity count, menopausal and marital status were not associated with treatment type. In addition to developing solutions that facilitate access to radiation facilities for breast cancer patients residing in remote locations, future qualitative research may help to elucidate how women and oncologists choose between BCS and mastectomy

  6. An Individual Claims History Simulation Machine

    Directory of Open Access Journals (Sweden)

    Andrea Gabrielli

    2018-03-01

    Full Text Available The aim of this project is to develop a stochastic simulation machine that generates individual claims histories of non-life insurance claims. This simulation machine is based on neural networks to incorporate individual claims feature information. We provide a fully calibrated stochastic scenario generator that is based on real non-life insurance data. This stochastic simulation machine allows everyone to simulate their own synthetic insurance portfolio of individual claims histories and back-test thier preferred claims reserving method.

  7. Reserving by detailed conditioning on individual claim

    Science.gov (United States)

    Kartikasari, Mujiati Dwi; Effendie, Adhitya Ronnie; Wilandari, Yuciana

    2017-03-01

    The estimation of claim reserves is an important activity in insurance companies to fulfill their liabilities. Recently, reserving method of individual claim have attracted a lot of interest in the actuarial science, which overcome some deficiency of aggregated claim method. This paper explores the Reserving by Detailed Conditioning (RDC) method using all of claim information for reserving with individual claim of liability insurance from an Indonesian general insurance company. Furthermore, we compare it to Chain Ladder and Bornhuetter-Ferguson method.

  8. 76 FR 41138 - Insurer Reporting Requirements; List of Insurers Required To File Reports

    Science.gov (United States)

    2011-07-13

    ... passenger motor vehicle insurers that are required to file reports on their motor vehicle theft loss... information about thefts and recoveries of motor vehicles, the rating rules used by the insurer to establish... companies with a fleet of 20 or more vehicles not covered by theft insurance policies issued by insurers of...

  9. Analysis of 127 peripartum hypoxic brain injuries from closed claims registered by the Danish Patient Insurance Association

    DEFF Research Database (Denmark)

    Bock, J.; Christoffersen, J.K.; Hedegaard, M.

    2008-01-01

    : The authors retrospectively investigated peripartum hypoxic brain injuries registered by the Danish Patient Insurance Association. RESULTS: From 1992 to 2004, 127 approved claims concerning peripartum hypoxic brain injuries were registered and subsequently analysed. Thirty-eight newborns died, and a majority...

  10. 77 FR 28343 - Insurer Reporting Requirements; List of Insurers Required To File Reports

    Science.gov (United States)

    2012-05-14

    ... vehicle insurers that are required to file reports on their motor vehicle theft loss experiences. An... vehicles not covered by theft insurance policies issued by insurers of motor vehicles, other than any... than any governmental entity) used for rental or lease whose vehicles are not covered by theft...

  11. A Logistic Regression Based Auto Insurance Rate-Making Model Designed for the Insurance Rate Reform

    Directory of Open Access Journals (Sweden)

    Zhengmin Duan

    2018-02-01

    Full Text Available Using a generalized linear model to determine the claim frequency of auto insurance is a key ingredient in non-life insurance research. Among auto insurance rate-making models, there are very few considering auto types. Therefore, in this paper we are proposing a model that takes auto types into account by making an innovative use of the auto burden index. Based on this model and data from a Chinese insurance company, we built a clustering model that classifies auto insurance rates into three risk levels. The claim frequency and the claim costs are fitted to select a better loss distribution. Then the Logistic Regression model is employed to fit the claim frequency, with the auto burden index considered. Three key findings can be concluded from our study. First, more than 80% of the autos with an auto burden index of 20 or higher belong to the highest risk level. Secondly, the claim frequency is better fitted using the Poisson distribution, however the claim cost is better fitted using the Gamma distribution. Lastly, based on the AIC criterion, the claim frequency is more adequately represented by models that consider the auto burden index than those do not. It is believed that insurance policy recommendations that are based on Generalized linear models (GLM can benefit from our findings.

  12. 75 FR 54041 - Insurer Reporting Requirements; List of Insurers Required To File Reports

    Science.gov (United States)

    2010-09-03

    .... Each insurer's report includes information about thefts and recoveries of motor vehicles, the rating... state and; (3) Rental and leasing companies with a fleet of 20 or more vehicles not covered by theft...) used for rental or lease whose vehicles are not covered by theft insurance policies issued by insurers...

  13. 75 FR 1548 - Insurer Reporting Requirements; List of Insurers Required To File Reports

    Science.gov (United States)

    2010-01-12

    ... vehicle insurers that are required to file reports on their motor vehicle theft loss experiences. An.... Each insurer's report includes information about thefts and recoveries of motor vehicles, the rating... state and; (3) rental and leasing companies with a fleet of 20 or more vehicles not covered by theft...

  14. Tuberculosis Prevention in the Private Sector: Using Claims-Based Methods to Identify and Evaluate Latent Tuberculosis Infection Treatment With Isoniazid Among the Commercially Insured.

    Science.gov (United States)

    Stockbridge, Erica L; Miller, Thaddeus L; Carlson, Erin K; Ho, Christine

    Targeted identification and treatment of people with latent tuberculosis infection (LTBI) are key components of the US tuberculosis elimination strategy. Because of recent policy changes, some LTBI treatment may shift from public health departments to the private sector. To (1) develop methodology to estimate initiation and completion of treatment with isoniazid for LTBI using claims data, and (2) estimate treatment completion rates for isoniazid regimens from commercial insurance claims. Medical and pharmacy claims data representing insurance-paid services rendered and prescriptions filled between January 2011 and March 2015 were analyzed. Four million commercially insured individuals 0 to 64 years of age. Six-month and 9-month treatment completion rates for isoniazid LTBI regimens. There was an annual isoniazid LTBI treatment initiation rate of 12.5/100 000 insured persons. Of 1074 unique courses of treatment with isoniazid for which treatment completion could be assessed, almost half (46.3%; confidence interval, 43.3-49.3) completed 6 or more months of therapy. Of those, approximately half (48.9%; confidence interval, 44.5-53.3) completed 9 months or more. Claims data can be used to identify and evaluate LTBI treatment with isoniazid occurring in the commercial sector. Completion rates were in the range of those found in public health settings. These findings suggest that the commercial sector may be a valuable adjunct to more traditional venues for tuberculosis prevention. In addition, these newly developed claims-based methods offer a means to gain important insights and open new avenues to monitor, evaluate, and coordinate tuberculosis prevention.

  15. Nuclear liability insurance: the Price-Anderson reparations system and the claims experience of the nuclear industry

    International Nuclear Information System (INIS)

    Marrone, J.

    1983-01-01

    The manner in which the Price-Anderson Law operates to provide reparations is reviewed, and the changes made in the law by Congress in 1975 are outlined. Nuclear liability insurers' response to the Three Mile Island accident is described, including emergency assistance funds advanced to qualified evacuees and the claims and litigations that followed. Other nuclear liability claims that have been asserted are described as being brought chiefly by onsite workers. Good health physics protection of workers is acknowledged, but the need to improve record keeping for transient workers is stressed. The nuclear industry is urged to implement a more effective record-keeping program for such workers

  16. Medication errors: an analysis comparing PHICO's closed claims data and PHICO's Event Reporting Trending System (PERTS).

    Science.gov (United States)

    Benjamin, David M; Pendrak, Robert F

    2003-07-01

    Clinical pharmacologists are all dedicated to improving the use of medications and decreasing medication errors and adverse drug reactions. However, quality improvement requires that some significant parameters of quality be categorized, measured, and tracked to provide benchmarks to which future data (performance) can be compared. One of the best ways to accumulate data on medication errors and adverse drug reactions is to look at medical malpractice data compiled by the insurance industry. Using data from PHICO insurance company, PHICO's Closed Claims Data, and PHICO's Event Reporting Trending System (PERTS), this article examines the significance and trends of the claims and events reported between 1996 and 1998. Those who misread history are doomed to repeat the mistakes of the past. From a quality improvement perspective, the categorization of the claims and events is useful for reengineering integrated medication delivery, particularly in a hospital setting, and for redesigning drug administration protocols on low therapeutic index medications and "high-risk" drugs. Demonstrable evidence of quality improvement is being required by state laws and by accreditation agencies. The state of Florida requires that quality improvement data be posted quarterly on the Web sites of the health care facilities. Other states have followed suit. The insurance industry is concerned with costs, and medication errors cost money. Even excluding costs of litigation, an adverse drug reaction may cost up to $2500 in hospital resources, and a preventable medication error may cost almost $4700. To monitor costs and assess risk, insurance companies want to know what errors are made and where the system has broken down, permitting the error to occur. Recording and evaluating reliable data on adverse drug events is the first step in improving the quality of pharmacotherapy and increasing patient safety. Cost savings and quality improvement evolve on parallel paths. The PHICO data

  17. 76 FR 5248 - Insurer Reporting Requirements; Annual Insurer Report on Motor Vehicle Theft for the 2005...

    Science.gov (United States)

    2011-01-28

    ...] Insurer Reporting Requirements; Annual Insurer Report on Motor Vehicle Theft for the 2005 Reporting Year... on motor vehicle theft for the 2005 reporting year. Section 33112(h) of Title 49 of the U.S. Code... report provides information on theft and recovery of vehicles; rating rules and plans used by motor...

  18. [Preparation and assignment of medical reports: basis for settlement of compensation claims].

    Science.gov (United States)

    Thomann, K D

    2011-03-01

    Medical reporting represents an essential element in the settlement of personal claims. Moreover, the report prepares the basis for determing the compensation which is appropriate to the injury. The practice of instructing the expert medical assessor to obtain the medical documents required has proved a failure and causes delays in completion of the report. The doctor who is the expert medical assessor is often unsuccessful in obtaining these vital documents. In doubtful cases the expert will deliver his report without access to the vital documents. Incomplete reports affect the settlement adversely and promote unnecessary legal disputes. Many errors can be avoided if the officials of the relevant insurance company prepare the report assignment carefully. Such preparation includes clarification of the accident circumstances, requests for copies of the primary diagnosis and requests for hospital and medical reports, including full details of surgery carried out. Printouts of the daily reports by the doctors involved are also required. Of course these doctors must be released from the obligation to treat medical records confidentially. Furthermore, if the original documents are used, results of the injury which may seem insignificant will not be overlooked. The report assignment and primary medical documents should be sent to the medical assessor at the same time. The report assignment contains a detailed questionnaire which takes into account the particular aspects of the individual claim.

  19. Planning outstanding reserves in general insurance

    Science.gov (United States)

    Raeva, E.; Pavlov, V.

    2017-10-01

    Each insurance company have to ensure its solvency through presentation of accounts for its own reserves in the start of the year. Usually the task of the actuary is to estimate the state of the company on an annual basis and the expectation of the status of the company for a future period. One of the major problem when calculating the liabilities of the incurred claims, is related to the delay of payments. Object of consideration in the present note are the outstanding claim reserves, which are set aside to cover claims, occurred before the date of the annual account, but still not paid, and related with them expenses. There may be different reasons for the delay of claims settlement. For example, continuation the process of the liquidation of the damage waiting for necessary documents or the presence of controversial cases whose permission takes time, etc. Thus the claims, which determine the outstanding reserves could be divided in the following types: claims, which are reported, but not settled (RBNS); claims, which are incurred but not reported (IBNR); claims, whose case is finished, but it is possible to be reopened. When calculating the reserves for IBNR claims, most widely used is the Chain-ladder method and its modification presented by the Bornhuetter - Ferguson method. For modeling the outstanding claims, the available data should be presented in so called run-off triangle, which underlies in the basis of such methods. The present work provides a review of the algorithm for calculating insurance outstanding claim reserves according to the Chain-ladder method. Using available data for claims related to liability of drivers, registered in Bulgaria an example is constructed to illustrate the methodology of the Chain-Ladder method. Back-testing approach is used for validating the results.

  20. Premium Forecasting of an Insurance Company: Automobile Insurance

    OpenAIRE

    Fouladvand, M. Ebrahim; Darooneh, Amir H.

    2002-01-01

    We present an analytical study of an insurance company. We model the company's performance on a statistical basis and evaluate the predicted annual income of the company in terms of insurance parameters namely the premium, total number of the insured, average loss claims etc. We restrict ourselves to a single insurance class the so-called automobile insurance. We show the existence a crossover premium p_c below which the company is loss-making. Above p_c, we also give detailed statistical ana...

  1. Premium Pricing of Liability Insurance Using Random Sum Model

    OpenAIRE

    Kartikasari, Mujiati Dwi

    2017-01-01

    Premium pricing is one of important activities in insurance. Nonlife insurance premium is calculated from expected value of historical data claims. The historical data claims are collected so that it forms a sum of independent random number which is called random sum. In premium pricing using random sum, claim frequency distribution and claim severity distribution are combined. The combination of these distributions is called compound distribution. By using liability claim insurance data, we ...

  2. American nuclear insurers

    International Nuclear Information System (INIS)

    Oliveira, R.A.

    1988-01-01

    Nuclear liability insurance covers liability for damages directly caused by the nuclear energy hazard. This coverage includes offsite bodily injury and property damage sustained by members of the general public, and bodily injury to onsite third party personnel. Recent nuclear liability claims allege bodily injury and property damage resulting from releases or radioactive materials to the environmental and occupational radiation worker exposures. Routine reactor operations involving radioactive waste have the potential to result in such claims. The nuclear insurance Pools believe that one way such claims can be minimized is through the implementation of an effective radioactive waste management program

  3. Willingness to Pay for Insurance in Denmark

    DEFF Research Database (Denmark)

    Hansen, Jan V.; Højbjerg Jacobsen, Rasmus; Lau, Morten I.

    We estimate the maximum amount that Danish households are willing to pay for three different types of insurance: auto, home and house insurance. We use a unique combination of claims data from the largest private insurance company in Denmark, measures of individual risk attitudes and discount rates...... possible states of nature, where all uncertainty is realized in the initial period and any loss incurred by an accident is subtracted from initial wealth. The estimated willingness to pay is based on annual claims and should thus be considered as an annual premium. Since there is some uncertainty about...... of the insurance claims....

  4. Risk adjustment model of credit life insurance using a genetic algorithm

    Science.gov (United States)

    Saputra, A.; Sukono; Rusyaman, E.

    2018-03-01

    In managing the risk of credit life insurance, insurance company should acknowledge the character of the risks to predict future losses. Risk characteristics can be learned in a claim distribution model. There are two standard approaches in designing the distribution model of claims over the insurance period i.e, collective risk model and individual risk model. In the collective risk model, the claim arises when risk occurs is called individual claim, accumulation of individual claim during a period of insurance is called an aggregate claim. The aggregate claim model may be formed by large model and a number of individual claims. How the measurement of insurance risk with the premium model approach and whether this approach is appropriate for estimating the potential losses occur in the future. In order to solve the problem Genetic Algorithm with Roulette Wheel Selection is used.

  5. Premium Pricing of Liability Insurance Using Random Sum Model

    Directory of Open Access Journals (Sweden)

    Mujiati Dwi Kartikasari

    2017-03-01

    Full Text Available Premium pricing is one of important activities in insurance. Nonlife insurance premium is calculated from expected value of historical data claims. The historical data claims are collected so that it forms a sum of independent random number which is called random sum. In premium pricing using random sum, claim frequency distribution and claim severity distribution are combined. The combination of these distributions is called compound distribution. By using liability claim insurance data, we analyze premium pricing using random sum model based on compound distribution

  6. RISK PREMIUM IN MOTOR VEHICLE INSURANCE

    Directory of Open Access Journals (Sweden)

    BANU ÖZGÜREL

    2013-06-01

    Full Text Available The pure premium or risk premium is the premium that would exactly meet the expected cost of the risk covered ignoring management expenses, commissions, contingency loading, etc. Claim frequency rate and mean claim size are required for estimation in calculating risk premiums. In this study, we discussed to estimate claim frequency rate and mean claim size with several methods and calculated risk premiums. Data, which supported our study, is provided by insurance company involving with motor vehicle insurance.

  7. Data scan. With access to a newly available trove of private insurers' claims data, new institute aims to study what's driving spiraling healthcare costs.

    Science.gov (United States)

    Evans, Melanie

    2011-09-26

    A new research initiative aims to delve into private-insurer claims data to study utilization and what's driving healthcare costs. The Health Care Cost Institute will help researchers, who have been limited to Medicare data or limited private claims. "We're optimistic. We have nothing to hide here," says Michael Richards, left, of Gundersen Lutheran Medical Center.

  8. Development of a claim review and payment model utilizing diagnosis related groups under the Korean health insurance.

    Science.gov (United States)

    Shin, Y S; Yeom, Y K; Hwang, H

    1993-02-01

    This paper describes the development of a claim review and payment model utilizing the diagnosis related groups (DRGs) for the fee for service-based payment system of the Korean health insurance. The present review process, which examines all claims manually on a case-by-case basis, has been considered to be inefficient, costly, and time-consuming. Differences in case mix among hospitals are controlled in the proposed model using the Korean DRGs. They were developed by modifying the US-DRG system. An empirical test of the model indicated that it can enhance the efficiency as well as the credibility and objectivity of the claim review. Furthermore, it is expected that it can contribute effectively to medical cost containments and to optimal practice pattern of hospitals by establishing a useful mechanism in monitoring the performance of hospitals. However, the performance of this model needs to be upgraded by refining the Korean DRGs which play a key role in the model.

  9. THE ANALYSIS OF THE COMPREHENSIVE INSURANCE DEMAND FOR TURKEY USING UTILITY THEORY AND SYSTEM SIMULATION

    Directory of Open Access Journals (Sweden)

    Murat KIRKAĞAÇ

    2017-03-01

    Full Text Available In this study, the demand for comprehensive insurance is analysed using utility theory and system simulation. A simulation study is performed to assess the behaviour of individuals with different income levels for the demand of comprehensive insurance. Simulation assumptions and input-output variables are determined using the real data set from a Turkish insurance company and the report about the insurance activities in Turkey for year 2014. The effects of income level, expected claim severity and premium level on the demand for insurance are investigated. It is concluded that while an increase in income level and expected claim severity causes an increase in the demand, an increase in premium level causes a decrease in the demand.

  10. Farmers Insures Success

    Science.gov (United States)

    Freifeld, Lorri

    2012-01-01

    Farmers Insurance claims the No. 2 spot on the Training Top 125 with a forward-thinking training strategy linked to its primary mission: FarmersFuture 2020. It's not surprising an insurance company would have an insurance policy for the future. But Farmers takes that strategy one step further, setting its sights on 2020 with a far-reaching plan to…

  11. Use of major surgery in south India: A retrospective audit of hospital claim data from a large, community health insurance program.

    Science.gov (United States)

    Shaikh, Maaz; Woodward, Mark; Rahimi, Kazem; Patel, Anushka; Rath, Santosh; MacMahon, Stephen; Jha, Vivekanand

    2015-05-01

    Information on the use of major surgery in India is scarce. In this study we aimed to bridge this gap by auditing hospital claims from Rajiv Aarogyasri Community Health Insurance Scheme, which provides access to free hospital care through state-funded insurance to 68 million beneficiaries, an estimated 81% of population in the states of Telangana and Andhra Pradesh. Publicly available deidentified hospital claim data for all surgery procedures conducted between mid-2008 and mid-2012 were compiled across all 23 districts in Telangana and Andhra Pradesh. A total of 677,332 operative admissions (80% at private hospitals) were recorded at an annual rate of 259 per 100,000 beneficiaries, with male subjects accounting for 56% of admissions. Injury was the most common cause for operative admission (27%) with operative correction of long bone fractures being the most common procedure (20%) identified in the audit. Diseases of the digestive (16%), genitourinary (12%), and musculoskeletal (10%) systems were other leading causes for operative admissions. Most hospital bed-days were used by admissions for injuries (31%) and diseases of the digestive (17%) and musculoskeletal system (11%) costing 19%, 13%, and 11% of reimbursement. Operations on the circulatory system (8%) accounted for 21% of reimbursements. Annual per capita cost of operative claims was US$1.48. The use of surgery by an insured population in India continued to be low despite access to financing comparable with greater spending countries, highlighting need for strategies, beyond traditional health financing, that prioritize improvement in access, delivery, and use of operative care. Copyright © 2015 Elsevier Inc. All rights reserved.

  12. The influence of motor vehicle legislation on injury claim incidence.

    Science.gov (United States)

    Lemstra, Mark; Olszynski, W P

    2005-01-01

    Although there have been numerous strategies to prevent motor vehicle collisions and their subsequent injuries, few have been effective in preventing motor vehicle injury claims. In this paper, we examine the role of legislation and compensation system in altering injury claim incidence. The population base for our natural experiment was all Saskatchewan, Manitoba, British Columbia and Quebec residents who submitted personal injury claims to their respective motor vehicle insurance provider from 1990 to 1999. The provinces of Saskatchewan and Manitoba switched from Tort to pure No-Fault insurance on January 1, 1995 and on March 1, 1994 respectively. British Columbia maintained tort insurance and Quebec maintained pure no-fault insurance throughout the entire 10-year period. The conversion from tort insurance to pure no-fault motor vehicle insurance resulted in a five-year 31% (RR = 0.69; 95% CI 0.68-0.70) reduction in total injury claims per 100,000 residents in Saskatchewan and a five-year 43% (RR = 0.57; 95% CI 0.56-0.58) reduction in Manitoba. At the same time, the province of British Columbia retained tort insurance and had a five-year 5% reduction (RR = 0.95; 95% CI 0.94-0.99). Quebec, which retained pure no-fault throughout the entire 10-year period, had less than one third of the injury claims per 100,000 residents than the tort province of British Columbia. The conversion from tort to pure no-fault legislation has a large influence in reducing motor vehicle injury claim incidence in Canada. Legislative system and injury compensation scheme have an observable impact on injury claim incidence and can therefore have significant impact on the health care system.

  13. Insurance Salespeople's Attitudes towards Collusion: The Case of Taiwan’s Car Insurance Industry

    OpenAIRE

    Lu-Ming Tseng; Wen-Pin Su

    2014-01-01

    Insurance researchers believe that the increase in insurance fraud may be associated with the unethical decisions made by some insurance salespeople. However, to date, research that has empirically investigated the link between insurance salespeople and collusion is scant. Using the car insurance industry in Taiwan as an example, this paper explores the impact of the opportunity to obtain the fraudulent claim and that of the size of actual loss on car insurance salespeople's attitudes towards...

  14. Nuclear liability insurance in the United States: an insurer's perspective

    International Nuclear Information System (INIS)

    Quattrocchi, J.

    2000-01-01

    By the mid-1950's the United States recognised that it was in the interest to promote commercial development of nuclear energy. But the uncertainties of the technology and the potential for severe accidents were clear obstacles to commercial development. Exposure to potentially serious uninsured liability inhibited the private sector. These impediments led Congress to enact the Price-Anderson Act in 1957. The Act had several purposes: the first was to encourage private development of nuclear power; the second was to establish a legal framework for handling potential liability claims; and the third was to provide a ready source of funds to compensate injured victims of a nuclear accident. Insurers chose the pooling technique by creating in the US the American Nuclear Insurers. ANI acts as a managing agent for its members insurance companies. The accident of three Miles Island occurred on 28 March 1979 and with came the claims experience in US. The 1988 amendments to the Price-Anderson Act directed the President to establish a Commission for the purpose of developing a means to assure full compensation of victims of a catastrophic nuclear accident that exceeds the limitation on aggregate public liability, or currently just over US$ 9.7 billion. The Presidential Commission issued its report in August 1990, in which it reached a number of conclusions and offered a number of recommendations.The US Congress has not acted on the Commission's report, but may revisit its recommendations as debate begins this year (1999) or next on the renewal of the Price-Anderson Act. (N.C.)

  15. An Analysis of the Number of Medical Malpractice Claims and Their Amounts.

    Directory of Open Access Journals (Sweden)

    Marco Bonetti

    Full Text Available Starting from an extensive database, pooling 9 years of data from the top three insurance brokers in Italy, and containing 38125 reported claims due to alleged cases of medical malpractice, we use an inhomogeneous Poisson process to model the number of medical malpractice claims in Italy. The intensity of the process is allowed to vary over time, and it depends on a set of covariates, like the size of the hospital, the medical department and the complexity of the medical operations performed. We choose the combination medical department by hospital as the unit of analysis. Together with the number of claims, we also model the associated amounts paid by insurance companies, using a two-stage regression model. In particular, we use logistic regression for the probability that a claim is closed with a zero payment, whereas, conditionally on the fact that an amount is strictly positive, we make use of lognormal regression to model it as a function of several covariates. The model produces estimates and forecasts that are relevant to both insurance companies and hospitals, for quality assurance, service improvement and cost reduction.

  16. Incidence of workers compensation indemnity claims across socio-demographic and job characteristics.

    Science.gov (United States)

    Du, Juan; Leigh, J Paul

    2011-10-01

    We hypothesized that low socioeconomic status, employer-provided health insurance, low wages, and overtime were predictors of reporting workers compensation indemnity claims. We also tested for gender and race disparities. Responses from 17,190 (person-years) Americans participating in the Panel Study of Income Dynamics, 1997-2005, were analyzed with logistic regressions. The dependent variable indicated whether the subject collected benefits from a claim. Odds ratios for men and African-Americans were relatively large and strongly significant predictors of claims; significance for Hispanics was moderate and confounded by education. Odds ratios for variables measuring education were the largest for all statistically significant covariates. Neither low wages nor employer-provided health insurance was a consistent predictor. Due to confounding from the "not salaried" variable, overtime was not a consistently significant predictor. Few studies use nationally representative longitudinal data to consider which demographic and job characteristics predict reporting workers compensation indemnity cases. This study did and tested some common hypotheses about predictors. Copyright © 2011 Wiley-Liss, Inc.

  17. National Flood Insurance Program (NFIP) Residential Historical Claims

    Data.gov (United States)

    Department of Homeland Security — The National Flood Insurance Program (NFIP) aims to reduce the impact of flooding—a burden not covered by homeowner’s insurance—by providing insurance to homeowners,...

  18. Assessing the impact of space weather on the electric power grid based on insurance claims for industrial electrical equipment

    Science.gov (United States)

    Schrijver, C. J.; Dobbins, R.; Murtagh, W.; Petrinec, S. M.

    2014-07-01

    Geomagnetically induced currents are known to induce disturbances in the electric power grid. Here we perform a statistical analysis of 11,242 insurance claims from 2000 through 2010 for equipment losses and related business interruptions in North American commercial organizations that are associated with damage to, or malfunction of, electrical and electronic equipment. We find that claim rates are elevated on days with elevated geomagnetic activity by approximately 20% for the top 5% and by about 10% for the top third of most active days ranked by daily maximum variability of the geomagnetic field. When focusing on the claims explicitly attributed to electrical surges (amounting to more than half the total sample), we find that the dependence of claim rates on geomagnetic activity mirrors that of major disturbances in the U.S. high-voltage electric power grid. The claim statistics thus reveal that large-scale geomagnetic variability couples into the low-voltage power distribution network and that related power-quality variations can cause malfunctions and failures in electrical and electronic devices that, in turn, lead to an estimated 500 claims per average year within North America. We discuss the possible magnitude of the full economic impact associated with quality variations in electrical power associated with space weather.

  19. 78 FR 70856 - Information Reporting of Mortgage Insurance Premiums

    Science.gov (United States)

    2013-11-27

    ... Information Reporting of Mortgage Insurance Premiums AGENCY: Internal Revenue Service (IRS), Treasury. ACTION... regulations that require information reporting by persons who receive mortgage insurance premiums, including... reporting requirements that result from the extension of the treatment of mortgage insurance premiums made...

  20. Administrative and clinical denials by a large dental insurance provider

    Directory of Open Access Journals (Sweden)

    Geraldo Elias MIRANDA

    2015-01-01

    Full Text Available The objective of this study was to assess the prevalence and the type of claim denials (administrative, clinical or both made by a large dental insurance plan. This was a cross-sectional, observational study, which retrospectively collected data from the claims and denial reports of a dental insurance company. The sample consisted of the payment claims submitted by network dentists, based on their procedure reports, reviewed in the third trimester of 2012. The denials were classified and grouped into ‘administrative’, ‘clinical’ or ‘both’. The data were tabulated and submitted to uni- and bivariate analyses. The confidence intervals were 95% and the level of significance was set at 5%. The overall frequency of denials was 8.2% of the total number of procedures performed. The frequency of administrative denials was 72.88%, whereas that of technical denials was 25.95% and that of both, 1.17% (p < 0.05. It was concluded that the overall prevalence of denials in the studied sample was low. Administrative denials were the most prevalent. This type of denial could be reduced if all dental insurance providers had unified clinical and administrative protocols, and if dentists submitted all of the required documentation in accordance with these protocols.

  1. Response to health insurance by previously uninsured rural children.

    Science.gov (United States)

    Tilford, J M; Robbins, J M; Shema, S J; Farmer, F L

    1999-08-01

    To examine the healthcare utilization and costs of previously uninsured rural children. Four years of claims data from a school-based health insurance program located in the Mississippi Delta. All children who were not Medicaid-eligible or were uninsured, were eligible for limited benefits under the program. The 1987 National Medical Expenditure Survey (NMES) was used to compare utilization of services. The study represents a natural experiment in the provision of insurance benefits to a previously uninsured population. Premiums for the claims cost were set with little or no information on expected use of services. Claims from the insurer were used to form a panel data set. Mixed model logistic and linear regressions were estimated to determine the response to insurance for several categories of health services. The use of services increased over time and approached the level of utilization in the NMES. Conditional medical expenditures also increased over time. Actuarial estimates of claims cost greatly exceeded actual claims cost. The provision of a limited medical, dental, and optical benefit package cost approximately $20-$24 per member per month in claims paid. An important uncertainty in providing health insurance to previously uninsured populations is whether a pent-up demand exists for health services. Evidence of a pent-up demand for medical services was not supported in this study of rural school-age children. States considering partnerships with private insurers to implement the State Children's Health Insurance Program could lower premium costs by assembling basic data on previously uninsured children.

  2. 33 CFR 136.111 - Insurance.

    Science.gov (United States)

    2010-07-01

    ... POLLUTION FINANCIAL RESPONSIBILITY AND COMPENSATION OIL SPILL LIABILITY TRUST FUND; CLAIMS PROCEDURES... which compensation is claimed: (1) The name and address of each insurer. (2) The kind and amount of...

  3. Can Medicaid Claims Validly Ascertain Foster Care Status?

    Science.gov (United States)

    Raghavan, Ramesh; Brown, Derek S; Allaire, Benjamin T

    2017-08-01

    Medicaid claims have been used to identify populations of children in foster care in the current literature; however, the ability of such an approach to validly ascertain a foster care population is unknown. This study linked children in the National Survey of Child and Adolescent Well-Being-I to their Medicaid claims from 36 states using their Social Security numbers. Using this match, we examined discordance between caregiver report of foster care placement and the foster care eligibility code contained in the child's Medicaid claims. Only 73% of youth placed in foster care for at least a year displayed a Medicaid code for foster care eligibility. Half of all youth coming into contact with child welfare displayed discordance between caregiver report and Medicaid claims. Children with emergency department utilization, and those in primary care case management health insurance arrangements, had the highest odds of accurate ascertainment. The use of Medicaid claims to identify a cohort of children in foster care results in high rates of underascertainment. Supplementing administrative data with survey data is one way to enhance validity of ascertainment.

  4. Characteristics of claims in the management of septic arthritis in Japan: Retrospective analyses of judicial precedents and closed claims.

    Science.gov (United States)

    Otaki, Yasuhiro; DaSilva, Makiko Ishida; Saito, Yuichi; Oyama, Yasuaki; Oiso, Giichiro; Yoshida, Tomohiko; Fukuhara, Masakazu; Moriyama, Mitsuru

    2018-03-01

    Septic arthritis (SA) cases can result in claims or litigation because of poor prognosis even if it is unavoidable. Although these claims or litigation are useful for understanding causes and background factors of medical errors, the characteristics of malpractice claims associated with SA remain undetermined in Japan. This study aimed to increase our understanding of malpractice claims in the clinical management of SA. We analyzed 6 civil precedents and 16 closed claims of SA from 8530 malpractice claims processed between July 2004 and June 2014 by the Tokyo office of Sompo Japan Nipponkoa Insurance, Incorporated. We also studied 5 accident and 21 incident reports of SA based on project data compiled by the Japan Council for Quality Health Care. The rate of negligence was 83.3% in the precedents and 75.0% in closed claims. Two main malpractice claim patterns were revealed: SA in a lower extremity joint following sepsis caused by methicillin-resistant Staphylococcus aureus in newborns and SA in an injection site following joint injection. These two patterns accounted for 83.3% and 56.3% of judicial cases and closed claim cases, respectively. Breakdowns in care process of accident and incident reports were clearly differentiated from judicial cases or closed claim cases (Fisher's exact test, p < 0.001). It is important to pay particular attention to SA following sepsis in newborns and to monitor for any signs of SA after joint injection to ensure early diagnosis. Analysis of both malpractice claims and accident and incident reports is essential to ensure a full understanding of the situation in Japan. Copyright © 2017. Published by Elsevier Taiwan LLC.

  5. 76 FR 64174 - Public Input on the Report to Congress on How To Modernize and Improve the System of Insurance...

    Science.gov (United States)

    2011-10-17

    ... submit views on: 1. Systemic risk regulation with respect to insurance; 2. Capital standards and the... risk; 3. Consumer protection for insurance products and practices, including gaps in State regulation... general creditor claims; iii. In the case of life insurance companies, on the loss of the special status...

  6. Major surgery in south India: a retrospective audit of hospital claim data from a large community health insurance programme.

    Science.gov (United States)

    Shaikh, Maaz; Woodward, Mark; Rahimi, Kazem; Patel, Anushka; Rath, Santosh; MacMahon, Stephen; Jha, Vivekanand

    2015-04-27

    Information about use of major surgery in India is scarce. This study aims to bridge this gap by auditing hospital claims from the Rajiv Aarogyasri Community Health Insurance Scheme (RACHIS) that provides access to free tertiary care for major surgery through state-funded insurance to 68 million beneficiaries with limited household incomes-81% of population in states of Telangana and Andhra Pradesh (combined Human Development Index 0·485). Beneficiary households receive an annual coverage of INR 200 000 (US$3333) for admissions to any empanelled public or private hospital. Publicly available deidentified hospital claim data for all surgical procedures conducted between mid-2008 and mid-2012 were compiled across all 23 districts in Telangana and Andhra Pradesh. 677 332 surgical admissions (80% at private hospitals) were recorded at a mean annual rate of 259 per 100 000 beneficiaries (95% CI 235-283), excluding cataract and caesarean sections as these were not covered under the insurance programme. Men accounted for 56% of admissions. Injury was the most common cause for surgical admission (185 733; 27%) with surgical correction of long bone fractures being the most common procedure (144 997; 20%) identified in the audit. Diseases of digestive (110 922; 16%), genitourinary (82 505; 12%), and musculoskeletal system (70 053; 10%) were other leading causes for surgical admissions. Most hospital bed-days were used for injuries (584 days per 100 000 person years; 31%), digestive diseases (314 days; 17%), and musculoskeletal system (207 days; 11%), costing 19% (INR 4·4 billion), 13% (3·03 billion), and 11% (2·5 billion) of claims, respectively. Cardiovascular surgeries (53 023; 8%) alone accounted for 21% (INR 4·9 billion) of cost. Annual per capita cost of surgical claims was US$1·49 (95% CI 1·32-1·65). Our findings are limited to a population socioeconomically representative of India and other countries with low-income and middle

  7. Worst-Case-Optimal Dynamic Reinsurance for Large Claims

    DEFF Research Database (Denmark)

    Korn, Ralf; Menkens, Olaf; Steffensen, Mogens

    2012-01-01

    We control the surplus process of a non-life insurance company by dynamic proportional reinsurance. The objective is to maximize expected (utility of the) surplus under the worst-case claim development. In the large claim case with a worst-case upper limit on claim numbers and claim sizes, we fin...

  8. Nuclear liability claims handling and costs - Germany and some comparative solutions

    International Nuclear Information System (INIS)

    Harbruecker, D.

    2000-01-01

    Comparison of legal status in Central Europe: coverage by insurance and State intervention, coverage of legal expenses and interests on awards technical problems of claims handing after a nuclear incident: guidelines to be prepared by insurer before and not after an incident occurred, demands on provider of financial security claims handling for part guaranteed by State to be transferred to insurer, necessary regulations of such arrangements (author)

  9. Long-term follow-up of whiplash injuries reported to insurance companies: a cohort study on patient-reported outcomes and impact of financial compensation.

    Science.gov (United States)

    Rydman, Eric; Ponzer, Sari; Brisson, Rosa; Ottosson, Carin; Pettersson-Järnbert, Hans

    2018-02-10

    The long-term outcome of Whiplash-associated disorder (WADs) has been reported to be poor in populations from medical settings. However, no trials have investigated the long-term prognosis of patients from medico-legal environment. For this group, the "compensation hypothesis" suggests financial compensation being associated with worsened outcome. The aims of this study were to describe long-term (2-4 years) non-recovery rates in participants with WAD recruited from insurance companies and to investigate the association between self-reported non-recovery and financial compensation. 144 participants, reporting neck pain after a motor vehicle accident, were recruited from two major insurance companies in Sweden. Self-reported recovery was measured at 6 months and 2-4 years. Those who received financial compensation from an insurance company were compared with those who received no compensation. The overall non-recovery rate after 2-4 years was 55.9% (66/118). In the non-compensated group, the non-recovery rate was 51.0% (25/49) and in the compensated group 73% (27/37) (p = 0.039). Adjusted OR was 4.33 (1.37-13.66). High level of pain at baseline was a strong predictor of non-recovery [OR 46 (4.7-446.0)]. However, no association was found between pain level at baseline and financial compensation. The non-recovery rate among patients making insurance claims is high, especially among those receiving financial compensation even if causal relationship cannot be determined based on this study. However, lack of association between baseline level of pain and compensation supports the compensation hypothesis.

  10. Geothermal reservoir insurance study. Final report

    Energy Technology Data Exchange (ETDEWEB)

    1981-10-09

    The principal goal of this study was to provide analysis of and recommendations on the need for and feasibility of a geothermal reservoir insurance program. Five major tasks are reported: perception of risk by major market sectors, status of private sector insurance programs, analysis of reservoir risks, alternative government roles, and recommendations.

  11. The Potential and Uptake of Remote Sensing in Insurance: A Review

    Directory of Open Access Journals (Sweden)

    Jan de Leeuw

    2014-11-01

    Full Text Available Global insurance markets are vast and diverse, and may offer many opportunities for remote sensing. To date, however, few operational applications of remote sensing for insurance exist. Papers claiming potential application of remote sensing typically stress the technical possibilities, without considering its contribution to customer value for the insured or to the profitability of the insurance industry. Based on a systematic search of available literature, this review investigates the potential and actual support of remote sensing to the insurance industry. The review reveals that research on remote sensing in classical claim-based insurance described in the literature revolve around crop damage and flood and fire risk assessment. Surprisingly, the use of remote sensing in claim-based insurance appears to be instigated by government rather than the insurance industry. In contrast, insurance companies are offering various index insurance products that are based on remote sensing. For example, remotely sensed index insurance for rangelands and livestock are operational, while various applications in crop index insurance are being considered or under development. The paper discusses these differences and concludes that there is particular scope for application of remote sensing by the insurance industry in index insurance because (1 indices can be constructed that correlate well with what is insured; (2 these indices can be delivered at low cost; and (3 it opens up new markets that are not served by claim-based insurance. The paper finally suggests that limited adoption of remote sensing in insurance results from a lack of mutual understanding and calls for greater cooperation between the insurance industry and the remote sensing community.

  12. Linking individual medicare health claims data with work-life claims and other administrative data.

    Science.gov (United States)

    Mokyr Horner, Elizabeth; Cullen, Mark R

    2015-09-30

    Researchers investigating health outcomes for populations over age 65 can utilize Medicare claims data, but these data include no direct information about individuals' health prior to age 65 and are not typically linkable to files containing data on exposures and behaviors during their worklives. The current paper is a proof-of-concept, of merging employers' administrative data and private, employment-based health claims with Medicare data. Characteristics of the linked data, including sensitivity and specificity, are evaluated with an eye toward potential uses of such linked data. This paper uses a sample of former manufacturing workers from an industrial cohort as a test case. The dataset created by this integration could be useful to research in areas such as social epidemiology and occupational health. Medicare and employment administrative data were linked for a large cohort of manufacturing workers (employed at some point during 1996-2008) who transitioned onto Medicare between 2001-2009. Data on work-life health, including biometric indicators, were used to predict health at age 65 and to investigate the concordance of employment-based insurance claims with subsequent Medicare insurance claims. Chronic diseases were found to have relatively high levels of concordance between employment-based private insurance and subsequent Medicare insurance. Information about patient health prior to receipt of Medicare, including biometric indicators, were found to predict health at age 65. Combining these data allows for evaluation of continuous health trajectories, as well as modeling later-life health as a function of work-life behaviors and exposures. It also provides a potential endpoint for occupational health research. This is the first harmonization of its kind, providing a proof-of-concept. The dataset created by this integration could be useful for research in areas such as social epidemiology and occupational health.

  13. Algorithms to identify colonic ischemia, complications of constipation and irritable bowel syndrome in medical claims data: development and validation.

    Science.gov (United States)

    Sands, Bruce E; Duh, Mei-Sheng; Cali, Clorinda; Ajene, Anuli; Bohn, Rhonda L; Miller, David; Cole, J Alexander; Cook, Suzanne F; Walker, Alexander M

    2006-01-01

    A challenge in the use of insurance claims databases for epidemiologic research is accurate identification and verification of medical conditions. This report describes the development and validation of claims-based algorithms to identify colonic ischemia, hospitalized complications of constipation, and irritable bowel syndrome (IBS). From the research claims databases of a large healthcare company, we selected at random 120 potential cases of IBS and 59 potential cases each of colonic ischemia and hospitalized complications of constipation. We sought the written medical records and were able to abstract 107, 57, and 51 records, respectively. We established a 'true' case status for each subject by applying standard clinical criteria to the available chart data. Comparing the insurance claims histories to the assigned case status, we iteratively developed, tested, and refined claims-based algorithms that would capture the diagnoses obtained from the medical records. We set goals of high specificity for colonic ischemia and hospitalized complications of constipation, and high sensitivity for IBS. The resulting algorithms substantially improved on the accuracy achievable from a naïve acceptance of the diagnostic codes attached to insurance claims. The specificities for colonic ischemia and serious complications of constipation were 87.2 and 92.7%, respectively, and the sensitivity for IBS was 98.9%. U.S. commercial insurance claims data appear to be usable for the study of colonic ischemia, IBS, and serious complications of constipation. (c) 2005 John Wiley & Sons, Ltd.

  14. Nonlife Insurance Pricing:

    Science.gov (United States)

    Darooneh, Amir H.

    We consider the insurance company as a physical system which is immersed in its environment (the financial market). The insurer company interacts with the market by exchanging the money through the payments for loss claims and receiving the premium. Here, in the equilibrium state, we obtain the premium by using the canonical ensemble theory, and compare it with the Esscher principle, the well-known formula in actuary for premium calculation. We simulate the case of car insurance for quantitative comparison.

  15. On a Stochastic Model in Insurance

    Indian Academy of Sciences (India)

    Insurance mathematics today is considered a part of applied probability theory. Main objectives are modelling of claims that arrive in an insurance business, and decide how premiums are to be charged to avoid ruin of the insurance company. GENERAL I ARTICLE various results and the heuristics can be appreciated.

  16. Deterministic claims reserving in short-term insuarance contracts ...

    African Journals Online (AJOL)

    Claims reserving for general insurance business has developed significantly over the recent past. This has been occasioned by the growth of the insurance market, with the risk underwriting process becoming more and more complex. New insurance products have been developed that cater for the more specific needs of ...

  17. 24 CFR 241.885 - Insurance benefits.

    Science.gov (United States)

    2010-04-01

    ... 24 Housing and Urban Development 2 2010-04-01 2010-04-01 false Insurance benefits. 241.885 Section... § 241.885 Insurance benefits. (a) Method of payment. Payment of claims shall be made in the following... acceptable assignment of the note and security instrument to the Commissioner, the insurance benefits shall...

  18. A cohort study of epilepsy among 665,000 insured dogs

    DEFF Research Database (Denmark)

    Heske, L.; Nødtvedt, A.; Jäderlund, K. Hultin

    2014-01-01

    The main objective of this study was to estimate the incidence and mortality rates of epilepsy in a large population of insured dogs and to evaluate the importance of a variety of risk factors. Survival time after a diagnosis of epilepsy was also investigated. The Swedish animal insurance database...... used in this study has previously been helpful in canine epidemiological investigations. More than 2,000,000 dog-years at-risk (DYAR) were available in the insurance database. In total, 5013 dogs had at least one veterinary care claim for epilepsy, and 2327 dogs were euthanased or died because...... of epilepsy. Based on veterinary care claims the incidence rate of epilepsy (including both idiopathic and symptomatic cases) was estimated to be 18 per 10,000 DYAR. Dogs were followed up until they were 10 (for life insurance claims) or 12 years of age (veterinary care claims). Among the 35 most common...

  19. Risk segmentation in Chilean social health insurance.

    Science.gov (United States)

    Hidalgo, Hector; Chipulu, Maxwell; Ojiako, Udechukwu

    2013-01-01

    The objective of this study is to identify how risk and social variables are likely to be impacted by an increase in private sector participation in health insurance provision. The study focuses on the Chilean health insurance industry, traditionally dominated by the public sector. Predictive risk modelling is conducted using a database containing over 250,000 health insurance policy records provided by the Superintendence of Health of Chile. Although perceived with suspicion in some circles, risk segmentation serves as a rational approach to risk management from a resource perspective. The variables that have considerable impact on insurance claims include the number of dependents, gender, wages and the duration a claimant has been a customer. As shown in the case study, to ensure that social benefits are realised, increased private sector participation in health insurance must be augmented by regulatory oversight and vigilance. As it is clear that a "community-rated" health insurance provision philosophy impacts on insurance firm's ability to charge "market" prices for insurance provision, the authors explore whether risk segmentation is a feasible means of predicting insurance claim behaviour in Chile's private health insurance industry.

  20. Health and Stress Management and Mental-health Disability Claims.

    Science.gov (United States)

    Marchand, Alain; Haines, Victor Y; Harvey, Steve; Dextras-Gauthier, Julie; Durand, Pierre

    2016-12-01

    This study examines the associations between health and stress management (HSM) practices and mental-health disability claims. Data from the Salveo study was collected during 2009-2012 within 60 workplaces nested in 37 companies located in Canada (Quebec) and insured by a large insurance company. In each company, 1 h interviews were conducted with human resources managers in order to obtain data on 63 HSM practices. Companies and workplaces were sorted into the low-claims and high-claims groups according to the median rate of the population of the insurer's corporate clients. Logistic regression adjusted for design effect and multidimensional scaling was used to analyse the data. After controlling for company size and economic sector, task design, demands control, gratifications, physical activity and work-family balance were associated with low mental-health disability claims rates. Further analyses revealed three company profiles that were qualified as laissez-faire, integrated and partially integrated approaches to HSM. Of the three, the integrated profile was associated with low mental-health disability claims rates. The results of this study provide evidence-based guidance for a better control of mental-health disability claims. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

  1. Evaluation of the crash mitigation effect of low-speed automated emergency braking systems based on insurance claims data.

    Science.gov (United States)

    Isaksson-Hellman, Irene; Lindman, Magdalena

    2016-09-01

    The aim of the present study was to evaluate the crash mitigation performance of low-speed automated emergency braking collision avoidance technologies by examining crash rates, car damage, and personal injuries. Insurance claims data were used to identify rear-end frontal collisions, the specific situations where the low-speed automated emergency braking system intervenes. We compared cars of the same model (Volvo V70) with and without the low-speed automated emergency braking system (AEB and no AEB, respectively). Distributions of spare parts required for car repair were analyzed to identify car damage, and crash severity was estimated by comparing the results with laboratory crash tests. Repair costs and occupant injuries were investigated for both the striking and the struck vehicle. Rear-end frontal collisions were reduced by 27% for cars with low-speed AEB compared to cars without the system. Those of low severity were reduced by 37%, though more severe crashes were not reduced. Accordingly, the number of injured occupants in vehicles struck by low-speed AEB cars was reduced in low-severity crashes. In offset crash configurations, the system was found to be less effective. This study adds important information about the safety performance of collision avoidance technologies, beyond the number of crashes avoided. By combining insurance claims data and information from spare parts used, the study demonstrates a mitigating effect of low-speed AEB in real-world traffic.

  2. Value and Service Quality Assessment of the National Health Insurance Scheme in Ghana: Evidence from Ashiedu Keteke District.

    Science.gov (United States)

    Nsiah-Boateng, Eric; Aikins, Moses; Asenso-Boadi, Francis; Andoh-Adjei, Francis-Xavier

    2016-09-01

    Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 to provide financial access to health care for all residents. This article analyzed claims reimbursement data of the NHIS to assess the value of the benefit package to the insured and responsiveness of the service to the financial needs of health services providers. Medical claims data reported between January 1, 2010, and December 31, 2014, were retrieved from the database of Ashiedu Keteke District Office of the National Health Insurance Authority. The incurred claims ratio, promptness of claims settlements, and claims adjustment rate were analyzed over the 5-year period. In all, 644,663 medical claims with a cost of Ghana cedi (GHS) 11.8 million (US $3.1 million) were reported over the study period. The ratio of claims cost to contributions paid increased from 4.3 to 7.2 over the 2011-2013 period, and dropped to 5.0 in 2014. The proportion of claims settled beyond 90 days also increased from 26% to 100% between 2011 and 2014. Generally, the amount of claims adjusted was low; however, it increased consistently from 1% to about 4% over the 2011-2014 period. The reasons for claims adjustments included provision of services to ineligible members, overbilling of services, and misapplication of diagnosis related groups. There is increased value of the NHIS benefit package to subscribers; however, the scheme's responsiveness to the financial needs of health services providers is low. This calls for a review of the NHIS policy to improve financial viability and service quality. Copyright © 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

  3. Impact of a Comprehensive Workplace Hand Hygiene Program on Employer Health Care Insurance Claims and Costs, Absenteeism, and Employee Perceptions and Practices.

    Science.gov (United States)

    Arbogast, James W; Moore-Schiltz, Laura; Jarvis, William R; Harpster-Hagen, Amanda; Hughes, Jillian; Parker, Albert

    2016-06-01

    The aim of this study was to determine the efficacy of a multimodal hand hygiene intervention program in reducing health care insurance claims for hygiene preventable infections (eg, cold and influenza), absenteeism, and subjective impact on employees. A 13.5-month prospective, randomized cluster controlled trial was executed with alcohol-based hand sanitizer in strategic workplace locations and personal use (intervention group) and brief hand hygiene education (both groups). Four years of retrospective data were collected for all participants. Hygiene-preventable health care claims were significantly reduced in the intervention group by over 20% (P Employee survey data showed significant improvements in hand hygiene behavior and perception of company concern for employee well-being. Providing a comprehensive, targeted, yet simple to execute hand hygiene program significantly reduced the incidence of health care claims and increased employee workplace satisfaction.

  4. The insurance refund request: a legal analysis.

    Science.gov (United States)

    Rollman, S O

    1998-12-01

    When an insurance payment is made erroneously to a healthcare provider and no contract between the insurer and provider addresses the issue of refunding such payments, the law relating to restitution generally applies. Restitution does not apply, however, to three exceptions that the courts have used to refuse claims by insurers for refunds of overpayments: the innocent third-party creditor exception, whereby the healthcare provider cannot be unjustly enriched by the overpayment, cannot have induced the mistaken payment, and cannot have known beforehand that the insurer was not obligated to pay; the material change in position exception, whereby the healthcare provider in good faith accepts an overpayment and so does not pursue other means of payment; and the assumption of the risk exception, which occurs when the insurer pays a claim without having complete information about it.

  5. 32 CFR 842.46 - Who may file a claim.

    Science.gov (United States)

    2010-07-01

    ... authorized agents may file claims for personal injury. (c) Duly appointed guardians of minor children or any other persons legally entitled to do so under applicable local law may file claims for minors' personal... action surviving an individual's death. (e) Insurers with subrogation rights may file claims for losses...

  6. On a Stochastic Model in Insurance

    Indian Academy of Sciences (India)

    day is considered a part of applied probability theory, and a major portion ... claims that arrive in an insurance business, and decide ... Study of probability of ruin and obtaining ...... An important development of late is to consider claim sizes that ...

  7. The Multiplication Effect of Legal Insurance

    NARCIS (Netherlands)

    J.P.B. De Mot (Jef); B. Depoorter (Ben); M.G. Faure (Michael)

    2016-01-01

    textabstractBecause legal insurance policies cover the expenses of plaintiffs in bringing legal claims, such policies increase the risk of negligent or careless acts by tortfeasors. For this reason, potential tortfeasors would prefer to avoid injuring holders of legal insurance policies. Since

  8. Insurance payment process for HANDI 2000 business management system

    Energy Technology Data Exchange (ETDEWEB)

    Wilson, D.

    1998-08-24

    The Pensions and Savings group handles three types of payment into and out of Fluor Daniel Hanford related to insurance benefits: Premium payment to insurance company; Application of employee insurance withholding against insurance costs; Remittance of insurance claims, and administrative fees. General approach in making and recording the remittance is by forwarding payment information to Accounts Payable Master.

  9. Trade Credit Insurance and Asymmetric Information Problem

    Directory of Open Access Journals (Sweden)

    Sokolovska Olena

    2017-03-01

    Full Text Available The presence of different risk factors in international trade gives evidence of the necessity of support in gaps that may affect exporters’ activity. To maximize the trade volumes and in the same time to minimize the exporters’ risks the stakeholders use trade credit insurance. The paper provides analysis of conceptual background of the trade credit insurance in the world. We analyzed briefly the problems, arising in insurance markets due to asymmetric information, such as adverse selection and moral hazard. Also we discuss the main stages of development of trade credit insurance in countries worldwide. Using comparative and graphical analysis we provide a brief evaluation of the dynamics of claims and recoveries for different forms of trade credit insurance. We found that the claims related to the commercial risk for medium and long trade credits in recent years exceed the recoveries, while with the political risk the reverse trend holds. And we originally consider these findings in terms of information asymmetry in the trade credit insurance differentiated by type of risk.

  10. Dental treatment injuries in the Finnish Patient Insurance Centre in 2000-2011.

    Science.gov (United States)

    Karhunen, Sini; Virtanen, Jorma I

    2016-01-01

    Objective The Patient Insurance Centre in Finland reimburses patients who sustained injuries associated with medical and dental care without having to demonstrate malpractice. The aim was to analyse all dental injuries claimed through the Patient Insurance Centre over a 12-year period in order to identify factors affecting reimbursement of claims. Methods This study investigated all dental patient insurance claims in Finland during 2000-2011. The injury cases were grouped as (K00-K08) according to the International Classification of Diseases (ICD-10). Calendar year, claimant's age and gender, dental disease group and health service sector were the explanatory factors and the outcome was the decision of a claim. Multiple logistic regression modelling was used in the statistical analyses. Results The total number of decisions related to dental claims at the PIC in 2000-2011 was 7662, of which women claimed a clear majority (72%). Diseases of the pulp and periapical tissues (K04) and dental caries (K02) were the major disease groups (both 29%). Of the claims 40% were eligible for reimbursement, 27% were classified as insignificant or unavoidable injuries and 32% were rejected for other reasons. The proportion of reimbursed claims declined during the period. Patients from the private sector were more likely to be eligible for compensation than were those from the public sector (OR = 1.89, 95% CI = 1.71-2.10). Conclusions The number of dental patient insurance claims in Finland clearly rose, while the proportion of reimbursed claims declined. More claims received compensation in the private sector than in the public sector.

  11. 20 CFR 325.4 - Claim for unemployment benefits.

    Science.gov (United States)

    2010-04-01

    ... 20 Employees' Benefits 1 2010-04-01 2010-04-01 false Claim for unemployment benefits. 325.4 Section 325.4 Employees' Benefits RAILROAD RETIREMENT BOARD REGULATIONS UNDER THE RAILROAD UNEMPLOYMENT INSURANCE ACT REGISTRATION FOR RAILROAD UNEMPLOYMENT BENEFITS § 325.4 Claim for unemployment benefits. (a...

  12. An EM Algorithm for Double-Pareto-Lognormal Generalized Linear Model Applied to Heavy-Tailed Insurance Claims

    Directory of Open Access Journals (Sweden)

    Enrique Calderín-Ojeda

    2017-11-01

    Full Text Available Generalized linear models might not be appropriate when the probability of extreme events is higher than that implied by the normal distribution. Extending the method for estimating the parameters of a double Pareto lognormal distribution (DPLN in Reed and Jorgensen (2004, we develop an EM algorithm for the heavy-tailed Double-Pareto-lognormal generalized linear model. The DPLN distribution is obtained as a mixture of a lognormal distribution with a double Pareto distribution. In this paper the associated generalized linear model has the location parameter equal to a linear predictor which is used to model insurance claim amounts for various data sets. The performance is compared with those of the generalized beta (of the second kind and lognorma distributions.

  13. Attitudes towards evaluation of psychiatric disability claims: a survey of Swiss stakeholders.

    Science.gov (United States)

    Schandelmaier, Stefan; Leibold, Andrea; Fischer, Katrin; Mager, Ralph; Hoffmann-Richter, Ulrike; Bachmann, Monica Susanne; Kedzia, Sarah; Busse, Jason Walter; Guyatt, Gordon Henry; Jeger, Joerg; Marelli, Renato; De Boer, Wout Ernst Lodewijk; Kunz, Regina

    2015-01-01

    In Switzerland, evaluation of work capacity in individuals with mental disorders has come under criticism. We surveyed stakeholders about their concerns and expectations of the current claim process. We conducted a nationwide online survey among five stakeholder groups. We asked 37 questions addressing the claim process and the evaluation of work capacity, the maximum acceptable disagreement in judgments on work capacity, and its documentation. Response rate among 704 stakeholders (95 plaintiff lawyers, 285 treating psychiatrists, 129 expert psychiatrists evaluating work capacity, 64 social judges, 131 insurers) varied between 71% and 29%. Of the lawyers, 92% were dissatisfied with the current claim process, as were psychiatrists (73%) and experts (64%), whereas the majority of judges (72%) and insurers (81%) were satisfied. Stakeholders agreed in their concerns, such as the lack of a transparent relationship between the experts' findings and their conclusions regarding work capacity, medical evaluations inappropriately addressing legal issues, and the experts' delay in finalising the report. Findings mirror the characteristics that stakeholders consider important for an optimal work capacity evaluation. For a scenario where two experts evaluate the same claimant, stakeholders considered an inter-rater difference of 10%‒20% in work capacity at maximum acceptable. Plaintiff lawyers, treating psychiatrists and experts perceive major problems in work capacity evaluation of psychiatric claims whereas judges and insurers see the process more positively. Efforts to improve the process should include clarifying the basis on which judgments are made, restricting judgments to areas of expertise, and ensuring prompt submission of evaluations.

  14. 24 CFR 232.885 - Insurance benefits.

    Science.gov (United States)

    2010-04-01

    ... 24 Housing and Urban Development 2 2010-04-01 2010-04-01 false Insurance benefits. 232.885 Section 232.885 Housing and Urban Development Regulations Relating to Housing and Urban Development (Continued....885 Insurance benefits. (a) Method of payment. Payment of claim shall be made in the following manner...

  15. Artificial intelligence applied in claims management: Bet on the right customer with claims satisfaction predictive modeling

    OpenAIRE

    Lamarsaude, Benoit

    2017-01-01

    Insurance companies suffer from loss of customer consecutively to claims. Only a small portion of dissatisfied customer expresses themselves, creating difficulties in establishing a long term relationship. Increase customer loyalty is a major subject for insurers, because they have to maintain a minimum portfolio size and acquiring newclients is more expensive than retains the existing. In this work we use artificial intelligence techniques to assess and manage the customer satisfaction when ...

  16. The German insurance industry. 1988 yearbook of the Gesamtverband der Deutschen Versicherungswirtschaft e.V

    International Nuclear Information System (INIS)

    1988-01-01

    The annual report presents among other things the figures of the nuclear insurance line. The Association of Nuclear Insurers in the F.R.G., the DKVG, counts 105 member companies in the year 1988, who offer reinsurance protection for West German nuclear power stations up to DM 1.5 billions in the property insurance sector, and up to DM 200 millions in the nuclear liability sector. The inland portfolio of the DKVG' covers 22 nuclear power stations. The expenses to satisfy claims in 1987 amounted to DM 6.5 millions. (DG) [de

  17. Alleged B. anthracis exposure claims in a workers' compensation setting.

    Science.gov (United States)

    Jewell, Gregory; Dunning, Kari; Lockey, James E

    2006-01-01

    Workers' compensation insurance in some states may not provide coverage for medical evaluation costs of workplace exposures related to potential bioterrorism acts if there is no diagnosed illness or disease. Personal insurance also may not provide coverage for these exposures occurring at the workplace. Governmental entities, insurers, and employers need to consider how to address such situations and the associated costs. The objective of this study was to examine characteristics of workers and total costs associated with workers' compensation claims alleging potential exposure to the bioterrorism organism B. anthracis. We examined 192 claims referred for review to the Ohio Bureau of Workers' Compensation (OBWC) from October 10, 2001, through December 20, 2004. Although some cases came from out-of-state areas where B. anthracis exposure was known to exist, no Ohio claim was associated with true B. anthracis exposure or B. anthracis-related illness. Of the 155 eligible claims, 126 included medical costs averaging dollar 219 and ranging from dollar 24 to dollar 3,126. There was no difference in mean cost for government and non-government employees (p = 0.202 Wilcoxon). The number of claims and associated medical costs for evaluation and treatment of potential workplace exposure to B. anthracis were relatively small. These results can be attributed to several factors, including no documented B. anthracis exposures and disease in Ohio and prompt transmission of recommended diagnostic and prophylactic treatment protocols to physicians. How employers, insurers, and jurisdictions address payment for evaluation and treatment of potential or documented exposures resulting from a potential terrorism-related event should be addressed proactively.

  18. 75 FR 58468 - Terrorism Risk Insurance Program; Program Loss Reporting

    Science.gov (United States)

    2010-09-24

    ... DEPARTMENT OF THE TREASURY Terrorism Risk Insurance Program; Program Loss Reporting AGENCY: Departmental Offices, Terrorism Risk Insurance Program Office, Treasury. ACTION: Notice and request for... 1995, Public Law 104-13 (44 U.S.C. 3506(c)(2)(A)). Currently, the Terrorism Risk Insurance Program...

  19. Avoiding the known prior acts exclusion when insuring newly acquired entities.

    Science.gov (United States)

    Gasior, J P; Passannante, W G

    1998-09-01

    Adding a new entity to an organization's existing insurance program can be problematic if the existing policy contains a known prior acts exclusion clause. By purportedly excluding claims that a policyholder "could have reasonably foreseen or discovered," the known prior acts exclusion allows the insurer to reject those claims after a lawsuit has been filed policyholders should have known prior acts exclusion clauses removed from their policies or work with their insurers on language that will clarify the policy regarding this exclusion.

  20. The Great Recession of 2007-2009 and Public Insurance Coverage for Children in Alabama: Enrollment and Claims Data from 1999-2011.

    Science.gov (United States)

    Morrisey, Michael A; Blackburn, Justin; Becker, David J; Sen, Bisakha; Kilgore, Meredith L; Caldwell, Cathy; Menachemi, Nir

    2016-01-01

    This study examined the impact of the Great Recession of 2007-2009 on public health insurance enrollment and expenditures in Alabama. Our analysis was designed to provide a framework for other states to conduct similar analyses to better understand the relationship between macroeconomic conditions and public health insurance costs. We analyzed enrollment and claims data from Medicaid and the Children's Health Insurance Program (CHIP) in Alabama from 1999 through 2011. We examined the relationship between county-level unemployment rates and enrollment in Medicaid and CHIP, as well as total county-level expenditures in the two programs. We used linear regressions with county fixed effects to estimate the impact of unemployment changes on enrollment and expenditures after controlling for population and programmatic changes in eligibility and cost sharing. A one-percentage-point increase in a county's unemployment rate was associated with a 4.3% increase in Medicaid enrollment, a 0.9% increase in CHIP enrollment, and an overall increase in public health insurance enrollment of 3.7%. Each percentage-point increase in unemployment was associated with a 6.2% increase in total public health insurance expenditures on children, with Medicaid spending rising by 7.5% and CHIP spending rising by 1.8%. In response to the 6.4 percentage-point increase in the state's unemployment rate during the Great Recession, combined enrollment of children in Alabama's public health insurance programs increased by 24% and total expenditures rose by 40%. Recessions have a substantial impact on the number of children enrolled in CHIP and Medicaid, and a disproportionate impact on program spending. Programs should be aware of the likely magnitudes of the effects in their budget planning.

  1. 76 FR 78741 - Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of...

    Science.gov (United States)

    2011-12-19

    ... Parts 402 and 403 [CMS-5060-P] RIN 0938-AR33 Medicare, Medicaid, Children's Health Insurance Programs...'s Health Insurance Program (CHIP) to report annually to the Secretary certain payments or transfers... State plan under title XIX (Medicaid) or XXI of the Act (the Children's Health Insurance Program, or...

  2. Applications of Solar Technology for Catastrophe Response, Claims Management, and Loss Prevention

    Energy Technology Data Exchange (ETDEWEB)

    Deering, A.; Thornton, J.P.

    1999-02-17

    Today's insurance industry strongly emphasizes developing cost-effective hazard mitigation programs, increasing and retaining commercial and residential customers through better service, educating customers on their exposure and vulnerabilities to natural disasters, collaborating with government agencies and emergency management organizations, and exploring the use of new technologies to reduce the financial impact of disasters. In June of 1998, the National Renewable Energy Laboratory (NREL) and the National Association of Independent Insurers (NAII) sponsored a seminar titled, ''Solar Technology and the Insurance Industry.'' Presentations were made by insurance company representatives, insurance trade groups, government and state emergency management organizations, and technology specialists. The meeting was attended by insurers, brokers, emergency managers, and consultants from more than 25 US companies. Leading insurers from the personal line and commercial carriers were shown how solar technology can be used in underwriting, claims, catastrophe response, loss control, and risk management. Attendees requested a follow-up report on solar technology, cost, and applications in disasters, including suggestions on how to collaborate with the utility industry and how to develop educational programs for business and consumers. This report will address these issues, with an emphasis on pre-disaster planning and mitigation alternatives. It will also discuss how energy efficiency and renewable technologies can contribute to reducing insurance losses.

  3. General report of the Insurance Study Committee

    International Nuclear Information System (INIS)

    1988-01-01

    This general report gives the main objectives which the Insurance Study Committee intends to follow, an overview of the work undertaken from 1985-1988 and some points that the Committee considers its duty to underline, propose or recommend in the field of risk management. It concludes with the report of the Group of Experts on Third Party Liability and Nuclear Insurance, set up in 1986 to study and prepare the position to be taken by UNIPEDE on nuclear third party liability matters at the Group of Governmental Experts on Nuclear Third Party Liability and at the IAEA Standing Committee on Civil Liability for Nuclear Damage [fr

  4. Captive insurance: is it the right choice for your insurance exposures?

    Science.gov (United States)

    Frese, Richard C

    2015-12-01

    Potential benefits of a captive insurance company include: Broader coverage Improved cash flow and stability. Direct access to reinsurance markets. Tax advantages. Better handling and control of risk management and claims. Potential drawbacks and challenges include: Startup capitalization. Underwriting losses. Administration and commitment.

  5. Multivariate Frequency-Severity Regression Models in Insurance

    Directory of Open Access Journals (Sweden)

    Edward W. Frees

    2016-02-01

    Full Text Available In insurance and related industries including healthcare, it is common to have several outcome measures that the analyst wishes to understand using explanatory variables. For example, in automobile insurance, an accident may result in payments for damage to one’s own vehicle, damage to another party’s vehicle, or personal injury. It is also common to be interested in the frequency of accidents in addition to the severity of the claim amounts. This paper synthesizes and extends the literature on multivariate frequency-severity regression modeling with a focus on insurance industry applications. Regression models for understanding the distribution of each outcome continue to be developed yet there now exists a solid body of literature for the marginal outcomes. This paper contributes to this body of literature by focusing on the use of a copula for modeling the dependence among these outcomes; a major advantage of this tool is that it preserves the body of work established for marginal models. We illustrate this approach using data from the Wisconsin Local Government Property Insurance Fund. This fund offers insurance protection for (i property; (ii motor vehicle; and (iii contractors’ equipment claims. In addition to several claim types and frequency-severity components, outcomes can be further categorized by time and space, requiring complex dependency modeling. We find significant dependencies for these data; specifically, we find that dependencies among lines are stronger than the dependencies between the frequency and average severity within each line.

  6. Double generalized linear compound poisson models to insurance claims data

    DEFF Research Database (Denmark)

    Andersen, Daniel Arnfeldt; Bonat, Wagner Hugo

    2017-01-01

    This paper describes the specification, estimation and comparison of double generalized linear compound Poisson models based on the likelihood paradigm. The models are motivated by insurance applications, where the distribution of the response variable is composed by a degenerate distribution...... implementation and illustrate the application of double generalized linear compound Poisson models using a data set about car insurances....

  7. Validation of a probabilistic model for hurricane insurance loss projections in Florida

    International Nuclear Information System (INIS)

    Pinelli, J.-P.; Gurley, K.R.; Subramanian, C.S.; Hamid, S.S.; Pita, G.L.

    2008-01-01

    The Florida Public Hurricane Loss Model is one of the first public models accessible for scrutiny to the scientific community, incorporating state of the art techniques in hurricane and vulnerability modeling. The model was developed for Florida, and is applicable to other hurricane-prone regions where construction practice is similar. The 2004 hurricane season produced substantial losses in Florida, and provided the means to validate and calibrate this model against actual claim data. This paper presents the predicted losses for several insurance portfolios corresponding to hurricanes Andrew, Charley, and Frances. The predictions are validated against the actual claim data. Physical damage predictions for external building components are also compared to observed damage. The analyses show that the predictive capabilities of the model were substantially improved after the calibration against the 2004 data. The methodology also shows that the predictive capabilities of the model could be enhanced if insurance companies report more detailed information about the structures they insure and the types of damage they suffer. This model can be a powerful tool for the study of risk reduction strategies

  8. Evaluating the Welfare of Index Insurance

    DEFF Research Database (Denmark)

    Harrison, Glenn W.; Martínez-Correa, Jimmy; Ng, Jia Min

    affects both the demand for the product and the welfare of individuals making take-up decisions. We study the impact of basis risk on insurance take-up and on expected welfare in a laboratory experiment with an insurance frame. We measure the expected welfare of index insurance to individuals while......Index insurance was conceived to be a product that would simplify the claim settlement process and make it more objective, reducing transaction costs and moral hazard. However, index insurance also exposes the insured to basis risk, which arises because there can be a mismatch between the index...... risks that are different from preferences exhibited for their actuarially-equivalent counterparts. We study the potential link between index insurance demand and attitudes towards compound risks. We test the hypothesis that the compound risk nature of index insurance induced by basis risk negatively...

  9. Cost of work-related injuries in insured workplaces in Lebanon.

    OpenAIRE

    Fayad, Rim; Nuwayhid, Iman; Tamim, Hala; Kassak, Kassem; Khogali, Mustafa

    2003-01-01

    OBJECTIVE: To estimate the medical and compensation costs of work-related injuries in insured workplaces in Lebanon and to examine cost distributions by worker and injury characteristics. METHODS: A total of 3748 claims for work injuries processed in 1998 by five major insurance companies in Lebanon were reviewed. Medical costs (related to emergency room fees, physician consultations, tests, and medications) and wage and indemnity compensation costs were identified from the claims. FINDINGS: ...

  10. The contribution of bone scintigraphy in occupational health or medical insurance claims: a retrospective study

    Energy Technology Data Exchange (ETDEWEB)

    Versijpt, J.; Dierckx, R.A.; Bondt, P. de [Division of Nuclear Medicine, University Hospital Gent (Belgium); Dierckx, I. [Department of Radiology, St. Elisabeth Hospital Antwerpen (Belgium); Lambrecht, L. [Outpatient Internal Medicine Clinic, Gent (Belgium); Sadeleer, C. de [Division of Nuclear Medicine, University Hospital Gent (Belgium)]|[Department of Nuclear Medicine, O.L.V. Hospital Geraardsbergen (Belgium)

    1999-08-01

    Patients with a suspicion of bone damage following an industrial or traffic accident are often referred for bone scintigraphy as part of an occupational health or medical insurance investigation. The aim of this study was to assess the contribution and the potential role of bone scintigraphy compared with X-ray investigations in the aforementioned situation. To this end we evaluated 70 consecutive patients referred for bone scintigraphy during 1996 and 1997 by occupational health or medical insurance physicians. The most common reasons for referral were the exclusion of occult fractures of hands and feet, whiplash injuries, reflex sympathetic dystrophy or avascular necrosis, or the differentiation between an old and a recent vertebral fracture. X-rays were only available for comparative review of 53 patients, so only those were analysed. The results of bone scintigraphy were compared with X-rays, and their contribution and potential role in occupational health or medical insurance investigations assessed. In 31 out of the 53 patients investigated, bone scintigraphy findings concurred with X-rays as to the number and location of abnormalities. For 19 of the 53 patients, bone scintigraphy showed clinically relevant additional foci when compared with X-rays, predominantly involving lesions to hands/wrists and feet/ankles. Among these 19 patients, scintigraphic diagnoses were subsequently confirmed in ten cases by means of X-ray or computed tomography. In four patients, supplementary radiological investigations revealed no abnormalities, and in five patients no further investigations were undertaken. Finally, in three of the 53 patients, X-rays revealed bone damage (burst fractures) whilst the corresponding bone scintigraphy was negative, thus excluding recent injury. In conclusion, in 22 patients, representing 42% of the cases analysed, bone scintigraphy was conclusive compared with X-ray imaging in the final diagnosis and in this way in detecting occult or excluding

  11. The contribution of bone scintigraphy in occupational health or medical insurance claims: a retrospective study

    International Nuclear Information System (INIS)

    Versijpt, J.; Dierckx, R.A.; Bondt, P. de; Dierckx, I.; Lambrecht, L.; Sadeleer, C. de

    1999-01-01

    Patients with a suspicion of bone damage following an industrial or traffic accident are often referred for bone scintigraphy as part of an occupational health or medical insurance investigation. The aim of this study was to assess the contribution and the potential role of bone scintigraphy compared with X-ray investigations in the aforementioned situation. To this end we evaluated 70 consecutive patients referred for bone scintigraphy during 1996 and 1997 by occupational health or medical insurance physicians. The most common reasons for referral were the exclusion of occult fractures of hands and feet, whiplash injuries, reflex sympathetic dystrophy or avascular necrosis, or the differentiation between an old and a recent vertebral fracture. X-rays were only available for comparative review of 53 patients, so only those were analysed. The results of bone scintigraphy were compared with X-rays, and their contribution and potential role in occupational health or medical insurance investigations assessed. In 31 out of the 53 patients investigated, bone scintigraphy findings concurred with X-rays as to the number and location of abnormalities. For 19 of the 53 patients, bone scintigraphy showed clinically relevant additional foci when compared with X-rays, predominantly involving lesions to hands/wrists and feet/ankles. Among these 19 patients, scintigraphic diagnoses were subsequently confirmed in ten cases by means of X-ray or computed tomography. In four patients, supplementary radiological investigations revealed no abnormalities, and in five patients no further investigations were undertaken. Finally, in three of the 53 patients, X-rays revealed bone damage (burst fractures) whilst the corresponding bone scintigraphy was negative, thus excluding recent injury. In conclusion, in 22 patients, representing 42% of the cases analysed, bone scintigraphy was conclusive compared with X-ray imaging in the final diagnosis and in this way in detecting occult or excluding

  12. Resolving Malpractice Claims after Tort Reform: Experience in a Self-Insured Texas Public Academic Health System.

    Science.gov (United States)

    Sage, William M; Harding, Molly Colvard; Thomas, Eric J

    2016-12-01

    To describe the litigation experience in a state with strict tort reform of a large public university health system that has committed to transparency with patients and families in resolving medical errors. Secondary data collected from The University of Texas System, which self-insures approximately 6,000 physicians at six health campuses across the state. We obtained internal case management data for all medical malpractice claims closed during 1 year before and 6 recent years following the enactment of state tort reform legislation. We retrospectively reviewed information about malpractice claimants, malpractice claims, and the process and outcome of dispute resolution. We accessed an internal case management database, supplemented by both electronic and paper records compiled by the university's Office of General Counsel. Closed claims dropped from 244 in 2001-2002 to an annual mean of 96 in 2009-2015, closures following lawsuits from 136 in 2001-2002 to an annual mean of 28 in 2009-2015, and paid claims from 60 in 2001 to an annual mean of 20 in 2009-2015. Patterns of resolution suggest efforts by the university to provide some compensation to injured patients in cases that were no longer economically viable for plaintiffs' lawyers to litigate. The percentage of payments relating to cases in which lawsuits had been filed decreased from 82 percent in 2001-2002 to 47 percent in 2009-2012 and again to 29 percent in 2012-2015, although most paid claimants were represented by attorneys. Unrepresented patients received payment in 13 cases closed in 2009-2012 (22 percent of payments; mean amount $60,566) and in 24 cases closed in 2012-2015 (41 percent of payments; mean amount $109,410). Even after tort reform, however, claims that resulted in payment remained slow to resolve, which was worsened for claimants subject to Medicare secondary payer rules. Strict confidentiality became a more common condition of settlement, although restrictions were subsequently relaxed

  13. Patient reported outcomes: looking beyond the label claim

    Directory of Open Access Journals (Sweden)

    Doward Lynda C

    2010-08-01

    Full Text Available Abstract The use of patient reported outcome scales in clinical trials conducted by the pharmaceutical industry has become more widespread in recent years. The use of such outcomes is particularly common for products developed to treat chronic, disabling conditions where the intention is not to cure but to ameliorate symptoms, facilitate functioning or, ultimately, to improve quality of life. In such cases, patient reported evidence is increasingly viewed as an essential complement to traditional clinical evidence for establishing a product's competitive advantage in the marketplace. In a commercial setting, the value of patient reported outcomes is viewed largely in terms of their potential for securing a labelling claim in the USA or inclusion in the summary of product characteristics in Europe. Although, the publication of the recent US Food and Drug Administration guidance makes it difficult for companies to make claims in the USA beyond symptom improvements, the value of these outcomes goes beyond satisfying requirements for a label claim. The European regulatory authorities, payers both in the US and Europe, clinicians and patients all play a part in determining both the availability and the pricing of medicinal products and all have an interest in patient-reported data that go beyond just symptoms. The purpose of the current paper is to highlight the potential added value of patient reported outcome data currently collected and held by the industry for these groups.

  14. Type 2 diabetes detection and management among insured adults.

    Science.gov (United States)

    Dall, Timothy M; Yang, Weyna; Halder, Pragna; Franz, Jerry; Byrne, Erin; Semilla, April P; Chakrabarti, Ritashree; Stuart, Bruce

    2016-01-01

    The Centers for Disease Control and Prevention estimates that 28.9 million adults had diabetes in 2012 in the US, though many patients are undiagnosed or not managing their condition. This study provides US national and state estimates of insured adults with type 2 diabetes who are diagnosed, receiving exams and medication, managing glycemic levels, with diabetes complications, and their health expenditures. Such information can be used for benchmarking and to identify gaps in diabetes detection and management. The study combines analysis of survey data with medical claims analysis for the commercially insured, Medicare, and Medicaid populations to estimate the number of adults with diagnosed type 2 diabetes and undiagnosed diabetes by insurance type, age, and sex. Medical claims analysis used the 2012 de-identified Normative Health Information database covering a nationally representative commercially insured population, the 2011 Medicare 5% Sample, and the 2008 Medicaid Mini-Max. Among insured adults in 2012, approximately 16.9 million had diagnosed type 2 diabetes, 1.45 million had diagnosed type 1 diabetes, and 6.9 million had undiagnosed diabetes. Of those with diagnosed type 2, approximately 13.0 million (77%) received diabetes medication-ranging from 70% in New Jersey to 82% in Utah. Suboptimal percentages had claims indicating recommended exams were performed. Of those receiving diabetes medication, 43% (5.6 million) had medical claims indicating poorly controlled diabetes-ranging from 29% with poor control in Minnesota and Iowa to 53% in Texas. Poor control was correlated with higher prevalence of neurological complications (+14%), renal complications (+14%), and peripheral vascular disease (+11%). Patients with poor control averaged $4,860 higher average annual health care expenditures-ranging from $6,680 for commercially insured patients to $4,360 for Medicaid and $3,430 for Medicare patients. This study highlights the large number of insured adults with

  15. A study on the effect of exclusion period on the suicidal risk among the insured.

    Science.gov (United States)

    Yip, Paul S F; Chen, Feng

    2014-06-01

    An exclusion period (usually from 12 months to 2 years) is usually found in life insurance policies as a precautionary measure to prohibit people from insuring their lives with the intent to kill themselves shortly thereafter. Several studies have been conducted to investigate the effect of exclusion periods on the risk of suicide among the insured in the US and Australia. However, while Hong Kong has experienced an increase in the number of suicides among the insured, little is known about the dynamic between the exclusion period and suicide in Asia. Here we make use of death claims data from one of the major life insurance companies in Hong Kong to ascertain the impact of a 12-month exclusion period on suicide risk. We also use utility functions derived from economic theory to better understand individual choices regarding suicide among the insured. More specifically, we sought to determine whether there is a greater risk of suicide immediately following the 12-month exclusion period. We also examined whether the risk of suicide claims was higher than that of other non-suicidal claims. The study period for this investigation was from January 1, 1997 to December 31, 2011, during which time there were 1935 claims based on 1243 deaths. Of these, 197 were suicide-related claims for 106 suicide deaths. The mean number of life policies held by suicidal claimants and non-suicidal claimants was 1.6 and 1.4, respectively. The average/median size of the claims (total payment made on all policies held by the insured life) was HK$665,800/426,600 and HK$497,700/276,200 for suicidal and non-suicidal deaths, respectively. The policy lifetime of the claims, or the number of days from policy issuance to suicide occurrence, ranged from 38 to 7561 days, with a mean of 2209 days, a median of 1941 days, and a standard deviation of 1544 days. The peak density of suicide claims occurred on day 1039 of the policy. Our results revealed that suicide claims tend to occur earlier than other

  16. Utilization Trends in Diagnostic Imaging for a Commercially Insured Population: A Study of Massachusetts Residents 2009 to 2013.

    Science.gov (United States)

    Flaherty, Stephen; Mortele, Koenraad J; Young, Gary J

    2018-06-01

    To report utilization trends in diagnostic imaging among commercially insured Massachusetts residents from 2009 to 2013. Current Procedural Terminology codes were used to identify diagnostic imaging claims in the Massachusetts All-Payer Claims Database for the years 2009 to 2013. We reported utilization and spending annually by imaging modality using total claims, claims per 1,000 individuals, total expenditures, and average per claim payments. The number of diagnostic imaging claims per insured MA resident increased only 0.6% from 2009 to 2013, whereas nonradiology claims increased by 6% annually. Overall diagnostic imaging expenditures, adjusted for inflation, were 27% lower in 2009 than 2013, compared with an 18% increase in nonimaging expenditures. Average payments per claim were lower in 2013 than 2009 for all modalities except nuclear medicine. Imaging procedure claims per 1,000 MA residents increased from 2009 to 2013 by 13% in MRI, from 147 to 166; by 17% in ultrasound, from 453 to 530; and by 12% in radiography (x-ray), from 985 to 1,100. However, CT claims per 1,000 fell by 37%, from 341 to 213, and nuclear medicine declined 57%, from 89 claims per 1,000 to 38. Diagnostic imaging utilization exhibited negligible growth over the study period. Diagnostic imaging expenditures declined, largely the result of falling payments per claim in most imaging modalities, in contrast with increased utilization and spending on nonimaging services. Utilization of MRI, ultrasound, and x-ray increased from 2009 to 2013, whereas CT and nuclear medicine use decreased sharply, although CT was heavily impacted by billing code changes. Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.

  17. Insurer risk control and nuclear liability

    International Nuclear Information System (INIS)

    DeMerchant, C.

    2015-01-01

    We specialize in high quality insurance risk management, underwriting and inspections for Canadian nuclear exposures. We provide true risk transfer, secure insurance capacity and collaborate with the world's nuclear experts to create innovative domestic solutions for our clients and members. The benefit of our experience works for all stake holders: insured clients, members, multi-level government agencies and all Canadians. NIAC has a 55-year history of partnering with insurers around the globe to create reliable risk management for the nuclear industry. We offer Canadian risk solutions, thought leadership and expertise that provides security and confidence to our customers and members. NIAC leads in the areas of nuclear insurance law, good governance and claims administration to create a true Centre of Excellence.

  18. Premium Forecasting of AN Insurance Company:

    Science.gov (United States)

    Fouladvand, M. Ebrahim; Darooneh, Amir H.

    We present an analytical study of an insurance company. We model the company's performance on a statistical basis and evaluate the predicted annual income of the company in terms of insurance parameters namely the premium, the total number of insured, average loss claims etc. We restrict ourselves to a single insurance class the so-called automobile insurance. We show the existence of a crossover premium pc below which the company is operating at a loss. Above pc, we also give a detailed statistical analysis of the company's financial status and obtain the predicted profit along with the corresponding risk as well as ruin probability in terms of premium. Furthermore we obtain the optimal premium popt which maximizes the company's profit.

  19. Insurer risk control and nuclear liability

    Energy Technology Data Exchange (ETDEWEB)

    DeMerchant, C. [Nuclear Insurance Association of Canada, Toronto, ON (Canada)

    2015-07-01

    We specialize in high quality insurance risk management, underwriting and inspections for Canadian nuclear exposures. We provide true risk transfer, secure insurance capacity and collaborate with the world's nuclear experts to create innovative domestic solutions for our clients and members. The benefit of our experience works for all stake holders: insured clients, members, multi-level government agencies and all Canadians. NIAC has a 55-year history of partnering with insurers around the globe to create reliable risk management for the nuclear industry. We offer Canadian risk solutions, thought leadership and expertise that provides security and confidence to our customers and members. NIAC leads in the areas of nuclear insurance law, good governance and claims administration to create a true Centre of Excellence.

  20. Level of Agreement and Factors Associated With Discrepancies Between Nationwide Medical History Questionnaires and Hospital Claims Data

    Directory of Open Access Journals (Sweden)

    Yeon-Yong Kim

    2017-09-01

    Full Text Available Objectives The objectives of this study were to investigate the agreement between medical history questionnaire data and claims data and to identify the factors that were associated with discrepancies between these data types. Methods Data from self-reported questionnaires that assessed an individual’s history of hypertension, diabetes mellitus, dyslipidemia, stroke, heart disease, and pulmonary tuberculosis were collected from a general health screening database for 2014. Data for these diseases were collected from a healthcare utilization claims database between 2009 and 2014. Overall agreement, sensitivity, specificity, and kappa values were calculated. Multiple logistic regression analysis was performed to identify factors associated with discrepancies and was adjusted for age, gender, insurance type, insurance contribution, residential area, and comorbidities. Results Agreement was highest between questionnaire data and claims data based on primary codes up to 1 year before the completion of self-reported questionnaires and was lowest for claims data based on primary and secondary codes up to 5 years before the completion of self-reported questionnaires. When comparing data based on primary codes up to 1 year before the completion of self-reported questionnaires, the overall agreement, sensitivity, specificity, and kappa values ranged from 93.2 to 98.8%, 26.2 to 84.3%, 95.7 to 99.6%, and 0.09 to 0.78, respectively. Agreement was excellent for hypertension and diabetes, fair to good for stroke and heart disease, and poor for pulmonary tuberculosis and dyslipidemia. Women, younger individuals, and employed individuals were most likely to under-report disease. Conclusions Detailed patient characteristics that had an impact on information bias were identified through the differing levels of agreement.

  1. Level of Agreement and Factors Associated With Discrepancies Between Nationwide Medical History Questionnaires and Hospital Claims Data.

    Science.gov (United States)

    Kim, Yeon-Yong; Park, Jong Heon; Kang, Hee-Jin; Lee, Eun Joo; Ha, Seongjun; Shin, Soon-Ae

    2017-09-01

    The objectives of this study were to investigate the agreement between medical history questionnaire data and claims data and to identify the factors that were associated with discrepancies between these data types. Data from self-reported questionnaires that assessed an individual's history of hypertension, diabetes mellitus, dyslipidemia, stroke, heart disease, and pulmonary tuberculosis were collected from a general health screening database for 2014. Data for these diseases were collected from a healthcare utilization claims database between 2009 and 2014. Overall agreement, sensitivity, specificity, and kappa values were calculated. Multiple logistic regression analysis was performed to identify factors associated with discrepancies and was adjusted for age, gender, insurance type, insurance contribution, residential area, and comorbidities. Agreement was highest between questionnaire data and claims data based on primary codes up to 1 year before the completion of self-reported questionnaires and was lowest for claims data based on primary and secondary codes up to 5 years before the completion of self-reported questionnaires. When comparing data based on primary codes up to 1 year before the completion of self-reported questionnaires, the overall agreement, sensitivity, specificity, and kappa values ranged from 93.2 to 98.8%, 26.2 to 84.3%, 95.7 to 99.6%, and 0.09 to 0.78, respectively. Agreement was excellent for hypertension and diabetes, fair to good for stroke and heart disease, and poor for pulmonary tuberculosis and dyslipidemia. Women, younger individuals, and employed individuals were most likely to under-report disease. Detailed patient characteristics that had an impact on information bias were identified through the differing levels of agreement.

  2. Poor agreement between data from the National Patient Registry and the Danish Patient Insurance Association

    DEFF Research Database (Denmark)

    Majholm, Birgitte; Bartholdy, Jens; Christoffersen, Jens Krogh

    2012-01-01

    Septic arthritis after knee arthroscopy requires in-patient treatment and should thus be reported to the National Patient Registry (NPR). It also meets the requirements for financial compensation if claimed to the Danish Patient Insurance Association (DPIA). The aim of this study was to assess data...

  3. Extending the Scope of Services in the Insurance Industry

    OpenAIRE

    von Watzdorf, Stephan; Gebauer, Heiko; Staake, Thorsten; Fleisch, Elgar

    2011-01-01

    The study at hand explores the influence of value-added services offered in addition to a motor insurance product on the customer's preference structure. It addresses the need of insurance companies to extend their core business with different types of supplementary services. A choice-based conjoint analysis is conducted which considers the price for the insurance product, the insurance franchise, the non-claims bonus as well as post-accident services and value-added services. Based on the re...

  4. Lessons to be learned: a retrospective analysis of physiotherapy injury claims.

    Science.gov (United States)

    Johnson, Gillian M; Skinner, Margot A; Stephen, Rachel E

    2012-08-01

    Retrospective, descriptive analysis. To describe the prevalence and nature of insurance claims for injuries attributed to physiotherapy care. In New Zealand, a national insurance scheme, the Accident Compensation Corporation, provides comprehensive, no-fault personal injury coverage. The patterns of injury sustained during physiotherapy care have not previously been described. De-identified data for all injuries registered with the Accident Compensation Corporation from 2005 to 2010 and attributed to physiotherapy were accessed. Prevalence patterns (percentages) of new-claim data were determined for physiotherapy intervention category, injury site, nature of injury, age, and sex. A subcategory, exercise-related injuries, was analyzed according to injury site and whether the injury was related (primary) or unrelated (secondary) to the intended therapeutic goal. There were 279 claims related to physiotherapy care filed with the Accident Compensation Corporation during the studied reporting period. Injury was attributed predominantly to exercise (n = 88, 31.5% of cases) and manual therapy (n = 74, 26.5% of cases). The prevalence of events categorized as exercise related was greatest in those who were 55 to 59 years of age (n = 14, 16.3%) and greater in females (n = 47, 54.7%). Of the exercise-related injuries, 39.8% were in the lower-limb region and 35.2% were categorized as sprains/strains. Injuries attributed to exercise exceeded those linked to other therapies provided by physiotherapists, yet exercise therapy rarely features as a cause of adverse events reported to the physiotherapy profession. The proportion of exercise-related injury events underlines the need for ensuring safe and careful consideration of exercise prescription. Harm, level 4.

  5. Lawsuits After Primary and Revision Total Hip Arthroplasties: A Malpractice Claims Analysis.

    Science.gov (United States)

    Patterson, Diana C; Grelsamer, Ronald P; Bronson, Michael J; Moucha, Calin S

    2017-10-01

    As the prevalence of total hip arthroplasty (THA) expands, so too will complications and patient dissatisfaction. The goal of this study was to identify the common etiologies of malpractice suits and costs of claims after primary and revision THAs. Analysis of 115 malpractice claims filed for alleged neglectful primary and revision THA surgeries by orthopedic surgeons insured by a large New York state malpractice carrier between 1983 and 2011. The incidence of malpractice claims filed for negligent THA procedures is only 0.15% per year in our population. In primary cases, nerve injury ("foot drop") was the most frequent allegation with 27 claims. Negligent surgery causing dislocation was alleged in 18 and leg length discrepancy in 14. Medical complications were also reported, including 3 thromboembolic events and 6 deaths. In revision cases, dislocation and infection were the most common source of suits. The average indemnity payment was $386,153 and the largest single settlement was $4.1 million for an arterial injury resulting in amputation after a primary hip replacement. The average litigation cost to the insurer was $61,833. Nerve injury, dislocation, and leg length discrepancy are the most common reason for malpractice after primary THA. Orthopedic surgeons should continue to focus on minimizing the occurrence of these complications while adequately incorporating details about the risks and limitations of surgery into their preoperative education. Copyright © 2017 Elsevier Inc. All rights reserved.

  6. 26 CFR 1.801-4 - Life insurance reserves.

    Science.gov (United States)

    2010-04-01

    ... is claimed. However, reserves held by the company with respect to the net value of risks reinsured in..., life insurance reserves, as in the case of level premium life insurance, are held to supplement the... amount (if any) by which: (i) The present value of the future net premiums required for such contract...

  7. Examining the influence of health insurance literacy and perception on the people preference to purchase private voluntary health insurance.

    Science.gov (United States)

    Mathur, Tanuj; Das, Gurudas; Gupta, Hemendra

    2018-01-01

    Most studies have associated "un-affordability" as a plausible cause for the lower take-up of private voluntary health insurance plans. However, others refuted this claim on the pretext that when people can afford "inpatient-care" from pocket then insurance premium cost is far less than those payments. Thus, economic factors remain insufficient in clearly explaining the reason for poor private voluntary health insurance take-up. An attempt is being made by shifting the focus towards non-economic factors and understanding the role of perception and health insurance literacy in transforming people preferences to invest in private voluntary health insurance plans. The study findings will conspicuously support decision-makers in developing strategy to increase the private voluntary health insurance take-up.

  8. 78 FR 7484 - Insurer Reporting Requirements; Reports Under 49 U.S.C. on Section 33112(c)

    Science.gov (United States)

    2013-02-01

    .... SUMMARY: This notice announces publication by NHTSA of the annual insurer report on motor vehicle theft... information on theft and recovery of vehicles; rating rules and plans used by motor vehicle insurers to reduce premiums due to a reduction in motor vehicle thefts; and actions taken by insurers to assist in deterring...

  9. 78 FR 9457 - Medicare, Medicaid, Children's Health Insurance Programs; Transparency Reports and Reporting of...

    Science.gov (United States)

    2013-02-08

    ... Parts 402 and 403 [CMS-5060-F] RIN 0938-AR33 Medicare, Medicaid, Children's Health Insurance Programs...'s Health Insurance Program (CHIP) to report annually to the Secretary certain payments or transfers... Vol. 78 Friday, No. 27 February 8, 2013 Part II Department of Health and Human Services Centers...

  10. Health insurance and the demand for medical care: Instrumental variable estimates using health insurer claims data.

    Science.gov (United States)

    Dunn, Abe

    2016-07-01

    This paper takes a different approach to estimating demand for medical care that uses the negotiated prices between insurers and providers as an instrument. The instrument is viewed as a textbook "cost shifting" instrument that impacts plan offerings, but is unobserved by consumers. The paper finds a price elasticity of demand of around -0.20, matching the elasticity found in the RAND Health Insurance Experiment. The paper also studies within-market variation in demand for prescription drugs and other medical care services and obtains comparable price elasticity estimates. Published by Elsevier B.V.

  11. Generalized Linear Models in Vehicle Insurance

    Directory of Open Access Journals (Sweden)

    Silvie Kafková

    2014-01-01

    Full Text Available Actuaries in insurance companies try to find the best model for an estimation of insurance premium. It depends on many risk factors, e.g. the car characteristics and the profile of the driver. In this paper, an analysis of the portfolio of vehicle insurance data using a generalized linear model (GLM is performed. The main advantage of the approach presented in this article is that the GLMs are not limited by inflexible preconditions. Our aim is to predict the relation of annual claim frequency on given risk factors. Based on a large real-world sample of data from 57 410 vehicles, the present study proposed a classification analysis approach that addresses the selection of predictor variables. The models with different predictor variables are compared by analysis of deviance and Akaike information criterion (AIC. Based on this comparison, the model for the best estimate of annual claim frequency is chosen. All statistical calculations are computed in R environment, which contains stats package with the function for the estimation of parameters of GLM and the function for analysis of deviation.

  12. 26 CFR 1.6050H-3T - Information reporting of mortgage insurance premiums (temporary).

    Science.gov (United States)

    2010-04-01

    ... Information reporting of mortgage insurance premiums (temporary). (a) Information reporting requirements. Any... section applies to the receipt of all payments of mortgage insurance premiums, by cash or financing... premiums is determined on a mortgage-by-mortgage basis. A recipient need not aggregate mortgage insurance...

  13. NATO Advanced Study Institute on Insurance and Risk Theory

    CERN Document Server

    Vylder, F; Haezendonck, J

    1986-01-01

    Canadian financial institutions have been in rapid change in the past five years. In response to these changes, the Department of Finance issued a discussion paper: The Regulation of Canadian Financial Institutions, in April 1985, and the government intends to introduce legislation in the fall. This paper studi.es the combinantion of financial institutions from the viewpoint of ruin probability. In risk theory developed to describe insurance companies [1,2,3,4,5J, the ruin probability of a company with initial reserve (capital) u is 6 1 -:;-7;;f3 u 1jJ(u) = H6 e H6 (1) Here,we assume that claims arrive as a Poisson process, and the claim amount is distributed as exponential distribution with expectation liS. 6 is the loading, i.e., premium charged is (1+6) times expected claims. Financial institutions are treated as "insurance companies": the difference between interest charged and interest paid is regarded as premiums, loan defaults are treated as claims.

  14. The insurability of product recall in food supply chains

    NARCIS (Netherlands)

    Meuwissen, M.P.M.; Valeeva, N.I.; Velthuis, A.G.J.; Huirne, R.B.M.

    2006-01-01

    Insurers face growing difficulties with insuring food-related risks among others due to an increasing number of product recalls and an increasing amount of claims being pushed back into the chain. This paper focuses on the risk of product recall in dairy supply chains. The paper aims at providing

  15. The Concentration on the Motor third Party Liability Insurance Market in Romania

    Directory of Open Access Journals (Sweden)

    Florina Oana VIRLANUTA

    2018-05-01

    Full Text Available The current paper proposes an analysis of the Romanian car insurance validity market. The topic is relevant at national and European level, and our analysis will be based on indicators such as gross written premiums, motor claims paid for bodily injuries, motor claims paid for property damage, market share on Motor Insurance market. We will also determine the degree of concentration on this market using Gini Struck Concentration Index.

  16. 27 CFR 70.413 - Claims.

    Science.gov (United States)

    2010-04-01

    ... file a bond in double the amount of the tax in order to insure collection of the tax if the claim is... 5620.8 for allowance of loss, credit of tax, or relief from tax liability, as applicable, on (1....413 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE BUREAU, DEPARTMENT OF THE...

  17. Pricing of General Insurance and the Impact of Asymmetric Information

    DEFF Research Database (Denmark)

    Englund, Martin

    To set the insurance premium correctly is of outmost importance on a competitive insurance market. Hence the overall objective of this thesis is to improve the pricing, first by using individual claims information, and second by using information about the individuals choice of coverage. Regarding...

  18. Solar technology and the insurance industry: Issues and applications

    Energy Technology Data Exchange (ETDEWEB)

    Deering, A.; Thornton, J. P.

    1999-07-01

    Today's insurance industry strongly emphasizes developing cost-effective hazard mitigation programs, increasing and retaining commercial and residential customers through better service, educating customers on their exposure and vulnerabilities to natural disasters, collaborating with government agencies and emergency management organizations, and exploring the use of new technologies to reduce the financial impact of disasters. Solar technology can be used in underwriting, claims, catastrophe response, loss control, and risk management. This report will address the above issues, with an emphasis on pre-disaster planning and mitigation alternatives. It will also discuss how energy efficiency and renewable technologies can contribute to reducing insurance losses and offer suggestions on how to collaborate with the utility industry and how to develop educational programs for business and consumers.

  19. 78 FR 12623 - Insurer Reporting Requirements

    Science.gov (United States)

    2013-02-25

    ... NHTSA's regulation requiring motor vehicle insurers to submit information on the number of thefts and recoveries of insured vehicles and actions taken by the insurer to deter or reduce motor vehicle theft. NHTSA..., which requires insurers to submit information about the make, model, and year of all vehicle thefts, the...

  20. Compensation culture reviewed: incentives to claim and damages levels

    OpenAIRE

    Lewis, Richard Kurt

    2014-01-01

    This article reviews some recent developments which have affected the debate concerning ‘compensation culture.’ It focuses upon the number of claims and the cost of claims, looking especially at the level of damages. The role of insurers and the changing nature of personal injury practice are also discussed. The conclusion is that issues arising from the debate will continue for some time to come.

  1. Agricultural insurance under the Solvency II Directive

    Directory of Open Access Journals (Sweden)

    Njegomir Vladimir

    2014-01-01

    Full Text Available Solvency II Directive represents a new framework of unique solvency regulation of insurance and reinsurance companies in the European Union. Although it has not yet been implemented in national legislations, it can be concluded, based on the directive wording and conducted quantitative studies, that it will have implications on agricultural producers since they are the users of insurance services. The aim of the research presented in this paper is to analyse the implications of the new directive to agricultural producers since they are the insureds and the main actors of agribusiness. Firstly, the paper gives an overview of the basic features of the new regulatory framework and then it points at the issues and the needs for intensive application of Directive in order to improve the insurance business in Serbia. The process will direct the settlement of major claims, the ones that are typical of catastrophic risks in agriculture, towards the insurance, while the expectations from the government will be directed towards the regulation of the setting and economic measures (development and investment subsidies, cooperative movement. In addition, the paper points at the demands of the new regulation and analyses the implications of the new regulation regarding the settlement of claims resulting from major flood since it represents the example that proves the basic postulate.

  2. Exploring fraud and abuse in National Health Insurance Scheme ...

    African Journals Online (AJOL)

    This study explored patterns of fraud and abuse that exist in the National Health Insurance Scheme (NHIS) claims in the Awutu-Effutu-Senya District using data mining techniques, with a specific focus on malaria-related claims. The study employed quantitative research approach with survey design as a strategy of enquiry.

  3. Claims-based definition of death in Japanese claims database: validity and implications.

    Science.gov (United States)

    Ooba, Nobuhiro; Setoguchi, Soko; Ando, Takashi; Sato, Tsugumichi; Yamaguchi, Takuhiro; Mochizuki, Mayumi; Kubota, Kiyoshi

    2013-01-01

    For the pending National Claims Database in Japan, researchers will not have access to death information in the enrollment files. We developed and evaluated a claims-based definition of death. We used healthcare claims and enrollment data between January 2005 and August 2009 for 195,193 beneficiaries aged 20 to 74 in 3 private health insurance unions. We developed claims-based definitions of death using discharge or disease status and Charlson comorbidity index (CCI). We calculated sensitivity, specificity and positive predictive values (PPVs) using the enrollment data as a gold standard in the overall population and subgroups divided by demographic and other factors. We also assessed bias and precision in two example studies where an outcome was death. The definition based on the combination of discharge/disease status and CCI provided moderate sensitivity (around 60%) and high specificity (99.99%) and high PPVs (94.8%). In most subgroups, sensitivity of the preferred definition was also around 60% but varied from 28 to 91%. In an example study comparing death rates between two anticancer drug classes, the claims-based definition provided valid and precise hazard ratios (HRs). In another example study comparing two classes of anti-depressants, the HR with the claims-based definition was biased and had lower precision than that with the gold standard definition. The claims-based definitions of death developed in this study had high specificity and PPVs while sensitivity was around 60%. The definitions will be useful in future studies when used with attention to the possible fluctuation of sensitivity in some subpopulations.

  4. Health insurance premium tax credit. Final regulations.

    Science.gov (United States)

    2013-02-01

    This document contains final regulations relating to the health insurance premium tax credit enacted by the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010.These final regulations provide guidance to individuals related to employees who may enroll in eligible employer-sponsored coverage and who wish to enroll in qualified health plans through Affordable Insurance Exchanges (Exchanges) and claim the premium tax credit.

  5. Energy-Efficiency Options for Insurance Loss Prevention

    Energy Technology Data Exchange (ETDEWEB)

    Mills, E. [Ernest Orlando Lawrence Berkeley National Lab., CA (United States). Environmental Energy Technologies Div.; Knoepfel, I. [Swiss Reinsurance Co., Zurich (Switzerland)

    1997-06-09

    Energy-efficiency improvements offer the insurance industry two areas of opportunity: reducing ordinary claims and avoiding greenhouse gas emissions that could precipitate natural disaster losses resulting from global climate change. We present three vehicles for taking advantage of this opportunity, including research and development, in- house energy management, and provision of key information to insurance customers and risk managers. The complementary role for renewable energy systems is also introduced.

  6. Implications of European Directives in the Assessment of Insurance Companies

    Directory of Open Access Journals (Sweden)

    Ionel BOSTAN

    2011-03-01

    Full Text Available The objective of this paper is to present a vision in the sphere of the problematic of assets and liabilities’ evaluation that are reflected in the balance sheet of the insurance companies, inside the theory of the contingent claims, and of the marginal theory inside the insurance sphere. Our references take into consideration all the principles and evaluation norms of a company’s liabilities, company operating in the life insurance domain, including the general request introduced by the IFRS. Also, we argument the fact that the making of the new IFRS standards’ frame must take into consideration the accelerated globalization of the trading and the internalization of the financial markets, factors that have made pass onto the first place the necessity of a standardized financial reporting system. Because for so long the evaluating inadequacy of the assets at their fair value and the liabilities at their fair cost has persisted for so long, we underline that we find even in this a vast debate subject between the insurance companies’ representatives and the IASB, especially in the second step of the IFRS4’s implementation in the life insurance contract.

  7. Analysis of your professional liability insurance policy.

    Science.gov (United States)

    SADUSK, J F; HASSARD, H; WATERSON, R

    1958-01-01

    The most important lessons for the physician to learn in regard to his professional liability insurance coverage are the following:1. The physician should carefully read his professional liability policy and should secure the educated aid of his attorney and his insurance broker, if they are conversant with this field.2. He should particularly read the definition of coverage and carefully survey the exclusion clauses which may deny him coverage under certain circumstances.3. If the physician is in partnership or in a group, he should be certain that he has contingent partnership coverage.4. The physician should accept coverage only from an insurance carrier of sufficient size and stability that he can be sure his coverage will be guaranteed for "latent liability" claims as the years go along-certainly for his lifetime.5. The insurance carrier offering the professional liability policy should be prepared to offer coverages up to at least $100,000/$300,000.6. The physician should be assured that the insurance carrier has claims-handling personnel and legal counsel who are experienced and expert in the professional liability field and who are locally available for service.7. The physician is best protected by a local or state group program, next best by a national group program, and last, by individual coverage.8. The physician should look with suspicion on a cancellation clause in which his policy may be summarily cancelled on brief notice.9. The physician should not buy professional liability insurance on the basis of price alone; adequacy of coverage and service and a good insurance company for his protection should be the deciding factors.

  8. 31 CFR 103.16 - Reports by insurance companies of suspicious transactions.

    Science.gov (United States)

    2010-07-01

    ..., such as terrorist financing or ongoing money laundering schemes, the insurance company shall... fraudulent submission relates to money laundering or terrorist financing. (e) Retention of records. An... 31 Money and Finance: Treasury 1 2010-07-01 2010-07-01 false Reports by insurance companies of...

  9. Factors affecting the insurance sector development: Evidence from Albania

    Directory of Open Access Journals (Sweden)

    Eglantina Zyka

    2014-03-01

    Full Text Available In this paper we explore factors potentially affecting the size of Albanian insurance market, over the period 1999 to 2009. The results of co- integration regression show that GDP and fraction urban population, both one lagged value, size of population and paid claims, both at contemporary value, have significant positive effect on aggregate insurance premium in Albania while the market share of the largest company in the insurance market, one lagged value, has significant negative effect on aggregate insurance premiums. Granger causality test shows statistically significance contribution of GDP growth to insurance premium growth, GDP drives insurance premium growth but not vice versa. The Albanian insurance market is under development, indicators as: insurance penetration, premium per capita, ect are still at low level and this can justify the insignificant role of the insurance in the economy

  10. The insurance of bulk oil cargoes and adjustment of shortage claims

    International Nuclear Information System (INIS)

    Tavendale, R.

    1993-01-01

    Shortage claims discussed in this article include those due to a definite disaster such as a fire, those due to cargo contamination and storage, and those identified in documentation as occurring between loading and unloading. The principal types of cover are examined, and the distinction between gross and net quantities, claim documentation, the petroleum measurement tables, and guaranteed out turn cover are described in detail. (UK)

  11. Improving user-insurance communication on accident reports

    OpenAIRE

    Fardoun, Habib Moussa; Alghazzawi, Daniyal M.; Paules Ciprés, Antonio

    2014-01-01

    This paper presents an easy to use methodology and system for insurance companies targeting at managing traffic accidents reports process. The main objective is to facilitate and accelerate the process of creating and finalizing the necessary accident reports in cases without mortal victims involved. The diverse entities participating in the process from the moment an accident occurs until the related final actions needed are included. Nowadays, this market is limited to the consulting platfo...

  12. 48 CFR 952.231-71 - Insurance-litigation and claims.

    Science.gov (United States)

    2010-10-01

    ... agencies, in connection with this contract. The Contractor shall proceed with such litigation in good faith... litigation in good faith and as directed from time to time by the Contracting Officer. (c)(1) Except as... insurance as required by law or approved in writing by the Contracting Officer. (2) The Contractor may, with...

  13. 48 CFR 970.5228-1 - Insurance-litigation and claims.

    Science.gov (United States)

    2010-10-01

    ... agencies, in connection with this contract. The Contractor shall proceed with such litigation in good faith... litigation in good faith and as directed from time to time by the Contracting Officer. (c)(1) Except as... insurance as required by law or approved in writing by the Contracting Officer. (2) The Contractor may, with...

  14. Sensitivity of Billing Claims for Cardiovascular Disease Events among Kidney Transplant Recipients

    Science.gov (United States)

    Lentine, Krista L.; Schnitzler, Mark A.; Abbott, Kevin C.; Bramesfeld, Kosha; Buchanan, Paula M.; Brennan, Daniel C.

    2009-01-01

    Background and objectives: Billing claims are increasingly examined beyond administrative functions as outcomes measures in observational research. Few studies have described the performance of billing claims as surrogate measures of clinical events among kidney transplant recipients. Design, setting, participants, & measurements: We investigated the sensitivity of Medicare billing claims for clinically verified cardiovascular diagnoses (five categories) and procedures (four categories) in a novel database linking Medicare claims to electronic medical records of one transplant program. Cardiovascular events identified in medical records for 571 Medicare-insured transplant recipients in 1991 through 2002 served as reference measures. Results: Within a claims-ascertainment period spanning ±30 d of clinically recorded dates, aggregate sensitivity of single claims was higher for case definitions incorporating Medicare Parts A and B for diagnoses and procedures (90.9%) compared with either Part A (82.3%) or Part B (84.6%) alone. Perfect capture of the four procedures was possible within ±30 d or with short claims window expansion, but sensitivity for the diagnoses trended lower with all study algorithms (91.2% with window up to ±90 d). Requirement for additional confirmatory diagnosis claims did not appreciably reduce sensitivity. Sensitivity patterns were similar in the early compared with late periods of the study. Conclusions: Combined use of Medicare Parts A and B billing claims composes a sensitive measure of cardiovascular events after kidney transplant. Further research is needed to define algorithms that maximize specificity as well as sensitivity of claims from Medicare and other insurers as research measures in this population. PMID:19541817

  15. A report on 15 years of clinical negligence claims in rhinology.

    Science.gov (United States)

    Geyton, Thomas; Odutoye, Tunde; Mathew, Rajeev

    2014-01-01

    This study was designed to determine the characteristics of medical negligence claims in rhinology. In 2010-2011 the National Health Service (NHS) litigation bill surpassed 1 billion Great British Pounds (GBP; 1.52 billion U.S. dollars [US$]). Systematic analysis of malpractice complaints allows for the identification of errors and can thereby improve patient safety and reduce the burden of litigation claims on health services. Claims relating to ear, nose, and throat between 1995 and 2010 were obtained from the NHS Litigation Authority and were analyzed. The series contains 65 closed claims that resulted in payment totaling 3.1 million GBP (US$4.7 million). Fifty claims were related to surgical complications. Functional endoscopic sinus surgery and septoplasty were the procedures most commonly associated with successful claims. There were 11 cases of orbital injury including 6 cases of visual loss and 5 cases of diplopia. The most common cause of a claim was failure to recognize the complication or manage it appropriately. Lack of informed consent was claimed in eight cases. Other claims arose because of errors in outpatient procedures (two), diagnosis (six), delayed surgery (one), and errors in medical management (three). This is the first study to report the outcomes of negligence claims in rhinology in the United Kingdom. Claims in rhinology are associated with a high success rate. Steps that can be taken to reduce litigation include careful patient workup and ensuring adequate informed consent. Where there is a suspicion of orbital damage early recognition and intervention is needed to reduce long-term injury to the patient.

  16. On the occurrence of rainstorm damage based on home insurance and weather data

    Science.gov (United States)

    Spekkers, M. H.; Clemens, F. H. L. R.; ten Veldhuis, J. A. E.

    2015-02-01

    Rainstorm damage caused by the malfunction of urban drainage systems and water intrusion due to defects in the building envelope can be considerable. Little research on this topic focused on the collection of damage data, the understanding of damage mechanisms and the deepening of data analysis methods. In this paper, the relative contribution of different failure mechanisms to the occurrence of rainstorm damage is investigated, as well as the extent to which these mechanisms relate to weather variables. For a case study in Rotterdam, the Netherlands, a property level home insurance database of around 3100 water-related damage claims was analysed. The records include comprehensive transcripts of communication between insurer, insured and damage assessment experts, which allowed claims to be classified according to their actual damage cause. The results show that roof and wall leakage is the most frequent failure mechanism causing precipitation-related claims, followed by blocked roof gutters, melting snow and sewer flooding. Claims related to sewer flooding were less present in the data, but are associated with significantly larger claim sizes than claims in the majority class, i.e. roof and wall leakages. Rare events logistic regression analysis revealed that maximum rainfall intensity and rainfall volume are significant predictors for the occurrence probability of precipitation-related claims. Moreover, it was found that claims associated with rainfall intensities smaller than 7-8 mm in a 60-min window are mainly related to failure processes in the private domain, such as roof and wall leakages. For rainfall events that exceed the 7-8 mm h-1 threshold, the failure of systems in the public domain, such as sewer systems, start to contribute considerably to the overall occurrence probability of claims. The communication transcripts, however, lacked information to be conclusive about to which extent sewer-related claims were caused by overloading of sewer systems or

  17. Claims-Based Definition of Death in Japanese Claims Database: Validity and Implications

    Science.gov (United States)

    Ooba, Nobuhiro; Setoguchi, Soko; Ando, Takashi; Sato, Tsugumichi; Yamaguchi, Takuhiro; Mochizuki, Mayumi; Kubota, Kiyoshi

    2013-01-01

    Background For the pending National Claims Database in Japan, researchers will not have access to death information in the enrollment files. We developed and evaluated a claims-based definition of death. Methodology/Principal Findings We used healthcare claims and enrollment data between January 2005 and August 2009 for 195,193 beneficiaries aged 20 to 74 in 3 private health insurance unions. We developed claims-based definitions of death using discharge or disease status and Charlson comorbidity index (CCI). We calculated sensitivity, specificity and positive predictive values (PPVs) using the enrollment data as a gold standard in the overall population and subgroups divided by demographic and other factors. We also assessed bias and precision in two example studies where an outcome was death. The definition based on the combination of discharge/disease status and CCI provided moderate sensitivity (around 60%) and high specificity (99.99%) and high PPVs (94.8%). In most subgroups, sensitivity of the preferred definition was also around 60% but varied from 28 to 91%. In an example study comparing death rates between two anticancer drug classes, the claims-based definition provided valid and precise hazard ratios (HRs). In another example study comparing two classes of anti-depressants, the HR with the claims-based definition was biased and had lower precision than that with the gold standard definition. Conclusions/Significance The claims-based definitions of death developed in this study had high specificity and PPVs while sensitivity was around 60%. The definitions will be useful in future studies when used with attention to the possible fluctuation of sensitivity in some subpopulations. PMID:23741526

  18. Prevalence of diabetes mellitus among insured of a health insurance company in Puerto Rico: 1997-1998.

    Science.gov (United States)

    Pérez-Perdomo, R; Pérez-Cardona, C; Rodríguez-Lugo, L

    2001-06-01

    The purpose of this study was to determine the prevalence of diabetes mellitus in persons covered by a health insurance company. The medical claims of persons insured with Triple S Health Insurance Co. of Puerto Rico, whose main diagnosis was diabetes (ICD9-250.0-9), were selected for analysis. Prevalence and medical utilization rates were estimated. General characteristics and services utilization were compared by age and sex using the chi-square distribution. Overall prevalence was 4.73%. Prevalence in the male population (5.07%) was higher than that of females (4.43%) in all age groups, but the difference was not statistically significant (p > 0.05). The proportion of diabetic cases was larger in the > 60 age group. 64% of the cases had 1 or more visits to a physician office, 2% were hospitalized, and almost 3% had emergency room visits. 29% of the cases had insulin prescriptions while 59% had oral prescriptions. The younger age group (diabetes in this group was lower than the prevalence reported in the Behavioral Risk Factor Surveillance System. This may be partially explained by the fact that the study group did not represent the composition of the Puerto Rican population. Prevalence studies using other groups will be helpful to determine the prevalence of diabetes in Puerto Rico.

  19. [Epidemiology of the medico-legal risk associated with the practice of ambulatory surgery in France: a study based on insurance data].

    Science.gov (United States)

    Theissen, A; Fuz, F; Catineau, J; Sultan, W; Beaussier, M; Carles, M; Raucoules-Aimé, M; Niccolai, P

    2014-03-01

    The medico-legal risk specifically associated with the practice of ambulatory surgery is still not well studied. SHAM insurances are the biggest French provider of medical liability insurances. The study of the insurance claims provided by this insurer is therefore a relevant source of data on the complications related to ambulatory surgery. The aim of this study was to compare the claim rate related to ambulatory surgery with non-ambulatory surgery. We did a retrospective study on insurance claims provided by SHAM insurances between 2007 and 2011 to compare the claim rate related to ambulatory surgery with non-ambulatory surgery. We searched the files in the SHAM database, and then analyzed them. On the study period, out of a total of 29565 registered claims, 467 (1.6%) originated from ambulatory surgery. On the total of 29,098 registered claims for non-ambulatory surgery, 2151 (7.4%) led to a condemnation whereas the rate was 7% (33 out of 467 claims) for ambulatory surgery. The condemnations linked to ambulatory surgery amounted to 1.5% of the total (33 out of 2184), for a cost of 1.7 M€ (versus 400,3 M€ for non-ambulatory surgery). The average cost of a compensation is therefore 50,500 € for ambulatory surgery and 186,000 € for non-ambulatory surgery. The medical specialties concerned are primarily ophthalmology, abdominal and orthopedics surgery. The main identified causes were medical errors (n=16) and nosocomial infections (n=13). The claim rate in ambulatory surgery is proportionally less frequent with compensations three times less and were related to the most frequent type of surgery done in ambulatory settings. These data should help strengthen quality approach in ambulatory surgery. Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

  20. How Family Status and Social Security Claiming Options Shape Optimal Life Cycle Portfolios.

    Science.gov (United States)

    Hubener, Andreas; Maurer, Raimond; Mitchell, Olivia S

    2016-04-01

    We show how optimal household decisions regarding work, retirement, saving, portfolio allocations, and life insurance are shaped by the complex financial options embedded in U.S. Social Security rules and uncertain family transitions. Our life cycle model predicts sharp consumption drops on retirement, an age-62 peak in claiming rates, and earlier claiming by wives versus husbands and single women. Moreover, life insurance is mainly purchased on men's lives. Our model, which takes Social Security rules seriously, generates wealth and retirement outcomes that are more consistent with the data, in contrast to earlier and less realistic models.

  1. [The essentials of workplace analysis for examining occupational disability claims].

    Science.gov (United States)

    Wachholz, St

    2015-12-01

    The insurance branch that covers the risk of occupational disability ranks among the most important private entities for offering security as far as the limitation or loss of one's ability to work is concerned. The financial risk of the insurer, the existential concerns and expectations of the claimant, as well as the legal framework and the need for a careful interdisciplinary evaluation, necessitate a professional review and assessment of the facts conducted with a sense of both responsibility and sensitivity. Carefully deliberated and sustainable decisions benefit both insurers and the insured. In order to achieve this, an opinion is required in many--and especially the more complex--cases from an external medical expert, which in turn can only be plausible and conclusive when based on a comprehensive review of the claimant's working environment and its particular (and often unique) requirements. This article is intended to increase the reader's understanding of the coherencies of workplace analysis and medical assessments, as required by insurance law and legislation. In addition, the article delivers valuable clues and guidance, both for medical experts and claims managers at insurance companies. Primarily, the claimant's occupation, as conceived in the terms and conditions of the insurance companies, is explained. The reader is then introduced to the various criteria to be considered when a claimant has several jobs at the same time, is self-employed, could be transferred to another job, is simply unable to commute to the workplace, or is prevented from working due to legal restrictions related to an illness. The article goes on to address the crucial aspect of how the degree of disability is to be measured under different circumstances, namely using the quantitative and the qualitative approach. As a reliable method for obtaining the essential data regarding the claimant's specific working conditions, which are required by both the medical expert and the

  2. 25 CFR 103.6 - To what extent will BIA guarantee or insure a loan?

    Science.gov (United States)

    2010-04-01

    ... insurance percentage rate that satisfies the lender's risk management requirements. (d) Absent exceptional... lender has insured under the Program as of the date the lender makes a claim under its insurance coverage... outstanding loans from the same lender to the same borrower; or (2) One loan guaranty under the Program when...

  3. Pediatric radiology malpractice claims - characteristics and comparison to adult radiology claims

    Energy Technology Data Exchange (ETDEWEB)

    Breen, Micheal A.; Taylor, George A. [Boston Children' s Hospital, Department of Radiology, Boston, MA (United States); Dwyer, Kathy; Yu-Moe, Winnie [CRICO Risk Management Foundation, Boston, MA (United States)

    2017-06-15

    Medical malpractice is the primary method by which people who believe they have suffered an injury in the course of medical care seek compensation in the United States and Canada. An increasing body of research demonstrates that failure to correctly diagnose is the most common allegation made in malpractice claims against radiologists. Since the 1994 survey by the Society of Chairmen of Radiology in Children's Hospitals (SCORCH), no other published studies have specifically examined the frequency or clinical context of malpractice claims against pediatric radiologists or arising from pediatric imaging interpretation. We hypothesize that the frequency, character and outcome of malpractice claims made against pediatric radiologists differ from those seen in general radiology practice. We searched the Controlled Risk Insurance Co. (CRICO) Strategies' Comparative Benchmarking System (CBS), a private repository of approximately 350,000 open and closed medical malpractice claims in the United States, for claims related to pediatric radiology. We further queried these cases for the major allegation, the clinical environment in which the claim arose, the clinical severity of the alleged injury, indemnity paid (if payment was made), primary imaging modality involved (if applicable) and primary International Classification of Diseases, 9th revision (ICD-9) diagnosis underlying the claim. There were a total of 27,056 fully coded claims of medical malpractice in the CBS database in the 5-year period between Jan. 1, 2010, and Dec. 31, 2014. Of these, 1,472 cases (5.4%) involved patients younger than 18 years. Radiology was the primary service responsible for 71/1,472 (4.8%) pediatric cases. There were statistically significant differences in average payout for pediatric radiology claims ($314,671) compared to adult radiology claims ($174,033). The allegations were primarily diagnosis-related in 70% of pediatric radiology claims. The most common imaging modality

  4. Pediatric radiology malpractice claims - characteristics and comparison to adult radiology claims

    International Nuclear Information System (INIS)

    Breen, Micheal A.; Taylor, George A.; Dwyer, Kathy; Yu-Moe, Winnie

    2017-01-01

    Medical malpractice is the primary method by which people who believe they have suffered an injury in the course of medical care seek compensation in the United States and Canada. An increasing body of research demonstrates that failure to correctly diagnose is the most common allegation made in malpractice claims against radiologists. Since the 1994 survey by the Society of Chairmen of Radiology in Children's Hospitals (SCORCH), no other published studies have specifically examined the frequency or clinical context of malpractice claims against pediatric radiologists or arising from pediatric imaging interpretation. We hypothesize that the frequency, character and outcome of malpractice claims made against pediatric radiologists differ from those seen in general radiology practice. We searched the Controlled Risk Insurance Co. (CRICO) Strategies' Comparative Benchmarking System (CBS), a private repository of approximately 350,000 open and closed medical malpractice claims in the United States, for claims related to pediatric radiology. We further queried these cases for the major allegation, the clinical environment in which the claim arose, the clinical severity of the alleged injury, indemnity paid (if payment was made), primary imaging modality involved (if applicable) and primary International Classification of Diseases, 9th revision (ICD-9) diagnosis underlying the claim. There were a total of 27,056 fully coded claims of medical malpractice in the CBS database in the 5-year period between Jan. 1, 2010, and Dec. 31, 2014. Of these, 1,472 cases (5.4%) involved patients younger than 18 years. Radiology was the primary service responsible for 71/1,472 (4.8%) pediatric cases. There were statistically significant differences in average payout for pediatric radiology claims ($314,671) compared to adult radiology claims ($174,033). The allegations were primarily diagnosis-related in 70% of pediatric radiology claims. The most common imaging modality implicated in

  5. Pediatric radiology malpractice claims - characteristics and comparison to adult radiology claims.

    Science.gov (United States)

    Breen, Micheál A; Dwyer, Kathy; Yu-Moe, Winnie; Taylor, George A

    2017-06-01

    Medical malpractice is the primary method by which people who believe they have suffered an injury in the course of medical care seek compensation in the United States and Canada. An increasing body of research demonstrates that failure to correctly diagnose is the most common allegation made in malpractice claims against radiologists. Since the 1994 survey by the Society of Chairmen of Radiology in Children's Hospitals (SCORCH), no other published studies have specifically examined the frequency or clinical context of malpractice claims against pediatric radiologists or arising from pediatric imaging interpretation. We hypothesize that the frequency, character and outcome of malpractice claims made against pediatric radiologists differ from those seen in general radiology practice. We searched the Controlled Risk Insurance Co. (CRICO) Strategies' Comparative Benchmarking System (CBS), a private repository of approximately 350,000 open and closed medical malpractice claims in the United States, for claims related to pediatric radiology. We further queried these cases for the major allegation, the clinical environment in which the claim arose, the clinical severity of the alleged injury, indemnity paid (if payment was made), primary imaging modality involved (if applicable) and primary International Classification of Diseases, 9th revision (ICD-9) diagnosis underlying the claim. There were a total of 27,056 fully coded claims of medical malpractice in the CBS database in the 5-year period between Jan. 1, 2010, and Dec. 31, 2014. Of these, 1,472 cases (5.4%) involved patients younger than 18 years. Radiology was the primary service responsible for 71/1,472 (4.8%) pediatric cases. There were statistically significant differences in average payout for pediatric radiology claims ($314,671) compared to adult radiology claims ($174,033). The allegations were primarily diagnosis-related in 70% of pediatric radiology claims. The most common imaging modality implicated in

  6. Asymmetric Information, Self-selection, and Pricing of Insurance Contracts

    DEFF Research Database (Denmark)

    Donnelly, Catherine; Englund, Martin Kristian; Nielsen, Jens Perch

    2014-01-01

    This article presents an optional bonus-malus contract based on a priori risk classification of the underlying insurance contract. By inducing self-selection, the purchase of the bonus-malus contract can be used as a screening device. This gives an even better pricing performance than both...... an experience rating scheme and a classical no-claims bonus system. An application to the Danish automobile insurance market is considered....

  7. The assessment of solvency and determination of limits for risk acceptance in insurance companies

    Directory of Open Access Journals (Sweden)

    Drljača Dejan

    2017-01-01

    Full Text Available The subject of this paper is the presentation of key requirements for Solvency II project, the methodology for testing of capital adequacy and methods for identification, definition and establishment of risk limits, as a limit for acceptance, bearing and control of exposure to certain risks in insurance companies. The aim of the paper is to show that the capital adequacy is the key factor for insurers' safety, i.e. guarantee of capability of an insurer to settle any future liabilities and leverage for strengthening of insurer's market position. Business operations of insurance companies are exposed to a significant number of risks that differ by their nature, character and influence, due to which adequacy of calculated technical reserves does not provide a satisfactory level of safety in case of more significant impairments of assets and funds of insurers, as well as in case of significant deviations between amounts of settled claims and actuarially expected amounts of liabilities based on claims. Stress testing of capital adequacy will show that losses due to impairment of risky securities, difficult collection of low liquid, i.e. securities that are difficult to market, inability to collect receivables from reinsurers, as well as losses due to inadequately calculated reserved claims, must be covered by a solvent capital. The paper is structured so as to provide a review of rules, elements and principles that are the foundation of solvency requirements in insurance companies, methodologies of calculation of guarantee reserve, technical basis for stress testing which assesses capital adequacy of insurers, as well as methods for establishment of limits of exposure to certain risks.

  8. The evaluation of trustworthiness to identify health insurance fraud in dentistry.

    Science.gov (United States)

    Wang, Shu-Li; Pai, Hao-Ting; Wu, Mei-Fang; Wu, Fan; Li, Chen-Lin

    2017-01-01

    According to the investigations of the U.S. Government Accountability Office (GAO), health insurance fraud has caused an enormous pecuniary loss in the U.S. In Taiwan, in dentistry the problem is getting worse if dentists (authorized entities) file fraudulent claims. Several methods have been developed to solve health insurance fraud; however, these methods are like a rule-based mechanism. Without exploring the behavior patterns, these methods are time-consuming and ineffective; in addition, they are inadequate for managing the fraudulent dentists. Based on social network theory, we develop an evaluation approach to solve the problem of cross-dentist fraud. The trustworthiness score of a dentist is calculated based upon the amount and type of dental operations performed on the same patient and the same tooth by that dentist and other dentists. The simulation provides the following evidence. (1) This specific type of fraud can be identified effectively using our evaluation approach. (2) A retrospective study for the claims is also performed. (3) The proposed method is effective in identifying the fraudulent dentists. We provide a new direction for investigating the genuineness of claims data. If the insurer can detect fraudulent dentists using the traditional method and the proposed method simultaneously, the detection will be more transparent and ultimately reduce the losses caused by fraudulent claims. Copyright © 2016 Elsevier B.V. All rights reserved.

  9. How health care reform can lower the costs of insurance administration.

    Science.gov (United States)

    Collins, Sara R; Nuzum, Rachel; Rustgi, Sheila D; Mika, Stephanie; Schoen, Cathy; Davis, Karen

    2009-07-01

    The United States leads all industrialized countries in the share of national health care expenditures devoted to insurance administration. The U.S. share is over 30 percent greater than Germany's and more than three times that of Japan. This issue brief examines the sources of administrative costs and describes how a private-public approach to health care reform--with the central feature of a national insurance exchange (largely replacing the present individual and small-group markets)--could substantially lower such costs. In three variations on that approach, estimated administrative costs would fall from 12.7 percent of claims to an average of 9.4 percent. Savings--as much as $265 billion over 2010-2020--would be realized through less marketing and underwriting, reduced costs of claims administration, less time spent negotiating provider payment rates, and fewer or standardized commissions to insurance brokers.

  10. [Guideline to prevent claims due to medical malpractice, on how to act when they do occur and how to defend oneself through the courts].

    Science.gov (United States)

    Bruguera, M; Arimany, J; Bruguera, R; Barberia, E; Ferrer, F; Sala, J; Pujol Robinat, A; Medallo Muñiz, J

    2012-04-01

    Claims due to presumed medical malpractice are increasing in all developed countries and many of them have no basis. To prevent legal complaints, the physicians should know the reasons why complaints are made by their patients and adopt the adequate preventive measures. In the case of a complaint, it is essential to follow the guidelines that allow for adequate legal defense and the action of the physician before the judge that inspires confidence and credibility. The risk of the claims can be reduced with adequate information to the patient, the following of the clinical guidelines, control of the risk factors and adoption of verification lists in each invasive procedure. In case of complication or serious adverse effect, explanations should be given to the patient and family and it should be reported to the facility where one works and to the insurance company. If the physician received a claim, he/she should report it to the insurance compare so that it can name a lawyer responsible for the legal defense who will advise the physician regarding the appearance in court before the judge. Copyright © 2011 Elsevier España, S.L. All rights reserved.

  11. 38 CFR 6.7 - Claims of creditors, taxation.

    Science.gov (United States)

    2010-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2010-07-01 2010-07-01 false Claims of creditors, taxation. 6.7 Section 6.7 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS UNITED... creditors, taxation. (a) Effective January 1, 1958, payments of insurance to a beneficiary under a United...

  12. Transparency, Trust and Security: An Evaluation of the Insurer's Precontractual Duties

    Directory of Open Access Journals (Sweden)

    Daleen Millard

    2014-12-01

    insurance legislation. The insurer's duty to disclose is in the last instance also derived from the common law duty not to make misrepresentations by commission or omission. When negotiating an insurance contract, the insurer's duty to speak is not based on a general requirement of bona fides, but is recognised as an ex lege duty due to the involuntary reliance of the prospective insured on information supplied by insurers in the market. A lack of transparency should lead to the insurer's accountability. A failure to disclose material information or a disclosure of false information that goes to the root of the matter and that induces the prospective policyholder to buy the insurance product is recognised as an actionable misrepresentation. Statutory provisions do not diminish the common-law duty not to make misrepresentations, but provide details of the nature and extent of the information duty to provide clarity and legal certainty in the determination of the standards of transparency required in law. In addition, statutes provide for enforcement actions by regulators, orders that could affect the licence of the insurer and provide for punishable offences and penalties. In terms of common law, a misrepresentation by omission or commission renders the insurance contract wholly or in part voidable. The policyholder may decide to rescind the contract and claim restitution. He may also, in conjunction with rescission, or as an alternative when deciding to maintain the contract, claim delictual damages or even constitutional damages when judged by a court of law as appropriate relief. Statutory remedies include a monetary award by the Insurance Ombud. Even though such an award is capped at R800 000, it is submitted that it is preferred to a civil law damages claim.

  13. 77 FR 50671 - Withdrawal of Proposed Rule on Insurer Reporting Requirements; List of Insurers Required To File...

    Science.gov (United States)

    2012-08-22

    ... reports on their motor vehicle theft loss experiences. An insurer included in any of the appendices that...: Congress enacted the Motor Vehicle Theft Law Enforcement Act of 1984 (Pub. L. 98-547). This legislation... report includes information about thefts and recoveries of motor vehicles, the rating rules used by the...

  14. 78 FR 25909 - Minimum Value of Eligible Employer-Sponsored Plans and Other Rules Regarding the Health Insurance...

    Science.gov (United States)

    2013-05-03

    ... Minimum Value of Eligible Employer-Sponsored Plans and Other Rules Regarding the Health Insurance Premium.... SUMMARY: This document contains proposed regulations relating to the health insurance premium tax credit... who enroll in qualified health plans through Affordable Insurance Exchanges (Exchanges) and claim the...

  15. On the occurrence of rainstorm damage based on home insurance and weather data

    Directory of Open Access Journals (Sweden)

    M. H. Spekkers

    2015-02-01

    Full Text Available Rainstorm damage caused by the malfunction of urban drainage systems and water intrusion due to defects in the building envelope can be considerable. Little research on this topic focused on the collection of damage data, the understanding of damage mechanisms and the deepening of data analysis methods. In this paper, the relative contribution of different failure mechanisms to the occurrence of rainstorm damage is investigated, as well as the extent to which these mechanisms relate to weather variables. For a case study in Rotterdam, the Netherlands, a property level home insurance database of around 3100 water-related damage claims was analysed. The records include comprehensive transcripts of communication between insurer, insured and damage assessment experts, which allowed claims to be classified according to their actual damage cause. The results show that roof and wall leakage is the most frequent failure mechanism causing precipitation-related claims, followed by blocked roof gutters, melting snow and sewer flooding. Claims related to sewer flooding were less present in the data, but are associated with significantly larger claim sizes than claims in the majority class, i.e. roof and wall leakages. Rare events logistic regression analysis revealed that maximum rainfall intensity and rainfall volume are significant predictors for the occurrence probability of precipitation-related claims. Moreover, it was found that claims associated with rainfall intensities smaller than 7–8 mm in a 60-min window are mainly related to failure processes in the private domain, such as roof and wall leakages. For rainfall events that exceed the 7–8 mm h−1 threshold, the failure of systems in the public domain, such as sewer systems, start to contribute considerably to the overall occurrence probability of claims. The communication transcripts, however, lacked information to be conclusive about to which extent sewer-related claims were caused by

  16. What drives insurer participation and premiums in the Federally-Facilitated Marketplace?

    Science.gov (United States)

    Abraham, Jean Marie; Drake, Coleman; McCullough, Jeffrey S; Simon, Kosali

    2017-12-01

    We investigate determinants of market entry and premiums within the context of the Affordable Care Act's Marketplaces for individual insurance. Using Bresnahan and Reiss (1991) as the conceptual framework, we study how competition and firm heterogeneity relate to premiums in 36 states using Federally Facilitated or Supported Marketplaces in 2016. Our primary data source is the Qualified Health Plan Landscape File, augmented with market characteristics from the American Community Survey and Area Health Resource File as well as insurer-level information from federal Medical Loss Ratio annual reports. We first estimate a model of insurer entry and then investigate the relationship between a market's predicted number of entrants and insurer-level premiums. Our entry model results suggest that competition is increasing with the number of insurers, most notably as the market size increases from 3 to 4 entrants. Results from the premium regression suggest that each additional entrant is associated with approximately 4% lower premiums, controlling for other factors. An alternative explanation for the relationship between entrants and premiums is that more efficient insurers (who can price lower) are the ones that enter markets with many entrants, and this is reflected in lower premiums. An exploratory analysis of insurers' non-claims costs (a proxy for insurer efficiency) reveals that average costs among entrants are rising slightly with the number of insurers in the market. This pattern does not support the hypothesis that premiums decrease with more entrants because those entrants are more efficient, suggesting instead that the results are being driven mostly by price competition.

  17. Incentive-compatible guaranteed renewable health insurance premiums.

    Science.gov (United States)

    Herring, Bradley; Pauly, Mark V

    2006-05-01

    Theoretical models of guaranteed renewable insurance display front-loaded premium schedules. Such schedules both cover lifetime total claims of low-risk and high-risk individuals and provide an incentive for those who remain low-risk to continue to purchase the policy. Questions have been raised of whether actual individual insurance markets in the US approximate the behavior predicted by these models, both because young consumers may not be able to "afford" front-loading and because insurers may behave strategically in ways that erode the value of protection against risk reclassification. In this paper, the optimal competitive age-based premium schedule for a benchmark guaranteed renewable health insurance policy is estimated using medical expenditure data. Several factors are shown to reduce the amount of front-loading necessary. Indeed, the resulting optimal premium path increases with age. Actual premium paths exhibited by purchasers of individual insurance are close to the optimal renewable schedule we estimate. Finally, consumer utility associated with the feature is examined.

  18. Who is where at risk for Chronic Obstructive Pulmonary Disease? A spatial epidemiological analysis of health insurance claims for COPD in Northeastern Germany.

    Science.gov (United States)

    Kauhl, Boris; Maier, Werner; Schweikart, Jürgen; Keste, Andrea; Moskwyn, Marita

    2018-01-01

    Chronic obstructive pulmonary disease (COPD) has a high prevalence rate in Germany and a further increase is expected within the next years. Although risk factors on an individual level are widely understood, only little is known about the spatial heterogeneity and population-based risk factors of COPD. Background knowledge about broader, population-based processes could help to plan the future provision of healthcare and prevention strategies more aligned to the expected demand. The aim of this study is to analyze how the prevalence of COPD varies across northeastern Germany on the smallest spatial-scale possible and to identify the location-specific population-based risk factors using health insurance claims of the AOK Nordost. To visualize the spatial distribution of COPD prevalence at the level of municipalities and urban districts, we used the conditional autoregressive Besag-York-Mollié (BYM) model. Geographically weighted regression modelling (GWR) was applied to analyze the location-specific ecological risk factors for COPD. The sex- and age-adjusted prevalence of COPD was 6.5% in 2012 and varied widely across northeastern Germany. Population-based risk factors consist of the proportions of insurants aged 65 and older, insurants with migration background, household size and area deprivation. The results of the GWR model revealed that the population at risk for COPD varies considerably across northeastern Germany. Area deprivation has a direct and an indirect influence on the prevalence of COPD. Persons ageing in socially disadvantaged areas have a higher chance of developing COPD, even when they are not necessarily directly affected by deprivation on an individual level. This underlines the importance of considering the impact of area deprivation on health for planning of healthcare. Additionally, our results reveal that in some parts of the study area, insurants with migration background and persons living in multi-persons households are at elevated risk

  19. When can insurers offer products that dominate delayed old-age pension benefit claiming?

    NARCIS (Netherlands)

    Sanders, L.; De Waegenaere, A.M.B.; Nijman, T.E.

    2013-01-01

    It is common practice for public pension schemes to offer individuals the option to delay benefit claiming until after the normal retirement age, and increase the annual benefit level as a result. Existing literature shows that for non-liquidity constrained individuals, delaying benefit claiming for

  20. 75 FR 43329 - Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal...

    Science.gov (United States)

    2010-07-23

    ... 45 CFR Part 147 Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to... Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and... of Labor; Office of Consumer Information and Insurance Oversight, Department of Health and Human...

  1. 78 FR 54996 - Information Reporting by Applicable Large Employers on Health Insurance Coverage Offered Under...

    Science.gov (United States)

    2013-09-09

    ... Information Reporting by Applicable Large Employers on Health Insurance Coverage Offered Under Employer... credit to help individuals and families afford health insurance coverage purchased through an Affordable... or group health insurance coverage offered by an employer to the employee that is (1) a governmental...

  2. Willingness to Pay for Insurance in Denmark

    DEFF Research Database (Denmark)

    Hansen, Jan V.; Højbjerg Jacobsen, Rasmus; Lau, Morten

    2016-01-01

    Danish population, and information on household income and wealth from registers at Statistics Denmark. The results show that the willingness to pay is marginally higher than the actuarially fair value under expected utility theory, but significantly higher under rank-dependent utility theory, and up......We estimate how much Danish households are willing to pay for auto, home, and house insurance. We use a unique combination of claims data from a large Danish insurance company, measures of individual risk attitudes and discount rates from a field experiment with a representative sample of the adult...

  3. Demographic predictors of false negative self-reported tobacco use status in an insurance applicant population.

    Science.gov (United States)

    Palmier, James; Lanzrath, Brian; Dixon, Ammon; Idowu, Oluseun

    2014-01-01

    To identify and quantify demographic correlates of false-negative self-reporting of tobacco use in life insurance applicants. Several studies have assessed the sensitivity of self-reporting for tobacco use in various populations, but statistical examination of the causes of misreporting has been rarer. The very large (488,000 confirmed tobacco users) sample size, US-wide geographic scope, and unique incentive structure of the life insurance application process permit more robust and insurance industry-specific results in this study. Approximately 6.2 million life insurance applicants for whom both tobacco-use interview questions and a confirmatory urine cotinine test were completed between 1999 and 2012 were evaluated for consistency between self-reported and laboratory-confirmed tobacco-use status. The data set was subjected to logistic regression to identify predictors of false negative self-reports (FNSR). False-negative self-reporting was found to be strongly associated with male gender, applicant ages of less than 30 or greater than 60, and low cotinine positivity rates in the applicant's state of residence. Policy face value was also moderately predictive, values above $500,000 associated with moderately higher FNSR. The findings imply that FNSR in life insurance applicants may be the result of complex interactions among financial incentives, geography and presumptive peer groups, and gender.

  4. 78 FR 41339 - Federal Housing Administration (FHA) Multifamily Mortgage Insurance; Capturing Excess Claim Proceeds

    Science.gov (United States)

    2013-07-10

    ... mortgage insurance eligibility requirements and contract rights and obligations can be found at 24 CFR part... contract rights and obligations of mortgagees participating in FHA multifamily insurance programs and using...: Proposed rule. SUMMARY: This proposed rule would amend HUD's regulations covering the contract rights and...

  5. Transparency in the Assessment of Takaful Claims for Construction Works Loss & Damage

    OpenAIRE

    Puteri Nur Farah Naadia Mohd Fauzi; Khairuddin Abdul Rashid

    2016-01-01

    In the context of the construction industry, an alternative to the conventional insurance for works contracts is the Shariah compliant insurance otherwise known as takaful. Among the most frequently used takaful for construction works contracts is the Contractor’s All Risks (CAR) Takaful. However, the future of CAR Takaful may be affected should issues such as marketing and clarification on how it works including how claims are processed, valued and compensation ...

  6. The Application Law of Large Numbers That Predicts The Amount of Actual Loss in Insurance of Life

    Science.gov (United States)

    Tinungki, Georgina Maria

    2018-03-01

    The law of large numbers is a statistical concept that calculates the average number of events or risks in a sample or population to predict something. The larger the population is calculated, the more accurate predictions. In the field of insurance, the Law of Large Numbers is used to predict the risk of loss or claims of some participants so that the premium can be calculated appropriately. For example there is an average that of every 100 insurance participants, there is one participant who filed an accident claim, then the premium of 100 participants should be able to provide Sum Assured to at least 1 accident claim. The larger the insurance participant is calculated, the more precise the prediction of the calendar and the calculation of the premium. Life insurance, as a tool for risk spread, can only work if a life insurance company is able to bear the same risk in large numbers. Here apply what is called the law of large number. The law of large numbers states that if the amount of exposure to losses increases, then the predicted loss will be closer to the actual loss. The use of the law of large numbers allows the number of losses to be predicted better.

  7. ABOUT RISK PROCESS ESTIMATION TECHNIQUES EMPLOYED BY A VIRTUAL ORGANIZATION WHICH IS DIRECTED TOWARDS THE INSURANCE BUSINESS

    Directory of Open Access Journals (Sweden)

    Covrig Mihaela

    2008-05-01

    Full Text Available In a virtual organization directed on the insurance business, the estimations of the risk process and of the ruin probability are important concerns: for researchers, at the theoretical level, and for the management of the company, as these influence the insurer strategy. We consider the evolution over an extended period of time of the insurer surplus process. In this paper, we present some methods for the estimation of the ruin probability and for the evaluation of a reserve fund. We discuss the ruin probability with respect to: the parameters of the individual claim distribution, the load factor of premiums and the intensity parameter of the number of claims process. We analyze the model in which the premiums are computed according to the mean value principle. Also, we attempt the case when the initial capital is proportional to the expected value of the individual claim. We give numerical illustration.

  8. Nuclear liability act and nuclear insurance

    International Nuclear Information System (INIS)

    Clarke, Roy G.; Goyette, R.; Mathers, C.W.; Germani, T.R.

    1976-01-01

    The Nuclear Liability Act, enacted in June 1970 and proclaimed effective October 11, 1976, is a federal law governing civil liability for nuclear damage in Canada incorporating many of the basic principles of the international conventions. Exceptions to operator liability for breach of duty imposed by the Act and duty of the operator as well as right of recourse, time limit on bringing actions, special measures for compensation and extent of territory over which the operator is liable are of particular interest. An operator must maintain $75,000,000. of insurance for each nuclear installation for which he is the operator. The Nuclear Insurance Association of Canada (NIAC) administers two ΣPoolsΣ or groups of insurance companies where each member participates for the percentage of the total limit on a net basis, one pool being for Physical Damage Insurance and the other for Liability Insurance. The Atomic Energy Control Board recommends to the Treasury Board the amount of insurance (basic) for each installation. Basic insurance required depends on the exposure and can range from $4 million for a fuel fabricator to $75 million for a power reactor. Coverage under the Operator's Policy provides for bodily injury, property damage and various other claims such as damage from certain transportation incidents as well as nuclear excursions. Workmen's Compensation will continue to be handled by the usual channels. (L.L.)

  9. [Responsibility due to medication errors in France: a study based on SHAM insurance data].

    Science.gov (United States)

    Theissen, A; Orban, J-C; Fuz, F; Guerin, J-P; Flavin, P; Albertini, S; Maricic, S; Saquet, D; Niccolai, P

    2015-03-01

    The safe medication practices at the hospital constitute a major public health problem. Drug supply chain is a complex process, potentially source of errors and damages for the patient. SHAM insurances are the biggest French provider of medical liability insurances and a relevant source of data on the health care complications. The main objective of the study was to analyze the type and cause of medication errors declared to SHAM and having led to a conviction by a court. We did a retrospective study on insurance claims provided by SHAM insurances with a medication error and leading to a condemnation over a 6-year period (between 2005 and 2010). Thirty-one cases were analysed, 21 for scheduled activity and 10 for emergency activity. Consequences of claims were mostly serious (12 deaths, 14 serious complications, 5 simple complications). The types of medication errors were a drug monitoring error (11 cases), an administration error (5 cases), an overdose (6 cases), an allergy (4 cases), a contraindication (3 cases) and an omission (2 cases). Intravenous route of administration was involved in 19 of 31 cases (61%). The causes identified by the court expert were an error related to service organization (11), an error related to medical practice (11) or nursing practice (13). Only one claim was due to the hospital pharmacy. The claim related to drug supply chain is infrequent but potentially serious. These data should help strengthen quality approach in risk management. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

  10. Oncology patient-reported claims: maximising the chance for success.

    Science.gov (United States)

    Kitchen, H; Rofail, D; Caron, M; Emery, M-P

    2011-01-01

    To review Patient Reported Outcome (PRO) labelling claims achieved in oncology in Europe and in the United States and consider the benefits, and challenges faced. PROLabels database was searched to identify oncology products with PRO labelling approved in Europe since 1995 or in the United States since 1998. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) websites and guidance documents were reviewed. PUBMED was searched for articles on PRO claims in oncology. Among all oncology products approved, 22 were identified with PRO claims; 10 in the United States, 7 in Europe, and 5 in both. The language used in the labelling was limited to benefit (e.g. "…resulted in symptom benefits by significantly prolonging time to deterioration in cough, dyspnoea, and pain, versus placebo") and equivalence (e.g. "no statistical differences were observed between treatment groups for global QoL"). Seven products used a validated HRQoL tool; two used symptom tools; two used both; seven used single-item symptom measures (one was unknown). The following emerged as likely reasons for success: ensuring systematic PRO data collection; clear rationale for pre-specified endpoints; adequately powered trials to detect differences and clinically significant changes; adjusting for multiplicity; developing an a priori statistical analysis plan including primary and subgroup analyses, dealing with missing data, pooling multiple-site data; establishing clinical versus statistical significance; interpreting failure to detect change. End-stage patient drop-out rates and cessation of trials due to exceptional therapeutic benefit pose significant challenges to demonstrating treatment PRO improvement. PRO labelling claims demonstrate treatment impact and the trade-off between efficacy and side effects ultimately facilitating product differentiation. Reliable and valid instruments specific to the desired language, claim, and target population are required. Practical

  11. A Comparative Analysis of Outstanding Claim Reserves

    Directory of Open Access Journals (Sweden)

    Zlata Djuric

    2017-12-01

    Full Text Available The key processes in the business of insurance companies which define the financial viability of their business activities, as the most important element, are the adequate amount of technical reserves. A qualitative assessment of the technical reserves level is the basic support to the management of the key business processes and proper strategic and financial decision-making in order to maximize the viability, profitability, competitiveness, and further development of the company. Based on the data on the operations of an insurance company, within a single line of insurance, different, in practice, most frequently used methods were applied in order to determine the deviation amplitude of the projected amounts from the actual claims. Another direction of research focuses on actuarial practice in non-life insurance companies operating in the territory of the Republic of Serbia. The comparative analysis of the obtained projection points to the fact that the chosen methods, commonly used in actuarial practice in the Republic of Serbia, should be monitored and reviewed. The results of the multidirectional research and detection of the existing problems provide a useful framework and a stimulating mechanism, as well as the guidelines to improve the operations and better positioning of insurance in the commercial and economic environment of the Republic of Serbia.

  12. Price-Anderson Act and nuclear insurance

    International Nuclear Information System (INIS)

    Long, J.D.; Long, D.P.

    1979-01-01

    The nuclear incident at Three Mile Island has served to intensify debate about elimination of the federal limit on liability of utilities (and others) for operation of private nuclear reactions and about elimination of possible federal indemnification of utilities (or others) for claims paid in nuclear incidents. Not all those who debate these issues appear to be fully informed about the present nuclear liability and insurance system. This paper provides a brief description of the Price-Anderson Act, as amended, and of the operation of the nuclear insurance pools. It also includes a comment on the recent federal district court award against the Kerr-McGee Corporation

  13. Insurances in the petroleum industry; Seguros na industria do petroleo

    Energy Technology Data Exchange (ETDEWEB)

    Lima, Juliana S.F. [IRB-Brasil Resseguros, Rio de Janeiro, RJ (Brazil)

    2004-07-01

    This work shows an overview, focused mainly Brazil, of the insurance branch that deals with the upstream activities. The oil industry represents a substantial exposition for insurance international market because of the catastrophic nature of its risks, that entails a capacity dependency. The most of Insurance split into several insurers and reinsurer and are distributed into several markets and several regions of the world. The oil and gas branch of insurance covers: physical damage to equipment (platforms, vessels, drill ship etc), build, operation and liability in consequence of claims. The contract of insurance is complex because it is specific and demands much negotiation of rates and conditions. Moreover it is needed to find reliable insurers which want to accept the risk. There are alternatives to insurance market created by oil companies such as Captive and Mutual companies. The insurance international market built a complex and customized structure in order to be able to offer coverage to upstream risks and to participate in the amounts related to oil and gas production. (author)

  14. Can purchasing information be used to predict adherence to cardiovascular medications? An analysis of linked retail pharmacy and insurance claims data.

    Science.gov (United States)

    Krumme, Alexis A; Sanfélix-Gimeno, Gabriel; Franklin, Jessica M; Isaman, Danielle L; Mahesri, Mufaddal; Matlin, Olga S; Shrank, William H; Brennan, Troyen A; Brill, Gregory; Choudhry, Niteesh K

    2016-11-09

    The use of retail purchasing data may improve adherence prediction over approaches using healthcare insurance claims alone. Retrospective. A cohort of patients who received prescription medication benefits through CVS Caremark, used a CVS Pharmacy ExtraCare Health Care (ECHC) loyalty card, and initiated a statin medication in 2011. We evaluated associations between retail purchasing patterns and optimal adherence to statins in the 12 subsequent months. Among 11 010 statin initiators, 43% were optimally adherent at 12 months of follow-up. Greater numbers of store visits per month and dollar amount per visit were positively associated with optimal adherence, as was making a purchase on the same day as filling a prescription (ppurchase variables had low discriminative ability (C-statistic: 0.563), while models with both clinical and retail purchase variables achieved a C-statistic of 0.617. While the use of retail purchases may improve the discriminative ability of claims-based approaches, these data alone appear inadequate for adherence prediction, even with the addition of more complex analytical approaches. Nevertheless, associations between retail purchasing behaviours and adherence could inform the development of quality improvement interventions. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  15. Price--Anderson Act: the insurance industry's view

    International Nuclear Information System (INIS)

    Marrone, J.

    1977-01-01

    The insurance industry feels the expense of providing insurance coverage under the Price-Anderson Act is justified because it encouraged development of nuclear power and assured protection for the public in the event of an accident. Insurance pools have been instituted in about 20 countries in order to distribute the risk on a worldwide basis. Changes in the original Act allow an off-site claimant to get compensation with defense waived and provide for the transition of financial responsibility from the public to the private sector. To date the pools have refunded $9.7 of $12.7 million (73 percent) of the premiums to the insured and the remainder has grown into a $45 million fund, which reflects the success of the nuclear industry and the regulatory agencies in establishing a safe record. This record covers 60 power reactors, 50 research and development reactors, waste disposal sites, and about 50 nuclear facilities. With the exception of reactor operators and fuel reprocessors, the insurance is voluntary at premiums ranging from $1000 to $260,000. A total of $600,000 has been paid in claims

  16. Risk Management in Insurance Companies

    OpenAIRE

    Yang, Xufeng

    2006-01-01

    Insurance is the uncertain business in uncertain society. Today, insures face more complex and difficult risks. Efficient risk management mechanisms are essential for the insurers. The paper is set out initially to explore UK insurance companies risk management and risk disclosure by examining companies annual report after all the listed insurance companies are required to disclose risk information in their annual report, which seeks to reflect the recent development in UK insurance companies...

  17. Impact of the National Practitioner Data Bank on resolution of malpractice claims.

    Science.gov (United States)

    Waters, Teresa M; Studdert, David M; Brennan, Troyen A; Thomas, Eric J; Almagor, Orit; Mancewicz, Martha; Budetti, Peter P

    2003-01-01

    Policymakers and commentators are concerned that the National Practitioner Data Bank (NPDB) has influenced malpractice litigation dynamics. This study examines whether the introduction of the NPDB changed the outcomes, process, and equity of malpractice litigation. Using pre- and post-NPDB analyses, we examine rates of unpaid claims, trials, resolution time, physician defense costs, and payments on claims with a low/high probability of negligence. We find that physicians and their insurers have been less likely to settle claims since introduction of the NPDB, especially for payments less than dollars 50,000. Because this disruption appears to have decreased the proportion of questionable claims receiving compensation, the NPDB actually may have increased overall tort system specificity.

  18. Insurer is off the hook for settlement of job bias suit.

    Science.gov (United States)

    1999-03-05

    U.S. District Judge Charles R. Weiner said that a re-reading of the record showed that a policy issued by Zurich Insurance Co. to Sheraton Great Valley Hotel in Frazer, Pennsylvania covered only legal costs. The court determined the insurance policy's language to be ambiguous, but found a preponderance of evidence which showed that the hotel and insurance company negotiated a policy to indemnify the hotel against legal expenses, but not discrimination claims. An earlier judgment had said Zurich was liable for a $155,000 settlement in an HIV discrimination lawsuit.

  19. Turkish Compulsory Earthquake Insurance and "Istanbul Earthquake

    Science.gov (United States)

    Durukal, E.; Sesetyan, K.; Erdik, M.

    2009-04-01

    The city of Istanbul will likely experience substantial direct and indirect losses as a result of a future large (M=7+) earthquake with an annual probability of occurrence of about 2%. This paper dwells on the expected building losses in terms of probable maximum and average annualized losses and discusses the results from the perspective of the compulsory earthquake insurance scheme operational in the country. The TCIP system is essentially designed to operate in Turkey with sufficient penetration to enable the accumulation of funds in the pool. Today, with only 20% national penetration, and about approximately one-half of all policies in highly earthquake prone areas (one-third in Istanbul) the system exhibits signs of adverse selection, inadequate premium structure and insufficient funding. Our findings indicate that the national compulsory earthquake insurance pool in Turkey will face difficulties in covering incurring building losses in Istanbul in the occurrence of a large earthquake. The annualized earthquake losses in Istanbul are between 140-300 million. Even if we assume that the deductible is raised to 15%, the earthquake losses that need to be paid after a large earthquake in Istanbul will be at about 2.5 Billion, somewhat above the current capacity of the TCIP. Thus, a modification to the system for the insured in Istanbul (or Marmara region) is necessary. This may mean an increase in the premia and deductible rates, purchase of larger re-insurance covers and development of a claim processing system. Also, to avoid adverse selection, the penetration rates elsewhere in Turkey need to be increased substantially. A better model would be introduction of parametric insurance for Istanbul. By such a model the losses will not be indemnified, however will be directly calculated on the basis of indexed ground motion levels and damages. The immediate improvement of a parametric insurance model over the existing one will be the elimination of the claim processing

  20. Report on the Observance of Standards and Codes, Accounting and Auditing : Module B - Institutional Framework for Corporate Financial Reporting, B.4 Financial Sector - Insurance

    OpenAIRE

    World Bank

    2017-01-01

    The purpose of this report is to gain an understanding of the financial reporting requirements for insurance companies in a jurisdiction in addition to or instead of the requirements for commercial enterprises in general. Unless otherwise stated, the term insurance company refers to both insurance and reinsurance companies. There are also questions in relation to the monitoring and enforce...

  1. The Insuring of Schools: Everybody's Business. A C.A.R.E. Special Report.

    Science.gov (United States)

    Allen, Clifford H.

    Insurance is necessary to protect school district assets and assure the ongoing educational program. It may be purchased economically and serve its designed purpose only if trustees and administrators understand its function and seek professional help in its application. This report discusses in lay terms the nature of insurance as one means,…

  2. STUDY ON THE MAIN THEORETICAL ASPECTS RELATING TO THE PREMIUM TARIFFS IN THE PROPERTY INSURANCE

    Directory of Open Access Journals (Sweden)

    Vaduva Maria

    2012-03-01

    Full Text Available In the insurance market of goods, most of the first levied by the insurer is used for payment of damages due insured. The element mainly depending on which he fixes the level of share premium pricing is likely to size claims the insurer will pay insured. Part of the quota tariff intended for the first payment of damages is called net or share of first base. Adding to the addition cover expenditure on lodging and administering the fund insurance and financing of measures to prevent the damage, formation of the reserve fund and achieve the insurer has a specific benefit, get the first tariff or first gross.

  3. What can we learn from patient claims? - A retrospective analysis of incidence and patterns of adverse events after orthopaedic procedures in Sweden

    Directory of Open Access Journals (Sweden)

    Öhrn Annica

    2012-01-01

    Full Text Available Abstract Background Objective data on the incidence and pattern of adverse events after orthopaedic surgical procedures remain scarce, secondary to the reluctance for encompassing reporting of surgical complications. The aim of this study was to analyze the nature of adverse events after orthopaedic surgery reported to a national database for patient claims in Sweden. Methods In this retrospective review data from two Swedish national databases during a 4-year period were analyzed. We used the "County Councils' Mutual Insurance Company", a national no-fault insurance system for patient claims, and the "National Patient Register at the National Board of Health and Welfare". Results A total of 6,029 patient claims filed after orthopaedic surgery were assessed during the study period. Of those, 3,336 (55% were determined to be adverse events, which received financial compensation. Hospital-acquired infections and sepsis were the most common causes of adverse events (n = 741; 22%. The surgical procedure that caused the highest rate of adverse events was "decompression of spinal cord and nerve roots" (code ABC**, with 168 adverse events of 17,507 hospitals discharges (1%. One in five (36 of 168; 21.4% injured patient was seriously disabled or died. Conclusions We conclude that patients undergoing spinal surgery run the highest risk of being severely injured and that these patients also experienced a high degree of serious disability. The most common adverse event was related to hospital acquired infections. Claims data obtained in a no-fault system have a high potential for identifying adverse events and learning from them.

  4. Valuation of Non-Life Liabilities from Claims Triangles

    Directory of Open Access Journals (Sweden)

    Mathias Lindholm

    2017-07-01

    Full Text Available This paper provides a complete program for the valuation of aggregate non-life insurance liability cash flows based on claims triangle data. The valuation is fully consistent with the principle of valuation by considering the costs associated with a transfer of the liability to a so-called reference undertaking subject to capital requirements throughout the runoff of the liability cash flow. The valuation program includes complete details on parameter estimation, bias correction and conservative estimation of the value of the liability under partial information. The latter is based on a new approach to the estimation of mean squared error of claims reserve prediction.

  5. Characteristics of construction firms at risk for future workers' compensation claims using administrative data systems, Washington State.

    Science.gov (United States)

    Marcum, Jennifer L; Foley, Michael; Adams, Darrin; Bonauto, Dave

    2018-06-01

    Construction is high-hazard industry, and continually ranks among those with the highest workers' compensation (WC) claim rates in Washington State (WA). However, not all construction firms are at equal risk. We tested the ability to identify those construction firms most at risk for future claims using only administrative WC and unemployment insurance data. We collected information on construction firms with 10-50 average full time equivalent (FTE) employees from the WA unemployment insurance and WC data systems (n=1228). Negative binomial regression was used to test the ability of firm characteristics measured during 2011-2013 to predict time-loss claim rates in the following year, 2014. Claim rates in 2014 varied by construction industry groups, ranging from 0.7 (Land Subdivision) to 4.6 (Foundation, Structure, and Building Construction) claims per 100 FTE. Construction firms with higher average WC premium rates, a history of WC claims, increasing number of quarterly FTE, and lower average wage rates during 2011-2013 were predicted to have higher WC claim rates in 2014. We demonstrate the ability to leverage administrative data to identify construction firms predicted to have future WC claims. This study should be repeated to determine if these results are applicable to other high-hazard industries. Practical Applications: This study identified characteristics that may be used to further refine targeted outreach and prevention to construction firms at risk. Published by Elsevier Ltd.

  6. Cyber Insurance - Managing Cyber Risk

    Science.gov (United States)

    2015-04-01

    disaster response plans, how employees and others access data systems, and at a minimum, the antivirus and anti- malware software used by the business, the...a policy for insuring data stored in the cloud.[5] Typically, businesses that install or ser- vice software or networks or provide IT consulting for...security, and privacy. Errors and omissions covers claims related to performance of services such as software development or consulting services

  7. A Comparison of Self-reported Medication Adherence to Concordance Between Part D Claims and Medication Possession.

    Science.gov (United States)

    Savitz, Samuel T; Stearns, Sally C; Zhou, Lei; Thudium, Emily; Alburikan, Khalid A; Tran, Richard; Rodgers, Jo E

    2017-05-01

    Medicare Part D claims indicate medication purchased, but people who are not fully adherent may extend prescription use beyond the interval prescribed. This study assessed concordance between Part D claims and medication possession at a study visit in relation to self-reported medication adherence. We matched Part D claims for 6 common medications to medications brought to a study visit in 2011-2013 for the Atherosclerosis Risk in Communities study. The combined data consisted of 3027 medication events (claims, medications possessed, or both) for 2099 Atherosclerosis Risk in Communities study participants. Multinomial logistic regression estimated the association of concordance (visit only, Part D only, or both) with self-reported medication adherence while controlling for sociodemographic characteristics, veteran status, and availability under Generic Drug Discount Programs. Relative to participants with high adherence, medication events for participants with low adherence were approximately 25 percentage points less likely to match and more likely to be visit only (PDiscount Programs were 3 percentage points more likely to be visit only. Part D claims were substantially less likely to be concordant with medications possessed at study visit for participants with low self-reported adherence. This result supports the construction of adherence proxies such as proportion days covered using Part D claims.

  8. 30 CFR 210.205 - What reports must I submit to claim allowances on Indian coal leases?

    Science.gov (United States)

    2010-07-01

    ... on Indian coal leases? 210.205 Section 210.205 Mineral Resources MINERALS MANAGEMENT SERVICE... Minerals § 210.205 What reports must I submit to claim allowances on Indian coal leases? General. You must... coal leases: (1) Form MMS-4292, Coal Washing Allowance Report, to claim an allowance for the reasonable...

  9. Nonprofit health insurers: the story Wall Street doesn't tell.

    Science.gov (United States)

    Johnson, Susan R

    2003-01-01

    For several years, Wall Street investment firms have campaigned for conversion of nonprofit health insurers to investor ownership, arguing that an infusion of equity capital is critical to insurers' survival. However, closer examination of the financial performance and capital position of not-for-profit health plans shows that: The lower operating margins reported by not-for-profit health plans very likely reflect the organizations' corporate missions to serve their communities by minimizing the cost of coverage and their ability to invest all gains back into the company for the future benefit of their customers. Their investor-owned counterparts must generate higher margins to give shareholders a return on their investment. Compared with investor-owned insurers, not-for-profit health plans use a significantly higher percentage of the customers' premium dollar to pay health care claims. A lower percentage goes for administrative expenses. Over the past 10 years, not-for-profit health plans have succeeded in using operational and investment gains to build and retain a strong capital position--stronger than that of investor-owned companies--while investing heavily in infrastructure, product development, and market growth.

  10. Role of American Nuclear Insurers in reducing occupational radiation exposure

    International Nuclear Information System (INIS)

    Forbes, J.L.

    1980-01-01

    Since 1957 the nuclear insurance pools have provided liability and property insurance for the nation's nuclear power generating stations as mandated by the Price-Anderson Act. Although the insurance was originally structured to give financial protection to the insured in the event of a major accident, the potential for third-party claims arising from routine occupational exposure is becoming a more realistic pathway for a loss to the pools. In order to give maximum protection to the pools' assets, the Liability Engineering Department of American Nuclear Insurers (ANI) performs periodic inspections of the power plants. By concentrating on programs and management areas, ANI inspections complement regulatory inspections so that all major areas of common interest are reviewed. This paper presents the nature, results, and findings of those periodic inspections particularly in the general area of plant radiation protection

  11. Verification of flood damage modelling using insurance data

    DEFF Research Database (Denmark)

    Zhou, Qianqian; Petersen, Toke E. P.; Thorsen, Bo J.

    2012-01-01

    This paper presents the results of an analysis using insurance data for damage description and risk model verification, based on data from a Danish case. The results show that simple, local statistics of rainfall are not able to describe the variation in individual cost per claim, but are, howeve...

  12. Verification of flood damage modelling using insurance data

    DEFF Research Database (Denmark)

    Zhou, Qianqian; Panduro, T. E.; Thorsen, B. J.

    2013-01-01

    This paper presents the results of an analysis using insurance data for damage description and risk model verification, based on data from a Danish case. The results show that simple, local statistics of rainfall are not able to describe the variation in individual cost per claim, but are, howeve...

  13. Analysis of national pay-as-you-drive insurance systems and other variable driving charges

    Energy Technology Data Exchange (ETDEWEB)

    Wenzel, T.

    1995-07-01

    Under Pay as You Drive insurance (PAYD), drivers would pay part of their automobile insurance premium as a per-gallon surcharge every time they filled their gas tank. By transfering a portion of the cost of owning a vehicle from a fixed cost to a variable cost, PAYD would discourage driving. PAYD has been proposed recently in California as a means of reforming how auto insurance is provided. PAYD proponents claim that, by forcing drivers to purchase at least part of their insurance every time they refuel their car, PAYD would reduce or eliminate the need for uninsured motorist coverage. Some versions of PAYD proposed in California have been combined with a no-fault insurance system, with the intention of further reducing premiums for the average driver. Other states have proposed PAYD systems that would base insurance premiums on annual miles driven. In this report we discuss some of the qualitative issues surrounding adoption of PAYD and other policies that would convert other fixed costs of driving (vehicle registration, safety/emission control system inspection, and driver license renewal) to variable costs. We examine the effects of these policies on two sets of objectives: objectives related to auto insurance reform, and those related to reducing fuel consumption, CO{sub 2} emissions, and vehicle miles traveled. We pay particular attention to the first objective, insurance reform, since this has generated the most interest in PAYD to date, at least at the state level.

  14. Catastrophe Insurance Modeled by Shot-Noise Processes

    Directory of Open Access Journals (Sweden)

    Thorsten Schmidt

    2014-02-01

    Full Text Available Shot-noise processes generalize compound Poisson processes in the following way: a jump (the shot is followed by a decline (noise. This constitutes a useful model for insurance claims in many circumstances; claims due to natural disasters or self-exciting processes exhibit similar features. We give a general account of shot-noise processes with time-inhomogeneous drivers inspired by recent results in credit risk. Moreover, we derive a number of useful results for modeling and pricing with shot-noise processes. Besides this, we obtain some highly tractable examples and constitute a useful modeling tool for dynamic claims processes. The results can in particular be used for pricing Catastrophe Bonds (CAT bonds, a traded risk-linked security. Additionally, current results regarding the estimation of shot-noise processes are reviewed.

  15. Hancocked: manulife and the limits of private health insurance.

    Science.gov (United States)

    Evans, Robert G

    2011-08-01

    Long-term care (LTC) insurance is a salesman's dream. Millions of well-heeled boomers, anxious to protect their estates from the random expropriation of institutional dependency - what a market! But for Manulife, bleeding $1.5 million a day in LTC claims through subsidiary John Hancock, LTC is a nightmare. Company spokesmen blame unexpected increases in life expectancy. But management's fundamental error was insuring correlated risks. Risk pooling works only when individual risks are uncorrelated. Increases in life expectancy affect all contracts together. Manulife made the same mistake selling equity-linked annuities with guaranteed floors - essentially insuring against stock market declines. Results for shareholders have been catastrophic. Top management, meanwhile, have been honoured and richly rewarded.

  16. Impact of a Health Management Program on Healthcare Outcomes among Patients on Augmentation Therapy for Alpha 1-Antitrypsin Deficiency: An Insurance Claims Analysis.

    Science.gov (United States)

    Campos, Michael A; Runken, Michael C; Davis, Angela M; Johnson, Michael P; Stone, Glenda A; Buikema, Ami R

    2018-04-01

    Alpha 1-antitrypsin deficiency (AATD) is a genetic disorder which reduces serum alpha 1-antitrypsin (AAT or alpha1-proteinase inhibitor, A1PI) and increases the risk of chronic obstructive pulmonary disease (COPD). Management strategies include intravenous A1PI augmentation, and, in some cases, a health management program (Prolastin Direct ® ; PD). This study compared clinical and economic outcomes between patients with and without PD program participation. This retrospective study included commercial and Medicare Advantage health insurance plan members with ≥ 1 claim with diagnosis codes for COPD and ≥ 1 medical or pharmacy claim including A1PI (on index date). Outcomes were compared between patients receiving only Prolastin ® or Prolastin ® -C (PD cohort) and patients who received a different brand without PD (Comparator cohort). Demographic and clinical characteristics were captured during 6 months pre-index. Post-index exacerbation episodes and healthcare utilization and costs were compared between cohorts. The study sample comprised 445 patients (n = 213 in PD cohort; n = 232 in Comparator cohort), with a mean age 55.5 years, 50.8% male, and 78.9% commercially insured. The average follow-up was 822 days (2.25 years), and the average time on A1PI was 747 days (2.04 years). Few differences were observed in demographic or clinical characteristics. Adjusting for differences in patient characteristics, the rate of severe exacerbation episodes was reduced by 36.1% in the PD cohort. Adjusted total annual all-cause costs were 11.4% lower, and adjusted mean respiratory-related costs were 10.6% lower in the PD cohort than the Comparator cohort. Annual savings in all-cause total costs in the PD cohort relative to the Comparator cohort was US$25,529 per patient, largely due to significantly fewer and shorter hospitalizations. These results suggest that comprehensive health management services may improve both clinical and economic outcomes among

  17. Consumer preferences in social health insurance.

    Science.gov (United States)

    Kerssens, Jan J; Groenewegen, Peter P

    2005-03-01

    Allowing consumers greater choice of health plans is believed to be the key to high quality and low costs in social health insurance. This study investigates consumer preferences (361 persons, response rate 43%) for hypothetical health plans which differed in 12 characteristics (premium, deductibles, no-claim discount, extension of insurance and financial services, red tape involved, medical help-desk, choice of family physicians and hospitals, dental benefits, physical therapy benefits, benefits for prescription drugs and homeopathy). In 90% the health plan with the most attractive characteristics was preferred, indicating a predominantly rational kind of choice. The most decisive characteristics for preference were: complete dental benefits, followed by zero deductibles, and free choice of hospitals.

  18. Scientific relevance of Swiss property insurance data on flood risks and losses

    Science.gov (United States)

    Röthlisberger, Veronika; Bernet, Daniel; Keiler, Margreth

    2015-04-01

    The databases of Swiss flood insurance companies build a valuable but to date rarely used source of information for flood risk research. Detailed insights into the Swiss flood insurance system are crucial to evaluate the potential of the different databases for scientific analysis. Even though the flood insurance system modalities are mainly regulated on cantonal level there are some common principles that apply throughout Switzerland. First of all coverage against floods (and other particular natural hazards) is an integral part of every fire insurance policy for buildings or contents in Switzerland. This coupling of insurance as well as the statutory obligation to insure buildings in most of the cantons and movables in some of the cantons lead to a very high penetration. Second, in case of damage, the reinstatement costs (value as new) are compensated and third there are no (or little) deductible and co-pay. Thus the different datasets of the flood insurance companies would allow a very comprehensive data analysis. Moreover, insurance companies not only store electronically data about losses (typically date, amount of claims payment, cause of damage, identity of the insured object or policyholder) but also about insured objects. For insured objects the (insured) value and the details on the policy and its holder are the main feature to record. On buildings the insurance companies usually computerize additional information such as location, volume, year of construction or purpose of use. For the 19 (of total 26) cantons with a cantonal monopoly insurer the data of these insurance establishments have the additional value to represent (almost) the entire building stock of the respective canton. However, scientists face a wide range of the opportunities and challenges when using insurance data for flood research. The origin of flood insurance data implies that they are not generated for research but for business management. The presentation will highlighted pro and

  19. Economic Burden in Chinese Patients with Diabetes Mellitus Using Electronic Insurance Claims Data.

    Directory of Open Access Journals (Sweden)

    Yunyu Huang

    Full Text Available There is a paucity of studies that focus on the economic burden in daily care in China using electronic health data. The aim of this study is to describe the development of the economic burden of diabetic patients in a sample city in China from 2009 to 2011 using electronic data of patients' claims records.This study is a retrospective, longitudinal study in an open cohort of Chinese patients with diabetes. The patient population consisted of people living in a provincial capital city in east China, covered by the provincial urban employee basic medical insurance (UEBMI. We included any patient who had at least one explicit diabetes diagnosis or received blood glucose lowering medication in at least one registered outpatient visit or hospitalization during a calendar year in the years 2009-2011. Cross-sectional descriptions of different types of costs, prevalence of diabetic complications and related diseases, medication use were performed for each year separately and differences between three years were compared using a chi-square test or the non-parametric Kruskal-Wallis H test.Our results showed an increasing trend in total medical cost (from 2,383 to 2,780 USD, p = 0.032 and diabetes related cost (from 1,655 to 1,857 USD for those diabetic patients during the study period. The diabetes related economic burden was significantly related to the prevalence of complications and related diseases (p<0.001. The overall medication cost during diabetes related visits also increased (from 1,335 to 1,383 USD, p = 0.021. But the use pattern and cost of diabetes-related medication did not show significant changes during the study period.The economic burden of diabetes increased significantly in urban China. It is important to improve the prevention and treatment of diabetes to contribute to the sustainability of the Chinese health-care system.

  20. The German insurance industry. Yearbook 1990 of the Gesamtverband der Deutschen Versicherungswirtschaft e.V

    International Nuclear Information System (INIS)

    1990-01-01

    The DKVG (German nuclear power plant insurance association), founded in 1957, has 104 member insurance companies, all registered in the Federal Repbulic of Germany. At present property insurance amounts to 1.5 billion DM, and liability insurance to 200 million DM. The overall damage ratio was 15.4 (1988: 5.9) percent, whereby home business remained claim-free in 1989. The relatively low damage ratio of 15 percent should not deviate from the fact that nuclear insurers always have to reckon with large damage. At the moment it would cost them a maximum gross sum of 1.7 billion DM (property and liability insurance); on account of DKVG 685 million DM. (orig./HP) [de

  1. Effectiveness of employer financial incentives in reducing time to report worker injury: an interrupted time series study of two Australian workers' compensation jurisdictions.

    Science.gov (United States)

    Lane, Tyler J; Gray, Shannon; Hassani-Mahmooei, Behrooz; Collie, Alex

    2018-01-05

    Early intervention following occupational injury can improve health outcomes and reduce the duration and cost of workers' compensation claims. Financial early reporting incentives (ERIs) for employers may shorten the time between injury and access to compensation benefits and services. We examined ERI effect on time spent in the claim lodgement process in two Australian states: South Australia (SA), which introduced them in January 2009, and Tasmania (TAS), which introduced them in July 2010. Using administrative records of 1.47 million claims lodged between July 2006 and June 2012, we conducted an interrupted time series study of ERI impact on monthly median days in the claim lodgement process. Time periods included claim reporting, insurer decision, and total time. The 18-month gap in implementation between the states allowed for a multiple baseline design. In SA, we analysed periods within claim reporting: worker and employer reporting times (similar data were not available in TAS). To account for external threats to validity, we examined impact in reference to a comparator of other Australian workers' compensation jurisdictions. Total time in the process did not immediately change, though trend significantly decreased in both jurisdictions (SA: -0.36 days per month, 95% CI -0.63 to -0.09; TAS: 0.35, -0.50 to -0.20). Claim reporting time also decreased in both (SA: -1.6 days, -2.4 to -0.8; TAS: -5.4, -7.4 to -3.3). In TAS, there was a significant increase in insurer decision time (4.6, 3.9 to 5.4) and a similar but non-significant pattern in SA. In SA, worker reporting time significantly decreased (-4.7, -5.8 to -3.5), but employer reporting time did not (-0.3, -0.8 to 0.2). The results suggest that ERIs reduced claim lodgement time and, in the long-term, reduced total time in the claim lodgement process. However, only worker reporting time significantly decreased in SA, indicating that ERIs may not have shortened the process through the intended target of

  2. Warranty claim analysis considering human factors

    International Nuclear Information System (INIS)

    Wu Shaomin

    2011-01-01

    Warranty claims are not always due to product failures. They can also be caused by two types of human factors. On the one hand, consumers might claim warranty due to misuse and/or failures caused by various human factors. Such claims might account for more than 10% of all reported claims. On the other hand, consumers might not be bothered to claim warranty for failed items that are still under warranty, or they may claim warranty after they have experienced several intermittent failures. These two types of human factors can affect warranty claim costs. However, research in this area has received rather little attention. In this paper, we propose three models to estimate the expected warranty cost when the two types of human factors are included. We consider two types of failures: intermittent and fatal failures, which might result in different claim patterns. Consumers might report claims after a fatal failure has occurred, and upon intermittent failures they might report claims after a number of failures have occurred. Numerical examples are given to validate the results derived.

  3. Transparency in the Assessment of Takaful Claims for Construction Works Loss & Damage

    Directory of Open Access Journals (Sweden)

    Puteri Nur Farah Naadia Mohd Fauzi

    2016-06-01

    Full Text Available In the context of the construction industry, an alternative to the conventional insurance for works contracts is the Shariah compliant insurance otherwise known as takaful. Among the most frequently used takaful for construction works contracts is the Contractor’s All Risks (CAR Takaful. However, the future of CAR Takaful may be affected should issues such as marketing and clarification on how it works including how claims are processed, valued and compensation made are not made know to Contractors and Clients. In fact, previous studies have identified that issues on transparency in CAR Takaful products is among the major concerns expressed by the Contractors and Clients. Consequently, a study was conducted, the key objectives being to establish understanding on the concept of transparency in CAR Takaful claims and assess, from the perspectives of the Contractors and Clients, on whether the dealings in CAR Takaful claims are considered transparent or otherwise. The study was conducted principally via desk research and interviews with representative from takaful operators, Contractors and Clients organizations. Key results from the study suggest that transparency in CAR Takaful dealings is a concern especially those related to compliance with the Shariah and manner in which claims are valued and compensation decided. Such lack of transparency, if not addressed soonest possible, may not augur well for the future of the CAR Takaful industry.

  4. 45 CFR 95.631 - Cost identification for purpose of FFP claims.

    Science.gov (United States)

    2010-10-01

    ... INSURANCE PROGRAMS) Automatic Data Processing Equipment and Services-Conditions for Federal Financial Participation (FFP) Federal Financial Participation in Costs of Adp Acquisitions § 95.631 Cost identification... 45 Public Welfare 1 2010-10-01 2010-10-01 false Cost identification for purpose of FFP claims. 95...

  5. A scoping study on the costs of indoor air quality illnesses:an insurance loss reduction perspective

    Energy Technology Data Exchange (ETDEWEB)

    Chen, Allan; Vine, Edward L.

    1998-08-31

    The incidence of commercial buildings with poor indoor air quality (IAQ), and the frequency of litigation over the effects of poor IAQ is increasing. If so, these increases have ramifications for insurance carriers, which pay for many of the costs of health care and general commercial liability. However, little is known about the actual costs to insurance companies from poor IAQ in buildings. This paper reports on the results of a literature search of buildings-related, business and legal databases, and interviews with insurance and risk management representatives aimed at finding information on the direct costs to the insurance industry of poor building IAQ, as well as the costs of litigation. The literature search and discussions with insurance and risk management professionals reported in this paper turned up little specific information about the costs of IAQ-related problems to insurance companies. However, those discussions and certain articles in the insurance industry press indicate that there is a strong awareness and growing concern over the "silent crisis" of IAQ and its potential to cause large industry losses, and that a few companies are taking steps to address this issue. The source of these losses include both direct costs to insurers from paying health insurance and professional liability claims, as weIl as the cost of litigation. In spite of the lack of data on how IAQ-related health problems affect their business, the insurance industry has taken the anecdotal evidence about their reality seriously enough to alter their policies in ways that have lessened their exposure. We conclude by briefly discussing four activities that need to be addressed in the near future: (1) quantifying IAQ-related insurance costs by sector, (2) educating the insurance industry about the importance of IAQ issues, (3) examining IAQ impacts on the insurance industry in the residential sector, and (4) evaluating the relationship between IAQ improvements and their impact on

  6. Risks and nuclear insurance

    International Nuclear Information System (INIS)

    Debaets, M.; Springett, G.D.; Luotonen, K.; Virole, J.

    1988-01-01

    When analysing the nuclear insurance market, three elements must be taken into account: the nuclear operator's liability is regulated by national laws and/or international Conventions, such operators pay large premiums to insure their nuclear installations against property damage and finally, the nuclear insurance market is made up of pools and is mainly a monopoly. This report describes the different types of insurance coverage, the system governing nuclear third party liability under the Paris Convention and the Brussels Supplementary Convention and several national laws in that field. The last part of the report deals with liability and insurance aspects of international transport of nuclear materials [fr

  7. Should Governments engage health insurance intermediaries? A comparison of benefits with and without insurance intermediary in a large tax funded community health insurance scheme in the Indian state of Andhra Pradesh.

    Science.gov (United States)

    Nagulapalli, Srikant; Rokkam, Sudarsana Rao

    2015-09-10

    A peculiar phenomenon of engaging insurance intermediaries for government funded health insurance schemes for the poor, not usually found globally, is gaining ground in India. Rajiv Aarogyasri Scheme launched in the Indian state of Andhra Pradesh, is first largest tax funded community health insurance scheme in the country covering more than 20 million poor families. Aarogyasri Health Care Trust (trust), the scheme administrator, transfers funds to hospitals through two routes one, directly and the other through an insurance intermediary. The objective of this paper is to find out if engaging an insurance intermediary has any effect on cost efficiency of the insurance scheme. We used payment data of RAS for the period 2007-12, to find out the influence of insurance intermediary on the two variables, benefit cost ratio defined as benefit payment divided by premium payment, and claim denial ratio defined as benefit payment divided by treatment cost. Relationship between scheme expenditure and number of beds empanelled under the scheme is examined. OLS regression is used to perform all analyses. We found that adding an additional layer of insurance intermediary between the trust and hospitals reduced the benefit cost ratio under the scheme by 12.2% (p-value = 0.06). Every addition of 100 beds under the scheme increases the scheme payments by US$ 0.75 million (p-value insurance and trust modes narrowed down from 2.84% in government hospitals to 0.41% in private hospitals (p-value insurance intermediary has the twin effects of reduction in benefit payments to beneficiaries, and chocking fund flow to government hospitals. The idea of engaging insurance intermediary should be abandoned.

  8. Malpractice claims in interventional radiology: frequency, characteristics and protective measures.

    Science.gov (United States)

    Magnavita, N; Fileni, A; Mirk, P; Magnavita, G; Ricci, S; Cotroneo, A R

    2013-04-01

    The use of interventional radiology procedures has considerably increased in recent years, as has the number of related medicolegal litigations. This study aimed to highlight the problems underlying malpractice claims in interventional radiology and to assess the importance of the informed consent process. The authors examined all insurance claims relating to presumed errors in interventional radiology filed by radiologists over a period of 14 years after isolating them from the insurance database of all radiologists registered with the Italian Society of Medical Radiology (SIRM) between 1 January1993 and 31 December 2006. In the period considered, 98 malpractice claims were filed against radiologists who had performed interventional radiology procedures. In 21 cases (21.4%), the event had caused the patient's death. In >80% of cases, the event occurred in a public facility. The risk of a malpractice claim for a radiologist practising interventional procedures is 47 per 1,000, which corresponds to one malpractice claim for each 231 years of activity. Interventional radiology, a discipline with a biological risk profile similar to that of surgery, exposes practitioners to a high risk of medicolegal litigation both because of problems intrinsic to the techniques used and because of the need to operate on severely ill patients with compromised clinical status. Litigation prevention largely depends on both reducing the rate of medical error and providing the patient with correct and coherent information. Adopting good radiological practices, scrupulous review of procedures and efficiency of the instruments used and audit of organisational and management processes are all factors that can help reduce the likelihood of error. Improving communication techniques while safeguarding the patient's right to autonomy also implies adopting clear and rigorous processes for obtaining the patient's informed consent to the medical procedure.

  9. Nature of Medical Malpractice Claims Against Radiation Oncologists

    Energy Technology Data Exchange (ETDEWEB)

    Marshall, Deborah; Tringale, Kathryn [Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California (United States); Connor, Michael [Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California (United States); University of California Irvine School of Medicine, Irvine, California (United States); Punglia, Rinaa [Department of Radiation Oncology, Brigham and Women' s Hospital, Harvard Medical School, Boston, Massachusetts (United States); Recht, Abram [Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (United States); Hattangadi-Gluth, Jona, E-mail: jhattangadi@ucsd.edu [Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California (United States)

    2017-05-01

    Purpose: To examine characteristics of medical malpractice claims involving radiation oncologists closed during a 10-year period. Methods and Materials: Malpractice claims filed against radiation oncologists from 2003 to 2012 collected by a nationwide liability insurance trade association were analyzed. Outcomes included the nature of claims and indemnity payments, including associated presenting diagnoses, procedures, alleged medical errors, and injury severity. We compared the likelihood of a claim resulting in payment in relation to injury severity categories (death as referent) using binomial logistic regression. Results: There were 362 closed claims involving radiation oncology, 102 (28%) of which were paid, resulting in $38 million in indemnity payments. The most common alleged errors included “improper performance” (38% of closed claims, 18% were paid; 29% [$11 million] of total indemnity), “errors in diagnosis” (25% of closed claims, 46% were paid; 44% [$17 million] of total indemnity), and “no medical misadventure” (14% of closed claims, 8% were paid; less than 1% [$148,000] of total indemnity). Another physician was named in 32% of claims, and consent issues/breach of contract were cited in 18%. Claims for injury resulting in death represented 39% of closed claims and 25% of total indemnity. “Improper performance” was the primary alleged error associated with injury resulting in death. Compared with claims involving death, major temporary injury (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.29-5.85, P=.009), significant permanent injury (OR 3.1, 95% CI 1.48-6.46, P=.003), and major permanent injury (OR 5.5, 95% CI 1.89-16.15, P=.002) had a higher likelihood of a claim resulting in indemnity payment. Conclusions: Improper performance was the most common alleged malpractice error. Claims involving significant or major injury were more likely to be paid than those involving death. Insights into the nature of liability claims against

  10. Insurance: Profitability of the Medical Malpractice and General Liability Lines. Report to Congressional Requesters.

    Science.gov (United States)

    General Accounting Office, Washington, DC.

    This report on the profitability of the property/casualty insurance industry and in particular of the medical malpractice insurance line was prepared at the request of Representatives Henry A. Waxman and James J. Florio and Senators Paul Simon, Daniel K. Inouye, Albert Gore, Jr., and Jay D. Rockefeller. Four different estimates of medical…

  11. Using 'big data' to validate claims made in the pharmaceutical approval process.

    Science.gov (United States)

    Wasser, Thomas; Haynes, Kevin; Barron, John; Cziraky, Mark

    2015-01-01

    Big Data in the healthcare setting refers to the storage, assimilation, and analysis of large quantities of information regarding patient care. These data can be collected and stored in a wide variety of ways including electronic medical records collected at the patient bedside, or through medical records that are coded and passed to insurance companies for reimbursement. When these data are processed it is possible to validate claims as a part of the regulatory review process regarding the anticipated performance of medications and devices. In order to analyze properly claims by manufacturers and others, there is a need to express claims in terms that are testable in a timeframe that is useful and meaningful to formulary committees. Claims for the comparative benefits and costs, including budget impact, of products and devices need to be expressed in measurable terms, ideally in the context of submission or validation protocols. Claims should be either consistent with accessible Big Data or able to support observational studies where Big Data identifies target populations. Protocols should identify, in disaggregated terms, key variables that would lead to direct or proxy validation. Once these variables are identified, Big Data can be used to query massive quantities of data in the validation process. Research can be passive or active in nature. Passive, where the data are collected retrospectively; active where the researcher is prospectively looking for indicators of co-morbid conditions, side-effects or adverse events, testing these indicators to determine if claims are within desired ranges set forth by the manufacturer. Additionally, Big Data can be used to assess the effectiveness of therapy through health insurance records. This, for example, could indicate that disease or co-morbid conditions cease to be treated. Understanding the basic strengths and weaknesses of Big Data in the claim validation process provides a glimpse of the value that this research

  12. 76 FR 37207 - Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals...

    Science.gov (United States)

    2011-06-24

    ... Department of Health and Human Services 45 CFR Part 147 Group Health Plans and Health Insurance Issuers... SERVICES [CMS-9993-IFC2] 45 CFR Part 147 RIN 0938-AQ66 Group Health Plans and Health Insurance Issuers... for group health plans and health insurance coverage in the group and individual markets under...

  13. 76 FR 46684 - Medicaid and Children's Health Insurance Programs; Disallowance of Claims for FFP and Technical...

    Science.gov (United States)

    2011-08-03

    ..., 433, 447, and 457 [CMS-2292-P] RIN 0938-AQ32 Medicaid and Children's Health Insurance Programs... Children's Health Insurance Program (CHIP) disallowance process to allow States the option to retain... [[Page 46685

  14. Insurance issues and natural gas vehicles. Final report, January 1992

    International Nuclear Information System (INIS)

    Squadron, W.F.; Ward, C.O.; Brown, M.H.

    1992-01-01

    GRI has been funding research on natural gas vehicle (NGV) technology since 1986. To support the activity, GRI is evaluating a number of NGV issues including fuel storage, tank inspection, system safety, refueling, U.S. auto and truck use characteristics, and the fleet vehicle infrastructure. In addition, insurance and leasing companies will require new regulations and policies to address clean-fueled vehicle fleets' emergence into the marketplace. These policies may influence and partially determine the structure of the alternatively fueled vehicle industry, and the requirements, if any, imposed upon vehicle technologies. The report asseses the insurance and leasing industries' infrastructure/institutional barriers as they relate to the introduction of natural gas fueled vehicle fleets

  15. MOTOR THIRD PARTY LIABILITY INSURANCE – POLISH MARKET IN CONNECTIONS TO EUROPEAN TRENDS

    Directory of Open Access Journals (Sweden)

    Ilona Kwiecień

    2011-07-01

    Full Text Available Motor insurance, despite continuous product development, are still in most European countries, the predominant group of products sold by non-life Insurers. In the countries of Central and Eastern Europe is about 2/3 of the insurance written premiums. In the article authors analyze the areas and factors affecting the development of this class of insurance and current market changes in Poland in comparison to the European trends. The main attention has been devoted to number of accidents and road safety, frequency and amount of claims, other macroeconomics and legal factors. Also the financial issues, such as premium and profitability, were discussed.

  16. Clinical outcomes in low risk coronary artery disease patients treated with different limus-based drug-eluting stents--a nationwide retrospective cohort study using insurance claims database.

    Directory of Open Access Journals (Sweden)

    Chao-Lun Lai

    Full Text Available The clinical outcomes of different limus-based drug-eluting stents (DES in a real-world setting have not been well defined. The aim of this study was to investigate the clinical outcomes of three different limus-based DES, namely sirolimus-eluting stent (SES, Endeavor zotarolimus-eluting stent (E-ZES and everolimus-eluting stent (EES, using a national insurance claims database. We identified all patients who received implantation of single SES, E-ZES or EES between January 1, 2007 and December 31, 2009 from the National Health Insurance claims database, Taiwan. Follow-up was through December 31, 2011 for all selected clinical outcomes. The primary end-point was all-cause mortality. Secondary end-points included acute coronary events, heart failure needing hospitalization, and cerebrovascular disease. Cox regression model adjusting for baseline characteristics was used to compare the relative risks of different outcomes among the three different limus-based DES. Totally, 6584 patients were evaluated (n=2142 for SES, n=3445 for E-ZES, and n=997 for EES. After adjusting for baseline characteristics, we found no statistically significant difference in the risk of all-cause mortality in three DES groups (adjusted hazard ratio [HR]: 1.14, 95% confidence interval [CI]: 0.94-1.38, p=0.20 in E-ZES group compared with SES group; adjusted HR: 0.77, 95% CI: 0.54-1.10, p=0.15 in EES group compared with SES group. Similarly, we found no difference in the three stent groups in risks of acute coronary events, heart failure needing hospitalization, and cerebrovascular disease. In conclusion, we observed no difference in all-cause mortality, acute coronary events, heart failure needing hospitalization, and cerebrovascular disease in patients treated with SES, E-ZES, and EES in a real-world population-based setting in Taiwan.

  17. Analysis of the evidence-practice gap to facilitate proper medical care for the elderly: investigation, using databases, of utilization measures for National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB).

    Science.gov (United States)

    Nakayama, Takeo; Imanaka, Yuichi; Okuno, Yasushi; Kato, Genta; Kuroda, Tomohiro; Goto, Rei; Tanaka, Shiro; Tamura, Hiroshi; Fukuhara, Shunichi; Fukuma, Shingo; Muto, Manabu; Yanagita, Motoko; Yamamoto, Yosuke

    2017-06-06

    As Japan becomes a super-aging society, presentation of the best ways to provide medical care for the elderly, and the direction of that care, are important national issues. Elderly people have multi-morbidity with numerous medical conditions and use many medical resources for complex treatment patterns. This increases the likelihood of inappropriate medical practices and an evidence-practice gap. The present study aimed to: derive findings that are applicable to policy from an elucidation of the actual state of medical care for the elderly; establish a foundation for the utilization of National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), and present measures for the utilization of existing databases in parallel with NDB validation.Cross-sectional and retrospective cohort studies were conducted using the NDB built by the Ministry of Health, Labor and Welfare of Japan, private health insurance claims databases, and the Kyoto University Hospital database (including related hospitals). Medical practices (drug prescription, interventional procedures, testing) related to four issues-potential inappropriate medication, cancer therapy, chronic kidney disease treatment, and end-of-life care-will be described. The relationships between these issues and clinical outcomes (death, initiation of dialysis and other adverse events) will be evaluated, if possible.

  18. New CERN Health Insurance Scheme (CHIS) forms

    CERN Multimedia

    HR Department

    2015-01-01

    New versions of the following forms for claims and requests to the CERN Health Insurance Scheme (CHIS) have been released:   form for claiming reimbursement of medical expenses,   form for requesting advance reimbursement, and   dental estimate form (for treatments foreseen to exceed 800 CHF).   The new forms are available in French and English. They can either be completed electronically before being printed and signed, or completed in paper form. New detailed instructions can be found at the back of the claim form; CHIS members are invited to read them carefully. The electronic versions (PDF) of all the forms are available on the CHIS website and on the UNIQA Member Portal. CHIS Members are requested to use these new forms forthwith and to discard any previous version. Questions regarding the above should be addressed directly to UNIQA (72730 or 022.718 63 00 or uniqa.assurances@cern.ch).

  19. 77 FR 31499 - Medicaid and Children's Health Insurance Programs; Disallowance of Claims for FFP and Technical...

    Science.gov (United States)

    2012-05-29

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 430, 433, 447, and 457 [CMS-2292-F] RIN 0938-AQ32 Medicaid and Children's Health Insurance Programs... Children's Health Insurance Program (CHIP) disallowance process to allow States the option to retain...

  20. Risk of Cancer among Commercially Insured HIV-Infected Adults on Antiretroviral Therapy

    Directory of Open Access Journals (Sweden)

    Jeannette Y. Lee

    2016-01-01

    Full Text Available The objective of this study was to explore the cancer incidence rates among HIV-infected persons with commercial insurance who were on antiretroviral therapy and compare them with those rates in the general population. Paid health insurance claims for 63,221 individuals 18 years or older, with at least one claim with a diagnostic code for HIV and at least one filled prescription for an antiretroviral medication between January 1, 2006, and September 30, 2012, were obtained from the LifeLink® Health Plan Claims Database. The expected number of cancer cases in the general population for each gender-age group (60 years was estimated using incidence rates from the Surveillance Epidemiology and End Results (SEER program. Standardized incidence ratios (SIRs were estimated using their 95% confidence intervals (CIs. Compared to the general population, incidence rates for HIV-infected adults were elevated (SIR, 95% CI for Kaposi sarcoma (46.08; 38.74–48.94, non-Hodgkin lymphoma (4.22; 3.63–4.45, Hodgkin lymphoma (9.83; 7.45–10.84, and anal cancer (30.54; 25.62–32.46 and lower for colorectal cancer (0.69; 0.52–0.76, lung cancer (0.70; 0.54, 0.77, and prostate cancer (0.54; 0.45–0.58. Commercially insured, treated HIV-infected adults had elevated rates for infection-related cancers, but not for common non-AIDS defining cancers.

  1. Risk of Cancer among Commercially Insured HIV-Infected Adults on Antiretroviral Therapy

    International Nuclear Information System (INIS)

    Lee, J. Y.

    2016-01-01

    The objective of this study was to explore the cancer incidence rates among HIV-infected persons with commercial insurance who were on antiretroviral therapy and compare them with those rates in the general population. Paid health insurance claims for 63,221 individuals 18 years or older, with at least one claim with a diagnostic code for HIV and at least one filled prescription for an antiretroviral medication between January 1, 2006, and September 30, 2012, were obtained from the Life Link® Health Plan Claims Database. The expected number of cancer cases in the general population for each gender-age group (<30, 30-39, 40-49, 50-59, and >60 years) was estimated using incidence rates from the Surveillance Epidemiology and End Results (SEER) program. Standardized incidence ratios (SIRs) were estimated using their 95% confidence intervals (CIs). Compared to the general population, incidence rates for HIV-infected adults were elevated (SIR, 95% CI) for Kaposi sarcoma (46.08; 38.74-48.94), non-Hodgkin lymphoma (4.22; 3.63-4.45), Hodgkin lymphoma (9.83; 7.45-10.84), and anal cancer (30.54; 25.62-32.46) and lower for colorectal cancer (0.69; 0.52-0.76), lung cancer (0.70; 0.54, 0.77), and prostate cancer (0.54; 0.45-0.58). Commercially insured, treated HIV-infected adults had elevated rates for infection-related cancers, but not for common non-AIDS defining cancers.

  2. Effects of health information technology on malpractice insurance premiums.

    Science.gov (United States)

    Kim, Hye Yeong; Lee, Jinhyung

    2015-04-01

    The widespread adoption of health information technology (IT) will help contain health care costs by decreasing inefficiencies in healthcare delivery. Theoretically, health IT could lower hospitals' malpractice insurance premiums (MIPs) and improve the quality of care by reducing the number and size of malpractice. This study examines the relationship between health IT investment and MIP using California hospital data from 2006 to 2007. To examine the effect of hospital IT on malpractice insurance expense, a generalized estimating equation (GEE) was employed. It was found that health IT investment was not negatively associated with MIP. Health IT was reported to reduce medical error and improve efficiency. Thus, it may reduce malpractice claims from patients, which will reduce malpractice insurance expenses for hospitals. However, health IT adoption could lead to increases in MIPs. For example, we expect increases in MIPs of about 1.2% and 1.5%, respectively, when health IT and labor increase by 10%. This study examined the effect of health IT investment on MIPs controlling other hospital and market, and volume characteristics. Against our expectation, we found that health IT investment was not negatively associated with MIP. There may be some possible reasons that the real effect of health IT on MIPs was not observed; barriers including communication problems among health ITs, shorter sample period, lower IT investment, and lack of a quality of care measure as a moderating variable.

  3. Professional dental and oral surgery liability in Italy: a comparative analysis of the insurance products offered to health workers.

    Science.gov (United States)

    Di Lorenzo, Pierpaolo; Paternoster, Mariano; Nugnes, Mariarosaria; Pantaleo, Giuseppe; Graziano, Vincenzo; Niola, Massimo

    2016-01-01

    In Italy there has been an increase in claims for damages for alleged medical malpractice. A study was therefore conducted that aimed at assessing the content of the coverage of insurance policy contracts offered to oral health professionals by the insurance market. The sample analysed composed of 11 insurance policy contracts for professional dental liability offered from 2010 to 2015 by leading insurance companies operating in the Italian market. The insurance products analysed are structured on the "claims made" clause. No policy contract examined covers the damage due to the failure to acquire consent for dental treatment and, in most cases, damage due to unsatisfactory outcomes of treatment of an aesthetic nature and the failure to respect regulatory obligations on privacy. On entering into a professional liability insurance policy contract, the dentist should pay particular attention to the period covered by the guarantee, the risks both covered and excluded, as well as the extent of the limit of liability and any possible fixed/percentage excess. When choosing a professional liability contract, a dentist should examine the risks in relation to the professional activity carried out before signing.

  4. IBO Claim Taking Project

    Data.gov (United States)

    Social Security Administration — IBO manually tracks all Canadian Claims and DSU claims via this report. It also provides a summary for each region and office of origin that the DSU works with. This...

  5. Insurance. Part 3. Property, housing, and disaster insurance (a bibliography with abstracts). Report for 1964--Jun 1975

    International Nuclear Information System (INIS)

    Young, M.E.

    1975-08-01

    Several types of insurance are discussed in the three part bibliography. Part 3 includes citations on property and mortgage insurance, and insurance for such disasters as floods, fires, earthquakes, and nuclear accidents. (Contains 70 abstracts)

  6. HEALTH INFO SANTE ANNUAL DEDUCTIBLE AND REIMBURSEMENT CLAIMS: HINTS FOR USE

    CERN Multimedia

    1999-01-01

    Information from the CHIS Board and the Personnel DivisionOne should bear in mind that the annual deductible is an amount (currently CHF 100) charged automatically by the Administrator of the scheme for every adult aged 18 and above. This is what happens: The amount is deducted annually for all medical services received over a calendar year.It is triggered by the date of the treatment and not by the date of the bill nor that of the reimbursement claim.In other words, if you receive medical treatment in December for the first time in a given year, the CHF 100 will be deducted from the claim for that treatment. So, except for urgent cases, it would be better to wait till the following month, thus avoiding one annual deductible.It is also worth remembering that the cost of processing our reimbursement claims - and there were 55, 000 in 1998 - is part of the cost of our insurance.Help keep administrative costs down : do not submit reimbursement claims for amounts less than the annual deductible unless your claims...

  7. Small employers and self-insured health benefits: too small to succeed?

    Science.gov (United States)

    Yee, Tracy; Christianson, Jon B; Ginsburg, Paul B

    2012-07-01

    Over the past decade, large employers increasingly have bypassed traditional health insurance for their workers, opting instead to assume the financial risk of enrollees' medical care through self-insurance. Because self-insurance arrangements may offer advantages--such as lower costs, exemption from most state insurance regulation and greater flexibility in benefit design--they are especially attractive to large firms with enough employees to spread risk adequately to avoid the financial fallout from potentially catastrophic medical costs of some employees. Recently, with rising health care costs and changing market dynamics, more small firms--100 or fewer workers--are interested in self-insuring health benefits, according to a new qualitative study from the Center for Studying Health System Change (HSC). Self-insured firms typically use a third-party administrator (TPA) to process medical claims and provide access to provider networks. Firms also often purchase stop-loss insurance to cover medical costs exceeding a predefined amount. Increasingly competitive markets for TPA services and stop-loss insurance are making self-insurance attractive to more employers. The 2010 national health reform law imposes new requirements and taxes on health insurance that may spur more small firms to consider self-insurance. In turn, if more small firms opt to self-insure, certain health reform goals, such as strengthening consumer protections and making the small-group health insurance market more viable, may be undermined. Specifically, adverse selection--attracting sicker-than-average people--is a potential issue for the insurance exchanges created by reform.

  8. Developing algorithms for healthcare insurers to systematically monitor surgical site infection rates

    Directory of Open Access Journals (Sweden)

    Livingston James M

    2007-06-01

    Full Text Available Abstract Background Claims data provide rapid indicators of SSIs for coronary artery bypass surgery and have been shown to successfully rank hospitals by SSI rates. We now operationalize this method for use by payers without transfer of protected health information, or any insurer data, to external analytic centers. Results We performed a descriptive study testing the operationalization of software for payers to routinely assess surgical infection rates among hospitals where enrollees receive cardiac procedures. We developed five SAS programs and a user manual for direct use by health plans and payers. The manual and programs were refined following provision to two national insurers who applied the programs to claims databases, following instructions on data preparation, data validation, analysis, and verification and interpretation of program output. A final set of programs and user manual successfully guided health plan programmer analysts to apply SSI algorithms to claims databases. Validation steps identified common problems such as incomplete preparation of data, missing data, insufficient sample size, and other issues that might result in program failure. Several user prompts enabled health plans to select time windows, strata such as insurance type, and the threshold number of procedures performed by a hospital before inclusion in regression models assessing relative SSI rates among hospitals. No health plan data was transferred to outside entities. Programs, on default settings, provided descriptive tables of SSI indicators stratified by hospital, insurer type, SSI indicator (inpatient, outpatient, antibiotic, and six-month period. Regression models provided rankings of hospital SSI indicator rates by quartiles, adjusted for comorbidities. Programs are publicly available without charge. Conclusion We describe a free, user-friendly software package that enables payers to routinely assess and identify hospitals with potentially high SSI

  9. Mesothelioma incidence surveillance systems and claims for workers’ compensation. Epidemiological evidence and prospects for an integrated framework

    Directory of Open Access Journals (Sweden)

    Marinaccio Alessandro

    2012-07-01

    Full Text Available Abstract Background Malignant mesothelioma is an aggressive and lethal tumour strongly associated with exposure to asbestos (mainly occupational. In Italy a large proportion of workers are protected from occupational diseases by public insurance and an epidemiological surveillance system for incident mesothelioma cases. Methods We set up an individual linkage between the Italian national mesothelioma register (ReNaM and the Italian workers’ compensation authority (INAIL archives. Logistic regression models were used to identify and test explanatory variables. Results We extracted 3270 mesothelioma cases with occupational origins from the ReNaM, matching them with 1625 subjects in INAIL (49.7%; 91.2% (1,482 of the claims received compensation. The risk of not seeking compensation is significantly higher for women and the elderly. Claims have increased significantly in recent years and there is a clear geographical gradient (northern and more developed regions having higher claims rates. The highest rates of compensation claims were after work known to involve asbestos. Conclusions Our data illustrate the importance of documentation and dissemination of all asbestos exposure modalities. Strategies focused on structural and systematic interaction between epidemiological surveillance and insurance systems are needed.

  10. 7 CFR 457.122 - Walnut crop insurance provisions.

    Science.gov (United States)

    2010-01-01

    ... quarantine, boycott, or refusal of any person to accept production. 10. Duties in the Event of Damage or Loss... production on insured acreage that you intend to abandon or no longer care for, if you and we agree on the... do not agree with our appraisal, we may defer the claim only if you agree to continue to care for the...

  11. A COMPARATIVE ANALYSIS BETWEEN UNIT-LINKED LIFE INSURANCE AND OTHER ALTERNATIVE INVESTMENTS

    Directory of Open Access Journals (Sweden)

    CRISTINA CIUMAS

    2015-07-01

    Full Text Available The unit-linked life insurance has two important components: protection and investment. The protection component refers to the insured sum in case of the occurrence of insured risks and the investment component refers to the policyholder’s account that represents the present value of the units from the chosen investment funds.These financial products invest most of the premium paid by the insured person in the funds managed by the insurance company or an external administrator and the lower part of the premium is intended to cover the insured risk (death, disability, etc. An important component of the activity carried out by the insurance companies is the investment of the premiums paid by policyholders in various types of assets, in order to obtain higher yields than those guaranteed by the insurance contracts, while providing the necessary liquidity for the payment of insurance claims in case of occurrence of the assumed risks. This research contributes to the existing literature regarding the study of investment alternatives, with an exclusive focus on the investment in unit-linked life insurance. A special place in this study is the presentation of investments in unit-linked insurance versus other types of financial investments: deposits, treasury bills, shares (BET, currency (EURO and gold.

  12. Attitudes toward the dubious compensation claim.

    Science.gov (United States)

    LEGGO, C

    1951-07-01

    Laws providing for compensation of workmen for occupational injury are a powerful socio-economic force. In settlement of compensation claims the goal, difficult to achieve, is fairness to employee, employer and insurance carrier. Often, medical, legal, economic and social considerations conflict with one another. A "fact" in one field may not be considered so in another. Since medical data and testimony often guide the ultimate decision of a compensation claim, the physician's attitude is a large factor not only immediately and directly in determination of the case at hand but, perhaps more important, in the ultimate direction of the socio-economic forces which spring from the sum of all such determinations. To perpetuate the good in workmen's compensation laws, the next generation of physicians-and of lawyers and business administrators as well, for they, too, are involved-ought to have basic training in the social sciences in order that they may have a broad rather than a segmental view of the problems with which they deal.

  13. Financial risk and derivatives a special issue of the geneva papers on risk and insurance theory

    CERN Document Server

    Subrahmanyam, Marti

    1996-01-01

    Financial Risk and Derivatives provides an excellent illustration of the links that have developed in recent years between the theory of finance on one hand and insurance economics and actuarial science on the other. Advances in contingent claims analysis and developments in the academic and practical literature dealing with the management of financial risks reflect the close relationships between insurance and innovations in finance. The book represents an overview of the present state of the art in theoretical research dealing with financial issues of significance for insurance science. It will hopefully provide an impetus to further developments in applied insurance research.

  14. Impacts of a new insurance benefit with capitated provider payment on healthcare utilization, expenditure and quality of medication prescribing in China

    NARCIS (Netherlands)

    Sun, Jing; Zhang, Xiaotian; Zhang, Zou; Wagner, Anita K.; Ross-Degnan, Dennis; Hogerzeil, Hans V.

    ObjectivesTo assess a new Chinese insurance benefit with capitated provider payment for common diseases in outpatients. MethodsLongitudinal health insurance claims data, health administrative data and primary care facility data were used to assess trajectories in outpatient visits, inpatient

  15. Surgical exploration of hand wounds in the emergency room: Preliminary study of 80 personal injury claims.

    Science.gov (United States)

    Mouton, J; Houdre, H; Beccari, R; Tarissi, N; Autran, M; Auquit-Auckbur, I

    2016-12-01

    The SHAM Insurance Company in Lyon, France, estimated that inadequate hand wound exploration in the emergency room (ER) accounted for 10% of all ER-related personal injury claims in 2013. The objective of this study was to conduct a critical analysis of 80 claims that were related to hand wound management in the ER and led to compensation by SHAM. Eighty claims filed between 2007 and 2010 were anonymised then included into the study. To be eligible, claims had to be filed with SHAM, related to the ER management of a hand wound in an adult, and closed at the time of the study. Claims related to surgery were excluded. For each claim, we recorded 104 items (e.g., epidemiology, treatments offered, and impact on social and occupational activities) and analysed. Of the 70 patients, 60% were manual workers. The advice of a surgeon was sought in 16% of cases. The most common wound sites were the thumb (33%) and index finger (17%). Among the missed lesions, most involved tendons (74%) or nerves (29%). Many patients had more than one reason for filing a claim. The main reasons were inadequate wound exploration (97%), stiffness (49%), and dysaesthesia (41%). One third of patients were unable to return to their previous job. Mean sick-leave duration was 148 days and mean time from discharge to best outcome was 4.19%. Most claims (79%) were settled directly with the insurance company, 16% after involvement of a public mediator, and 12% in court. The mean compensatory damages award was 4595Euros. Inadequate surgical exploration of hand wounds is common in the ER, carries a risk of lasting and sometimes severe residual impairment, and generates considerable societal costs. IV. Copyright © 2016. Published by Elsevier Masson SAS.

  16. Frequent Users of Hospital Emergency Departments in Korea Characterized by Claims Data from the National Health Insurance: A Cross Sectional Study

    Science.gov (United States)

    Woo, Jung Hoon; Grinspan, Zachary; Shapiro, Jason; Rhee, Sang Youl

    2016-01-01

    The Korean National Health Insurance, which provides universal coverage for the entire Korean population, is now facing financial instability. Frequent emergency department (ED) users may represent a medically vulnerable population who could benefit from interventions that both improve care and lower costs. To understand the nature of frequent ED users in Korea, we analyzed claims data from a population-based national representative sample. We performed both bivariate and multivariable analyses to investigate the association between patient characteristics and frequent ED use (4+ ED visits in a year) using claims data of a 1% random sample of the Korean population, collected in 2009. Among 156,246 total ED users, 4,835 (3.1%) were frequent ED users. These patients accounted for 14% of 209,326 total ED visits and 17.2% of $76,253,784 total medical expenses generated from all ED visits in the 1% data sample. Frequent ED users tended to be older, male, and of lower socio-economic status compared with occasional ED users (p users had longer stays in the hospital when admitted, higher probability of undergoing an operative procedure, and increased mortality. Among 8,425 primary diagnoses, alcohol-related complaints and schizophrenia showed the strongest positive correlation with the number of ED visits. Among the frequent ED users, mortality and annual outpatient department visits were significantly lower in the alcohol-related patient subgroup compared with other frequent ED users; furthermore, the rate was even lower than that for non-frequent ED users. Our findings suggest that expanding mental health and alcohol treatment programs may be a reasonable strategy to decrease the dependence of these patients on the ED. PMID:26809051

  17. CHIP premiums, health status, and the insurance coverage of children.

    Science.gov (United States)

    Marton, James; Talbert, Jeffery C

    2010-01-01

    This study uses the introduction of premiums into Kentucky's Children's Health Insurance Program (KCHIP) to examine whether the enrollment impact of new premiums varies by child health type. We also examine the extent to which children find alternative coverage after premium nonpayment. Public insurance claims data suggest that those with chronic health conditions are less likely to leave public coverage. We find little evidence of a differential impact of premiums on enrollment among the chronically ill. Our survey of nonpayers shows that 56% of responding families found alternative private or public health coverage for their children after losing CHIP.

  18. 45 CFR 303.108 - Quarterly wage and unemployment compensation claims reporting to the National Directory of New...

    Science.gov (United States)

    2010-10-01

    ... 45 Public Welfare 2 2010-10-01 2010-10-01 false Quarterly wage and unemployment compensation... OPERATIONS § 303.108 Quarterly wage and unemployment compensation claims reporting to the National Directory of New Hires. (a) What definitions apply to quarterly wage and unemployment compensation claims...

  19. Managing and operating the reserve market as one insurance system

    International Nuclear Information System (INIS)

    Liu, Youfei; Cai, Bin; Wu, F.F.; Ni, Y.X.

    2007-01-01

    In this paper, it is suggested that the preference of an individual consumer for its power supply reliability should be considered when scheduling the system reserve. The mechanism of 'provider insurance' is introduced and the reserve market is to be managed as an insurance system. In our modeling, the generator who provides the insurance of reliable power supply via its reserve, should always collect the payment (the premium), and be rewarded with the spot market price for its called reserve. The consumer who buys the insurance, pays premium and thus obtains a reliable power supply (the claim). It is argued that such a market mechanism will result in the maximum social welfare. Moreover, it is shown that there is a kind of 'moral hazard in reverse' fact that will further improve the market efficiency. Later on, discussions on implementing the proposed method are given, and an illustrative example is provided to show basic features of the proposed method. (author)

  20. Leading Causes of Anesthesia-Related Liability Claims in Ambulatory Surgery Centers.

    Science.gov (United States)

    Ranum, Darrell; Beverly, Anair; Shapiro, Fred E; Urman, Richard D

    2017-11-16

    We present a contemporary analysis of patient injury, allegations, and contributing factors of anesthesia-related closed claims, which involved cases that specifically occurred in free-standing ambulatory surgery centers (ASCs). We examined ASC-closed claims data between 2007 and 2014 from The Doctors Company, a medical malpractice insurer. Findings were coded using the Comprehensive Risk Intelligence Tool developed by CRICO Strategies. We compared coded data from ASC claims with hospital operating room (HOR) claims, in terms of injury severity category, nature of injury, nature of allegation, contributing factors identified, and contributing comorbidities and claim value. Ambulatory surgery center claims were more likely to be classified as medium severity than HOR claims, more likely to involve dental damage or pain than HOR claims, but less likely to involve death or respiratory or cardiac arrest. Technical performance was the most common contributing factor: 47% of ASCs and 48% of HORs. Only 7% of allegations relating to technical performance were judged to be a direct result of poor technical performance. The most common anesthesia procedures resulting in ASC claims were injection of anesthesia into a peripheral nerve (34%) and intubation (29%). Obesity was the most common contributing comorbidity in both settings. Mean closed claim value was significantly lower for ASC than HOR claims, averaging US $87,888 versus $107,325. Analysis of ASC and HOR claims demonstrates significant differences and several common sources of liability. These include improving strategies for thorough screening, preoperative assessment and risk stratifying of patients, incorporating routine dental and airway assessment and documentation, diagnosing and treating perioperative pain adequately, and improving the efficacy of communication between patients and care providers.

  1. State of emergency preparedness for US health insurance plans.

    Science.gov (United States)

    Merchant, Raina M; Finne, Kristen; Lardy, Barbara; Veselovskiy, German; Korba, Caey; Margolis, Gregg S; Lurie, Nicole

    2015-01-01

    Health insurance plans serve a critical role in public health emergencies, yet little has been published about their collective emergency preparedness practices and policies. We evaluated, on a national scale, the state of health insurance plans' emergency preparedness and policies. A survey of health insurance plans. We queried members of America's Health Insurance Plans, the national trade association representing the health insurance industry, about issues related to emergency preparedness issues: infrastructure, adaptability, connectedness, and best practices. Of 137 health insurance plans queried, 63% responded, representing 190.6 million members and 81% of US plan enrollment. All respondents had emergency plans for business continuity, and most (85%) had infrastructure for emergency teams. Some health plans also have established benchmarks for preparedness (eg, response time). Regarding adaptability, 85% had protocols to extend claim filing time and 71% could temporarily suspend prior medical authorization rules. Regarding connectedness, many plans shared their contingency plans with health officials, but often cited challenges in identifying regulatory agency contacts. Some health insurance plans had specific policies for assisting individuals dependent on durable medical equipment or home healthcare. Many plans (60%) expressed interest in sharing best practices. Health insurance plans are prioritizing emergency preparedness. We identified 6 policy modifications that health insurance plans could undertake to potentially improve healthcare system preparedness: establishing metrics and benchmarks for emergency preparedness; identifying disaster-specific policy modifications, enhancing stakeholder connectedness, considering digital strategies to enhance communication, improving support and access for special-needs individuals, and developing regular forums for knowledge exchange about emergency preparedness.

  2. Comorbidity ascertainment from the ESRD Medical Evidence Report and Medicare claims around dialysis initiation: a comparison using US Renal Data System data.

    Science.gov (United States)

    Krishnan, Mahesh; Weinhandl, Eric D; Jackson, Scott; Gilbertson, David T; Lacson, Eduardo

    2015-11-01

    The end-stage renal disease Medical Evidence Report serves as a source of comorbid condition data for risk adjustment of quality metrics. We sought to compare comorbid condition data in the Medical Evidence Report around dialysis therapy initiation with diagnosis codes in Medicare claims. Observational cohort study using US Renal Data System data. Medicare-enrolled elderly (≥66 years) patients who initiated maintenance dialysis therapy July 1 to December 31, 2007, 2008, or 2009. 12 comorbid conditions ascertained from claims during the 6 months before dialysis therapy initiation, the Medical Evidence Report, and claims during the 3 months after dialysis therapy initiation. None. Comorbid condition prevalence according to claims before dialysis therapy initiation generally exceeded prevalence according to the Medical Evidence Report. The κ statistics for comorbid condition designations other than diabetes ranged from 0.06 to 0.43. Discordance of designations was associated with age, race, sex, and end-stage renal disease Network. During 23,930 patient-years of follow-up from 4 to 12 months after dialysis therapy initiation (8,930 deaths), designations from claims during the 3 months after initiation better discriminated risk of death than designations from the Medical Evidence Report (C statistics of 0.674 vs 0.616). Between the Medical Evidence Report and claims, standardized mortality ratios changed by >10% for more than half the dialysis facilities. Neither the Medical Evidence Report nor diagnosis codes in claims constitute a gold standard of comorbid condition data; results may not apply to nonelderly patients or patients without Medicare coverage. Discordance of comorbid condition designations from the Medical Evidence Report and claims around dialysis therapy initiation was substantial and significantly associated with patient characteristics, including location. These patterns may engender bias in risk-adjusted quality metrics. In lieu of the Medical

  3. Aviation or space policy: New challenges for the insurance sector to private human access to space

    Science.gov (United States)

    van Oijhuizen Galhego Rosa, Ana Cristina

    2013-12-01

    The phenomenon of private human access to space has introduced a new set of problems in the insurance sector. Orbital and suborbital space transportation will surely be unique commercial services for this new market. Discussions are under way regarding space insurance, in order to establish whether this new market ought to be regulated by aviation or space law. Alongside new definitions, infrastructures, legal frameworks and liability insurances, the insurance sector has also been introducing a new approach. In this paper, I aim to analyse some of the possibilities of new premiums, capacities, and policies (under aviation or space insurance rules), as well as the new insurance products related to vehicles, passengers and third party liability. This paper claims that a change toward new insurance regimes is crucial, due to the current stage in development of space tourism and the urgency to adapt insurance rules to support future development in this area.

  4. Prescriptions of Chinese Herbal Medicine for Constipation Under the National Health Insurance in Taiwan

    OpenAIRE

    Maw-Shiou Jong; Shinn-Jang Hwang; Yu-Chun Chen; Tzeng-Ji Chen; Fun-Jou Chen; Fang-Pey Chen

    2010-01-01

    Constipation is a common gastrointestinal problem worldwide. The aim of this study was to determine the frequency of use and prescriptive patterns of Chinese herbal medicine (CHM) in treating constipation by analyzing the claims data of traditional Chinese medicine (TCM) from the National Health Insurance (NHI) in Taiwan. Methods: The computerized claims dataset of the TCM office visits and the corresponding prescription files in 2004 compiled by the NHI Research Institute in Taiwan were l...

  5. Mediation as an alternative solution to medical malpractice court claims

    Directory of Open Access Journals (Sweden)

    Neels Claassen

    2016-05-01

    Full Text Available Is there a crisis in the healthcare industry? Most certainly there is. Dr Motsoaledi, Minister of Health, publicly acknowledged the existence of such a crisis at a Medico-Legal Summit held at his initiative in Pretoria on 9 and 10 March 2015 at St Georges Hotel.[1] Currently, as recently confirmed by the MEC for Health, Ms Mahlangu, there are about 2 000 pending court cases against the Gauteng Provincial Health Department, the total quantum being claimed amounting to approximately ZAR 3.5 billion. During 2013/2014 this department spent about ZAR 256 million on legal costs payable to claimants’ attorneys. No budget for these expenses exists, resulting in payment being made from funds designated for the acquisition of medical equipment and other purposes.[1] This undermines the department’s ability to renew old equipment and upgrade to more modern equipment, resulting in even further claims. More claims are therefore to be expected. The Medical Protection Society also confirmed an increase in medical malpractice claims against their members of nearly 550% compared to 10 years ago. The quantum of claims that exceeded ZAR 5 million per claim, also increased by 900%.[2,3] The ripple effect of these increases in medico-legal claims causes insurance premiums for healthcare professionals to become exorbitantly expensive, resulting in some practitioners leaving the medical profession. Practitioners also act more defensively in applying their trade, resulting in additional and sometimes unnecessary tests that increase the costs of medical care and often cause further grounds for the institution of claims.

  6. Health Care, Health Insurance, and the Relative Income of the Elderly and Nonelderly

    OpenAIRE

    Gary Burtless; Pavel Svaton

    2009-01-01

    Cash income offers an incomplete picture of the resources available to finance household consumption. Most American families are covered by an insurance plan that pays for some or all of the health care they consume. Only a comparatively small percentage of families pay for the full cost of this insurance out of their cash incomes. As health care has claimed a growing share of consumption, the percentage of care that is financed out of household incomes has declined. Because health care consu...

  7. Research on Supply Chain Coordination of Fresh Agricultural Products under Agricultural Insurance

    Directory of Open Access Journals (Sweden)

    Zhang Pei

    2017-01-01

    Full Text Available Based on the fact that the current fresh agricultural products are susceptible to natural risks and the coordination of supply chain is poor, This paper constructs the supply chain profit model under the two models of natural risk and agricultural insurance, Firstly, studying the coordination function of the supply chain system under Two-part Tariff; Then discussing the setting and claiming mechanism of agricultural insurance, compares the influence of agricultural insurance on supply chain profit and supply chain coordination; Finally, giving an example to validate the model results and give decision - making opinions. Research shows that the supply chain of fresh agricultural products can coordinated under Two-part Tariff, but the supply chain cooperation is poor in the natural risk , need to further stabilize and optimize the supply chain; When the risk factor is less than the non-participation insurance coefficient, not to participate in agricultural insurance is conducive to maintaining the coordination of the supply chain system; When the risk coefficient exceeds the non-participation insurance coefficient, the introduction of agricultural insurance can not only effectively manage the natural risks, but also help to improve the coordination of the supply chain system.

  8. Identifying health insurance predictors and the main reported reasons for being uninsured among US immigrants by legal authorization status.

    Science.gov (United States)

    Vargas Bustamante, Arturo; Chen, Jie; Fang, Hai; Rizzo, John A; Ortega, Alexander N

    2014-01-01

    This study identifies differences in health insurance predictors and investigates the main reported reasons for lacking health insurance coverage between short-stayed (≤ 10 years) and long-stayed (>10 years) US immigrant adults to parse the possible consequences of the Affordable Care Act among immigrants by length of stay and documentation status. Foreign-born adults (18-64 years of age) from the 2009 California Health Interview Survey are the study population. Health insurance coverage predictors and the main reasons for being uninsured are compared across cohorts and by documentation status. A logistic-regression two-part multivariate model is used to adjust for confounding factors. The analyses determine that legal status is a strong health insurance predictor, particularly among long-stayed undocumented immigrants. Immigration status is the main reported reason for lacking health insurance. Although long-stayed documented immigrants are likely to benefit from the Affordable Care Act implementation, undocumented immigrants and short-stayed documented immigrants may encounter difficulties getting health insurance coverage. Copyright © 2013 John Wiley & Sons, Ltd.

  9. 24 CFR 266.634 - Reinstatement of the contract of insurance.

    Science.gov (United States)

    2010-04-01

    ... insurance. (c) Payment. Within 30 days of the date of the notice under paragraph (b) of this section, the HFA shall pay HUD an amount equal to the initial claim amount, as determined under § 266.628(a)(1), plus an amount equal to the accrued and unpaid interest on the HFA Debenture through the reinstatement...

  10. PV electrofinance: A proposed product for insurers in a deregulated electric market

    International Nuclear Information System (INIS)

    Gordes, J.N.; Leggett, J.

    1999-01-01

    The thesis that global climate change could disrupt world-wide weather patterns is not new but the potential losses it represents have drawn attention from the financial community--particularly property-casualty insurers who are subject to large damage claims if climate change occurs. With the deregulation of the electricity sector, the specter of climate change can be transformed from a threat into an exciting opportunity for insurers, bankers and other financiers who have the need, foresight and capacity to invest in energy conservation and photovoltaics as mitigation strategies

  11. Insurance billing and coding.

    Science.gov (United States)

    Napier, Rebecca H; Bruelheide, Lori S; Demann, Eric T K; Haug, Richard H

    2008-07-01

    The purpose of this article is to highlight the importance of understanding various numeric and alpha-numeric codes for accurately billing dental and medically related services to private pay or third-party insurance carriers. In the United States, common dental terminology (CDT) codes are most commonly used by dentists to submit claims, whereas current procedural terminology (CPT) and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD.9.CM) codes are more commonly used by physicians to bill for their services. The CPT and ICD.9.CM coding systems complement each other in that CPT codes provide the procedure and service information and ICD.9.CM codes provide the reason or rationale for a particular procedure or service. These codes are more commonly used for "medical necessity" determinations, and general dentists and specialists who routinely perform care, including trauma-related care, biopsies, and dental treatment as a result of or in anticipation of a cancer-related treatment, are likely to use these codes. Claim submissions for care provided can be completed electronically or by means of paper forms.

  12. Effect of health insurance on direct hospitalisation costs for in-patients with ischaemic stroke in China.

    Science.gov (United States)

    Yong, Ma; Xianjun, Xiong; Jinghu, Li; Yunyun, Fang

    2018-02-01

    Objectives The aim of the present study was to determine the direct medical costs of hospitalisations for ischaemic stroke (IS) in-patients with different types of health insurance in China and to analyse the demographic characteristics of hospitalised patients, based on data supplied by the China Health Insurance Research Association (CHIRA). Methods A nationwide and cross-sectional sample of IS in-patients with International Classifications of Diseases 10th Revision (ICD-10) Code I63 who were ensured under either the Basic Medical Insurance Scheme for Employees (BMISE) or the Basic Medical Insurance Scheme for Urban Residents (BMISUR) was extracted from the CHIRA claims database. A retrospective analysis was used with regard to patient demographics, total hospital charges and costs. Results Of the 49588 hospitalised patients who had been diagnosed with IS in the CHIRA claims database, 28850 (58.2%) were men (mean age 67.34 years) and 20738 (41.8%) were women (mean age 69.75 years). Of all patients, 40347 (81.4%) were insured by the BMISE, whereas 8724 (17.6%) were insured by the BMISUR; the mean age of these groups was 68.55 and 67.62 years respectively. For BMISE-insured in-patients, the cost per hospitalisation was RMB10131 (95% confidence interval (CI) 10014-10258), the cost per hospital day was RMB787 (95% CI 766-808), the out-of-pocket costs per patient were RMB2346 (95% CI 2303-2388) and the reimbursement rate was 74.61% (95% CI 74.48-74.73%). For BMISUR-insured in-patients the cost per hospitalisation was RMB7662 (95% CI 7473-7852), the cost per hospital day was RMB744 (95% CI 706-781), the out-of-pocket costs per patient were RMB3356 (95% CI 3258-3454) and the reimbursement rate was 56.46% (95% CI 56.08-56.84%). Conclusions Costs per hospitalisation, costs per hospital day and the reimbursement rate were higher for BMISE- than BMISUR-insured in-patients, but BMISE-insured patients had lower out-of-pocket costs. The financial burden was higher for BMISUR

  13. The economic crisis and the insurance industry: The evidence from the ex-Yugoslavia region

    Directory of Open Access Journals (Sweden)

    Njegomir Vladimir

    2010-01-01

    Full Text Available The paper analyses the impact of the economic crisis on the insurance industries of the ex-Yugoslavia region. The analysis encompasses five countries: Slovenia, Croatia, Serbia, Bosnia and Herzegovina, and FYR Macedonia. We examine insurance industry specifics separately for each country for the period 2004-2008 and for the first six months of 2009. While the impact of the crisis varies between countries, the research results indicate that the global financial crisis has had limited overall impact on the regional insurance industry. However the current recession resulted in negative premium growth in Serbia, Croatia and FYR Macedonia while the growth in Slovenia and Bosnia and Herzegovina declined. At the same time investment returns have declined and claims have risen in all countries. The crisis had more pronounced impact on non-life insurance premium growth in less developed insurance markets. In developed markets, namely Slovenia and Croatia, the crisis had greater impact on life insurance premium growth.

  14. FraudBuster: Reducing Fraud in an Auto Insurance Market.

    Science.gov (United States)

    Nagrecha, Saurabh; Johnson, Reid A; Chawla, Nitesh V

    2018-03-01

    Nonstandard insurers suffer from a peculiar variant of fraud wherein an overwhelming majority of claims have the semblance of fraud. We show that state-of-the-art fraud detection performs poorly when deployed at underwriting. Our proposed framework "FraudBuster" represents a new paradigm in predicting segments of fraud at underwriting in an interpretable and regulation compliant manner. We show that the most actionable and generalizable profile of fraud is represented by market segments with high confidence of fraud and high loss ratio. We show how these segments can be reported in terms of their constituent policy traits, expected loss ratios, support, and confidence of fraud. Overall, our predictive models successfully identify fraud with an area under the precision-recall curve of 0.63 and an f-1 score of 0.769.

  15. Frequent Users of Hospital Emergency Departments in Korea Characterized by Claims Data from the National Health Insurance: A Cross Sectional Study.

    Directory of Open Access Journals (Sweden)

    Jung Hoon Woo

    Full Text Available The Korean National Health Insurance, which provides universal coverage for the entire Korean population, is now facing financial instability. Frequent emergency department (ED users may represent a medically vulnerable population who could benefit from interventions that both improve care and lower costs. To understand the nature of frequent ED users in Korea, we analyzed claims data from a population-based national representative sample. We performed both bivariate and multivariable analyses to investigate the association between patient characteristics and frequent ED use (4+ ED visits in a year using claims data of a 1% random sample of the Korean population, collected in 2009. Among 156,246 total ED users, 4,835 (3.1% were frequent ED users. These patients accounted for 14% of 209,326 total ED visits and 17.2% of $76,253,784 total medical expenses generated from all ED visits in the 1% data sample. Frequent ED users tended to be older, male, and of lower socio-economic status compared with occasional ED users (p < 0.001 for each. Moreover, frequent ED users had longer stays in the hospital when admitted, higher probability of undergoing an operative procedure, and increased mortality. Among 8,425 primary diagnoses, alcohol-related complaints and schizophrenia showed the strongest positive correlation with the number of ED visits. Among the frequent ED users, mortality and annual outpatient department visits were significantly lower in the alcohol-related patient subgroup compared with other frequent ED users; furthermore, the rate was even lower than that for non-frequent ED users. Our findings suggest that expanding mental health and alcohol treatment programs may be a reasonable strategy to decrease the dependence of these patients on the ED.

  16. Second WCB claims: who is at risk?

    Science.gov (United States)

    Cherry, Nicola M; Sithole, Fortune; Beach, Jeremy R; Burstyn, Igor

    2010-01-01

    Many workers with one Workers' Compensation Board (WCB) claim make further claims. If the characteristics of the job, initial injury or worker were predictive of an early second claim, interventions at the time of return to work after the first claim might be effective in reducing the burden of work-related injury. This report explores the characteristic of those who make a second claim. Records of all Alberta WCB claims from January 1, 1995, to December 31, 2004, for individuals 18 to claim, sex and age of claimant, type of injury, type of accident, occupation, industry, an indicator of company size, and industry claim rate were extracted, as well as the date of any second claim. The likelihood of second claim and mean time to second claim were estimated. Multivariate analyses were performed using Cox regression. 1,047,828 claims were identified from 490,230 individuals. Of these, 49.2% had at least two claims. In the multivariate model a reduced time to second claim was associated with male sex, younger age and some types of injury and accident. Machining trades were at highest risk of early second claim (hazard ratio [HR] 2.54 compared with administration), and of the industry sectors manufacturing was at highest risk (HR 1.37 compared with business, personal and professional services). Some caution is needed in interpreting these data as they may be affected by under-reporting and job changes between claims. Nonetheless, they suggest that there remains room for interventions to reduce the considerable differences in risk of a second claim among workers, jobs and industries.

  17. Experiences obtaining insurance after live kidney donation.

    Science.gov (United States)

    Boyarsky, B J; Massie, A B; Alejo, J L; Van Arendonk, K J; Wildonger, S; Garonzik-Wang, J M; Montgomery, R A; Deshpande, N A; Muzaale, A D; Segev, D L

    2014-09-01

    The impact of kidney donation on the ability to change or initiate health or life insurance following donation is unknown. To quantify this risk, we surveyed 1046 individuals who donated a kidney at our center between 1970 and 2011. Participants were asked whether they changed or initiated health or life insurance after donation, and if they had any difficulty doing so. Among 395 donors who changed or initiated health insurance after donation, 27 (7%) reported difficulty; among those who reported difficulty, 15 were denied altogether, 12 were charged a higher premium and 8 were told they had a preexisting condition because they were kidney donors. Among 186 donors who changed or initiated life insurance after donation, 46 (25%) reported difficulty; among those who reported difficulty, 23 were denied altogether, 27 were charged a higher premium and 17 were told they had a preexisting condition because they were kidney donors. In this single-center study, a high proportion of kidney donors reported difficulty changing or initiating insurance, particularly life insurance. These practices by insurers create unnecessary burden and stress for those choosing to donate and could negatively impact the likelihood of live kidney donation among those considering donation. © Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons.

  18. Implementation of an Interorganizational System: The Case of Medical Insurance E-Clearance

    Science.gov (United States)

    Bose, Indranil; Liu, Han; Ye, Alex

    2012-01-01

    The patients receiving treatment from a hospital need to interact with multiple entities when claiming reimbursements. The complexities of the medical service supply chain can be simplified with an electronic clearance management system that allows hospitals, medical insurance bureau, bank, and patients to interact in a seamless and cashless…

  19. What new policies should South Africa's life insurance industry adopt?

    Science.gov (United States)

    Solomon, G

    1996-12-01

    By February 1996, the South African life insurance industry had paid out more than R75 million in AIDS-related claims. This situation requires imposition of controls that will make economic sense while reflecting the social responsibility of the insurance companies. AIDS mortality rates suggest that for each 10% of the infected insured population, the risk premium rates should increase 400%. Thus, without controls, the life insurance sector may collapse. While it has been charged that HIV testing associated with the provision of life insurance discriminates against infected individuals, failure to test compromises the rights of uninfected individuals in the individual assurance market. HIV test protocols can be used that protect applicants from false positive results, prevent fraud, and preserve confidentiality. Proposals to require five-year retesting have also been criticized but would protect the interests of uninfected individuals who want life insurance to remain affordable. In an innovative move, South Africa now includes "full-blown AIDS" among the list of "dreaded diseases" that trigger an immediate pay-out. While purchasing life insurance may fall low on the list of priorities of an infected person, demand continues, and two companies offer expensive products to those with Stage I and II disease. Medical insurance is also threatened by the increased costs associated with HIV/AIDS, and treatment protocols may be the only way to control medical expenses and assure the future of medical insurance. At this stage of the epidemic, no one seems prepared to meet their share of the costs associated with HIV/AIDS.

  20. Considerations for the analysis of longitudinal electronic health records linked to claims data to study the effectiveness and safety of drugs.

    Science.gov (United States)

    Lin, K J; Schneeweiss, S

    2016-08-01

    Health insurance claims and electronic health records (EHR) databases have been considered the preferred data sources with which to study drug safety and effectiveness in routine care. Linking claims data to EHR allows researchers to leverage the complementary advantages of each data source to enhance study validity. We propose a framework to evaluate the need for supplementing claims data with EHR and vice versa to optimize outcome ascertainment, exposure assessment, and confounding adjustment. © 2016 American Society for Clinical Pharmacology and Therapeutics.

  1. [Neurosis as a mental disease--controversies surrounding insurance certification].

    Science.gov (United States)

    Jabłoński, Christian; Kobek, Mariusz; Kowalczyk-Jabłońska, Dorota

    2011-01-01

    In the years 2008-2009, experts from the Department of Forensic Medicine in Katowice issued a dozen of expert opinions on the nature of the neurosis, addressing the question whether neurosis is a mental disease as understood under the general insurance conditions or whether neurosis is a mental disease as such. All the submitted cases involved policemen who had been diagnosed as neurotic and were refused insurance payments since the insurance company claimed payments could not have been effected due to the diagnosis of mental disease, meaning neurosis in the discussed cases. The plaintiffs invoked the fact that medical terminology describes such states as "mental disorders". In the article, the authors present the adopted model of opinionating, make an attempt at explaining the controversy and discuss the subtleties of medical terminology and the core differences between the terms "mental disorder" and "mental disease" as employed in medico-legal opinionating in such cases.

  2. Analysis of medication-related malpractice claims: causes, preventability, and costs.

    Science.gov (United States)

    Rothschild, Jeffrey M; Federico, Frank A; Gandhi, Tejal K; Kaushal, Rainu; Williams, Deborah H; Bates, David W

    2002-11-25

    Adverse drug events (ADEs) may lead to serious injury and may result in malpractice claims. While ADEs resulting in claims are not representative of all ADEs, such data provide a useful resource for studying ADEs. Therefore, we conducted a review of medication-related malpractice claims to study their frequency, nature, and costs and to assess the human factor failures associated with preventable ADEs. We also assessed the potential benefits of proved effective ADE prevention strategies on ADE claims prevention. We conducted a retrospective analysis of a New England malpractice insurance company claims records from January 1, 1990, to December 31, 1999. Cases were electronically screened for possible ADEs and followed up by independent review of abstracts by 2 physician reviewers (T.K.G. and R.K.). Additional in-depth claims file reviews identified potential human factor failures associated with ADEs. Adverse drug events represented 6.3% (129/2040) of claims. Adverse drug events were judged preventable in 73% (n = 94) of the cases and were nearly evenly divided between outpatient and inpatient settings. The most frequently involved medication classes were antibiotics, antidepressants or antipsychotics, cardiovascular drugs, and anticoagulants. Among these ADEs, 46% were life threatening or fatal. System deficiencies and performance errors were the most frequent cause of preventable ADEs. The mean costs of defending malpractice claims due to ADEs were comparable for nonpreventable inpatient and outpatient ADEs and preventable outpatient ADEs (mean, $64,700-74,200), but costs were considerably greater for preventable inpatient ADEs (mean, $376,500). Adverse drug events associated with malpractice claims were often severe, costly, and preventable, and about half occurred in outpatients. Many interventions could potentially have prevented ADEs, with error proofing and process standardization covering the greatest proportion of events.

  3. 7 CFR 457.121 - Arizona-California citrus crop insurance provisions.

    Science.gov (United States)

    2010-01-01

    ... quarantine, boycott, or refusal of any person to accept production. 10. Duties in the Event of Damage or Loss... insured acreage that you intend to abandon or no longer care for, if you and we agree on the appraised... agree with our appraisal, we may defer the claim only if you agree to continue to care for the crop. We...

  4. Income, Poverty, and Health Insurance Coverage in the United States: 2012. Current Population Reports P60-245

    Science.gov (United States)

    DeNavas-Walt, Carmen; Proctor, Bernadette D.; Smith, Jessica C.

    2013-01-01

    This report presents data on income, poverty, and health insurance coverage in the United States based on information collected in the 2013 and earlier Current Population Survey Annual Social and Economic Supplements (CPS ASEC) conducted by the U.S. Census Bureau. For most groups, the 2012 income, poverty, and health insurance estimates were not…

  5. Forecasting Fire Insurance Loss Ratio in Misr Insurance Company

    Directory of Open Access Journals (Sweden)

    Tarek TAHA

    2017-06-01

    Full Text Available Loss ratio is one of the most important indicator that has many strategic decisions applications, such as pricing, underwriting, investment, reinsurance and reserving decisions. It serves as an early warning of financial solvency of insurance companies and it can be judged on the strength of the financial position of these companies. The aim of this study is to identify the reliable time series-forecasting model to forecast loss ratio estimates of fire segment in Misr insurance company. Box-Jenkins Analysis is applied on actual reported loss ratios data for Misr insurance company for the period 1980/1981– 2013/2014. The study concludes that the best forecasting model is ARMA(1,1.

  6. PRICING AND ASSESSING UNIT-LINKED INSURANCE CONTRACTS WITH INVESTMENT GUARANTEES

    Directory of Open Access Journals (Sweden)

    Ciumas Cristina

    2014-07-01

    Full Text Available One of the most interesting life insurance products to have emerged in recent years in the Romanian insurance market has been the unit-linked contract. Unit-linked insurance products are life insurance policies with investment component. A unit-linked life insurance has two important components: protection and investment. The protection component refers to the insured sum in case of the occurrence of insured risks and the investment component refers to the policyholders’ account that represents the present value of the units from the chosen investment funds. Due to the financial instability caused by the Global Crisis and the amplification of market competitiveness, insurers from international markets have started to incorporate guarantees in unit-linked products. So a unit- linked life insurance policy with an asset value guarantee is an insurance policy whose benefit payable on death or at maturity consists of the greater of some guaranteed amount and the value of the units from the investment funds. One of the most challenging issues concerns the pricing of minimum death benefit and maturity benefit guarantees and the establishing of proper reserves for these guarantees. Insurers granting guarantees of this type must estimate the cost and include the cost in the premium. An important component of the activity carried out by the insurance companies is the investment of the premiums paid by policyholders in various types of assets, in order to obtain higher yields than those guaranteed by the insurance contracts, while providing the necessary liquidity for the payment of insurance claims in case of occurrence of the assumed risks. So the guaranteed benefits can be broadly matched or immunized with various types of financial assets, especially with fixed-interest instruments. According to Romanian legislation which regulates the unit-linked life insurance market, unit-linked life insurance contracts pass most of the investment risk to the

  7. Comparison of Swiss basic health insurance costs of complementary and conventional medicine.

    Science.gov (United States)

    Studer, Hans-Peter; Busato, André

    2011-01-01

    From 1999 to 2005, 5 methods of complementary and alternative medicine (CAM) applied by physicians were provisionally included into mandatory Swiss basic health insurance. Between 2012 and 2017, this will be the case again. Within this process, an evaluation of cost-effectiveness is required. The goal of this study is to compare practice costs of physicians applying CAM with those of physicians applying solely conventional medicine (COM). The study was designed as a cross-sectional investigation of claims data of mandatory health insurance. For the years 2002 and 2003, practice costs of 562 primary care physicians with and without a certificate for CAM were analyzed and compared with patient-reported outcomes. Linear models were used to obtain estimates of practice costs controlling for different patient populations and structural characteristics of practices across CAM and COM. Statistical procedures show similar total practice costs for CAM and COM, with the exception of homeopathy with 15.4% lower costs than COM. Furthermore, there were significant differences between CAM and COM in cost structure especially for the ratio between costs for consultations and costs for medication at the expense of basic health insurance. Patients reported better quality of the patient-physician relationship and fewer adverse side effects in CAM; higher cost-effectiveness for CAM can be deduced from this perspective. This study uses a health system perspective and demonstrates at least equal or better cost-effectiveness of CAM in the setting of Swiss ambulatory care. CAM can therefore be seen as a valid complement to COM within Swiss health care. Copyright © 2011 S. Karger AG, Basel.

  8. Brief biopsychosocially informed education can improve insurance workers? back pain beliefs: Implications for improving claims management behaviours

    OpenAIRE

    Beales, Darren; Mitchell, Tim; Pole, Naomi; Weir, James

    2016-01-01

    BACKGROUND: Biopsychosocially informed education is associated with improved back pain beliefs and positive changes in health care practitioners? practice behaviours. OBJECTIVE: Assess the effect of this type of education for insurance workers who are important non-clinical stakeholders in the rehabilitation of injured workers. METHODS: Insurance workers operating in the Western Australian workers? compensation system underwent two, 1.5 hour sessions of biopsychosocially informed education fo...

  9. Pattern of prophylaxis administration for chemotherapy-induced nausea and vomiting: an analysis of city-based health insurance data.

    Science.gov (United States)

    Nakamura, Fumiaki; Higashi, Takahiro

    2013-12-01

    Chemotherapy-induced nausea and vomiting (CINV) substantially affects patient quality of life. Although several guidelines have recommended the use of 5-hydroxytryptamine 3 (5HT3) receptor antagonists with glucocorticoids to alleviate acute CINV, studies in other countries have reported that these recommendations were often not followed. We aimed to assess antiemetic use in community practices just before the Japanese Guidelines for the Appropriate Use of Antiemetics were published. Using the insurance claims submitted to a public insurance program that covers residents up to 75 years old operated by a city with a population of 250,000, we examined the concurrent use of 5HT3 receptor antagonists and glucocorticoids with high or moderate emetic risk chemotherapy. Overall, 448 patients received high or moderate emetic risk chemotherapy 1,342 times during the study period. The recommended antiemetic therapy was provided in 61.9 % (95 % confidence interval 55.5-68.3 %) of the treated patients, but the moderate emetic risk chemotherapy group received the recommended antiemetic therapy less frequently than the high emetic risk chemotherapy group (55.5 vs. 82.1 %, P chemotherapy were associated with the recommended antiemetic therapy. Breast and lung cancer patients receiving high emetic risk chemotherapy received the recommended antiemetics in 100 % of cases, while only 67 % of patients with other cancer types received the recommended antiemetics. Despite several limitations associated with analysis of insurance claims, our study indicates that substantial room for improvement exists in the practice of preventing CINV.

  10. Interagency task force on the health effects of ionizing radiation: report of the work group on care and benefits

    International Nuclear Information System (INIS)

    1979-06-01

    The report examines existing systems for providing care and benefits to persons who may have been injured by radiation exposure and recommends additional guidelines for handling radiation-related claims. The benefits systems examined are Veterans' benefits, Federal Employees Compensation Act, Longshoremen's and Harbor Workers' Compensation Act, State Workers' Compensation programs, Government and private 'back-up' program, Social Security Disability Insurance (Medicare), Supplemental Security Income (Medicaid), private health insurance, government hospitals, and remedies available under the judicial system. The report recommends that the Federal Government develop guidelines to determine the likelihood of a causal relationship between a person's illness and his exposure to radiation; that Federal compensation programs and State programs develop criteria for deciding radiation exposure claims, based on those guidelines; that a national registry of radiation workers be established to maintain individual radiation exposure records; and that the Federal Government annually compile compensation claims based on radiation exposure. Appendixes list those groups of people most likely to be exposed to radiation, and the benefits available under the various compensation programs listed above

  11. Insurance of Radioisotopes and Ionizing Radiation Sources in France

    International Nuclear Information System (INIS)

    Stanislas, A.

    2008-01-01

    Since the early sixties, Assuratome has amassed quite a long experience in the insurance of radioisotopes and more generally of ionising radiation sources when they are used transported or stored outside a nuclear installation. Aware of the specific dangers of such devices, and having no experience in this domain French insurers were looking for a pragmatic solution which would permit to continue to provide cover for users or fabricants of small radioactive sources and in the meantime to keep a rigorous control on the claims and on the loss ratio which would be achieved over the years. Hence the decision was taken by the French Insurance market to entrust the French Nuclear Insurance Pool, Assuratome, as the recommended body for delivering specific 'nuclear policies' as an expert for this category of business. The next step was to make sure that the 'conventional policies' would not provide the same cover. Therefore, an appropriate exclusion clause was introduced in all the general conditions of the TPL Policies of the conventional market and consequently in the majority, if not all, the reinsurance treaties. Besides the obvious advantage resulting in the management of this category of business in a centralised body, a major benefit of this situation is based on the strict control by the insurer of the compulsory authorisation delivered by the authorities to the owner of the radioactive source. Unofficial sources having in principal no insurance possibilities in France their use would be virtually impossible.(author)

  12. Nuclear property insurance: status and outlook

    International Nuclear Information System (INIS)

    1982-05-01

    The report addresses the problem of the unavailability of adequate levels of property insurance for commercial power reactors to pay for decontamination and cleanup costs arising from accidents. The report is designed to answer six questions, as follows: (1) What has been the development of each principal source of nuclear property insurance used as of early 1982 by nuclear utilities in the United States; (2) What are some of the distinguishing features of nuclear property insurance as offered by the principal sources; (3) How much nuclear property insurance was offered by each of these sources as of January 1, 1982; (4) Assuming that present plans came to fruition, how much nuclear property insurance is likely to be offered by each of these sources as of January 1, 1983; (5) What, if any, principal sources of nuclear property insurance are likely to emerge in the private sector by January 1, 1983; (6) What problems serious enough to warrant action of the NRC exist with respect to nuclear property insurance and what action should NRC take in response to each problem

  13. The effect of the National Health Insurance Scheme (NHIS) on health service delivery in mission facilities in Ghana: a retrospective study.

    Science.gov (United States)

    Aryeetey, Genevieve Cecilia; Nonvignon, Justice; Amissah, Caroline; Buckle, Gilbert; Aikins, Moses

    2016-06-07

    In 2004, Ghana began implementation of a National Health Insurance Scheme (NHIS) to minimize out-of-pocket expenditure at the point of use of service. The implementation of the scheme was accompanied by increased access and use of health care services. Evidence suggests most health facilities are faced with management challenges in the delivery of services. The study aimed to assess the effect of the introduction of the NHIS on health service delivery in mission health facilities in Ghana. We conceptualised the effect of NHIS on facilities using service delivery indicators such as outpatient and inpatient turn out, estimation of general service readiness, revenue and expenditure, claims processing and availability of essential medicines. We collected data from 38 mission facilities, grouped into the three ecological zones; southern, middle and northern. Structured questionnaires and exit interviews were used to collect data for the periods 2003 and 2010. The data was analysed in SPSS and MS Excel. The facilities displayed high readiness to deliver services. There were significant increases in outpatient and inpatient attendance, revenue, expenditure and improved access to medicines. Generally, facilities reported increased readiness to deliver services. However, challenging issues around high rates of non-reimbursement of NHIS claims due to errors in claims processing, lack of feedback regarding errors, and lack of clarity on claims reporting procedures were reported. The implementation of the NHIS saw improvement and expansion of services resulting in benefits to the facilities as well as constraints. The constraints could be minimized if claims processing is improved at the facility level and delays in reimbursements also reduced.

  14. Distribution and characteristics of occupational injuries and diseases among farmers: a retrospective analysis of workers' compensation claims.

    Science.gov (United States)

    Karttunen, Janne P; Rautiainen, Risto H

    2013-08-01

    Research indicates occupational injuries and diseases are not evenly distributed among workers. We investigated the distribution and characteristics of compensated occupational injuries and diseases requiring medical care in the Finnish farming population. The study population consisted of 93,564 Finnish farmers, spouses, and salaried family members who were covered by the mandatory workers' compensation insurance in 2002. This population had a total of 133,207 occupational injuries and 9,148 occupational diseases over a 26-year period (1982-2008). Clustering of claims was observed. Nearly half (47.1%) of the population had no compensated claims while 52.9% had at least one; 50.9% of farmers had one or more injuries and 8.1% had one or more diseases. Ten percent of the population had half of injury cases, and 3% of the population had half of occupational disease cases. Claims frequently involved work tasks related to animal husbandry and repair and maintenance of farm machinery. Injury and disease characteristics (work activity, cause, ICD-10 code) differed between individuals with high and low personal claim rate. Injuries and diseases of the musculoskeletal system had a tendency to reoccur among those with high claim rate. These outcomes were often related to strenuous working motions and postures in labor-intensive animal husbandry. Analyses of longitudinal insurance data contributes to better understanding of the long-term risk of occupational injury and disease among farmers. We suggest focusing on recurrent health outcomes and their causes among high risk populations could help design more effective interventions in agriculture and other industries. Copyright © 2013 Wiley Periodicals, Inc.

  15. The Effects of Health Shocks on Employment and Health Insurance: The Role of Employer-Provided Health Insurance

    Science.gov (United States)

    Bradley, Cathy J.; Neumark, David; Motika, Meryl

    2012-01-01

    Background Employment-contingent health insurance (ECHI) has been criticized for tying insurance to continued employment. Our research sheds light on two central issues regarding employment-contingent health insurance: whether such insurance “locks” people who experience a health shock into remaining at work; and whether it puts people at risk for insurance loss upon the onset of illness, because health shocks pose challenges to continued employment. Objective To determine how men’s dependence on their own employer for health insurance affects labor supply responses and health insurance coverage following a health shock. Data Sources We use the Health and Retirement Study (HRS) surveys from 1996 through 2008 to observe employment and health insurance status at interviews two years apart, and whether a health shock occurred in the intervening period between the interviews. Study Selection All employed married men with health insurance either through their own employer or their spouse’s employer, interviewed in at least two consecutive HRS waves with non-missing data on employment, insurance, health, demographic, and other variables, and under age 64 at the second interview. We limited the sample to men who were initially healthy. Data Extraction Our analytical sample consisted of 1,582 men of whom 1,379 had ECHI at the first interview, while 203 were covered by their spouse’s employer. Hospitalization affected 209 men with ECHI and 36 men with spouse insurance. A new disease diagnosis was reported by 103 men with ECHI and 22 men with other insurance. There were 171 men with ECHI and 25 men with spouse employer insurance who had a self-reported health decline. Data Synthesis Labor supply response differences associated with ECHI – with men with health shocks and ECHI more likely to continue working – appear to be driven by specific types of health shocks associated with future higher health care costs but not with immediate increases in morbidity that

  16. Court rejects claim of mental illness from needlestick.

    Science.gov (United States)

    1998-05-29

    The Montana Supreme Court rejected the bid of a medical technician to remain on workers' compensation, based on his claims that he suffered from psychosis, depression, and hallucinations after pricking himself with a needle used on an HIV-positive patient. [Name removed], a respiratory therapist at Community Medical Center in Missoula, tested negative for HIV, but claimed that the psychological trauma from the needlestick injury caused him to become disabled. Based on expert testimony, the Workers' Compensation Court determined that [name removed] was faking his symptoms to collect benefits from his employer's insurer, EBI/Orion Group. [Name removed] appealed, and the Supreme Court remanded the case, stating that psychologists are not included among the medical professionals able to conduct medical reviews. The Workers' Compensation Court again found that [name removed] was faking his symptoms, and [name removed] unsuccessfully appealed. The compensation panel cited conflicting evidence from psychological tests, [name removed]'s friends' testimonies, and [name removed]'s personal diary. The Supreme Court upheld the verdict.

  17. Linked Patient-Reported Outcomes Data From Patients With Multiple Sclerosis Recruited on an Open Internet Platform to Health Care Claims Databases Identifies a Representative Population for Real-Life Data Analysis in Multiple Sclerosis.

    Science.gov (United States)

    Risson, Valery; Ghodge, Bhaskar; Bonzani, Ian C; Korn, Jonathan R; Medin, Jennie; Saraykar, Tanmay; Sengupta, Souvik; Saini, Deepanshu; Olson, Melvin

    2016-09-22

    An enormous amount of information relevant to public health is being generated directly by online communities. To explore the feasibility of creating a dataset that links patient-reported outcomes data, from a Web-based survey of US patients with multiple sclerosis (MS) recruited on open Internet platforms, to health care utilization information from health care claims databases. The dataset was generated by linkage analysis to a broader MS population in the United States using both pharmacy and medical claims data sources. US Facebook users with an interest in MS were alerted to a patient-reported survey by targeted advertisements. Eligibility criteria were diagnosis of MS by a specialist (primary progressive, relapsing-remitting, or secondary progressive), ≥12-month history of disease, age 18-65 years, and commercial health insurance. Participants completed a questionnaire including data on demographic and disease characteristics, current and earlier therapies, relapses, disability, health-related quality of life, and employment status and productivity. A unique anonymous profile was generated for each survey respondent. Each anonymous profile was linked to a number of medical and pharmacy claims datasets in the United States. Linkage rates were assessed and survey respondents' representativeness was evaluated based on differences in the distribution of characteristics between the linked survey population and the general MS population in the claims databases. The advertisement was placed on 1,063,973 Facebook users' pages generating 68,674 clicks, 3719 survey attempts, and 651 successfully completed surveys, of which 440 could be linked to any of the claims databases for 2014 or 2015 (67.6% linkage rate). Overall, no significant differences were found between patients who were linked and not linked for educational status, ethnicity, current or prior disease-modifying therapy (DMT) treatment, or presence of a relapse in the last 12 months. The frequencies of the

  18. Report: Passaic Valley Sewerage Commissioners – Unallowable Costs Claimed Under EPA Grant XP98237601

    Science.gov (United States)

    Report #08-2-0226, August 6, 2008. The grantee claimed $2,385,634 for pre-award costs under Grant XP98237601 that were incurred prior to the grant award and thus were unallowable under the grant administrative conditions and OMB Circular A-87.

  19. Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: current experiences and challenges.

    Science.gov (United States)

    Ranson, Michael Kent

    2002-01-01

    To assess the Self Employed Women's Association's Medical Insurance Fund in Gujarat in terms of insurance coverage according to income groups, protection of claimants from costs of hospitalization, time between discharge and reimbursement, and frequency of use. One thousand nine hundred and thirty claims submitted over six years were analysed. Two hundred and fifteen (11%) of 1927 claims were rejected. The mean household income of claimants was significantly lower than that of the general population. The percentage of households below the poverty line was similar for claimants and the general population. One thousand seven hundred and twelve (1712) claims were reimbursed: 805 (47%) fully and 907 (53%) at a mean reimbursement rate of 55.6%. Reimbursement more than halved the percentage of catastrophic hospitalizations (>10% of annual household income) and hospitalizations resulting in impoverishment. The average time between discharge and reimbursement was four months. The frequency of submission of claims was low (18.0/1000 members per year: 22-37% of the estimated frequency of hospitalization). The findings have implications for community-based health insurance schemes in India and elsewhere. Such schemes can protect poor households against the uncertain risk of medical expenses. They can be implemented in areas where institutional capacity is too weak to organize nationwide risk-pooling. Such schemes can cover poor people, including people and households below the poverty line. A trade off exists between maintaining the scheme's financial viability and protecting members against catastrophic expenditures. To facilitate reimbursement, administration, particularly processing of claims, should happen near claimants. Fine-tuning the design of a scheme is an ongoing process - a system of monitoring and evaluation is vital.

  20. Workplace Injuries in Thoroughbred Racing: An Analysis of Insurance Payments and Injuries amongst Jockeys in Australia from 2002 to 2010

    Directory of Open Access Journals (Sweden)

    Beverley A. Curry

    2015-09-01

    Full Text Available Background: There is no comprehensive study of the costs of horse-related workplace injuries to Australian Thoroughbred racing jockeys. Objectives: To analyse the characteristics of insurance payments and horse-related workplace injuries to Australian jockeys during Thoroughbred racing or training. Methods: Insurance payments to Australian jockeys and apprentice jockeys as a result of claims for injury were reviewed. The cause and nature of injuries, and the breakdown of payments associated with claims were described. Results: The incidence of claims was 2.1/1000 race rides, with an average cost of AUD 9 million/year. Race-day incidents were associated with 39% of claims, but 52% of the total cost. The mean cost of race-day incidents (AUD 33,756 was higher than non-race day incidents (AUD 20,338. Weekly benefits and medical expenses made up the majority of costs of claims. Fractures were the most common injury (29.5%, but head injuries resulting from a fall from a horse had the highest mean cost/claim (AUD 127,127. Conclusions: Costs of workplace injuries to the Australian Thoroughbred racing industry have been greatly underestimated because the focus has historically been on incidents that occur on race-days. These findings add to the evidence base for developing strategies to reduce injuries and their associated costs.

  1. Correlations between rainfall data and insurance damage data related to sewer flooding for the case of Aarhus, Denmark

    DEFF Research Database (Denmark)

    Spekkers, Matthieu; Zhou, Qianqian; Arnbjerg-Nielsen, Karsten

    Sewer flooding due to extreme rainfall may result in considerable damage. Damage data to quantify costs of cleaning, drying, and replacing materials and goods are rare in literature. In this study, insurance claim data related to property damages were analysed for the municipality of Aarhus...... to underestimations of correlations between rainfall and damage variables. Rainfall data from two rain gauges were used to extract rainfall characteristics. From cross correlations between time series of rainfall and claim data, it can be concluded that rainfall events induce claims mostly on the same day, but also...

  2. Professional liability insurance in Obstetrics and Gynaecology: estimate of the level of knowledge about malpractice insurance policies and definition of an informative tool for the management of the professional activity

    Directory of Open Access Journals (Sweden)

    Scurria Serena

    2011-12-01

    Full Text Available Abstract Background In recent years, due to the increasingly hostile environment in the medical malpractice field and related lawsuits in Italy, physicians began informing themselves regarding their comprehensive medical malpractice coverage. Methods In order to estimate the level of knowledge of medical professionals on liability insurance coverage for healthcare malpractice, a sample of 60 hospital health professionals of the obstetrics and gynaecology area of Messina (Sicily, Italy were recluted. A survey was administered to evaluate their knowledge as to the meaning of professional liability insurance coverage but above all on the most frequent policy forms ("loss occurrence", "claims made" and "I-II risk". Professionals were classified according to age and professional title and descriptive statistics were calculated for all the professional groups and answers. Results Most of the surveyed professionals were unaware or had very bad knowledge of the professional liability insurance coverage negotiated by the general manager, so most of the personnel believed it useful to subscribe individual "private" policies. Several subjects declared they were aware of the possibility of obtaining an extended coverage for gross negligence and substantially all the surveyed had never seen the loss occurrence and claims made form of the policy. Moreover, the sample was practically unaware of the related issues about insurance coverage for damages related to breaches on informed consent. The results revealed the relative lack of knowledge--among the operators in the field of obstetrics and gynaecology--of the effective coverage provided by the policies signed by the hospital managers for damages in medical malpractice. The authors thus proposed a useful information tool to help professionals working in obstetrics and gynaecology regarding aspects of insurance coverage provided on the basis of Italian civil law. Conclusion Italy must introduce a compulsory

  3. Efficacy of insurance for organisational disaster recovery: case study of the 2010 and 2011 Canterbury earthquakes.

    Science.gov (United States)

    Brown, Charlotte; Seville, Erica; Vargo, John

    2017-04-01

    Insurance is widely acknowledged to be an important component of an organisation's disaster preparedness and resilience. Yet, little analysis exists of how well current commercial insurance policies and practices support organisational recovery in the wake of a major disaster. This exploratory qualitative research, supported by some quantitative survey data, evaluated the efficacy of commercial insurance following the sequence of earthquakes in Canterbury, New Zealand, in 2010 and 2011. The study found that, generally, the commercial insurance sector performed adequately, given the complexity of the events. However, there are a number of ways in which insurers could improve their operations to increase the efficacy of commercial insurance cover and to assist organisational recovery following a disaster. The most notable of these are: (i) better wording of policies; (ii) the availability of sector-specific policies; (iii) the enhancement of claims assessment systems; and (iv) risk-based policy pricing to incentivise risk reduction measures. © 2017 The Author(s). Disasters © Overseas Development Institute, 2017.

  4. Optimal Reinsurance-Investment Problem for an Insurer and a Reinsurer with Jump-Diffusion Process

    Directory of Open Access Journals (Sweden)

    Hanlei Hu

    2018-01-01

    Full Text Available The optimal reinsurance-investment strategies considering the interests of both the insurer and reinsurer are investigated. The surplus process is assumed to follow a jump-diffusion process and the insurer is permitted to purchase proportional reinsurance from the reinsurer. Applying dynamic programming approach and dual theory, the corresponding Hamilton-Jacobi-Bellman equations are derived and the optimal strategies for exponential utility function are obtained. In addition, several sensitivity analyses and numerical illustrations in the case with exponential claiming distributions are presented to analyze the effects of parameters about the optimal strategies.

  5. Psychiatric inpatient expenditures and public health insurance programmes: analysis of a national database covering the entire South Korean population

    Directory of Open Access Journals (Sweden)

    Chung Woojin

    2010-09-01

    Full Text Available Abstract Background Medical spending on psychiatric hospitalization has been reported to impose a tremendous socio-economic burden on many developed countries with public health insurance programmes. However, there has been no in-depth study of the factors affecting psychiatric inpatient medical expenditures and differentiated these factors across different types of public health insurance programmes. In view of this, this study attempted to explore factors affecting medical expenditures for psychiatric inpatients between two public health insurance programmes covering the entire South Korean population: National Health Insurance (NHI and National Medical Care Aid (AID. Methods This retrospective, cross-sectional study used a nationwide, population-based reimbursement claims dataset consisting of 1,131,346 claims of all 160,465 citizens institutionalized due to psychiatric diagnosis between January 2005 and June 2006 in South Korea. To adjust for possible correlation of patients characteristics within the same medical institution and a non-linearity structure, a Box-Cox transformed, multilevel regression analysis was performed. Results Compared with inpatients 19 years old or younger, the medical expenditures of inpatients between 50 and 64 years old were 10% higher among NHI beneficiaries but 40% higher among AID beneficiaries. Males showed higher medical expenditures than did females. Expenditures on inpatients with schizophrenia as compared to expenditures on those with neurotic disorders were 120% higher among NHI beneficiaries but 83% higher among AID beneficiaries. Expenditures on inpatients of psychiatric hospitals were greater on average than expenditures on inpatients of general hospitals. Among AID beneficiaries, institutions owned by private groups treated inpatients with 32% higher costs than did government institutions. Among NHI beneficiaries, inpatients medical expenditures were positively associated with the proportion of

  6. Utilization and Costs of Compounded Medications for Commercially Insured Patients, 2012-2013.

    Science.gov (United States)

    McPherson, Timothy; Fontane, Patrick; Iyengar, Reethi; Henderson, Rochelle

    2016-02-01

    Although compounding has a long-standing tradition in clinical practice, insurers and pharmacy benefit managers have instituted policies to decrease claims for compounded medications, citing questions about their safety, efficacy, high costs, and lack of FDA approval. There are no reliable published data on the extent of compounding by community pharmacists nor on the fraction of patients who use compounded medications. Prior research suggests that compounded medications represent a relatively small proportion of prescription medications, but those surveys were limited by small sample sizes, subjective data collection methods, and low response rates. To determine the number of claims for compounded medications on a per user per year (PUPY) basis and the average ingredient cost of these claims among commercially insured patients in the United States for 2012 and 2013. This study used prescription claims data from a nationally representative sample of commercially insured members whose pharmacy benefits were managed by a large pharmacy benefit management company. A retrospective claims analysis was conducted from January 1, 2012, through December 31, 2013. Annualized prevalence, cost, and utilization estimates were drawn from the data. All prescription claims were adjusted to 30-day equivalents. Data-mining techniques (association rule mining) were employed in order to identify the most commonly combined ingredients in compounded medications. The prevalence of compound users was 1.1% (245,285) of eligible members in 2012 and 1.4% (323,501) in 2013, an increase of 27.3%. Approximately 66% of compound users were female, and the average age of a compound user was approximately 42 years throughout the study period. The geographic distribution of compound user prevalence was consistent across the United States. Compound users' prescription claims increased 36.6% from 2012 to 2013, from approximately 7.1 million to approximately 9.7 million prescriptions. The number of

  7. Development of an electronic claim system based on an integrated electronic health record platform to guarantee interoperability.

    Science.gov (United States)

    Kim, Hwa Sun; Cho, Hune; Lee, In Keun

    2011-06-01

    We design and develop an electronic claim system based on an integrated electronic health record (EHR) platform. This system is designed to be used for ambulatory care by office-based physicians in the United States. This is achieved by integrating various medical standard technologies for interoperability between heterogeneous information systems. The developed system serves as a simple clinical data repository, it automatically fills out the Centers for Medicare and Medicaid Services (CMS)-1500 form based on information regarding the patients and physicians' clinical activities. It supports electronic insurance claims by creating reimbursement charges. It also contains an HL7 interface engine to exchange clinical messages between heterogeneous devices. The system partially prevents physician malpractice by suggesting proper treatments according to patient diagnoses and supports physicians by easily preparing documents for reimbursement and submitting claim documents to insurance organizations electronically, without additional effort by the user. To show the usability of the developed system, we performed an experiment that compares the time spent filling out the CMS-1500 form directly and time required create electronic claim data using the developed system. From the experimental results, we conclude that the system could save considerable time for physicians in making claim documents. The developed system might be particularly useful for those who need a reimbursement-specialized EHR system, even though the proposed system does not completely satisfy all criteria requested by the CMS and Office of the National Coordinator for Health Information Technology (ONC). This is because the criteria are not sufficient but necessary condition for the implementation of EHR systems. The system will be upgraded continuously to implement the criteria and to offer more stable and transparent transmission of electronic claim data.

  8. Using Medicaid and CHIP claims data to support pediatric quality measurement: lessons from 3 centers of excellence in measure development.

    Science.gov (United States)

    Gidengil, Courtney; Mangione-Smith, Rita; Bailey, L Charles; Cawthon, Mary Lawrence; McGlynn, Elizabeth A; Nakamura, Mari M; Schiff, Jeffrey; Schuster, Mark A; Schneider, Eric C

    2014-01-01

    We sought to explore the claims data-related issues relevant to quality measure development for Medicaid and the Children's Health Insurance Program (CHIP), illustrating the challenges encountered and solutions developed around 3 distinct performance measure topics: care coordination for children with complex needs, quality of care for high-prevalence conditions, and hospital readmissions. Each of 3 centers of excellence presents an example that illustrates the challenges of using claims data for quality measurement. Our Centers of Excellence in pediatric quality measurement used innovative methods to develop algorithms that use Medicaid claims data to identify children with complex needs; overcome some shortcomings of existing data for measuring quality of care for common conditions such as otitis media; and identify readmissions after hospitalizations for lower respiratory infections. Our experience constructing quality measure specifications using claims data suggests that it will be challenging to measure key quality of care constructs for Medicaid-insured children at a national level in a timely and consistent way. Without better data to underpin pediatric quality measurement, Medicaid and CHIP will have difficulty using some existing measures for accountability, value-based purchasing, and quality improvement both across states and within states. Copyright © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

  9. Myths and memes about single-payer health insurance in the United States: a rebuttal to conservative claims.

    Science.gov (United States)

    Geyman, John P

    2005-01-01

    Recent years have seen the rapid growth of private think tanks within the neoconservative movement that conduct "policy research" biased to their own agenda. This article provides an evidence-based rebuttal to a 2002 report by one such think tank, the Dallas-based National Center for Policy Analysis (NCPA), which was intended to discredit 20 alleged myths about single-payer national health insurance as a policy option for the United States. Eleven "myths" are rebutted under eight categories: access, cost containment, quality, efficiency, single-payer as solution, control of drug prices, ability to compete abroad (the "business case"), and public support for a single-payer system. Six memes (self-replicating ideas that are promulgated without regard to their merits) are identified in the NCPA report. Myths and memes should have no place in the national debate now underway over the future of a failing health care system, and need to be recognized as such and countered by experience and unbiased evidence.

  10. Diabetes diagnosis and management among insured adults across metropolitan areas in the U.S.

    Directory of Open Access Journals (Sweden)

    Wenya Yang

    2018-06-01

    Full Text Available This study provides diabetes-related metrics for the 50 largest metropolitan areas in the U.S. in 2012—including prevalence of diagnosed and undiagnosed diabetes, insurance status of the population with diabetes, diabetes medication use, and prevalence of poorly controlled diabetes.Diabetes prevalence estimates were calculated using cross-sectional data combining the Behavioral Risk Factor Surveillance System, American Community Survey, National Nursing Home Survey, Census population files, and National Health and Nutrition Examination Survey. Analysis of medical claims files (2012 de-identified Normative Health Information database, 2011 Medicare Standard Analytical Files, and 2008 Medicaid Analytic eXtract produced information on treatment and poorly controlled diabetes by geographic location, insurance type, sex, and age group.Among insured adults with diagnosed type 2 diabetes in 2012, the proportion receiving diabetes medications ranged from 83% in Oklahoma City, Oklahoma, to 65% in West Palm Beach, Florida. The proportion of treated patients with medical claims indicating poorly controlled diabetes was lowest in Minneapolis, Minnesota (36% and highest in Texas metropolitan areas of Austin (51%, San Antonio (51%, and Houston (50%.Estimates of diabetes detection and management across metropolitan areas often differ from state and national estimates. Local metrics of diabetes management can be helpful for tracking improvements in communities over time. Keywords: Diabetes, Management

  11. Dystocia in the cat evaluated using an insurance database.

    Science.gov (United States)

    Holst, Bodil Ström; Axnér, Eva; Öhlund, Malin; Möller, Lotta; Egenvall, Agneta

    2017-01-01

    Objectives The aim of this study was to describe the incidence of feline dystocia with respect to breed. Methods The data used were reimbursed claims for veterinary care insurance and/or life insurance claims in cats registered in a Swedish insurance database from 1999-2006. Results The incidence rates for dystocia were about 22 cats per 10,000 cat-years at risk, 67 per 10,000 for purebred cats and seven per 10,000 for domestic shorthair cats. The median age was 2.5 years. A significant effect of breed was seen. An incidence rate ratio (IRR) that was significantly higher compared with other purebred cats was seen in the British Shorthair (IRR 2.5), the Oriental group (IRR 2.2), Birman (IRR 1.7), Ragdoll (IRR 1.5) and the Abyssinian group (IRR 1.5). A significantly lower IRR was seen in the Norwegian Forest Cat (IRR 0.38), the Maine Coon (IRR 0.48), the Persian/Exotic group (IRR 0.49) and the Cornish Rex (IRR 0.50). No common factor among the high-risk breeds explained their high risk for dystocia. There was no effect of location; that is, the incidence rate did not differ depending on whether the cat lived in an urban or rural area. Caesarean section was performed in 56% of the cats with dystocia, and the case fatality was 2%. Conclusions and relevance The incidence rate for dystocia was of a similar magnitude in purebred cats as in dogs. The IRR varied significantly among breeds, and the main cause for dystocia should be identified separately for each breed. A selection for easy parturitions in breeding programmes is suggested.

  12. Operator-related aspects in endodontic malpractice claims in Finland.

    Science.gov (United States)

    Vehkalahti, Miira M; Swanljung, Outi

    2017-04-01

    We analyzed operator-related differences in endodontic malpractice claims in Finland. Data comprised the endodontic malpractice claims handled at the Patient Insurance Centre (PIC) in 2002-2006 and 2011-2013. Two dental advisors at the PIC scrutinized the original documents of the cases (n = 1271). The case-related information included patient's age and gender, type of tooth, presence of radiographs, and methods of instrumentation and apex location. As injuries, we recorded broken instrument, perforation, injuries due to root canal irrigants/medicaments, and miscellaneous injuries. We categorized the injuries according to the PIC decisions as avoidable, unavoidable, or no injury. Operator-related information included dentist's age, gender, specialization, and service sector. We assessed level of patient documentation as adequate, moderate, or poor. Chi-squared tests, t-tests, and logistic regression modelling served in statistical analyses. Patients' mean age was 44.7 (range 8-85) years, and 71% were women. The private sector constituted 54% of claim cases. Younger patients, female dentists, and general practitioners predominated in the public sector. We found no sector differences in patients' gender, dentists' age, or type of injured tooth. PIC advisors confirmed no injury in 24% of claim cases; the advisors considered 65% of injury cases (n = 970) as avoidable and 35% as unavoidable. We found no operator-related differences in these figures. Working methods differed by operator's age and gender. Adequate patient documentation predominated in the public sector and among female, younger, or specialized dentists. Operator-related factors had no impact on endodontic malpractice claims.

  13. HEALTH INFO SANTÉ – REMINDER ANNUAL DEDUCTIBLE AND REIMBURSEMENT CLAIMS HINTS FOR USE

    CERN Multimedia

    CHIS Board

    2000-01-01

    Information from the CHIS Board and the Human Resources Division:Annual deductible and reimbursement claims: hints for useOne should bear in mind that the annual deductible is an amount (currently CHF 100) charged automatically by the Administrator of the scheme for every adult aged 18 and above. This is what happens: The amount is deducted annually for all medical services received over a calendar year.It is triggered by the date of the treatment and neither by the date of the bill nor that of the reimbursement claim.In other words, if you receive medical treatment in December for the first time in a given year, the CHF 100 will be deducted from the claim for that treatment. So, except for urgent cases, it would be better to wait till the following month, thus avoiding one annual deductible.It is also worth remembering that the cost of processing our reimbursement claims - and there were 54, 000 in 1999 - is part of the cost of our insurance.Help keep administrative costs down: do not submit reimbursement cl...

  14. Amendment of liability and financial security under atomic energy law. Position of the insurers

    International Nuclear Information System (INIS)

    Boetius, J.

    1991-01-01

    Since Chernobyl in 1986, there have also been intensive activities in the insurance business in reviewing the legal framework conditions in terms of there consequences for a possible settlement of claims and in dealing with the question whether the old organizational rulings can still be considered sufficient in the light of the aforementioned disaster that has occured. This leads to the deliberations on a legal canalization of liability, on third party liability, financial security, indemnification by the state, damages through precautionary measures (evacuation) and organisation of the settlement of claims. (orig./HSCH) [de

  15. Dynamical insurance models with investment: Constrained singular problems for integrodifferential equations

    Science.gov (United States)

    Belkina, T. A.; Konyukhova, N. B.; Kurochkin, S. V.

    2016-01-01

    Previous and new results are used to compare two mathematical insurance models with identical insurance company strategies in a financial market, namely, when the entire current surplus or its constant fraction is invested in risky assets (stocks), while the rest of the surplus is invested in a risk-free asset (bank account). Model I is the classical Cramér-Lundberg risk model with an exponential claim size distribution. Model II is a modification of the classical risk model (risk process with stochastic premiums) with exponential distributions of claim and premium sizes. For the survival probability of an insurance company over infinite time (as a function of its initial surplus), there arise singular problems for second-order linear integrodifferential equations (IDEs) defined on a semiinfinite interval and having nonintegrable singularities at zero: model I leads to a singular constrained initial value problem for an IDE with a Volterra integral operator, while II model leads to a more complicated nonlocal constrained problem for an IDE with a non-Volterra integral operator. A brief overview of previous results for these two problems depending on several positive parameters is given, and new results are presented. Additional results are concerned with the formulation, analysis, and numerical study of "degenerate" problems for both models, i.e., problems in which some of the IDE parameters vanish; moreover, passages to the limit with respect to the parameters through which we proceed from the original problems to the degenerate ones are singular for small and/or large argument values. Such problems are of mathematical and practical interest in themselves. Along with insurance models without investment, they describe the case of surplus completely invested in risk-free assets, as well as some noninsurance models of surplus dynamics, for example, charity-type models.

  16. INSURER SEQUESTRATION OF THE DEBTOR’S IMMOVABLE PROPERTY IN BUSINESS

    Directory of Open Access Journals (Sweden)

    NICOLAE GRADINARU

    2011-04-01

    Full Text Available Insurer sequestration is the insurance measure that the creditor resorts to and that is applicable if the object of the litigation is the payment of a sum of money and that consists of the unavailability of the debtor-defendant’s sequestrable movable or immovable property, until the final (irrevocable decision given in the main trial in order to profit from the property when the creditor will obtain a writ of execution. In this regard, there are the provisions of Article 591 paragraph 1 thesis I of the Civil Procedure Code: “A creditor who does not have the writ of execution, but whose claim is proven by written act and is exigible, may request the setting up of an insurer sequestration of the debtor’s movable and immovable property, if he proves that he took legal action”. Thus, the provisions of article 907 are understood by reference to the provisions of article 591 paragraph 1 thesis I art.591 of the Civil Procedure Code, in that: in business, the insurer sequestration may also be set up on the debtor’s immovable property.

  17. Corporate social responsibility in the healthcare insurance industry: a cause-branding approach.

    Science.gov (United States)

    Smith, Alan D

    2009-01-01

    As citizens find healthcare issues to be the most important for companies to address, cause-branding as a suitable analysis for competitive comparison of any healthcare insurance firm's CSR would be in order. When these healthcare issues are properly addressed through CSR programmes of appropriate service providers, society benefits from better health, and the company benefits from decreased claims. Possible backlash of negative publicity may occur when stakeholders envision the company as merely contributing to community welfare as a means of advertising its compassion in exchange for a greater portion of the healthcare insurance marketplace. Several healthcare insurance providers were inspected, one in greater detail, on a series of principles grounded in cause-branding strategies were included in the case study of CSR initiatives, followed by the practical applications of lessons learned from the case studies.

  18. [Hypoxic brain injuries notified to the Danish Patient Insurance Association during 1992-2004. Secondary publication

    DEFF Research Database (Denmark)

    Bock, J.; Christoffersen, J.K.; Hedegaard, M.

    2008-01-01

    We investigated the files of the Danish Patient Insurance Association for newborns suffering from hypoxic brain injuries. From 1992 to 2004, a total of 127 approved claims concerning peripartum hypoxic injury were registered. Thirty-eight newborns died and the majority of the 89 surviving children...

  19. INCIDENCE AND PREVALENCE OF ACROMEGALY IN THE UNITED STATES: A CLAIMS-BASED ANALYSIS.

    Science.gov (United States)

    Broder, Michael S; Chang, Eunice; Cherepanov, Dasha; Neary, Maureen P; Ludlam, William H

    2016-11-01

    Acromegaly, a rare endocrine disorder, results from excessive growth hormone secretion, leading to multisystem-associated morbidities. Using 2 large nationwide databases, we estimated the annual incidence and prevalence of acromegaly in the U.S. We used 2008 to 2013 data from the Truven Health MarketScan ® Commercial Claims and Encounters Database and IMS Health PharMetrics healthcare insurance claims databases, with health plan enrollees acromegaly (International Classification of Diseases, 9th Revision, Clinical Modification Code [ICD-9CM] 253.0), or 1 claim with acromegaly and 1 claim for pituitary tumor, pituitary surgery, or cranial stereotactic radiosurgery. Annual incidence was calculated for each year from 2009 to 2013, and prevalence in 2013. Estimates were stratified by age and sex. Incidence was up to 11.7 cases per million person-years (PMPY) in MarketScan and 9.6 cases PMPY in PharMetrics. Rates were similar by sex but typically lowest in ≤17 year olds and higher in >24 year olds. The prevalence estimates were 87.8 and 71.0 per million per year in MarketScan and PharMetrics, respectively. Prevalence consistently increased with age but was similar by sex in each database. The current U.S. incidence of acromegaly may be up to 4 times higher and prevalence may be up to 50% higher than previously reported in European studies. Our findings correspond with the estimates reported by a recent U.S. study that used a single managed care database, supporting the robustness of these estimates in this population. Our study indicates there are approximately 3,000 new cases of acromegaly per year, with a prevalence of about 25,000 acromegaly patients in the U.S. CT = computed tomography GH = growth hormone IGF-1 = insulin-like growth factor 1 ICD-9-CM Code = International Classification of Diseases, 9th Revision, Clinical Modification Codes MRI = magnetic resonance imaging PMPY = per million person-years.

  20. Utilization of healthcare services and renewal of health insurance membership : evidence of adverse selection in Ghana

    NARCIS (Netherlands)

    Duku, Stephen Kwasi Opoku; Asenso-Boadi, Francis; Nketiah-Amponsah, Edward; Arhinful, Daniel Kojo

    2016-01-01

    Background: Utilization of healthcare in Ghana’s novel National Health Insurance Scheme (NHIS) has been increasing since inception with associated high claims bill which threatens the scheme’s financial sustainability. This paper investigates the presence of adverse selection by assessing the effect

  1. Patterns and Correlates of Tic Disorder Diagnoses in Privately and Publicly Insured Youth

    Science.gov (United States)

    Olfson, Mark; Crystal, Stephen; Gerhard, Tobias; Huang, Cecilia; Walkup, James T.; Scahill, Lawrence; Walkup, John T.

    2011-01-01

    Objective: This study examined the prevalence and demographic and clinical correlates of children diagnosed with Tourette disorder, chronic motor or vocal tic disorder, and other tic disorders in public and private insurance plans over the course of a 1-year period. Method: Claims were reviewed of Medicaid (n = 10,247,827) and privately (n =…

  2. Homogeneous Discrete Time Alternating Compound Renewal Process: A Disability Insurance Application

    Directory of Open Access Journals (Sweden)

    Guglielmo D’Amico

    2015-01-01

    Full Text Available Discrete time alternating renewal process is a very simple tool that permits solving many real life problems. This paper, after the presentation of this tool, introduces the compound environment in the alternating process giving a systematization to this important tool. The claim costs for a temporary disability insurance contract are presented. The algorithm and an example of application are also provided.

  3. 32 CFR 536.120 - Claims payable as maritime claims.

    Science.gov (United States)

    2010-07-01

    ... 32 National Defense 3 2010-07-01 2010-07-01 true Claims payable as maritime claims. 536.120... ACCOUNTS CLAIMS AGAINST THE UNITED STATES Maritime Claims § 536.120 Claims payable as maritime claims. A claim is cognizable under this subpart if it arises in or on a maritime location, involves some...

  4. RISK CORRIDORS AND REINSURANCE IN HEALTH INSURANCE MARKETPLACES: Insurance for Insurers

    OpenAIRE

    LAYTON, TIMOTHY J.; MCGUIRE, THOMAS G.; SINAIKO, ANNA D.

    2016-01-01

    In order to encourage entry and lower prices, most regulated markets for health insurance include policies that seek to reduce the uncertainty faced by insurers. In addition to risk adjustment of premiums paid to plans, the Health Insurance Marketplaces established by the Affordable Care Act implement reinsurance and risk corridors. Reinsurance limits insurer costs associated with specific individuals, while risk corridors protect against aggregate losses. Both tighten the insurer's distribut...

  5. Crop insurance: Risks and models of insurance

    Directory of Open Access Journals (Sweden)

    Čolović Vladimir

    2014-01-01

    Full Text Available The issue of crop protection is very important because of a variety of risks that could cause difficult consequences. One type of risk protection is insurance. The author in the paper states various models of insurance in some EU countries and the systems of subsidizing of insurance premiums by state. The author also gives a picture of crop insurance in the U.S., noting that in this country pays great attention to this matter. As for crop insurance in Serbia, it is not at a high level. The main problem with crop insurance is not only the risks but also the way of protection through insurance. The basic question that arises not only in the EU is the question is who will insure and protect crops. There are three possibilities: insurance companies under state control, insurance companies that are public-private partnerships or private insurance companies on a purely commercial basis.

  6. Insurance against climate change and flood risk: Insurability and decision processes of insurers

    Science.gov (United States)

    Hung, Hung-Chih; Hung, Jia-Yi

    2016-04-01

    1. Background Major portions of the Asia-Pacific region is facing escalating exposure and vulnerability to climate change and flood-related extremes. This highlights an arduous challenge for public agencies to improve existing risk management strategies. Conventionally, governmental funding was majorly responsible and accountable for disaster loss compensation in the developing countries in Asia, such as Taiwan. This is often criticized as an ineffective and inefficient measure of dealing with flood risk. Flood insurance is one option within the toolkit of risk-sharing arrangement and adaptation strategy to flood risk. However, there are numerous potential barriers for insurance companies to cover flood damage, which would cause the flood risk is regarded as uninsurable. This study thus aims to examine attitudes within the insurers about the viability of flood insurance, the decision-making processes of pricing flood insurance and their determinants, as well as to examine potential solutions to encourage flood insurance. 2. Methods and data Using expected-utility theory, an insurance agent-based decision-making model was developed to examine the insurers' attitudes towards the insurability of flood risk, and to scrutinize the factors that influence their decisions on flood insurance premium-setting. This model particularly focuses on how insurers price insurance when they face either uncertainty or ambiguity about the probability and loss of a particular flood event occurring. This study considers the factors that are expected to affect insures' decisions on underwriting and pricing insurance are their risk perception, attitudes towards flood insurance, governmental measures (e.g., land-use planning, building codes, risk communication), expected probabilities and losses of devastating flooding events, as well as insurance companies' attributes. To elicit insurers' utilities about premium-setting for insurance coverage, the 'certainty equivalent,' 'probability

  7. Analysis of multi drug resistant tuberculosis (MDR-TB) financial protection policy: MDR-TB health insurance schemes, in Chhattisgarh state, India.

    Science.gov (United States)

    Kundu, Debashish; Sharma, Nandini; Chadha, Sarabjit; Laokri, Samia; Awungafac, George; Jiang, Lai; Asaria, Miqdad

    2018-01-27

    There are significant financial barriers to access treatment for multi drug resistant tuberculosis (MDR-TB) in India. To address these challenges, Chhattisgarh state in India has established a MDR-TB financial protection policy by creating MDR-TB benefit packages as part of the universal health insurance scheme that the state has rolled out in their effort towards attaining Universal Health Coverage for all its residents. In these schemes the state purchases health insurance against set packages of services from third party health insurance agencies on behalf of all its residents. Provider payment reform by strategic purchasing through output based payments (lump sum fee is reimbursed as per the MDR-TB benefit package rates) to the providers - both public and private health facilities empanelled under the insurance scheme was the key intervention. To understand the implementation gap between policy and practice of the benefit packages with respect to equity in utilization of package claims by the poor patients in public and private sector. Data from primary health insurance claims from January 2013 to December 2015, were analysed using an extension of 'Kingdon's multiple streams for policy implementation framework' to explain the implementation gap between policy and practice of the MDR-TB benefit packages. The total number of claims for MDR-TB benefit packages increased over the study period mainly from poor patients treated in public facilities, particularly for the pre-treatment evaluation and hospital stay packages. Variations and inequities in utilizing the packages were observed between poor and non-poor beneficiaries in public and private sector. Private providers participation in the new MDR-TB financial protection mechanism through the universal health insurance scheme was observed to be much lower than might be expected given their share of healthcare provision overall in India. Our findings suggest that there may be an implementation gap due to weak

  8. Evaluating the influential priority of the factors on insurance loss of public transit

    Science.gov (United States)

    Su, Yongmin; Chen, Xinqiang

    2018-01-01

    Understanding correlation between influential factors and insurance losses is beneficial for insurers to accurately price and modify the bonus-malus system. Although there have been a certain number of achievements in insurance losses and claims modeling, limited efforts focus on exploring the relative role of accidents characteristics in insurance losses. The primary objective of this study is to evaluate the influential priority of transit accidents attributes, such as the time, location and type of accidents. Based on the dataset from Washington State Transit Insurance Pool (WSTIP) in USA, we implement several key algorithms to achieve the objectives. First, K-means algorithm contributes to cluster the insurance loss data into 6 intervals; second, Grey Relational Analysis (GCA) model is applied to calculate grey relational grades of the influential factors in each interval; in addition, we implement Naive Bayes model to compute the posterior probability of factors values falling in each interval. The results show that the time, location and type of accidents significantly influence the insurance loss in the first five intervals, but their grey relational grades show no significantly difference. In the last interval which represents the highest insurance loss, the grey relational grade of the time is significant higher than that of the location and type of accidents. For each value of the time and location, the insurance loss most likely falls in the first and second intervals which refers to the lower loss. However, for accidents between buses and non-motorized road users, the probability of insurance loss falling in the interval 6 tends to be highest. PMID:29298337

  9. Adverse Selection in the Children’s Health Insurance Program

    Directory of Open Access Journals (Sweden)

    Michael A. Morrisey PhD

    2015-06-01

    Full Text Available This study investigates whether new enrollees in the Alabama Children’s Health Insurance Program have different claims experience from renewing enrollees who do not have a lapse in coverage and from continuing enrollees. The analysis compared health services utilization in the first month of enrollment for new enrollees (who had not been in the program for at least 12 months with utilization among continuing enrollees. A second analysis compared first-month utilization of those who renew immediately with those who waited at least 2 months to renew. A 2-part model estimated the probability of usage and then the extent of usage conditional on any utilization. Claims data for 826 866 child-years over the period from 1999 to 2012 were used. New enrollees annually constituted a stable 40% share of participants. Among those enrolled in the program, 13.5% renewed on time and 86.5% of enrollees were late to renew their enrollment. In the multivariate 2-part models, controlling for age, gender, race, income eligibility category, and year, new enrollees had overall first-month claims experience that was nearly $29 less than continuing enrollees. This was driven by lower ambulatory use. Late renewals had overall first-month claims experience that was $10 less than immediate renewals. However, controlling for the presence of chronic health conditions, there was no statistically meaningful difference in the first-month claims experience of late and early renewals. Thus, differences in claims experience between new and continuing enrollees and between early and late renewals are small, with greater spending found among continuing and early renewing participants. Higher claims experience by early renewals is attributable to having chronic health conditions.

  10. Chinese nuclear insurance and Chinese nuclear insurance pool

    International Nuclear Information System (INIS)

    Gong Zhiqi

    2000-01-01

    Chinese Nuclear Insurance Started with Daya Bay Nuclear Power Station, PICC issued the insurance policy. Nuclear insurance cooperation between Chinese and international pool's organizations was set up in 1989. In 1996, the Chinese Nuclear Insurance Pool was prepared. The Chinese Nuclear Insurance Pool was approved by The Chinese Insurance Regulatory Committee in May of 1999. The principal aim is to centralize maximum the insurance capacity for nuclear insurance from local individual insurers and to strengthen the reinsurance relations with international insurance pools so as to provide the high quality insurance service for Chinese nuclear industry. The Member Company of Chinese Nuclear Pool and its roles are introduced in this article

  11. Report: Northwest Indian Fisheries Commission Complied With Most Federal Requirements but Claimed Some Unallowable Costs

    Science.gov (United States)

    Report #17-P-0184, April 24, 2017. The vast majority of costs claimed by NWIFC for cooperative agreements PA00J32201 and PA00J91201 were reasonable, allocable and allowable. Only $87,963 of indirect costs reimbursed to SSIT was questioned.

  12. Predicting Consumer Effort in Finding and Paying for Health Care: Expert Interviews and Claims Data Analysis.

    Science.gov (United States)

    Long, Sandra; Monsen, Karen A; Pieczkiewicz, David; Wolfson, Julian; Khairat, Saif

    2017-10-12

    For consumers to accept and use a health care information system, it must be easy to use, and the consumer must perceive it as being free from effort. Finding health care providers and paying for care are tasks that must be done to access treatment. These tasks require effort on the part of the consumer and can be frustrating when the goal of the consumer is primarily to receive treatments for better health. The aim of this study was to determine the factors that result in consumer effort when finding accessible health care. Having an understanding of these factors will help define requirements when designing health information systems. A panel of 12 subject matter experts was consulted and the data from 60 million medical claims were used to determine the factors contributing to effort. Approximately 60 million claims were processed by the health care insurance organization in a 12-month duration with the population defined. Over 292 million diagnoses from claims were used to validate the panel input. The results of the study showed that the number of people in the consumer's household, number of visits to providers outside the consumer's insurance network, number of adjusted and denied medical claims, and number of consumer inquiries are a proxy for the level of effort in finding and paying for care. The effort level, so measured and weighted per expert panel recommendations, differed by diagnosis. This study provides an understanding of how consumers must put forth effort when engaging with a health care system to access care. For higher satisfaction and acceptance results, health care payers ideally will design and develop systems that facilitate an understanding of how to avoid denied claims, educate on the payment of claims to avoid adjustments, and quickly find providers of affordable care. ©Sandra Long, Karen A. Monsen, David Pieczkiewicz, Julian Wolfson, Saif Khairat. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 12.10.2017.

  13. Development of the Health Insurance Literacy Measure (HILM): Conceptualizing and Measuring Consumer Ability to Choose and Use Private Health Insurance

    OpenAIRE

    Paez, Kathryn A.; Mallery, Coretta J.; Noel, HarmoniJoie; Pugliese, Christopher; McSorley, Veronica E.; Lucado, Jennifer L.; Ganachari, Deepa

    2014-01-01

    Understanding health insurance is central to affording and accessing health care in the United States. Efforts to support consumers in making wise purchasing decisions and using health insurance to their advantage would benefit from the development of a valid and reliable measure to assess health insurance literacy. This article reports on the development of the Health Insurance Literacy Measure (HILM), a self-assessment measure of consumers' ability to select and use private health insurance...

  14. Predictors of latent tuberculosis infection treatment completion in the US private sector: an analysis of administrative claims data.

    Science.gov (United States)

    Stockbridge, Erica L; Miller, Thaddeus L; Carlson, Erin K; Ho, Christine

    2018-05-29

    Factors that affect latent tuberculosis infection (LTBI) treatment completion in the US have not been well studied beyond public health settings. This gap was highlighted by recent health insurance-related regulatory changes that are likely to increase LTBI treatment by private sector healthcare providers. We analyzed LTBI treatment completion in the private healthcare setting to facilitate planning around this important opportunity for tuberculosis (TB) control in the US. We analyzed a national sample of commercial insurance medical and pharmacy claims data for people ages 0 to 64 years who initiated daily dose isoniazid treatment between July 2011 and March 2014 and who had complete data. All individuals resided in the US. Factors associated with treatment completion were examined using multivariable generalized ordered logit models and bivariate Kruskal-Wallis tests or Spearman correlations. We identified 1072 individuals with complete data who initiated isoniazid LTBI treatment. Treatment completion was significantly associated with less restrictive health insurance, age Private sector healthcare claims data provide insights into LTBI treatment completion patterns and patient/provider behaviors. Such information is critical to understanding the opportunities and limitations of private healthcare in the US to support treatment completion as this sector's role in protecting against and eliminating TB grows.

  15. Progressive or regressive? A second look at the tax exemption for employer-sponsored health insurance premiums.

    Science.gov (United States)

    Schoen, Cathy; Stremikis, Kristof; Collins, Sara; Davis, Karen

    2009-05-01

    The major argument for capping the exemption of health insurance benefits from income tax is that doing so will generate significant revenue that can be used to finance an expansion of health coverage. This analysis finds that given the state of insurance markets and current variations in premiums, limiting the current exemption could adversely affect individuals who are already at high risk of losing their health coverage. Evidence suggests that capping the exemption for employment-based health insurance could disproportionately affect workers in small firms, older workers, and wage-earners in industries with high expected claims costs. To avoid putting many families at increased health and financial risk, and to avoid undermining employer-sponsored group coverage, any consideration of a cap would have to be combined with coverage for all, changes in insurance market rules, and shared responsibility for financing.

  16. Adherence to tobramycin inhaled powder vs inhaled solution in patients with cystic fibrosis: analysis of US insurance claims data

    Directory of Open Access Journals (Sweden)

    Hamed K

    2017-04-01

    Full Text Available Kamal Hamed,1 Valentino Conti,2 Hengfeng Tian,1 Emil Loefroth3 1Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA; 2Novartis Global Service Center, Dublin, Ireland; 3Novartis Sverige AB, Täby, Sweden Purpose: Tobramycin inhalation powder (TIP, the first dry-powder inhaled antibiotic for pulmonary Pseudomonas aeruginosa infection, is associated with reduced treatment burden, increased patient satisfaction, and higher self-reported adherence for cystic fibrosis (CF patients. We compared adherence in CF patients newly treated with TIP with those newly treated with the traditional tobramycin inhalation solution (TIS, using US insurance claims data.Patients and methods: From the Truven MarketScan® database, we identified CF patients chronically infected with P. aeruginosa who had been prescribed TIP between May 1, 2013 to December 31, 2014, or TIS between September 1, 2010 to April 30, 2012 with at least 12 months of continuous medical and pharmacy benefits prior to and following prescription. TIP and TIS adherence levels were assessed.Results: A total of 145 eligible patients were identified for the TIP cohort and 306 for the TIS cohort. Significant differences in age distribution (25.0 vs 21.9 years for TIP vs TIS, respectively, P=0.017, type of health plan (P=0.014, employment status (72.4% vs 63.4% of TIP vs TIS patients in full-time employment, P=0.008, and some comorbidities were observed between the two cohorts. Although a univariate analysis found no significant differences between TIP and TIS (odds ratio [OR] 1.411, 95% confidence interval [CI] 0.949–2.098, TIP was moderately associated with higher adherence levels compared with TIS in a multivariable analysis, once various demographic and clinical characteristics were adjusted for. These included geographic location (OR: 1.566, CI: 1.016–2.413 and certain comorbidities.Conclusion: This study of US patient data supports previous findings that TIP is associated with better

  17. Towards equitable access to medicines for the rural poor: analyses of insurance claims reveal rural pharmacy initiative triggers price competition in Kyrgyzstan.

    Science.gov (United States)

    Waning, Brenda; Maddix, Jason; Tripodis, Yorghos; Laing, Richard; Leufkens, Hubert Gm; Gokhale, Manjusha

    2009-12-14

    A rural pharmacy initiative (RPI) designed to increase access to medicines in rural Kyrgyzstan created a network of 12 pharmacies using a revolving drug fund mechanism in 12 villages where no pharmacies previously existed. The objective of this study was to determine if the establishment of the RPI resulted in the unforeseen benefit of triggering medicine price competition in pre-existing (non-RPI) private pharmacies located in the region. We conducted descriptive and multivariate analyses on medicine insurance claims data from Kyrgyzstan's Mandatory Health Insurance Fund for the Jumgal District of Naryn Province from October 2003 to December 2007. We compared average quarterly medicine prices in competitor pharmacies before and after the introduction of the rural pharmacy initiative in October 2004 to determine the RPI impact on price competition. Descriptive analyses suggest competitors reacted to RPI prices for 21 of 30 (70%) medicines. Competitor medicine prices from the quarter before RPI introduction to the end of the study period decreased for 17 of 30 (57%) medicines, increased for 4 of 30 (13%) medicines, and remained unchanged for 9 of 30 (30%) medicines. Among the 9 competitor medicines with unchanged prices, five initially decreased in price but later reverted back to baseline prices. Multivariate analyses on 19 medicines that met sample size criteria confirm these findings. Fourteen of these 19 (74%) competitor medicines changed significantly in price from the quarter before RPI introduction to the quarter after RPI introduction, with 9 of 19 (47%) decreasing in price and 5 of 19 (26%) increasing in price. The RPI served as a market driver, spurring competition in medicine prices in competitor pharmacies, even when they were located in different villages. Initiatives designed to increase equitable access to medicines in rural regions of developing and transitional countries should consider the potential to leverage medicine price competition as a means

  18. Towards equitable access to medicines for the rural poor: analyses of insurance claims reveal rural pharmacy initiative triggers price competition in Kyrgyzstan

    Directory of Open Access Journals (Sweden)

    Leufkens Hubert GM

    2009-12-01

    Full Text Available Abstract Background A rural pharmacy initiative (RPI designed to increase access to medicines in rural Kyrgyzstan created a network of 12 pharmacies using a revolving drug fund mechanism in 12 villages where no pharmacies previously existed. The objective of this study was to determine if the establishment of the RPI resulted in the unforeseen benefit of triggering medicine price competition in pre-existing (non-RPI private pharmacies located in the region. Methods We conducted descriptive and multivariate analyses on medicine insurance claims data from Kyrgyzstan's Mandatory Health Insurance Fund for the Jumgal District of Naryn Province from October 2003 to December 2007. We compared average quarterly medicine prices in competitor pharmacies before and after the introduction of the rural pharmacy initiative in October 2004 to determine the RPI impact on price competition. Results Descriptive analyses suggest competitors reacted to RPI prices for 21 of 30 (70% medicines. Competitor medicine prices from the quarter before RPI introduction to the end of the study period decreased for 17 of 30 (57% medicines, increased for 4 of 30 (13% medicines, and remained unchanged for 9 of 30 (30% medicines. Among the 9 competitor medicines with unchanged prices, five initially decreased in price but later reverted back to baseline prices. Multivariate analyses on 19 medicines that met sample size criteria confirm these findings. Fourteen of these 19 (74% competitor medicines changed significantly in price from the quarter before RPI introduction to the quarter after RPI introduction, with 9 of 19 (47% decreasing in price and 5 of 19 (26% increasing in price. Conclusions The RPI served as a market driver, spurring competition in medicine prices in competitor pharmacies, even when they were located in different villages. Initiatives designed to increase equitable access to medicines in rural regions of developing and transitional countries should consider the

  19. An Application of EVT, GPD and POT Methods in the Albanian Insurance Market

    Directory of Open Access Journals (Sweden)

    Enkeleda Shehi

    2015-03-01

    Full Text Available Despite its relatively fast development, the insurance sector in Albania suffers from laco of experience, and lack of a database with historical records to make risk assessments feasible and to enable risk calculation. Consequently the newly established companies that operate in the insurance market in Albania cope with difficulties to make accurate calculations of reinsurance premium, i.e. the premium paid by a ceding company to an reinsurer in exchange of the liability assumed by the reinsurer. Given the situation, this research paper aims to provide an alternative way to make pure premium estimations. We have taken in consideration a dataset of fire insurance and other perils' claims, which have taken place in the Albanian insurance market during 2007 t 2014 period. Prices have been inflated to take into account the inflation of the period. There are n=401 fire insurance and other peril losses, the largest of them is Euro 1.203.798, the average is 20.156 Euro and the standard deviation is s= 83.037 Euro. The skewness coefficient of 9,94, indicates that the right tail is heavy, with considerable scope for llarge losses.

  20. Performance Assessment of the Juaboso District Office of the National Health Insurance Authority.

    Science.gov (United States)

    Effah, Paul; Appiah, Kingsley Opoku; Abor, Patience Aseweh

    2016-09-01

    To assess the performance of the National Health Insurance Authority (NHIA) in Ghana. Using a thorough case study of the Juaboso District Office of the NHIA, this study assessed the community coverage rate, the annual expenditure and income, and the trend of claims payment for the period 2009 to 2012 as well as factors influencing the level of patronage of the National Health Insurance Scheme. A self-administered structured questionnaire was used to gather data from the management of the scheme. Secondary data were also gathered from the scheme's audited financial statements. Informal discussions were held with the premium collectors and clients to throw more light on revenue generation challenges. The study found an increasing trend in the coverage rate on a yearly basis. Over the study period, the rate moved from 30.6 to 60.1, representing an increase of 96.7%. This shows that in terms of coverage rate, the Juaboso District Office of the NHIA is performing very well. The study also found that revenue has increased but the percentage rate of increase has decreased, compared with the coverage percentage rate. Expenditure has been on the rise, increasing by as much as 20.7% in 2011. Again, the study revealed a consistent year-on-year increase in the claims payment, consistent with the national trend. Constant clinical auditing of claims payments is required to ensure accountability. This would lead to transparency with regard to performance assessment of the claims. The findings have important implications for the effective management of the NHIA. Copyright © 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

  1. Predicting the Texas Windstorm Insurance Association claim payout of commercial buildings from Hurricane Ike

    Science.gov (United States)

    Kim, J. M.; Woods, P. K.; Park, Y. J.; Son, K.

    2013-08-01

    Following growing public awareness of the danger from hurricanes and tremendous demands for analysis of loss, many researchers have conducted studies to develop hurricane damage analysis methods. Although researchers have identified the significant indicators, there currently is no comprehensive research for identifying the relationship among the vulnerabilities, natural disasters, and economic losses associated with individual buildings. To address this lack of research, this study will identify vulnerabilities and hurricane indicators, develop metrics to measure the influence of economic losses from hurricanes, and visualize the spatial distribution of vulnerability to evaluate overall hurricane damage. This paper has utilized the Geographic Information System to facilitate collecting and managing data, and has combined vulnerability factors to assess the financial losses suffered by Texas coastal counties. A multiple linear regression method has been applied to develop hurricane economic damage predicting models. To reflect the pecuniary loss, insured loss payment was used as the dependent variable to predict the actual financial damage. Geographical vulnerability indicators, built environment vulnerability indicators, and hurricane indicators were all used as independent variables. Accordingly, the models and findings may possibly provide vital references for government agencies, emergency planners, and insurance companies hoping to predict hurricane damage.

  2. Danish Claims Data Indicators for Electronic Feedback in Oral-Health Care

    DEFF Research Database (Denmark)

    Rosing, Kasper; Christensen, Lisa Bøge; Listl, Stefan

    , as one of several steps in constructing a model on how to promote preventive rather than restorative oral health care. Methods: Danish oral health claims data cover the range of dental care services under the National Health Insurance reimbursement scheme. Demographic and dental claims data on Danish...... adults (age range 18-106 years), who saw a dentist during 2014, n=2,703,442 corresponding to 61% of eligible adults, were obtained from the Danish Health Authority. Approval was granted from the Danish Data Protection Agency. Results: The following indicators of dental clinic service delivery profiles...... health professional, to compare “own” results with relevant groups of dental clinics locally, on a municipality, regional or national level. The indicators may be, to some degree, either individually or combined, considered suitable for comparison in between countries, because of their relatively simple...

  3. Underutilization of social insurance among the poor: evidence from the Philippines.

    Directory of Open Access Journals (Sweden)

    Stella Quimbo

    Full Text Available Many developing countries promote social health insurance as a means to eliminate unmet health needs. However, this strategy may be ineffective if there are barriers to fully utilizing insurance.We analyzed the utilization of social health insurance in 30 hospital districts in the central regions of the Philippines between 2003 and 2007. Data for the study came from the Quality Improvement Demonstration Study (QIDS and included detailed patient information from exit interviews of children under 5 years of age conducted in seven waves among public hospital districts located in the four central regions of the Philippines. These data were used to estimate and identify predictors of underutilization of insurance benefits--defined as the likelihood of not filing claims despite having legitimate insurance coverage--using logistic regression.Multivariate analyses using QIDS data from 2004 to 2007 reveal that underutilization averaged about 15% throughout the study period. Underutilization, however, declined over time. Among insured hospitalized children, increasing length of stay in the hospital and mother's education, were associated with less underutilization. Being in a QIDS intervention site was also associated with less underutilization and partially accounts for the downward trend in underutilization over time.The surprisingly high level of insurance underutilization by insured patients in the QIDS sites undermines the potentially positive impact of social health insurance on the health of the marginalized. In the Philippines, where the largest burden of health care spending falls on households, underutilization suggests ineffective distribution of public funds, failing to reach a significant proportion of households which are by and large poor. Interventions that improve benefit awareness may combat the problem of underutilization and should be the focus of further research in this area.

  4. [Quality in Revision Arthroplasty: A Comparison between Claims Data Analysis and External Quality Assurance].

    Science.gov (United States)

    Wessling, M; Gravius, S; Gebert, C; Smektala, R; Günster, C; Hardes, J; Rhomberg, I; Koller, D

    2016-02-01

    External quality assurance for revisions of total knee arthroplasty (TKA) and total hip arthroplasty (THA) are carried out through the AQUA institute in Germany. Data are collected by the providers and are analyzed based on predefined quality indicators from the hospital stay in which the revision was performed. The present study explores the possibility to add routine data analysis to the existing external quality assurance (EQS). Differences between methods are displayed. The study aims to quantify the benefit of an additional analysis that allows patients to be followed up beyond the hospitalization itself. All persons insured in an AOK sickness fund formed the population for analysis. Revisions were identified using the same algorithm as the existing external quality assurance. Adverse events were defined according to the AQUA indicators for the years 2008 to 2011.The hospital stay in which the revision took place and a follow-up of 30 days were included. For re-operation and dislocation we also defined a 365 days interval for additional follow-up. The results were compared to the external quality control reports. Almost all indicators showed higher events in claims data analysis than in external quality control. Major differences are seen for dislocation (EQS SD: 1.87 vs. claims data [cd] SD: 2.06 %, cd+30 d: 2.91 %, cd+365 d: 7.27 %) and reoperation (hip revision: EQS SD: 5.88 % vs. claims data SD: 8.79 % cd+30 d: 9.82 %, cd+365 d: 15.0 %/knee revision: EQS SD: 3.21 % vs. claims data SD: 4.07 %, cd+30 d: 4.6 %, cd+365 d: 15.43 %). Claims data could show additional adverse events for all indicators after the initial hospital stay, rising to 77 % of all events. The number of adverse events differs between the existing external quality control and our claims data analysis. Claims data give the opportunity to complement existing methods of quality control though a longer follow-up, when many complications become evident. Georg

  5. Improving access for Medicaid-insured children: focus on front-office personnel.

    Science.gov (United States)

    Lam, M; Riedy, C A; Milgrom, P

    1999-03-01

    Access to dental services for low-income children is limited. Front-office personnel play a role regarding dentists' participation in the Medicaid program. Subjects (N = 24) represented general dental offices in Spokane County, Wash., and included participants and nonparticipants in the Access to Baby and Child Dentistry, or ABCD, program, a dental society/community program aimed at expanding dental services provided to Medicaid-insured children. The authors stratified the participants according to the number of claims their practices submitted to Medicaid for ABCD children: non-ABCD, low-ABCD and high-ABCD. Five two-hour focus group sessions were conducted to determine participants' beliefs about, attitudes toward and experiences in serving this population. The authors' data analysis consisted of a comprehensive content review of participants' responses from transcripted audiotapes. They synthesized frequently mentioned concepts and ideas into relevant themes. The major factors affecting practices' participation in Medicaid were office policy on seeing Medicaid-insured patients; staff members' personal connection to Medicaid-insured patients; staff members' attitudes about Medicaid-insured patients; and staff members' perceptions of Medicaid-insured patients' barriers to care. The data suggest that factors affecting dentists' participation in the Medicaid program are more complex than the often-stated dissatisfactions with low reimbursement fees and hassles with paperwork. Efforts to increase dentist participation in serving Medicaid-insured patients will continue to be relatively ineffective until many of the concerns raised by this study's subjects are better understood and addressed.

  6. Accuracy of claims-based algorithms for epilepsy research: Revealing the unseen performance of claims-based studies.

    Science.gov (United States)

    Moura, Lidia M V R; Price, Maggie; Cole, Andrew J; Hoch, Daniel B; Hsu, John

    2017-04-01

    To evaluate published algorithms for the identification of epilepsy cases in medical claims data using a unique linked dataset with both clinical and claims data. Using data from a large, regional health delivery system, we identified all patients contributing biologic samples to the health system's Biobank (n = 36K). We identified all subjects with at least one diagnosis potentially consistent with epilepsy, for example, epilepsy, convulsions, syncope, or collapse, between 2014 and 2015, or who were seen at the epilepsy clinic (n = 1,217), plus a random sample of subjects with neither claims nor clinic visits (n = 435); we then performed a medical chart review in a random subsample of 1,377 to assess the epilepsy diagnosis status. Using the chart review as the reference standard, we evaluated the test characteristics of six published algorithms. The best-performing algorithm used diagnostic and prescription drug data (sensitivity = 70%, 95% confidence interval [CI] 66-73%; specificity = 77%, 95% CI 73-81%; and area under the curve [AUC] = 0.73, 95%CI 0.71-0.76) when applied to patients age 18 years or older. Restricting the sample to adults aged 18-64 years resulted in a mild improvement in accuracy (AUC = 0.75,95%CI 0.73-0.78). Adding information about current antiepileptic drug use to the algorithm increased test performance (AUC = 0.78, 95%CI 0.76-0.80). Other algorithms varied in their included data types and performed worse. Current approaches for identifying patients with epilepsy in insurance claims have important limitations when applied to the general population. Approaches incorporating a range of information, for example, diagnoses, treatments, and site of care/specialty of physician, improve the performance of identification and could be useful in epilepsy studies using large datasets. Wiley Periodicals, Inc. © 2017 International League Against Epilepsy.

  7. FEATURES OF ACCOUNTING AND AUDIT OF INSURANCE ORGANIZATIONS IN UKRAINE

    Directory of Open Access Journals (Sweden)

    А. Sholoiko

    2015-04-01

    Full Text Available Features of accounting and audit of insurance organizations in Ukraine that are based on the specific characteristics of the insurance activity and legislation are considered. The main of them are the next: the proper organization of accounting is a necessary condition of the activity of the financial institution; there are three groups of requirements to accounting of insurer, including: accounting of contracts; accounting of insurance reserves, formation financial reports in the Ukrainian insurance legislation; the use of IFRS instead of national accounting standards in preparing financial reports of insurance organizations in Ukraine is obligatory and despite of this compilation of primary documents and application of National Chart of Accounts by insurance organizations of Ukraine remains mandatory; it is necessary to follow the frequency of reporting according to national legislation; insurance companies are classified as institutions that must necessarily publish annual financial statements together with the auditor’s report about its accuracy, and this category of institutions are prohibited from using such form of organization of accounting and reporting as directly by the owner or the head of organization; audit of the annual financial statements and consolidated financial statements of insurance companies is mandatory and conducted in accordance with International quality control, auditing, review, other assurance, and related services pronouncements which adopted as national auditing standards by the Audit Chamber of Ukraine. These generalizations are done to make possible the further investigations of developing and improving in this field.

  8. Finance issue brief: insurer liability: year end report-2003.

    Science.gov (United States)

    MacEachern, Lillian

    2003-12-31

    When a health plan denies payment for a procedure on grounds that it is not medically necessary or when it refuses a physician-ordered referral to a specialist, has it crossed the line from making an insurance judgment to practicing medicine? If the patient suffers harm as a result of the decision, is the plan liable for medical malpractice? Those were questions 35 states considered in 1999, and at least 32 states are grappling with this year as they seek to respond to physician and patient pressure to curb the power of the managed care industry. Traditionally, health insurers have been protected by state laws banning "the corporate practice of medicine," which means the patient's only recourse is to sue under a "vicarious liability" theory. Now, however, lawmakers are debating legislation to extend the scope of malpractice liability beyond individual practitioners to insurance carriers and plans themselves.

  9. Finance issue brief: insurer liability: year end report-2002.

    Science.gov (United States)

    Morgan, Rachel; MacEachern, Lillian

    2002-12-31

    When a health plan denies payment for a procedure on grounds that it is not medically necessary or when it refuses a physician-ordered referral to a specialist, has it crossed the line from making an insurance judgment to practicing medicine? If the patient suffers harm as a result of the decision, is the plan liable for medical malpractice? Those were questions 35 states considered in 1999, and at least 32 states are grappling with this year as they seek to respond to physician and patient pressure to curb the power of the managed care industry. Traditionally, health insurers have been protected by state laws banning "the corporate practice of medicine," which means the patient's only recourse is to sue under a "vicarious liability" theory. Now, however, lawmakers are debating legislation to extend the scope of malpractice liability beyond individual practitioners to insurance carriers and plans themselves.

  10. The cost of unintended pregnancies for employer-sponsored health insurance plans.

    Science.gov (United States)

    Dieguez, Gabriela; Pyenson, Bruce S; Law, Amy W; Lynen, Richard; Trussell, James

    2015-04-01

    Pregnancy is associated with a significant cost for employers providing health insurance benefits to their employees. The latest study on the topic was published in 2002, estimating the unintended pregnancy rate for women covered by employer-sponsored insurance benefits to be approximately 29%. The primary objective of this study was to update the cost of unintended pregnancy to employer-sponsored health insurance plans with current data. The secondary objective was to develop a regression model to identify the factors and associated magnitude that contribute to unintended pregnancies in the employee benefits population. We developed stepwise multinomial logistic regression models using data from a national survey on maternal attitudes about pregnancy before and shortly after giving birth. The survey was conducted by the Centers for Disease Control and Prevention through mail and via telephone interviews between 2009 and 2011 of women who had had a live birth. The regression models were then applied to a large commercial health claims database from the Truven Health MarketScan to retrospectively assign the probability of pregnancy intention to each delivery. Based on the MarketScan database, we estimate that among employer-sponsored health insurance plans, 28.8% of pregnancies are unintended, which is consistent with national findings of 29% in a survey by the Centers for Disease Control and Prevention. These unintended pregnancies account for 27.4% of the annual delivery costs to employers in the United States, or approximately 1% of the typical employer's health benefits spending for 1 year. Using these findings, we present a regression model that employers could apply to their claims data to identify the risk for unintended pregnancies in their health insurance population. The availability of coverage for contraception without employee cost-sharing, as was required by the Affordable Care Act in 2012, combined with the ability to identify women who are at high

  11. Exposure as Duration and Distance in Telematics Motor Insurance Using Generalized Additive Models

    Directory of Open Access Journals (Sweden)

    Jean-Philippe Boucher

    2017-09-01

    Full Text Available In Pay-As-You-Drive (PAYD automobile insurance, the premium is fixed based on the distance traveled, while in usage-based insurance (UBI the driving patterns of the policyholder are also considered. In those schemes, drivers who drive more pay a higher premium compared to those with the same characteristics who drive only occasionally, because the former are more exposed to the risk of accident. In this paper, we analyze the simultaneous effect of the distance traveled and exposure time on the risk of accident by using Generalized Additive Models (GAM. We carry out an empirical application and show that the expected number of claims (1 stabilizes once a certain number of accumulated distance-driven is reached and (2 it is not proportional to the duration of the contract, which is in contradiction to insurance practice. Finally, we propose to use a rating system that takes into account simultaneously exposure time and distance traveled in the premium calculation. We think that this is the trend the automobile insurance market is going to follow with the eruption of telematics data.

  12. An in-depth assessment of a diagnosis-based risk adjustment model based on national health insurance claims: the application of the Johns Hopkins Adjusted Clinical Group case-mix system in Taiwan.

    Science.gov (United States)

    Chang, Hsien-Yen; Weiner, Jonathan P

    2010-01-18

    Diagnosis-based risk adjustment is becoming an important issue globally as a result of its implications for payment, high-risk predictive modelling and provider performance assessment. The Taiwanese National Health Insurance (NHI) programme provides universal coverage and maintains a single national computerized claims database, which enables the application of diagnosis-based risk adjustment. However, research regarding risk adjustment is limited. This study aims to examine the performance of the Adjusted Clinical Group (ACG) case-mix system using claims-based diagnosis information from the Taiwanese NHI programme. A random sample of NHI enrollees was selected. Those continuously enrolled in 2002 were included for concurrent analyses (n = 173,234), while those in both 2002 and 2003 were included for prospective analyses (n = 164,562). Health status measures derived from 2002 diagnoses were used to explain the 2002 and 2003 health expenditure. A multivariate linear regression model was adopted after comparing the performance of seven different statistical models. Split-validation was performed in order to avoid overfitting. The performance measures were adjusted R2 and mean absolute prediction error of five types of expenditure at individual level, and predictive ratio of total expenditure at group level. The more comprehensive models performed better when used for explaining resource utilization. Adjusted R2 of total expenditure in concurrent/prospective analyses were 4.2%/4.4% in the demographic model, 15%/10% in the ACGs or ADGs (Aggregated Diagnosis Group) model, and 40%/22% in the models containing EDCs (Expanded Diagnosis Cluster). When predicting expenditure for groups based on expenditure quintiles, all models underpredicted the highest expenditure group and overpredicted the four other groups. For groups based on morbidity burden, the ACGs model had the best performance overall. Given the widespread availability of claims data and the superior explanatory

  13. The importance of subjective claims management.

    Science.gov (United States)

    Beger, C S

    1997-01-01

    This article discusses the causes and effects of "subjective disability" on today's workforce and employers. As employees feel out of control with both their careers and demands placed upon them, the number of claims characterized by self-reported symptoms are increasing. Subjective disabilities include chronic syndrome, fibromyalgia, psychiatric claims and chronic pain. The author discusses creative strategies in case studies that have helped employers contain the costs of disability claims, while empowering the employee to take control of their own situation and return to work sooner.

  14. Climate change and the insurance industry. The cost of increased risk and the impetus for action

    International Nuclear Information System (INIS)

    Tucker, Michael

    1997-01-01

    A convincing economic argument for taking action to prevent or ameliorate climate change has not developed because of both uncertainty about the degree of change and its timing. Recent costly weather-related catastrophes with consequent negative impacts on the insurance industry has made the insurance industry a potential advocate for slowing what has been identified as a causal factor in climate change: emissions of greenhouse gases. However, rising costs of claims, without a longer-term trend of such catastrophic losses, will make it difficult to present a strong case for taking costly economic action. Using the Black Scholes Option Pricing Model, it is shown that increasing levels of climate variability as embedded in the anticipated variability of damage to insured assets will have an immediate economic cost that could serve to bolster the argument for more immediate action. That cost is shown to be economically justified higher insurance premiums

  15. Minimum Value of Eligible Employer-Sponsored Plans and Other Rules Regarding the Health Insurance Premium Tax Credit. Final regulations.

    Science.gov (United States)

    2015-12-18

    This document contains final regulations on the health insurance premium tax credit enacted by the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, as amended by the Medicare and Medicaid Extenders Act of 2010, the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011, and the Department of Defense and Full-Year Continuing Appropriations Act, 2011. These final regulations affect individuals who enroll in qualified health plans through Affordable Insurance Exchanges (Exchanges, sometimes called Marketplaces) and claim the health insurance premium tax credit, and Exchanges that make qualified health plans available to individuals and employers.

  16. Pricing of premiums for equity-linked life insurance based on joint mortality models

    Science.gov (United States)

    Riaman; Parmikanti, K.; Irianingsih, I.; Supian, S.

    2018-03-01

    Life insurance equity - linked is a financial product that not only offers protection, but also investment. The calculation of equity-linked life insurance premiums generally uses mortality tables. Because of advances in medical technology and reduced birth rates, it appears that the use of mortality tables is less relevant in the calculation of premiums. To overcome this problem, we use a combination mortality model which in this study is determined based on Indonesian Mortality table 2011 to determine the chances of death and survival. In this research, we use the Combined Mortality Model of the Weibull, Inverse-Weibull, and Gompertz Mortality Model. After determining the Combined Mortality Model, simulators calculate the value of the claim to be given and the premium price numerically. By calculating equity-linked life insurance premiums well, it is expected that no party will be disadvantaged due to the inaccuracy of the calculation result

  17. How useful are Swiss flood insurance data for flood vulnerability assessments?

    Science.gov (United States)

    Röthlisberger, Veronika; Bernet, Daniel; Zischg, Andreas; Keiler, Margreth

    2015-04-01

    The databases of Swiss flood insurance companies build a valuable but to date rarely used source of information on physical flood vulnerability. Detailed insights into the Swiss flood insurance system are crucial for using the full potential of the different databases for research on flood vulnerability. Insurance against floods in Switzerland is a federal system, the modalities are manly regulated on cantonal level. However there are some common principles that apply throughout Switzerland. First of all coverage against floods (and other particular natural hazards) is an integral part of every fire insurance policy for buildings or contents. This coupling of insurance as well as the statutory obligation to insure buildings in most of the cantons and movables in some of the cantons lead to a very high penetration. Second, in case of damage, the reinstatement costs (value as new) are compensated and third there are no (or little) deductible and co-pay. High penetration and the fact that the compensations represent a large share of the direct, tangible losses of the individual policy holders make the databases of the flood insurance companies a comprehensive and therefore valuable data source for flood vulnerability research. Insurance companies not only store electronically data about losses (typically date, amount of claims payment, cause of damage, identity of the insured object or policyholder) but also about insured objects. For insured objects the (insured) value and the details on the policy and its holder are the main feature to record. On buildings the insurance companies usually computerize additional information such as location, volume, year of construction or purpose of use. For the 19 (of total 26) cantons with a cantonal monopoly insurer the data of these insurance establishments have the additional value to represent (almost) the entire building stock of the respective canton. Spatial referenced insurance data can be used for many aspects of

  18. Medical research using governments' health claims databases: with or without patients' consent?

    Science.gov (United States)

    Tsai, Feng-Jen; Junod, Valérie

    2018-03-01

    Taking advantage of its single-payer, universal insurance system, Taiwan has leveraged its exhaustive database of health claims data for research purposes. Researchers can apply to receive access to pseudonymized (coded) medical data about insured patients, notably their diagnoses, health status and treatments. In view of the strict safeguards implemented, the Taiwanese government considers that this research use does not require patients' consent (either in the form of an opt-in or in the form of an opt-out). A group of non-governmental organizations has challenged this view in the Taiwanese Courts, but to no avail. The present article reviews the arguments both against and in favor of patients' consent for re-use of their data in research. It concludes that offering patients an opt-out would be appropriate as it would best balance the important interests at issue.

  19. Occupational injuries and diseases in Alberta : lost-time claims, disabling injury claims and claim rates in the upstream oil and gas industries, 2002 to 2006

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2007-07-01

    Alberta Employment, Immigration and Industry (EII) prepares an annual report of the occupational injuries and diseases in the upstream oil and gas industries operating in the province. The purpose is to determine if the industries meet the demand from industry and safety association, labour organizations, employers and workers to improve workplace health and safety. This report described programs and initiatives undertaken by EII in pursuit of these goals. It analyzed provincial occupational injury and disease information against national statistics and estimated the risk of injury or disease at the provincial, industry sector and sub-sector level. The report also presented an analysis of aggregate injury claim data to allow for the tracking of workplace health and safety performance over time. For comparative purposes, 2006 data was presented beside 2005 data. Additional historical data was presented in some cases. It was noted that approximately 80 per cent of employed persons in Alberta are covered by the Workman's Compensation Board (WCB). Therefore, this report focused on all industry activity in Alberta covered by the WCB and by the provincial legislation of occupational health and safety. General descriptions about the incidents and injured workers were presented along with fatality rates for the major industry sectors as well as the occupational fatalities that the Workers Compensation Board (WCB) accepted for compensation. The number of employers that earned a certificate of recognition was also identified. Injury and disease analysis was discussed in terms of injured worker characteristics; nature of injury or disease; source of injury or disease; type of event or exposure; and, duration of disability. It was shown that the lost-time claim rate for the upstream oil and gas industries in Alberta decreased by 10 per cent in 2006, due to fewer injury claims. The disabling injury rate decreased by 4.9 per cent. The tar sand subsector had the lowest lost

  20. Differences in production between medical specialists: An inventory based on claims data to identify potential areas for quality-improvement activities

    NARCIS (Netherlands)

    A.F. Casparie (Anton); D. Post (Doeke); W.H. van Harten (Willem H); J.W. Gubbels (Jan)

    1993-01-01

    textabstractClaims data from sickness funds were used to describe practice patterns of all physician partnerships of six medical specialties in a region of The Netherlands. The numbers of admissions to hospital, patient days, in-patient and out-patient procedures were compared per 1,000 insured

  1. Factors influencing mode of claims settlement in workers' compensation cases.

    Science.gov (United States)

    Morrison, D L; Wood, G A; MacDonald, S

    1995-01-01

    This paper examines the variables that influence the means by which 10,192 injured workers settled their compensation claims during 1990. The data on which this study is based come from a state in Australia where there are three means by which workers' compensation claims can be settled by lump sum payment: settlement following a specific injury payment, early settlement payment and settlement following a common law payment. This paper is specifically concerned with identifying the variables that determine whether the claim will be settled by a lump sum payment and whether different modes of claims settlement by lump sum are unique and predictable from a range of variables that include injury characteristics and demographics. The results of logistic regression modelling revealed that those who received a lump sum settlement could be reliably distinguished from those who did not receive such a payment. Each mode of settlement varied in the extent to which it could be predicted. Contrary to expectations, the most difficult form of settlement mode to predict was that of specific injury payments (4% accurate) with the most predictive being early settlement payments (81% accurate). Common law payments were also highly predictable (48% accurate). The form of lump sum payment received by injured workers was found to depend on a range of injury characteristics, indices of severity and for common law payments, gender and potential income loss. It is argued that although injury characteristics play a part in the process of claims settlement, personal circumstances and insurance company policies are influential in dictating the form by which workers compensation cases are finalized.

  2. 32 CFR 536.121 - Claims not payable as maritime claims.

    Science.gov (United States)

    2010-07-01

    ... 32 National Defense 3 2010-07-01 2010-07-01 true Claims not payable as maritime claims. 536.121... ACCOUNTS CLAIMS AGAINST THE UNITED STATES Maritime Claims § 536.121 Claims not payable as maritime claims... (except at (e) and (k)), and 536.46; (b) Are not maritime in nature; (c) Are not in the best interests of...

  3. Correlations between reinfall data and insurance damage data related to sewer flooding for the case of Aarhus, Denmark

    NARCIS (Netherlands)

    Spekkers, M.H.; Zhou, Q.; Arnbjerg-Nielsen, K.; Clemens, F.H.L.R.; ten Veldhuis, J.A.E.

    2013-01-01

    Sewer flooding due to extreme rainfall may result in considerable damage. Damage data to quantify costs of cleaning, drying, and replacing materials and goods are rare in literature. In this study, insurance claim data related to property damages were analysed for the municipality of Aarhus,

  4. Unsupervised Labeling Of Data For Supervised Learning And Its Application To Medical Claims Prediction

    Directory of Open Access Journals (Sweden)

    Che Ngufor

    2013-01-01

    Full Text Available The task identifying changes and irregularities in medical insurance claim pay-ments is a difficult process of which the traditional practice involves queryinghistorical claims databases and flagging potential claims as normal or abnor-mal. Because what is considered as normal payment is usually unknown andmay change over time, abnormal payments often pass undetected; only to bediscovered when the payment period has passed.This paper presents the problem of on-line unsupervised learning from datastreams when the distribution that generates the data changes or drifts overtime. Automated algorithms for detecting drifting concepts in a probabilitydistribution of the data are presented. The idea behind the presented driftdetection methods is to transform the distribution of the data within a slidingwindow into a more convenient distribution. Then, a test statistics p-value ata given significance level can be used to infer the drift rate, adjust the windowsize and decide on the status of the drift. The detected concepts drifts areused to label the data, for subsequent learning of classification models by asupervised learner. The algorithms were tested on several synthetic and realmedical claims data sets.

  5. 24 CFR 266.602 - Mortgage insurance premium: Insured advances.

    Science.gov (United States)

    2010-04-01

    ... 24 Housing and Urban Development 2 2010-04-01 2010-04-01 false Mortgage insurance premium: Insured... Contract Rights and Obligations Mortgage Insurance Premiums § 266.602 Mortgage insurance premium: Insured.... On each anniversary of the initial closing, the HFA shall pay an interim mortgage insurance premium...

  6. Strategy for a transparent, accessible, and sustainable national claims database.

    Science.gov (United States)

    Gelburd, Robin

    2015-03-01

    The article outlines the strategy employed by FAIR Health, Inc, an independent nonprofit, to maintain a national database of over 18 billion private health insurance claims to support consumer education, payer and provider operations, policy makers, and researchers with standard and customized data sets on an economically self-sufficient basis. It explains how FAIR Health conducts all operations in-house, including data collection, security, validation, information organization, product creation, and transmission, with a commitment to objectivity and reliability in data and data products. It also describes the data elements available to researchers and the diverse studies that FAIR Health data facilitate.

  7. Research of the Behavior of Consumers in the Insurance Market in the Czech Republic

    Directory of Open Access Journals (Sweden)

    Marešová Petra

    2012-06-01

    Full Text Available The purpose of this article is to familiarize with research aim, goal of which is to map out consumer behavior in the choice of insurance against death was carried out. This insured risk was chosen because for most insurers in the product offering as one of the key and it occurs within the highly competitive bid. At consumer behavior specification is also taken into account their classifying that can influence potential irrational behavior elements and help to clarify studied dilemma more (e.g. income brackets, age or other demographic information. Results will contribute to decision-making theory enrichment in given specific segment. From view of practice, they will be used in co-operative institution with the aim of a better client comprehension, product optimization and thereby contracts decline prevention and permanent clientele expansion.The results of the research project showed that most consumers under the influence of certain factors act irrationally. These factors include media coverage of the causes of claims discount, offer extension of insurance coverage.

  8. 23 CFR 190.5 - Bonus project claims.

    Science.gov (United States)

    2010-04-01

    ... which advertising controls are in effect. The eligible system mileage reported in subsequent projects on... CONTROLLING OUTDOOR ADVERTISING ON THE INTERSTATE SYSTEM § 190.5 Bonus project claims. (a) The State may claim payment by submitting a form PR-20 voucher, supported by strip maps which identify advertising control...

  9. 32 CFR 536.129 - Claims cognizable as UCMJ claims.

    Science.gov (United States)

    2010-07-01

    ... Personnel Claims Act and chapter 11 of AR 27-20, which provides compensation only for tangible personal... 32 National Defense 3 2010-07-01 2010-07-01 true Claims cognizable as UCMJ claims. 536.129 Section 536.129 National Defense Department of Defense (Continued) DEPARTMENT OF THE ARMY CLAIMS AND ACCOUNTS...

  10. Non-fatal workplace violence workers' compensation claims (1993-1996).

    Science.gov (United States)

    Hashemi, L; Webster, B S

    1998-06-01

    More is known about fatal workplace violence than non-fatal workplace violence (NFWV). This study provides descriptive information on the number and cost of NFWV claims filed with a large workers' compensation carrier. NFWV claims from 51 US jurisdictions were selected either by cause codes or by word search from the accident-description narrative. Claims reported in 1993 through 1996 were analyzed to report the frequency, cost, gender, age, industry, and nature of injury. An analysis of a random sample of 600 claims provided information on perpetrator type, cause of events, and injury mechanism. A total of 28,692 NFWV claims were filed during the study period. No cost was incurred for 32.5% of the claims, and 15.5% received payments for lost work. As a percentage of all claims filed by industry, schools had the highest percentage (11.4%) of NFWV claims, and banking had the highest percentage (11.5%) of cost. The majority of claims in the banking random sample group (93%) were due to stress. In the random sample, 90.3% of claims were caused by criminals (51.8%) or by patients, clients, or customers (38.5%). Only 9.7% were caused by an employee (9.2%) or a personal acquaintance of the employee (0.5%). Employers should acknowledge that NFWV incidents occur, recognize that the majority of perpetrators are criminals or clients rather than employees, and develop appropriate prevention and intervention programs.

  11. The challenge of forecasting impacts of flash floods: test of a simplified hydraulic approach and validation based on insurance claim data

    Science.gov (United States)

    Le Bihan, Guillaume; Payrastre, Olivier; Gaume, Eric; Moncoulon, David; Pons, Frédéric

    2017-11-01

    Up to now, flash flood monitoring and forecasting systems, based on rainfall radar measurements and distributed rainfall-runoff models, generally aimed at estimating flood magnitudes - typically discharges or return periods - at selected river cross sections. The approach presented here goes one step further by proposing an integrated forecasting chain for the direct assessment of flash flood possible impacts on inhabited areas (number of buildings at risk in the presented case studies). The proposed approach includes, in addition to a distributed rainfall-runoff model, an automatic hydraulic method suited for the computation of flood extent maps on a dense river network and over large territories. The resulting catalogue of flood extent maps is then combined with land use data to build a flood impact curve for each considered river reach, i.e. the number of inundated buildings versus discharge. These curves are finally used to compute estimated impacts based on forecasted discharges. The approach has been extensively tested in the regions of Alès and Draguignan, located in the south of France, where well-documented major flash floods recently occurred. The article presents two types of validation results. First, the automatically computed flood extent maps and corresponding water levels are tested against rating curves at available river gauging stations as well as against local reference or observed flood extent maps. Second, a rich and comprehensive insurance claim database is used to evaluate the relevance of the estimated impacts for some recent major floods.

  12. Current situation and issue of Industrial Accident Compensation insurance.

    Science.gov (United States)

    Kim, Inah; Rhie, Jeongbae; Yoon, Jo-Duk; Kim, Jinsoo; Won, Jonguk

    2012-05-01

    Industrial Accident Compensation Insurance (IACI) has a history of about 50 yr, and is the oldest social insurance system in Korea. After more than 20 times of revision improvements in benefits, its contents and claim systems have been upgraded. It became the protector of injured workers and their families, and at the same time became the system which could cope with both financial burden of employers and their responsibilities. However, there are some issues to be reformed to upgrade the IACI: 1) the problems in the approval system of occupational diseases, 2) quality improvement of workers' compensation medical care, 3) vocational rehabilitation and return to work, 4) workers' compensation premiums and out-of-pocket money of injured workers, 5) issues in application of IACI. Growth of IACI cannot be achieved by an effort of an individual. Efforts by workers, owners, and government, in addition to physicians and welfare professionals toward the same goal are required for the next level improvement of IACI.

  13. Characteristics of and risk factors for compensated occupational injury and disease claims in dairy farmers: a case-control study.

    Science.gov (United States)

    Karttunen, J P; Rautiainen, R H

    2013-07-01

    Research indicates that dairy farmers have an elevated risk of work-related adverse health outcomes. This case-control study evaluated the characteristics of and risk factors for compensated occupational injury and disease claims among Finnish dairy farmers. The cases consisted of 19 farm couples in which both spouses had a history of multiple claims. There were 283 claims in total, a rate of 26.6 claims per 100 person-years. The controls consisted of 12 couples in which neither spouse had compensated or rejected claims during their work history as insured farmers. A combined mail/telephone survey charted potential risk factors for compensated claims. These claims frequently involved work tasks and causes related to animal husbandry. Cattle were the most common cause for injuries in general and for serious injuries in particular. Gender differences in farm work and claims were observed. Using logistic regression analyses, we identified personal and work-related risk factors including long work history, small-scale dairy farm operation, and conventional stanchion barn for dairy cattle. Outdated working conditions, while not statistically significant, were positively associated with claims as well. Declined current work ability and musculoskeletal or respiratory conditions were significantly associated with claims where each of these outcomes may contribute to the other. Identified factors could be used to select subgroups of dairy farmers with either elevated or reduced risk of claims. Prevention of adverse health outcomes could be most effective when targeted to farmers at highest risk of occupational injury and disease.

  14. A robustification of the chain-ladder method

    NARCIS (Netherlands)

    Verdonck, T.; van Wouwe, M.; Dhaene, J.

    2009-01-01

    In a non-life insurance business an insurer often needs to build up a reserve to able to meet his or her future obligations arising from incurred but not reported completely claims. To forecast these claims reserves, a simple but generally accepted algorithm is the classical chain-ladder method.

  15. Prognostic factors for disability claim duration due to musculoskeletal symptoms among self-employed persons

    Directory of Open Access Journals (Sweden)

    Richter JM

    2011-12-01

    Full Text Available Abstract Background Employees and self-employed persons have, among others, different personal characteristics and different working conditions, which may influence the prognosis of sick leave and the duration of a disability claim. The purpose of the current study is to identify prognostic factors for the duration of a disability claim due to non-specific musculoskeletal disorders (MSD among self-employed persons in the Netherlands. Methods The study population consisted of 276 self-employed persons, who all had a disability claim episode due to MSD with at least 75% work disability. The study was a cohort study with a follow-up period of 12 months. At baseline, participants filled in a questionnaire with possible individual, work-related and disease-related prognostic factors. Results The following prognostic factors significantly increased claim duration: age > 40 years (Hazard Ratio 0.54, no similar symptoms in the past (HR 0.46, having long-lasting symptoms of more than six months (HR 0.60, self-predicted return to work within more than one month or never (HR 0.24 and job dissatisfaction (HR 0.54. Conclusions The prognostic factors we found indicate that for self-employed persons, the duration of a disability claim not only depends on the (history of impairment of the insured, but also on age, self-predicted return to work and job satisfaction.

  16. Exploring the small-scale spatial distribution of hypertension and its association to area deprivation based on health insurance claims in Northeastern Germany.

    Science.gov (United States)

    Kauhl, B; Maier, W; Schweikart, J; Keste, A; Moskwyn, M

    2018-01-10

    Hypertension is one of the most frequently diagnosed chronic conditions in Germany. Targeted prevention strategies and allocation of general practitioners where they are needed most are necessary to prevent severe complications arising from high blood pressure. However, data on chronic diseases in Germany are mostly available through survey data, which do not only underestimate the actual prevalence but are also only available on coarse spatial scales. The discussion of including area deprivation for planning of healthcare is still relatively young in Germany, although previous studies have shown that area deprivation is associated with adverse health outcomes, irrespective of individual characteristics. The aim of this study is therefore to analyze the spatial distribution of hypertension at very fine geographic scales and to assess location-specific associations between hypertension, socio-demographic population characteristics and area deprivation based on health insurance claims of the AOK Nordost. To visualize the spatial distribution of hypertension prevalence at very fine geographic scales, we used the conditional autoregressive Besag-York-Mollié (BYM) model. Geographically weighted regression modelling (GWR) was applied to analyze the location-specific association of hypertension to area deprivation and further socio-demographic population characteristics. The sex- and age-adjusted prevalence of hypertension was 33.1% in 2012 and varied widely across northeastern Germany. The main risk factors for hypertension were proportions of insurants aged 45-64, 65 and older, area deprivation and proportion of persons commuting to work outside their residential municipality. The GWR model revealed important regional variations in the strength of the examined associations. Area deprivation has only a significant and therefore direct influence in large parts of Mecklenburg-West Pomerania. However, the spatially varying strength of the association between demographic

  17. Optimum amount of an insurance sum in life insurance

    Directory of Open Access Journals (Sweden)

    Janez Balkovec

    2001-01-01

    Full Text Available Personal insurance represents one of the sources of personal social security as a category of personal property. How to get a proper life insurance is a frequently asked question. When insuring material objects (car, house..., the problem is usually not in the amount of the taken insurance. With life insurance (abstract goods, problems as such occur. In this paper, we wish to present a model that, according to the financial situation and the anticipated future, makes it possible to calculate the optimum insurance sum in life insurance.

  18. Modifications to the Rules of the CERN Health Insurance Scheme

    CERN Multimedia

    HR Department

    2010-01-01

    On the proposal of the CHIS Board, and following examination by the Standing Concertation Committee on 29 April 2010, the Director-General has approved the new Rules of the CERN Health Insurance Scheme, which will come into effect on 1 June 2010. The Rules will shortly be available on the CHIS web site. As the Rules had not been revised since 2003, it had become necessary to make certain changes in order to bring them into line with other texts (such as the Staff Rules and Regulations and Administrative Circulars) and to clarify some practices. The new Rules do not introduce any new benefits or remove any existing ones. The following changes will affect all insured members:   Description of change Articles in the new Rules Time limit for claiming reimbursement The time period is measured from the invoice date (instead of the date of treatment). ...

  19. European consumers and health claims: attitudes, understanding and purchasing behaviour.

    Science.gov (United States)

    Wills, Josephine M; Storcksdieck genannt Bonsmann, Stefan; Kolka, Magdalena; Grunert, Klaus G

    2012-05-01

    Health claims on food products are often used as a means to highlight scientifically proven health benefits associated with consuming those foods. But do consumers understand and trust health claims? This paper provides an overview of recent research on consumers and health claims including attitudes, understanding and purchasing behaviour. A majority of studies investigated selective product-claim combinations, with ambiguous findings apart from consumers' self-reported generic interest in health claims. There are clear indications that consumer responses differ substantially according to the nature of carrier product, the type of health claim, functional ingredient used or a combination of these components. Health claims tend to be perceived more positively when linked to a product with an overall positive health image, whereas some studies demonstrate higher perceived credibility of products with general health claims (e.g. omega-3 and brain development) compared to disease risk reduction claims (e.g. bioactive peptides to reduce risk of heart disease), others report the opposite. Inconsistent evidence also exists on the correlation between having a positive attitude towards products with health claims and purchase intentions. Familiarity with the functional ingredient and/or its claimed health effect seems to result in a more favourable evaluation. Better nutritional knowledge, however, does not automatically lead to a positive attitude towards products carrying health messages. Legislation in the European Union requires that the claim is understood by the average consumer. As most studies on consumers' understanding of health claims are based on subjective understanding, this remains an area for more investigation.

  20. The Impact of Incident Disclosure Behaviors on Medical Malpractice Claims.

    Science.gov (United States)

    Giraldo, Priscila; Sato, Luke; Castells, Xavier

    2017-06-30

    To provide preliminary estimates of incident disclosure behaviors on medical malpractice claims. We conducted a descriptive analysis of data on medical malpractice claims obtained from the Controlled Risk Insurance Company and Risk Management Foundation of Harvard Medical Institutions (Cambridge, Massachusetts) between 2012 and 2013 (n = 434). The characteristics of disclosure and apology after medical errors were analyzed. Of 434 medical malpractice claims, 4.6% (n = 20) medical errors had been disclosed to the patient at the time of the error, and 5.9% (n = 26) had been followed by disclosure and apology. The highest number of disclosed injuries occurred in 2011 (23.9%; n = 11) and 2012 (34.8%; n = 16). There was no incremental increase during the financial years studied (2012-2013). The mean age of informed patients was 52.96 years, 58.7 % of the patients were female, and 52.2% were inpatients. Of the disclosed errors, 26.1% led to an adverse reaction, and 17.4% were fatal. The cause of disclosed medical error was improper surgical performance in 17.4% (95% confidence interval, 6.4-28.4). Disclosed medical errors were classified as medium severity in 67.4%. No apology statement was issued in 54.5% of medical errors classified as high severity. At the health-care centers studied, when a claim followed a medical error, providers infrequently disclosed medical errors or apologized to the patient or relatives. Most of the medical errors followed by disclosure and apology were classified as being of high and medium severity. No changes were detected in the volume of lawsuits over time.

  1. Sports-related injuries in New Zealand: National Insurance (Accident Compensation Corporation) claims for five sporting codes from 2012 to 2016.

    Science.gov (United States)

    King, Doug; Hume, Patria A; Hardaker, Natalie; Cummins, Cloe; Gissane, Conor; Clark, Trevor

    2018-03-12

    To provide epidemiological data and related costs for sport-related injuries of five sporting codes (cricket, netball, rugby league, rugby union and football) in New Zealand for moderate-to-serious and serious injury claims. A retrospective analytical review using detailed descriptive epidemiological data obtained from the Accident Compensation Corporation (ACC) for 2012-2016. Over the 5 years of study data, rugby union recorded the most moderate-to-serious injury entitlement claims (25 226) and costs (New Zealand dollars (NZD$)267 359 440 (£139 084 749)) resulting in the highest mean cost (NZD$10 484 (£5454)) per moderate-to-serious injury entitlement claim. Rugby union recorded more serious injury entitlement claims (n=454) than cricket (t (4) =-66.6; P<0.0001); netball (t (4) =-45.1; P<0.0001); rugby league (t (4) =-61.4; P<0.0001) and football (t (4) =66.6; P<0.0001) for 2012-2016. There was a twofold increase in the number of female moderate-to-serious injury entitlement claims for football (RR 2.6 (95%CI 2.2 to 2.9); P<0.0001) compared with cricket, and a threefold increase when compared with rugby union (risk ratio (RR) 3.1 (95%CI 2.9 to 3.3); P<0.0001). Moderate-to-serious concussion claims increased between 2012 and 2016 for netball (RR 3.7 (95%CI 1.9 to 7.1); P<0.0001), rugby union (RR 2.0 (95% CI 1.6 to 2.4); P<0.0001) and football (RR 2.3 (95%CI 1.6 to 3.2); P<0.0001). Nearly a quarter of moderate-to-serious entitlement claims (23%) and costs (24%) were to participants aged 35 years or older. Rugby union and rugby league have the highest total number and costs associated with injury. Accurate sport exposure data are needed to enable injury risk calculations. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  2. An in-depth assessment of a diagnosis-based risk adjustment model based on national health insurance claims: the application of the Johns Hopkins Adjusted Clinical Group case-mix system in Taiwan

    Directory of Open Access Journals (Sweden)

    Weiner Jonathan P

    2010-01-01

    Full Text Available Abstract Background Diagnosis-based risk adjustment is becoming an important issue globally as a result of its implications for payment, high-risk predictive modelling and provider performance assessment. The Taiwanese National Health Insurance (NHI programme provides universal coverage and maintains a single national computerized claims database, which enables the application of diagnosis-based risk adjustment. However, research regarding risk adjustment is limited. This study aims to examine the performance of the Adjusted Clinical Group (ACG case-mix system using claims-based diagnosis information from the Taiwanese NHI programme. Methods A random sample of NHI enrollees was selected. Those continuously enrolled in 2002 were included for concurrent analyses (n = 173,234, while those in both 2002 and 2003 were included for prospective analyses (n = 164,562. Health status measures derived from 2002 diagnoses were used to explain the 2002 and 2003 health expenditure. A multivariate linear regression model was adopted after comparing the performance of seven different statistical models. Split-validation was performed in order to avoid overfitting. The performance measures were adjusted R2 and mean absolute prediction error of five types of expenditure at individual level, and predictive ratio of total expenditure at group level. Results The more comprehensive models performed better when used for explaining resource utilization. Adjusted R2 of total expenditure in concurrent/prospective analyses were 4.2%/4.4% in the demographic model, 15%/10% in the ACGs or ADGs (Aggregated Diagnosis Group model, and 40%/22% in the models containing EDCs (Expanded Diagnosis Cluster. When predicting expenditure for groups based on expenditure quintiles, all models underpredicted the highest expenditure group and overpredicted the four other groups. For groups based on morbidity burden, the ACGs model had the best performance overall. Conclusions Given the

  3. Insuring against Health Shocks: Health Insurance and Household Choices

    OpenAIRE

    Liu, Kai

    2015-01-01

    This paper provides empirical evidence on the role of public health insurance in mitigating adverse outcomes associated with health shocks. Exploiting the rollout of a universal health insurance program in rural China, I find that total household income and consumption are fully insured against health shocks even without access to health insurance. Household labor supply is an important insurance mechanism against health shocks. Access to health insurance helps households to maintain investme...

  4. How does age affect the care dependency risk one year after stroke? A study based on claims data from a German health insurance fund.

    Science.gov (United States)

    Schnitzer, Susanne; von dem Knesebeck, Olaf; Kohler, Martin; Peschke, Dirk; Kuhlmey, Adelheid; Schenk, Liane

    2015-10-23

    The objective of this study is to investigate the effect of age on care dependency risk 1 year after stroke. Two research questions are addressed: (1) How strong is the association between age and care dependency risk 1 year after stroke and (2) can this association be explained by burden of disease? The study is based on claims data from a German statutory health insurance fund. The study population was drawn from all continuously insured members with principal diagnoses of ischaemic stroke, hemorrhagic stroke, or transient ischaemic attack in 2007 who survived for 1 year after stroke and who were not dependent on care before their first stroke (n = 2864). Data were collected over a 1-year period. People are considered to be dependent on care if they, due to a physical, mental or psychological illness or disability, require substantial assistance in carrying out activities of daily living for a period of at least 6 months. Burden of disease was assessed by stroke subtype, history of stroke, comorbidities as well as geriatric multimorbidity. Regression models were used for data analysis. 21.6 % of patients became care dependent during the observation period. Post-stroke care dependency risk was significantly associated with age. Relative to the reference group (0-65 years), the odds ratio of care dependency was 11.30 (95 % CI: 7.82-16.34) in patients aged 86+ years and 5.10 (95 % CI: 3.88-6.71) in patients aged 76-85 years. These associations were not explained by burden of disease. On the contrary, age effects became stronger when burden of disease was included in the regression model (by between 1.1 and 28 %). Our results show that age has an effect on care dependency risk that cannot be explained by burden of disease. Thus, there must be other underlying age-dependent factors that account for the remaining age effects (e.g., social conditions). Further studies are needed to explore the causes of the strong age effects observed.

  5. Leftist Movements, Gender, and the Argentinean Textile Industry. The Position of the Communist and Socialist Parties vis-à-vis the Claims of Female Workers, 1936-1946

    Directory of Open Access Journals (Sweden)

    Verónica Norando

    2017-07-01

    Full Text Available The article addresses the incorporation of gender demands into the claims of female textile workers in Argentina, as well as the positions assumed in that respect by the Socialist Party and the Communist Party, through the analysis of three case studies: two textile worker strikes and the claim for the reform of the Maternity Insurance Law. The objective is to study the relationships of these parties with the claims of female workers from a perspective that links gender and class relations, on the basis of both worker and State sources. One of the fundamental conclusions of this study is that the Socialist and Communist Parties played an active role in transforming those claims into concrete realizations.

  6. Nuclear Liability and Insurance Cover for Risk of Nuclear Power Plants - Situation for Nuclear Installations in Germany

    International Nuclear Information System (INIS)

    Boediker, T.

    1998-01-01

    A dispute about nuclear liability and insurance cover for risks of nuclear power plants from an insurer's point of view has to determine and to judge the essential risk relevant factors. These are beside plant and site specific factors considerations of insurance restrictions in the extent of cover compared with the legal scope of liability for (re-)insurability's sake. Among such consideration are: financial limitation and obligation for its reinstatement, exclusions for gradual emissions of approved activities, armed conflicts, hostilities, civil war, insurrections or grave natural disaster and restrictions in the limitation and preclusion periods. In comparison with conventional liability risks there are some specialties to be considered some of which prove to be a risk relief other as a risk burden for insurance: Salvage expenses or interests and court costs to be paid by unsuccessful party in a lost litigation do not fall under legal liability and hence are excluded from the financial security cover so that are compensation is subject to agreed separate limits. A serious burden for the insurers can result out of the loss regulation costs in case of a severe nuclear accident. These expenses, which can exceed hundred million DM by far, are to be carried by the insurers in the frame of their obligation to investigate raised claims. Therefore the insurers should aim a fixed limitation in order to restrict their limit. (author)

  7. Outcomes of direct pulp capping: interrogating an insurance database.

    Science.gov (United States)

    Raedel, M; Hartmann, A; Bohm, S; Konstantinidis, I; Priess, H W; Walter, M H

    2016-11-01

    To evaluate the effectiveness of direct pulp capping under general practice conditions. It was hypothesized that direct pulp capping is an effective procedure in the majority of cases and prevents the need for root canal treatment or extraction. Claims data were collected from the digital database of a major German national health insurance company. Only patients who had been insurance members for the entire 3 year period 2010 to 2012 were eligible. Kaplan-Meier survival analyses were conducted for all teeth with direct pulp capping. Success was defined as not undergoing root canal treatment. Survival was defined as not undergoing extraction. Differences between survival functions were tested with the log rank test. A total of 148 312 teeth were included. The overall success rate was 71.6% at 3 years. The overall survival rate was 95.9% at 3 years. The success rates for single-rooted teeth (71.8%) and multirooted teeth (71.5%) were similar although significantly different (P 85 years.). After direct pulp capping, more than two-thirds of the affected teeth did not undergo root canal treatment within 3 years. Although this study has the typical limits of a claims data analysis, it can be concluded that direct pulp capping is an effective intervention to avoid root canal treatment and extraction in a general practice setting. © 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd.

  8. Development of the Health Insurance Literacy Measure (HILM): Conceptualizing and Measuring Consumer Ability to Choose and Use Private Health Insurance

    Science.gov (United States)

    Paez, Kathryn A.; Mallery, Coretta J.; Noel, HarmoniJoie; Pugliese, Christopher; McSorley, Veronica E.; Lucado, Jennifer L.; Ganachari, Deepa

    2014-01-01

    Understanding health insurance is central to affording and accessing health care in the United States. Efforts to support consumers in making wise purchasing decisions and using health insurance to their advantage would benefit from the development of a valid and reliable measure to assess health insurance literacy. This article reports on the development of the Health Insurance Literacy Measure (HILM), a self-assessment measure of consumers' ability to select and use private health insurance. The authors developed a conceptual model of health insurance literacy based on formative research and stakeholder guidance. Survey items were drafted using the conceptual model as a guide then tested in two rounds of cognitive interviews. After a field test with 828 respondents, exploratory factor analysis revealed two HILM scales, choosing health insurance and using health insurance, each of which is divided into a confidence subscale and likelihood of behavior subscale. Correlations between the HILM scales and an objective measure of health insurance knowledge and skills were positive and statistically significant which supports the validity of the measure. PMID:25315595

  9. Healthcare Coinsurance Elasticity Coefficient Estimation Using Monthly Cross-sectional, Time-series Claims Data.

    Science.gov (United States)

    Scoggins, John F; Weinberg, Daniel A

    2017-06-01

    Published estimates of the healthcare coinsurance elasticity coefficient have typically relied on annual observations of individual healthcare expenditures even though health plan membership and expenditures are traditionally reported in monthly units and several studies have stressed the need for demand models to recognize the episodic nature of healthcare. Summing individual healthcare expenditures into annual observations complicates two common challenges of statistical inference, heteroscedasticity, and regressor endogeneity. This paper estimates the elasticity coefficient using a monthly panel data model that addresses the heteroscedasticity and endogeneity problems with relative ease. Healthcare claims data from employees of King County, Washington, during 2005 to 2011 were used to estimate the mean point elasticity coefficient: -0.314 (0.015 standard error) to -0.145 (0.015 standard error) depending on model specification. These estimates bracket the -0.2 point estimate (range: -0.22 to -0.17) derived from the famous Rand Health Insurance Experiment. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

  10. Insuring against health shocks: Health insurance and household choices.

    Science.gov (United States)

    Liu, Kai

    2016-03-01

    This paper provides empirical evidence on the role of public health insurance in mitigating adverse outcomes associated with health shocks. Exploiting the rollout of a universal health insurance program in rural China, I find that total household income and consumption are fully insured against health shocks even without access to health insurance. Household labor supply is an important insurance mechanism against health shocks. Access to health insurance helps households to maintain investment in children's human capital during negative health shocks, which suggests that one benefit of health insurance could arise from reducing the use of costly smoothing mechanisms. Copyright © 2016 Elsevier B.V. All rights reserved.

  11. Etiology of work-related electrical injuries: a narrative analysis of workers' compensation claims.

    Science.gov (United States)

    Lombardi, David A; Matz, Simon; Brennan, Melanye J; Smith, Gordon S; Courtney, Theodore K

    2009-10-01

    The purpose of this study was to provide new insight into the etiology of primarily nonfatal, work-related electrical injuries. We developed a multistage, case-selection algorithm to identify electrical-related injuries from workers' compensation claims and a customized coding taxonomy to identify pre-injury circumstances. Workers' compensation claims routinely collected over a 1-year period from a large U.S. insurance provider were used to identify electrical-related injuries using an algorithm that evaluated: coded injury cause information, nature of injury, "accident" description, and injury description narratives. Concurrently, a customized coding taxonomy for these narratives was developed to abstract the activity, source, initiating process, mechanism, vector, and voltage. Among the 586,567 reported claims during 2002, electrical-related injuries accounted for 1283 (0.22%) of nonfatal claims and 15 fatalities (1.2% of electrical). Most (72.3%) were male, average age of 36, working in services (33.4%), manufacturing (24.7%), retail trade (17.3%), and construction (7.2%). Body part(s) injured most often were the hands, fingers, or wrist (34.9%); multiple body parts/systems (25.0%); lower/upper arm; elbow; shoulder, and upper extremities (19.2%). The leading activities were conducting manual tasks (55.1%); working with machinery, appliances, or equipment; working with electrical wire; and operating powered or nonpowered hand tools. Primary injury sources were appliances and office equipment (24.4%); wires, cables/cords (18.0%); machines and other equipment (11.8%); fixtures, bulbs, and switches (10.4%); and lightning (4.3%). No vector was identified in 85% of cases. and the work process was initiated by others in less than 1% of cases. Injury narratives provide valuable information to overcome some of the limitations of precoded data, more specially for identifying additional injury cases and in supplementing traditional epidemiologic data for further

  12. ClaimAssociationService

    Data.gov (United States)

    Department of Veterans Affairs — Retrieves and updates a veteranÆs claim status and claim-rating association (claim association for current rating) from the Corporate database for a claim selected...

  13. Clinical safety and professional liability claims in Ophthalmology.

    Science.gov (United States)

    Dolz-Güerri, F; Gómez-Durán, E L; Martínez-Palmer, A; Castilla Céspedes, M; Arimany-Manso, J

    2017-11-01

    Patient safety is an international public health priority. Ophthalmology scientific societies and organisations have intensified their efforts in this field. As a tool to learn from errors, these efforts have been linked to the management of medical professional liability insurance through the analysis of claims. A review is performed on the improvements in patient safety, as well as professional liability issues in Ophthalmology. There is a high frequency of claims and risk of economic reparation of damage in the event of a claim in Ophthalmology. Special complaints, such as wrong surgery or lack of information, have a high risk of financial compensation and need strong efforts to prevent these potentially avoidable events. Studies focused on pathologies or specific procedures provide information of special interest to sub-specialists. The specialist in Ophthalmology, like any other doctor, is subject to the current legal provisions and appropriate mandatory training in the medical-legal aspects of health care is essential. Professionals must be aware of the fundamental aspects of medical professional liability, as well as specific aspects, such as defensive medicine and clinical safety. The understanding of these medical-legal aspects in the routine clinical practice can help to pave the way towards a satisfactory and safe professional career, and help in increasing patient safety. The aim of this review is to contribute to this training, for the benefit of professionals and patients. Copyright © 2017 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L.U. All rights reserved.

  14. Administrative Costs Associated With Physician Billing and Insurance-Related Activities at an Academic Health Care System.

    Science.gov (United States)

    Tseng, Phillip; Kaplan, Robert S; Richman, Barak D; Shah, Mahek A; Schulman, Kevin A

    2018-02-20

    Administrative costs in the US health care system are an important component of total health care spending, and a substantial proportion of these costs are attributable to billing and insurance-related activities. To examine and estimate the administrative costs associated with physician billing activities in a large academic health care system with a certified electronic health record system. This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system's total cost of processing an insurance claim. Estimated time required to perform billing and insurance-related activities, based on interviews with management personnel and physicians. Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures. Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of

  15. Defining the key-parameters of insurance product in Islamic insurance

    Directory of Open Access Journals (Sweden)

    Galim Zaribzyanovich Vakhitov

    2015-06-01

    Full Text Available Objective to define the range of actuarial calculations in Islamic insurance to study the main differences of the traditional and Islamic insurance to define what changes in calculations entail the above differences. Methods mathematical modeling probabilistic analysis of insurance risks adaptation of methods of actuarial mathematics to the principles of Islamic insurance. Results the mathematical form of the takafulfund models is presented the distribution is analyzed of a random variable of the resulting insurance fund or the insurance company balance in a particular fixed insurance portfolio. Scientific novelty calculation are presented of the optimal tariff rate in takaful. Islamic insurance is an innovative area of insurance industry. Actuarial calculations that meet the Sharia rules are still being developed. The authors set the new tasks of actuarial calculations including the specified changes in the calculation of the optimal tariff rate imposed by the Islamic insurance principles. Practical value the results obtained can be used in the actuarial calculations of the Islamic insurance companies. nbsp

  16. 32 CFR 536.35 - Unique issues related to environmental claims.

    Science.gov (United States)

    2010-07-01

    ... 32 National Defense 3 2010-07-01 2010-07-01 true Unique issues related to environmental claims... issues related to environmental claims. Claims for property damage, personal injury, or death arising in... reported by USARCS to the Environmental Law Division of the Army Litigation Center and the Environmental...

  17. Exploring health insurance services in Sudan from the perspectives of insurers.

    Science.gov (United States)

    Salim, Anas Mustafa Ahmed; Hamed, Fatima Hashim Mahmoud

    2018-01-01

    It has been 20 years since the introduction of health insurance in Sudan. This study was the first one that explored health insurance services in Sudan from the perspectives of the insurers. This was a qualitative, exploratory, interview study. The sampling frame was the list of Social Health Insurance and Private Health Insurance institutions in Sudan. Participants were selected from the four Social Health Insurance institutions and from five Private Health Insurance companies. The study was conducted in January and February 2017. In-depth individual interviews were conducted with a convenient sample of key executives from the different health insurers. Ideas and themes were identified and analysed using thematic analysis. The result showed that universal coverage was not achieved despite long time presence of Social Health Insurance and Private Health Insurance in Sudan. All participants described their services as comprehensive. All participants have good perception of the quality of the services they provide, although none of them investigated customer satisfaction. The main challenges facing Social Health Insurance are achieving universal coverage, ensuring sustainability and recruitment of the informal sector and self-employed population. Consumers' affordability of the premiums is the main obstacle for Private Health Insurance, while rising healthcare cost due to economic inflation is a challenge facing both Social Health Insurance and Private Health Insurance. In spite of the presence of Social Health Insurance and Private Health Insurance in Sudan, the country is still far from achieving universal coverage. Moreover, the sustainability of health insurance is questionable. The main reasons include low governmental financial resources and lack of affordability by beneficiaries especially for Private Health Insurance. This necessitates finding solutions to improve them or trying other types of health insurance. The quality of services provided by Social

  18. Out-of-pocket medical expenses for inpatient care among beneficiaries of the National Health Insurance Program in the Philippines.

    Science.gov (United States)

    Tobe, Makoto; Stickley, Andrew; del Rosario, Rodolfo B; Shibuya, Kenji

    2013-08-01

    OBJECTIVE The National Health Insurance Program (NHIP) in the Philippines is a social health insurance system partially subsidized by tax-based financing which offers benefits on a fee-for-service basis up to a fixed ceiling. This paper quantifies the extent to which beneficiaries of the NHIP incur out-of-pocket expenses for inpatient care, and examines the characteristics of beneficiaries making these payments and the hospitals in which these payments are typically made. METHODS Probit and ordinary least squares regression analyses were carried out on 94 531 insurance claims from Benguet province and Baguio city during the period 2007 to 2009. RESULTS Eighty-six per cent of claims involved an out-of-pocket payment. The median figure for out-of-pocket payments was Philippine Pesos (PHP) 3016 (US$67), with this figure varying widely [inter-quartile range (IQR): PHP 9393 (US$209)]. Thirteen per cent of claims involved very large out-of-pocket payments exceeding PHP 19 213 (US$428)-the equivalent of 10% of the average annual household income in the region. Membership type, disease severity, age and residential location of the patient, length of hospitalization, and ownership and level of the hospital were all significantly associated with making out-of-pocket payments and/or the size of these payments. CONCLUSION Although the current NHIP reduces the size of out-of-pocket payments, NHIP beneficiaries are not completely free from the risk of large out-of-pocket payments (as the size of these payments varies widely and can be extremely large), despite NHIP's attempts to mitigate this by setting different benefit ceilings based on the level of the hospital and the severity of the disease. To reduce these large out-of-pocket payments and to increase financial risk protection further, it is essential to ensure more investment for health from social health insurance and/or tax-based government funding as well as shifting the provider payment mechanism from a fee

  19. Defining hip fracture with claims data: outpatient and provider claims matter.

    Science.gov (United States)

    Berry, S D; Zullo, A R; McConeghy, K; Lee, Y; Daiello, L; Kiel, D P

    2017-07-01

    Medicare claims are commonly used to identify hip fractures, but there is no universally accepted definition. We found that a definition using inpatient claims identified fewer fractures than a definition including outpatient and provider claims. Few additional fractures were identified by including inconsistent diagnostic and procedural codes at contiguous sites. Medicare claims data is commonly used in research studies to identify hip fractures, but there is no universally accepted definition of fracture. Our purpose was to describe potential misclassification when hip fractures are defined using Medicare Part A (inpatient) claims without considering Part B (outpatient and provider) claims and when inconsistent diagnostic and procedural codes occur at contiguous fracture sites (e.g., femoral shaft or pelvic). Participants included all long-stay nursing home residents enrolled in Medicare Parts A and B fee-for-service between 1/1/2008 and 12/31/2009 with follow-up through 12/31/2011. We compared the number of hip fractures identified using only Part A claims to (1) Part A plus Part B claims and (2) Part A and Part B claims plus discordant codes at contiguous fracture sites. Among 1,257,279 long-stay residents, 40,932 (3.2%) met the definition of hip fracture using Part A claims, and 41,687 residents (3.3%) met the definition using Part B claims. 4566 hip fractures identified using Part B claims would not have been captured using Part A claims. An additional 227 hip fractures were identified after considering contiguous fracture sites. When ascertaining hip fractures, a definition using outpatient and provider claims identified 11% more fractures than a definition with only inpatient claims. Future studies should publish their definition of fracture and specify if diagnostic codes from contiguous fracture sites were used.

  20. Entitlement to Sickness Benefits in Sweden: The Social Insurance Officers Experiences

    Directory of Open Access Journals (Sweden)

    Ulrika Müssener

    2008-01-01

    Full Text Available Background: Social insurance offices (SIOs handle a wide range of complex assessments of the entitlement to sickness benefits for an increasing number of clients on sick leave and consequently, the demands on the SIOs have increased considerably.Aim: To gain deeper knowledge of the problems experienced by the SIOs in their work associated with entitlement to sickness benefits.Method: A descriptive and explorative qualitative approach was used to analyse data from two focus-group interviews, including six participants in each group.Results: The participants discussed different dilemmas in regard to; physicians’ responsibility for issuing sickness certificates, interactions with the insured individuals, disclosure of decisions, communications with medical consultants, documentation of sickness benefit claims, threats in the workplace, as well as their own competence. The SIOs regarded incomplete information on sickness certificates as a main problem, because they frequently had to contact the client and the physicians who issued the certificates in order to obtain further details, leading to delays in the decision-making whether to grant sickness benefits.Conclusions: More knowledge regarding SIOs work is required to improve the methods used in the sickness insurance system and to ensure adequate training of new staff members.

  1. Exaggerated Claims for Interactive Stories

    Science.gov (United States)

    Thue, David; Bulitko, Vadim; Spetch, Marcia; Webb, Michael

    As advertising becomes more crucial to video games' success, developers risk promoting their products beyond the features that they can actually include. For features of interactive storytelling, the effects of making such exaggerations are not well known, as reports from industry have been anecdotal at best. In this paper, we explore the effects of making exaggerated claims for interactive stories, in the context of the theory of advertising. Results from a human user study show that female players find linear and branching stories to be significantly less enjoyable when they are advertised with exaggerated claims.

  2. 24 CFR 266.600 - Mortgage insurance premium: Insurance upon completion.

    Science.gov (United States)

    2010-04-01

    ... 24 Housing and Urban Development 2 2010-04-01 2010-04-01 false Mortgage insurance premium... MULTIFAMILY PROJECT LOANS Contract Rights and Obligations Mortgage Insurance Premiums § 266.600 Mortgage insurance premium: Insurance upon completion. (a) Initial premium. For projects insured upon completion, on...

  3. Migrating from user fees to social health insurance: exploring the prospects and challenges for hospital management.

    Science.gov (United States)

    Atinga, Roger A; Mensah, Sylvester A; Asenso-Boadi, Francis; Adjei, Francis-Xavier Andoh

    2012-06-22

    In 2003 Ghana introduced a social health insurance scheme which resulted in the separation of purchasing of health services by the health insurance authority on the one hand and the provision of health services by hospitals at the other side of the spectrum. This separation has a lot of implications for managing accredited hospitals. This paper examines whether decoupling purchasing and service provision translate into opportunities or challenges in the management of accredited hospitals. A qualitative exploratory study of 15 accredited district hospitals were selected from five of Ghana's ten administrative regions for the study. A semi-structured interview guide was designed to solicit information from key informants, Health Service Administrators, Pharmacists, Accountants and Scheme Managers of the hospitals studied. Data was analysed thematically. The results showed that under the health insurance scheme, hospitals are better-off in terms of cash flow and adequate stock levels of drugs. Adequate stock of non-drugs under the scheme was reportedly intermittent. The major challenges confronting the hospitals were identified as weak purchasing power due to low tariffs, non computerisation of claims processing, unpredictable payment pattern, poor gate-keeping systems, lack of logistics and other new and emerging challenges relating to moral hazards and the use of false identity cards under pretence for medical care. Study's findings have a lot of policy implications for proper management of hospitals. The findings suggest rationalisation of the current tariff structure, the application of contract based payment system to inject efficiency into hospitals management and piloting facility based vetting systems to offset vetting loads of the insurance authority. Proper gate-keeping mechanisms are also needed to curtail the phenomenon of moral hazard and false documentation.

  4. Use of health care claims data to study patients with ophthalmologic conditions.

    Science.gov (United States)

    Stein, Joshua D; Lum, Flora; Lee, Paul P; Rich, William L; Coleman, Anne L

    2014-05-01

    To describe what information is or is not included in health care claims data, provide an overview of the main advantages and limitations of performing analyses using health care claims data, and offer general guidance on how to report and interpret findings of ophthalmology-related claims data analyses. Systematic review. Not applicable. A literature review and synthesis of methods for claims-based data analyses. Not applicable. Some advantages of using claims data for analyses include large, diverse sample sizes, longitudinal follow-up, lack of selection bias, and potential for complex, multivariable modeling. The disadvantages include (a) the inherent limitations of claims data, such as incomplete, inaccurate, or missing data, or the lack of specific billing codes for some conditions; and (b) the inability, in some circumstances, to adequately evaluate the appropriateness of care. In general, reports of claims data analyses should include clear descriptions of the following methodological elements: the data source, the inclusion and exclusion criteria, the specific billing codes used, and the potential confounding factors incorporated in the multivariable models. The use of claims data for research is expected to increase with the enhanced availability of data from Medicare and other sources. The use of claims data to evaluate resource use and efficiency and to determine the basis for supplementary payment methods for physicians is anticipated. Thus, it will be increasingly important for eye care providers to use accurate and descriptive codes for billing. Adherence to general guidance on the reporting of claims data analyses, as outlined in this article, is important to enhance the credibility and applicability of findings. Guidance on optimal ways to conduct and report ophthalmology-related investigations using claims data will likely continue to evolve as health services researchers refine the metrics to analyze large administrative data sets. Copyright

  5. The challenge of forecasting impacts of flash floods: test of a simplified hydraulic approach and validation based on insurance claim data

    Directory of Open Access Journals (Sweden)

    G. Le Bihan

    2017-11-01

    Full Text Available Up to now, flash flood monitoring and forecasting systems, based on rainfall radar measurements and distributed rainfall–runoff models, generally aimed at estimating flood magnitudes – typically discharges or return periods – at selected river cross sections. The approach presented here goes one step further by proposing an integrated forecasting chain for the direct assessment of flash flood possible impacts on inhabited areas (number of buildings at risk in the presented case studies. The proposed approach includes, in addition to a distributed rainfall–runoff model, an automatic hydraulic method suited for the computation of flood extent maps on a dense river network and over large territories. The resulting catalogue of flood extent maps is then combined with land use data to build a flood impact curve for each considered river reach, i.e. the number of inundated buildings versus discharge. These curves are finally used to compute estimated impacts based on forecasted discharges. The approach has been extensively tested in the regions of Alès and Draguignan, located in the south of France, where well-documented major flash floods recently occurred. The article presents two types of validation results. First, the automatically computed flood extent maps and corresponding water levels are tested against rating curves at available river gauging stations as well as against local reference or observed flood extent maps. Second, a rich and comprehensive insurance claim database is used to evaluate the relevance of the estimated impacts for some recent major floods.

  6. Indian community health insurance schemes provide partial protection against catastrophic health expenditure

    Directory of Open Access Journals (Sweden)

    Ranson Kent

    2007-03-01

    Full Text Available Abstract Background More than 72% of health expenditure in India is financed by individual households at the time of illness through out-of-pocket payments. This is a highly regressive way of financing health care and sometimes leads to impoverishment. Health insurance is recommended as a measure to protect households from such catastrophic health expenditure (CHE. We studied two Indian community health insurance (CHI schemes, ACCORD and SEWA, to determine whether insured households are protected from CHE. Methods ACCORD provides health insurance cover for the indigenous population, living in Gudalur, Tamil Nadu. SEWA provides insurance cover for self employed women in the state of Gujarat. Both cover hospitalisation expenses, but only upto a maximum limit of US$23 and US$45, respectively. We reviewed the insurance claims registers in both schemes and identified patients who were hospitalised during the period 01/04/2003 to 31/03/2004. Details of their diagnoses, places and costs of treatment and self-reported annual incomes were obtained. There is no single definition of CHE and none of these have been validated. For this research, we used the following definition; "annual hospital expenditure greater than 10% of annual income," to identify those who experienced CHE. Results There were a total of 683 and 3152 hospital admissions at ACCORD and SEWA, respectively. In the absence of the CHI scheme, all of the patients at ACCORD and SEWA would have had to pay OOP for their hospitalisation. With the CHI scheme, 67% and 34% of patients did not have to make any out-of-pocket (OOP payment for their hospital expenses at ACCORD and SEWA, respectively. Both CHI schemes halved the number of households that would have experienced CHE by covering hospital costs. However, despite this, 4% and 23% of households with admissions still experienced CHE at ACCORD and SEWA, respectively. This was related to the following conditions: low annual income, benefit

  7. Use of Data Mining Techniques to Detect Medical Fraud in Health Insurance

    Directory of Open Access Journals (Sweden)

    Kuo-Chung Lin

    2012-04-01

    Full Text Available The health insurance claims application case the inspection usually relies on experts’ experience for verification and experienced personnel in charge for checking. However, due to the heavy work load and the insufficiency of manpower and experience, the ratio of miscarriages of justice is high, leading to improper settlement of claims and the waste of social resources. This paper takes advantage of data-mining technology to design models and find out cases requiring for manual inspection so as to save time and manpower. Six models are designed in this paper. By the analysis of the 20/80 principle and the coverage and accuracy ratio, a great number of periodic data (over 2 million records are fed back to the data-mining models after repetitive verification. Also, it is discovered that to integrate the data-mining technology and feed back to different business stages so as to establish early warning system will be an important topic for the health insurance system in hospital’s EMR in the future. Meanwhile, as the information acquired by data-mining needs to be stored and the traditional database technology has limitations. Next time, this paper explores the ontology framework to be set up by semantic network technology in the future in order to assist the storage of knowledge gained by data-mining.

  8. [Rehabilitation in geriatric patients after ischemic stroke--a comparison of 2 organisational systems in Germany using claims data of a statutory health insurance fund].

    Science.gov (United States)

    Abbas, S; Ihle, P; Hein, R; Schubert, I

    2013-12-01

    Due to historical aspects in some federal states in Germany rehabilitation of geriatric patients is organized in geriatric departments in hospitals (§ 109 SGB V). In other states rehabilitation of these patients is mainly realized in geriatric rehabilitation facilities outside hospital care after approval by the health insurance (§ 111 SGB V). Thus, it is of interest to compare both types of health care with respect to differences in population characteristics, resource utilization and outcome parameters (i.e., excess costs, rehospitalization, fracture risk and mortality) using a common geriatric indication, the ischemic stroke, as an example. Claims data of the AOK (Local Health Care Fund) from seven federal states in Germany were used. Insured persons with a documented hospital stay with discharge diagnosis cerebral infarction/stroke (ICD-10 I63, I64, below denoted by "ischemic stroke") in 2007 (N=39,887) were included and allocated to the respective form of rehabilitative health care via the OPS (German procedure classification for inpatient procedures) procedure 8-550 (§ 109, N=1,272) or via admission to a geriatric rehabilitation unit within 1 month after hospital discharge (§ 111, N=2,200). All direct costs were ascertained and presented with and without costs of long-term care. Excess costs were calculated as the difference of costs between the first year after insult and the costs in the previous year. Excess costs in the 2 types of care were compared using multivariate quantile regression analysis. Risk of hospitalization (due to ischemic stroke or fracture) and risk of death in a 1-year follow-up was analysed using multivariate cox regression. Insured members treated according to health care type § 109 were somewhat older (mean: 81 vs. 80 years of age), more frequently female (72 vs. 67%), more often receiving long-term care (27 vs. 19%) and had more often documented sequelae after insult (>=4 diseases 39 vs. 28%). No significant differences in

  9. 76 FR 77442 - Mutual Insurance Holding Company Treated as Insurance Company

    Science.gov (United States)

    2011-12-13

    ... insurance industry traces its roots back to England, where, in 1696, the first mutual fire insurer was... FEDERAL DEPOSIT INSURANCE CORPORATION 12 CFR Part 380 RIN 3064-AD89 Mutual Insurance Holding Company Treated as Insurance Company AGENCY: Federal Deposit Insurance Corporation (FDIC). ACTION: Notice...

  10. Medicare Part D Claims Data

    Data.gov (United States)

    U.S. Department of Health & Human Services — This page contains information on Part D claims data for the purposes of research, analysis, reporting, and public health functions. These data will also be used to...

  11. The first report of Japanese antimicrobial use measured by national database based on health insurance claims data (2011-2013): comparison with sales data, and trend analysis stratified by antimicrobial category and age group.

    Science.gov (United States)

    Yamasaki, Daisuke; Tanabe, Masaki; Muraki, Yuichi; Kato, Genta; Ohmagari, Norio; Yagi, Tetsuya

    2018-04-01

    Our objective was to evaluate the utility of the national database (NDB) based on health insurance claims data for antimicrobial use (AMU) surveillance in medical institutions in Japan. The population-weighted total AMU expressed as defined daily doses (DDDs) per 1000 inhabitants per day (DID) was measured by the NDB. The data were compared with our previous study measured by the sales data. Trend analysis of DID from 2011 to 2013 and subgroup analysis stratified by antimicrobial category and age group were performed. There was a significant linear correlation between the AMUs measured by the sales data and the NDB. Total oral and parenteral AMUs (expressed in DID) were 1.04-fold from 12.654 in 2011 to 13.202 in 2013 and 1.13-fold from 0.734 to 0.829, respectively. Percentage of oral form among total AMU was high with more than 94% during the study period. AMU in the children group (0-14 years) decreased from 2011 to 2013 regardless of dosage form, although the working age group (15-64 years) and elderly group (65 and above years) increased. Oral AMU in the working age group was approximately two-thirds of those in the other age groups. In contrast, parenteral AMU in the elderly group was extremely high compared to the other age groups. The trend of AMU stratified by antimicrobial category and age group were successfully measured using the NDB, which can be a tool to monitor outcome indices for the national action plan on antimicrobial resistance.

  12. Trait self-esteem and claimed self-handicapping motives in sports situations.

    Science.gov (United States)

    Finez, Lucie; Berjot, Sophie; Rosnet, Elisabeth; Cleveland, Christena; Tice, Dianne M

    2012-12-01

    We examined the relationship between physical self-esteem and claimed self-handicapping among athletes by taking motives into consideration. In Study 1, 99 athletes were asked to report their tendency to engage in claimed self-handicapping for self-protective and self-enhancement motives (trait measures). Low self-esteem athletes reported a higher tendency to engage in claimed self-handicapping for these two motives compared with high self-esteem athletes. Neither low nor high self-esteem athletes reported a preference for one motive over the other. In Study 2, 107 athletes participated in a test that was ostensibly designed to assess high physical abilities - and thus to encourage self-handicapping for self-enhancement motives (success-meaningful condition) - or to assess low physical abilities, and thus to encourage self-handicapping for self-protective motives (failure-meaningful condition). Before starting the test, athletes were given the opportunity to claim handicaps that could impair their performance. Low self-esteem athletes claimed more handicaps than high self-esteem athletes in both conditions. Findings suggest that low physical self-esteem athletes engage more in claimed handicapping regardless of motives, relative to high physical self-esteem athletes.

  13. 49 CFR 544.6 - Contents of insurer reports.

    Science.gov (United States)

    2010-10-01

    ... thefts for vehicles manufactured in the 1983 or subsequent model years, subdivided into model year, model... manufactured in the 1983 or subsequent model years, subdivided into model year, model, make, and line, for this... vehicle superstructure, or other recovered parts, after the insurer had made a payment listed under...

  14. Questioning the claims from Kaiser.

    Science.gov (United States)

    Talbot-Smith, Alison; Gnani, Shamini; Pollock, Allyson M; Gray, Denis Pereira

    2004-06-01

    The article by Feachem et al, published in the BMJ in 2002, claimed to show that, compared with the United Kingdom (UK) National Health Service (NHS), the Kaiser Permanente healthcare system in the United States (US) has similar healthcare costs per capita, and performance that is considerably better in certain respects. To assess the accuracy of Feachem et al's comparison and conclusions. Detailed re-examination of the data and methods used and consideration of the 82 letters responding to the article. Analyses revealed four main areas in which Feachem et al's methodology was flawed. Firstly, the populations of patients served by Kaiser Permanente and by the NHS are fundamentally different. Kaiser's patients are mainly employed, significantly younger, and significantly less socially deprived and so are healthier. Feachem et al fail to adjust adequately for these factors. Secondly, Feachem et al have wrongly inflated NHS costs by omitting substantial user charges payable by Kaiser members for care, excluding the costs of marketing and administration, and deducting the surplus from Kaiser's costs while underestimating the capital charge element of the NHS budget and other costs. They also used two methods of converting currency, the currency rate and a health purchasing power parity conversion. This is double counting. Feachem et al reported that NHS costs were 10% less per head than Kaiser. Correcting for the double currency conversion gives the NHS a 40% cost advantage such that per capita costs are 1161 dollars and 1951 dollars for the NHS and Kaiser, respectively. Thirdly, Feachem et al use non-standardised data for NHS bed days from the Organisation for Economic Cooperation and Development, rather than official Department of Health bed availability and activity statistics for England. Leaving aside the non-comparability of the population and lack of standardisation of the data, the result is to inflate NHS acute bed use and underestimate the efficiency of

  15. Deposit Insurance Coverage, Credibility of Non-insurance, and Banking Crises

    DEFF Research Database (Denmark)

    Angkinand, Apanard; Wihlborg, Clas

    2005-01-01

    level require analyses of institutional factors affecting the credibility of non-insurance. In particular, the implementation of effective distress resolution procedures for banks would allow governments to reduce explicit deposit insurance coverage and, thereby, to strengthen market discipline......The ambiguity in existing empirical work with respect to effects of deposit insurance schemes on banks' risk-taking can be resolved if it is recognized that absence of deposit insurance is rarely credible and that the credibility of non-insurance can be enhanced by explicit deposit insurance...... schemes. We show that under reasonable conditions for effects on risk-taking of creditor protection in banking, and for effects on credibility of non-insurance of explicit coverage of deposit insurance schemes, there exists a partial level of coverage that maximizes market discipline and minimizes moral...

  16. Insurance premiums and insurance coverage of near-poor children.

    Science.gov (United States)

    Hadley, Jack; Reschovsky, James D; Cunningham, Peter; Kenney, Genevieve; Dubay, Lisa

    States increasingly are using premiums for near-poor children in their public insurance programs (Medicaid/SCHIP) to limit private insurance crowd-out and constrain program costs. Using national data from four rounds of the Community Tracking Study Household Surveys spanning the seven years from 1996 to 2003, this study estimates a multinomial logistic regression model examining how public and private insurance premiums affect insurance coverage outcomes (Medicaid/SCHIP coverage, private coverage, and no coverage). Higher public premiums are significantly associated with a lower probability of public coverage and higher probabilities of private coverage and uninsurance; higher private premiums are significantly related to a lower probability of private coverage and higher probabilities of public coverage and uninsurance. The results imply that uninsurance rates will rise if both public and private premiums increase, and suggest that states that impose or increase public insurance premiums for near-poor children will succeed in discouraging crowd-out of private insurance, but at the expense of higher rates of uninsurance. Sustained increases in private insurance premiums will continue to create enrollment pressures on state insurance programs for children.

  17. Nuclear insurance

    International Nuclear Information System (INIS)

    Anon.

    1992-01-01

    The yearbook contains among others the figures of the nuclear insurance line. According to these these the DKVG (German nuclear power plant insurance association) has 102 member insurance companies all registered in the Federal Republic of Germany. By using reinsurance capacities of the other pools at present property insurance amounts to 1.5 billion DM and liability insurance to 200 million DM. In 1991 the damage charges on account of DKV amounted to 3.1 (1990 : 4.3) million DM. From these 0.6 million DM are apportioned to payments and 2.5 million DM to reserves. One large damage would cost a maximum gross sum of 2.2 billion DM property and liability insurance; on account of DKVG 750 million DM. (orig./HSCH) [de

  18. Optimal Control for Insurers with a Jump-diffusion Risk Pro cess

    Institute of Scientific and Technical Information of China (English)

    WU Kun; XIAO Jian-wu; LUO Rong-hua

    2015-01-01

    In this paper, the optimal XL-reinsurance of an insurer with jump-diffusion risk process is studied. With the assumptions that the risk process is a compound Possion pro-cess perturbed by a standard Brownian motion and the reinsurance premium is calculated according to the variance principle, the implicit expression of the priority and corresponding value function when the utility function is exponential are obtained. At last, the value func-tion is argued, the properties of the priority about parameters are discussed and numerical results of the priority for various claim-size distributions are shown.

  19. Health insurance and use of medical services by men infected with HIV.

    Science.gov (United States)

    Katz, M H; Chang, S W; Buchbinder, S P; Hessol, N A; O'Malley, P; Doll, L S

    1995-01-01

    Among 178 HIV-infected men from the San Francisco City Clinic Cohort (SFCCC), we examined the association between health insurance and use of outpatient services and treatment. For men with private insurance, we also assessed the frequency of avoiding the use of health insurance. Men without private insurance reported fewer outpatient visits than men with fee-for-service or managed-care plans. Use of zidovudine for eligible men was similar for those with fee-for-service plans (74%), managed-care plans (77%), or no insurance (61%). Use of Pneumocytstis carinii pneumonia prophylaxis was similar for those with fee-for-service (93%) and managed-care plans (83%) but lower for those with no insurance (63%). Of 149 men with private insurance, 31 (21%) reported that they had avoided using their health insurance for medical expenses in the previous year. In multivariate analysis, the independent predictors of avoiding the use of insurance were working for a small company and living outside the San Francisco Bay Area. Having private insurance resulted in higher use of outpatient services, but the type of private insurance did not appear to affect the use of service or treatment. Fears of loss of coverage and confidentiality may negate some benefits of health insurance for HIV-infected persons.

  20. Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem?

    Science.gov (United States)

    Kusi, Anthony; Enemark, Ulrika; Hansen, Kristian S; Asante, Felix A

    2015-01-17

    Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources. The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified. Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS. Affordability

  1. Value Relevance of Embedded Value and IFRS 4 Insurance Contracts

    OpenAIRE

    Rebecca Chung-Fern Wu; Audrey Wen-Hsin Hsu

    2011-01-01

    In light of the recent exodus of foreign insurers from Taiwan and the local insurers’ outcries against the International Financial Reporting Standard (IFRS) 4 Insurance Contracts, we examine the value relevance of financial statements for life insurance firms, with particular interests to the embedded value (EV) disclosure. We find that the EV of equity has an incremental information role for book value of equity, which indicates that the accounting mismatching problem in the insurance indust...

  2. Prevalence of Low-Cost Generic Program Use in a Nationally Representative Cohort of Privately Insured Adults.

    Science.gov (United States)

    Pauly, Nathan James; Brown, Joshua David

    2015-12-01

    Administrative claims data are used for a wide variety of research and quality assurance purposes. Despite their utility, they are prone to medication exposure misclassification if medications are purchased without utilizing an insurance benefit. Low-cost generic programs (LCGPs) offered at major chain pharmacies are a relatively new and sparsely investigated source of exposure misclassification. Since they were implemented in 2006, LCGPs are now available at 8 of the 10 largest pharmacy chains and include a wide variety of medication classes. LCGP medications are often purchased out of pocket; thus, a pharmacy claim may never be submitted and exposure may go unobserved in claims data. There are little data regarding the utilization of these programs, and estimates of their use can provide important insights into the potential impact LCGPs may have on exposure misclassification in claims data. To (a) quantify the prevalence of LCGP users in a privately insured adult population, (b) assess patterns of LCGP use, and (c) compare clinical and demographic characteristics associated with LCGP users and nonusers. The study cohort consisted of 19,037 privately insured adults aged 18-64 who participated in the Medical Expenditure Panel Survey (MEPS) from 2007-2011. MEPS captures medication utilization at the pharmacy level, so prescription fills can be observed irrespective of a claim being filed. Pharmaceutical utilization was assessed at the individual level for each year of the study period, and LCGP use was recorded as a binary variable for each individual. An LCGP medication fill was identified if the total cost of the drug was paid out of pocket and matched the cost of medications listed on LCGP formularies available from Target, Walmart, CVS, or other major pharmacy retailers during these years. Cohort demographics and characteristics of interest included age, gender, race, employment status, marital status, family income, education level, residence in a metropolitan

  3. Increased Risk of Hospitalization for Heart Failure with Newly Prescribed Dipeptidyl Peptidase-4 Inhibitors and Pioglitazone Using the Korean Health Insurance Claims Database

    Directory of Open Access Journals (Sweden)

    Sunghwan Suh

    2015-06-01

    Full Text Available BackgroundWe assessed the association of dipeptidyl peptidase 4 inhibitors (DPP4i with hospitalization for heart failure (HF using the Korean Health Insurance claims database.MethodsWe collected data on newly prescribed sitagliptin, vildagliptin, and pioglitazone between January 1, 2009 and December 31, 2012 (mean follow-up of 336.8 days to 935,519 patients with diabetes (518,614 males and 416,905 females aged 40 to 79 years (mean age of 59.4 years.ResultsDuring the study, 998 patients were hospitalized for primary HF (115.7 per 100,000 patient-years. The incidence rate of hospitalization for HF was 117.7 per 100,000 per patient-years among patients on pioglitazone, 105.7 for sitagliptin, and 135.8 for vildagliptin. The hospitalization rate for HF was greatest in the first 30 days after starting the medication, which corresponded to a significantly higher incidence at days 0 to 30 compared with days 31 to 360 for all three drugs. The hazard ratios were 1.85 (pioglitazone, 2.00 (sitagliptin, and 1.79 (vildagliptin. The incidence of hospitalization for HF did not differ between the drugs for any time period.ConclusionThis study showed an increase in hospitalization for HF in the initial 30 days of the DPP4i and pioglitazone compared with the subsequent follow-up period. However, the differences between the drugs were not significant.

  4. Insurance crisis

    International Nuclear Information System (INIS)

    Williams, P.L.

    1996-01-01

    The article discusses the effects of financing and technology advances on the availability of insurance for independent power producers operating gas turbines. Combined cycle units which require new materials and processes make it difficult to assess risk. Insurers are denying coverage, or raising prices and deductibles. Many lenders, however, are requiring insurance prior to financing. Some solutions proposed include information sharing by industry participants and insurers and increased risk acceptance by plant owners/operators

  5. Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data.

    Science.gov (United States)

    Panczak, Radoslaw; Luta, Xhyljeta; Maessen, Maud; Stuck, Andreas E; Berlin, Claudia; Schmidlin, Kurt; Reich, Oliver; von Wyl, Viktor; Goodman, David C; Egger, Matthias; Zwahlen, Marcel; Clough-Gorr, Kerri M

    2017-02-01

    Health care spending increases sharply at the end of life. Little is known about variation of cost of end of life care between regions and the drivers of such variation. We studied small-area patterns of cost of care in the last year of life in Switzerland. We used mandatory health insurance claims data of individuals who died between 2008 and 2010 to derive cost of care. We used multilevel regression models to estimate differences in costs across 564 regions of place of residence, nested within 71 hospital service areas. We examined to what extent variation was explained by characteristics of individuals and regions, including measures of health care supply. The study population consisted of 113,277 individuals. The mean cost of care during last year of life was 32.5k (thousand) Swiss Francs per person (SD=33.2k). Cost differed substantially between regions after adjustment for patient age, sex, and cause of death. Variance was reduced by 52%-95% when we added individual and regional characteristics, with a strong effect of language region. Measures of supply of care did not show associations with costs. Remaining between and within hospital service area variations were most pronounced for older females and least for younger individuals. In Switzerland, small-area analysis revealed variation of cost of care during the last year of life according to linguistic regions and unexplained regional differences for older women. Cultural factors contribute to the delivery and utilization of health care during the last months of life and should be considered by policy makers.

  6. Relationships between treated hypertension and subsequent mortality in an insured population.

    Science.gov (United States)

    Ivanovic, Brian; Cumming, Marianne E; Pinkham, C Allen

    2004-01-01

    -gender-smoking status subsets examined. The differential in mortality was 125% to 160% of standard mortality based on the ratio of actual-to-expected claims. In this insured cohort, a designation of treated hypertension is associated with increased relative mortality compared to life insurance policyholders not so coded.

  7. Migrating from user fees to social health insurance: exploring the prospects and challenges for hospital management

    Science.gov (United States)

    2012-01-01

    Background In 2003 Ghana introduced a social health insurance scheme which resulted in the separation of purchasing of health services by the health insurance authority on the one hand and the provision of health services by hospitals at the other side of the spectrum. This separation has a lot of implications for managing accredited hospitals. This paper examines whether decoupling purchasing and service provision translate into opportunities or challenges in the management of accredited hospitals. Methods A qualitative exploratory study of 15 accredited district hospitals were selected from five of Ghana’s ten administrative regions for the study. A semi-structured interview guide was designed to solicit information from key informants, Health Service Administrators, Pharmacists, Accountants and Scheme Managers of the hospitals studied. Data was analysed thematically. Results The results showed that under the health insurance scheme, hospitals are better-off in terms of cash flow and adequate stock levels of drugs. Adequate stock of non-drugs under the scheme was reportedly intermittent. The major challenges confronting the hospitals were identified as weak purchasing power due to low tariffs, non computerisation of claims processing, unpredictable payment pattern, poor gate-keeping systems, lack of logistics and other new and emerging challenges relating to moral hazards and the use of false identity cards under pretence for medical care. Conclusion Study’s findings have a lot of policy implications for proper management of hospitals. The findings suggest rationalisation of the current tariff structure, the application of contract based payment system to inject efficiency into hospitals management and piloting facility based vetting systems to offset vetting loads of the insurance authority. Proper gate-keeping mechanisms are also needed to curtail the phenomenon of moral hazard and false documentation. PMID:22726666

  8. Migrating from user fees to social health insurance: exploring the prospects and challenges for hospital management

    Directory of Open Access Journals (Sweden)

    Atinga Roger A

    2012-06-01

    Full Text Available Abstract Background In 2003 Ghana introduced a social health insurance scheme which resulted in the separation of purchasing of health services by the health insurance authority on the one hand and the provision of health services by hospitals at the other side of the spectrum. This separation has a lot of implications for managing accredited hospitals. This paper examines whether decoupling purchasing and service provision translate into opportunities or challenges in the management of accredited hospitals. Methods A qualitative exploratory study of 15 accredited district hospitals were selected from five of Ghana’s ten administrative regions for the study. A semi-structured interview guide was designed to solicit information from key informants, Health Service Administrators, Pharmacists, Accountants and Scheme Managers of the hospitals studied. Data was analysed thematically. Results The results showed that under the health insurance scheme, hospitals are better-off in terms of cash flow and adequate stock levels of drugs. Adequate stock of non-drugs under the scheme was reportedly intermittent. The major challenges confronting the hospitals were identified as weak purchasing power due to low tariffs, non computerisation of claims processing, unpredictable payment pattern, poor gate-keeping systems, lack of logistics and other new and emerging challenges relating to moral hazards and the use of false identity cards under pretence for medical care. Conclusion Study’s findings have a lot of policy implications for proper management of hospitals. The findings suggest rationalisation of the current tariff structure, the application of contract based payment system to inject efficiency into hospitals management and piloting facility based vetting systems to offset vetting loads of the insurance authority. Proper gate-keeping mechanisms are also needed to curtail the phenomenon of moral hazard and false documentation.

  9. Flood risk and insurance loss potential in the Thames Gateway

    Science.gov (United States)

    Eldridge, J.; Horn, D.

    2009-04-01

    The Thames Gateway, currently Europe's largest regeneration project, is an area of redevelopment located in the South East of England, with Government plans to create up to 160,000 new homes and 180,000 new jobs by 2016. Although the new development is intended to contribute £12bn annually to the economy, the potential flood risk is high, with much of the area situated on Thames tidal floodplain and vulnerable to both storm surges and peak river flows. This poses significant hazard to those inhabiting the area and has raised concern amongst the UK insurance industry, who would be liable for significant financial claims if a large flood event were to occur, particularly with respect to the number of new homes and businesses being built in flood risk areas. Flood risk and the potential damage to both lives and assets in vulnerable areas have gained substantial recognition, in light of recent flooding events, from both governmental agencies and in the public's awareness of flood hazard. This has resulted in a change in UK policy with planning policy for flood risk (PPS25, Planning Policy Statement 25) adopting a more strategic approach to development, as well as a new Flooding and Water Bill which is due for consultation in 2009. The Government and the Association of British Insurers, who represent the UK insurance industry, have also recently changed their Statement of Principles which guides provision of flood insurance in the future. This PhD research project aims to quantify flood risk in the Thames Gateway area with a view to evaluating the insurance loss potential under different insurance and planning scenarios. Using current sources of inundation extent, and incorporating varying insurance penetration rates and degrees of adoption of planning policy and guidance, it focuses on estimating flood risk under these different scenarios. This presentation introduces the development of the project and the theory and methodology which will be used to address the

  10. Nuclear Liability and Insurance Protection for Nuclear Transport Accidents Involving Non-Contracting EU States: An assessment

    International Nuclear Information System (INIS)

    Horbach, N. L. J. T.

    2006-01-01

    This paper provides an analysis of the possible complications and consequences with respect to nuclear liability and insurance protection applicable in respect of transport activities resulting in damage suffered and/or accidents occurring in EU States that are not party to the Paris Convention. It looks at the different legal aspects (jurisdiction, applicable law, liability amounts, reciprocity) should the revised Vienna and Paris Convention become applicable in comparison with the unrevised Conventions. Within Europe, a large number of States are party to the 1960 Paris Convention and the 1963 Brussels Supplementary Convention, providing liability and insurance protection, in general, up to a limit of 300 million SDRs (or even higher). In principle, such protection is confined to nuclear incidents occurring and nuclear damage suffered in the territory of Contracting Parties, including, as recommended, the high seas, unless the legislation of the Installation State determines otherwise (Article 2). The geographical scope of application of the Paris Convention would thus vary according to the law of the Installation State. However, some EU States never became party to the Paris Convention, and are not bound by its the liability principles (notably, channelling of liability), such as Austria, Luxembourg and Ireland. Transport accidents involving these countries might therefore result in liability claims outside the treaty liability regime against operators, suppliers, carriers or persons involved and for types of damages different from those currently covered by the Paris Convention (e.g., environmental damage). It is uncertain to what extent liability insurance of the installation operators would provide adequate protection and whether related damage claims can be enforceable. In addition, a number of newly entered EU States are party to the Vienna Convention, which, although bound by liability principles basically similar to those of the Paris Convention, will

  11. Mitigation Index Insurance for Developing Countries: Insure the Loss or Insure the Signal?

    OpenAIRE

    Li, Yiting; Miranda, Mario J.

    2015-01-01

    Conventional agricultural index insurance indemnifies based on the observed value of a specified variable, such as rainfall, that is correlated with agricultural production losses. Typically, indemnities are paid to the policyholder after the losses have been experienced. This paper explores alternate timing for index insurance payouts. In particular, we explore the potential benefits of what we call “mitigation index insurance” in which the payouts of the insurance contract arrive before los...

  12. Brief report: Quantifying the impact of autism coverage on private insurance premiums.

    Science.gov (United States)

    Bouder, James N; Spielman, Stuart; Mandell, David S

    2009-06-01

    Many states are considering legislation requiring private insurance companies to pay for autism-related services. Arguments against mandates include that they will result in higher premiums. Using Pennsylvania legislation as an example, which proposed covering services up to $36,000 per year for individuals less than 21 years of age, this paper estimates potential premium increases. The estimate relies on autism treated prevalence, the number of individuals insured by affected plans, mean annual autism expenditures, administrative costs, medical loss ratio, and total insurer revenue. Current treated prevalence and expenditures suggests that premium increases would approximate 1%, with a lower bound of 0.19% and an upper bound of 2.31%. Policy makers can use these results to assess the cost-effectiveness of similar legislation.

  13. Disability Insurance and Health Insurance Reform: Evidence from Massachusetts

    OpenAIRE

    Nicole Maestas; Kathleen J. Mullen; Alexander Strand

    2014-01-01

    As health insurance becomes available outside of the employment relationship as a result of the Affordable Care Act (ACA), the cost of applying for Social Security Disability Insurance (SSDI)–potentially going without health insurance coverage during a waiting period totaling 29 months from disability onset–will decline for many people with employer-sponsored health insurance. At the same time, the value of SSDI and Supplemental Security Income (SSI) participation will decline for individuals...

  14. Probabilistic Insurance

    NARCIS (Netherlands)

    Wakker, P.P.; Thaler, R.H.; Tversky, A.

    1997-01-01

    Probabilistic insurance is an insurance policy involving a small probability that the consumer will not be reimbursed. Survey data suggest that people dislike probabilistic insurance and demand more than a 20% reduction in premium to compensate for a 1% default risk. These observations cannot be

  15. Probabilistic Insurance

    NARCIS (Netherlands)

    P.P. Wakker (Peter); R.H. Thaler (Richard); A. Tversky (Amos)

    1997-01-01

    textabstractProbabilistic insurance is an insurance policy involving a small probability that the consumer will not be reimbursed. Survey data suggest that people dislike probabilistic insurance and demand more than a 20% reduction in the premium to compensate for a 1% default risk. While these

  16. Health Insurance Basics

    Science.gov (United States)

    ... Staying Safe Videos for Educators Search English Español Health Insurance Basics KidsHealth / For Teens / Health Insurance Basics What's ... thought advanced calculus was confusing. What Exactly Is Health Insurance? Health insurance is a plan that people buy ...

  17. Pet insurance--essential option?

    Science.gov (United States)

    Stowe, J D

    2000-08-01

    As Hawn (2) says, "insurance is about risk and peace of mind." She reports that the American Humane Society supports pet insurance because companion animals are able to be treated for disease or accidents that are life-threatening where, otherwise, they would have been euthanized. For veterinarians, she suggests that pet insurance allows them to practice veterinary medicine "as if it were free." It is inevitable that pet insurance will grow as a recourse for veterinary fees. This may be a savior to some families whose budget is stretched to the limit at a critical moment in the health care of their cherished pet. We in the veterinary profession have an advantage over other professions. We have seen the good, the bad, and the ugly of insurance, as it applies to human health and dental care. If we work hand-in-hand with our own industries, collectively we may be able to develop a system that wins for everyone, with fees that allow practice to thrive and growth strategies that accommodate new treatment and diagnostic modalities, as well as consistent and exemplary customer service. The path ahead is always fraught with bumps and potholes. We can be a passive passenger and become a victim of the times or an active driver to steer the profession to a clearer route. Pet insurance is but one of the solutions for the profession; the others are a careful assessment of our fees--charging what we are worth, not what we think the client will pay; business management; customer service; leadership of our health care team; lifelong learning; and more efficient delivery systems. Let us stop being a victim, stop shooting ourselves in the professional foot, and seize the day!

  18. Native title claim puts Roxby in fluid situation

    International Nuclear Information System (INIS)

    Hine, M.

    1993-01-01

    Aboriginal land rights and water supply have long been issues raised in relation to the Olympic Dam Mine at Roxby Downs. Now a native title claim has revealed the vulnerability of the water supply. The author reports that the mine's owner, Western Mining Corporation, has to confront issues it has inflamed by favouring one interest group claiming to represent Aboriginal interests 8 refs

  19. Federal Deposit Insurance Corporation (FDIC) Insured Banks

    Data.gov (United States)

    Department of Homeland Security — The Summary of Deposits (SOD) is the annual survey of branch office deposits for all FDIC-insured institutions including insured U.S. branches of foreign banks. Data...

  20. [Evidence-based medicine and public health law: statutory health insurance].

    Science.gov (United States)

    Dreher, Wolfgang

    2004-09-01

    Beyond all differences in terminology and legal principles between the laws governing private health insurance, the governmental financial support for civil, servants and statutory health insurance the fundamental issues to be solved by the courts in case of litigation are quite similar. But only a part of these refer to the quality of medical services, which is the main concern of Evidence-based Medicine (EbM); EbM, though, is not able to contribute towards answering the equally important question of how to distinguish between "treatment" and "(health-relevant) lifestyle". The respective definitions that have been developed in the particular fields of law are only seemingly divergent from each other and basically unsuitable to aid the physician in his clinical decision-making because the common blanket clauses of public health law are regularly interpreted as rules for the exclusion of certain claims and not as a confirmatory paraphrase of what is clinically necessary. If on the other hand medical quality is what lies at the core of litigation, reference to EbM may become necessary. In fact, it is already common practice in the statutory health insurance system that decision-making processes in the Federal Committee being responsible for quality assurance (Bundesausschuss) are based on EbM principles and that in exceptional cases only the courts have to medically review the Federal Committee's decisions.

  1. Low-Cost Generic Program Use by Medicare Beneficiaries: Implications for Medication Exposure Misclassification in Administrative Claims Data.

    Science.gov (United States)

    Pauly, Nathan J; Talbert, Jeffery C; Brown, Joshua

    2016-06-01

    Administrative claims data are used for a wide variety of research and quality assurance purposes; however, they are prone to medication exposure misclassification if medications are purchased without using an insurance benefit. Low-cost generic drug programs (LCGPs) offered at major chain pharmacies are a relatively new and sparsely investigated source of exposure misclassification. LCGP medications are often purchased out of pocket; thus, a pharmacy claim may never be submitted, and the exposure may go unobserved in claims data. As heavy users of medications, Medicare beneficiaries have much to gain from the affordable medications offered through LCGPs. This use may put them at increased risk of exposure misclassification in claims data. Many high-risk medications (HRMs) and medications tracked for adherence and utilization quality metrics are available through LCGPs, and exposure misclassification of these medications may impact the quality assurance efforts reliant on administrative claims data. Presently, there is little information regarding the use of these programs among a geriatric population. To (a) quantify the prevalence of LCGP users in a nationally representative population of Medicare beneficiaries; (b) compare clinical and demographic characteristics of LCGP users and nonusers; (c) assess determinants of LCGP use and medications acquired through these programs; and (d) analyze patterns of LCGP use during the years 2007-2012. This study relied on data from the Medical Expenditure Panel Survey (MEPS) from 2007 to 2012. The first 3 objectives were completed with a cohort of individuals in the most recent MEPS panel, while the fourth objective was completed with a separate cohort composed of individuals who participated in MEPS from 2007 to 2012. Inclusion in either study cohort required that individuals were Medicare beneficiaries aged 65 years or greater, used at least 1 prescription drug during their 2-year panel period, and participated in all 5

  2. 20 CFR 702.221 - Claims for compensation; time limitations.

    Science.gov (United States)

    2010-04-01

    ... which the last compensation payment was made. (b) In the case of a hearing loss claim, the time for... report which indicates the employee has sustained a hearing loss that is related to his or her employment... LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION ACT AND RELATED STATUTES ADMINISTRATION AND PROCEDURE Claims...

  3. 75 FR 15603 - Common Crop Insurance Regulations; Florida Avocado Crop Insurance Provisions

    Science.gov (United States)

    2010-03-30

    ... to: (1) Theft; or (2) Inability to market the avocados for any reason other than actual physical... Crop Insurance Regulations; Florida Avocado Crop Insurance Provisions AGENCY: Federal Crop Insurance... Common Crop Insurance Regulations; Florida Avocado Crop Insurance Provisions to convert the Florida...

  4. To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?

    Directory of Open Access Journals (Sweden)

    van der Wal Gerrit

    2011-02-01

    Full Text Available Abstract Background Patient record review is believed to be the most useful method for estimating the rate of adverse events among hospitalised patients. However, the method has some practical and financial disadvantages. Some of these disadvantages might be overcome by using existing reporting systems in which patient safety issues are already reported, such as incidents reported by healthcare professionals and complaints and medico-legal claims filled by patients or their relatives. The aim of the study is to examine to what extent the hospital reporting systems cover the adverse events identified by patient record review. Methods We conducted a retrospective study using a database from a record review study of 5375 patient records in 14 hospitals in the Netherlands. Trained nurses and physicians using a method based on the protocol of The Harvard Medical Practice Study previously reviewed the records. Four reporting systems were linked with the database of reviewed records: 1 informal and 2 formal complaints by patients/relatives, 3 medico-legal claims by patients/relatives and 4 incident reports by healthcare professionals. For each adverse event identified in patient records the equivalent was sought in these reporting systems by comparing dates and descriptions of the events. The study focussed on the number of adverse event matches, overlap of adverse events detected by different sources, preventability and severity of consequences of reported and non-reported events and sensitivity and specificity of reports. Results In the sample of 5375 patient records, 498 adverse events were identified. Only 18 of the 498 (3.6% adverse events identified by record review were found in one or more of the four reporting systems. There was some overlap: one adverse event had an equivalent in both a complaint and incident report and in three cases a patient/relative used two or three systems to complain about an adverse event. Healthcare professionals

  5. Medico-legal claims against English radiologists: 1995-2006.

    Science.gov (United States)

    Halpin, S F S

    2009-12-01

    A list of claims against radiologists from 1995-2006 was obtained from the NHS Litigation Authority. It shows a total of 440 claims. The largest number of claims (199) related to delayed or missed diagnoses of cancer, and 73 claims related to breast radiology. There is a trend for a mild increase in the number of claims each year. 30 claims were made after a false-positive diagnosis of cancer. Just under pound8.5 million has so far been paid in damages, with a further pound5 million in legal fees. A claim for multiple missed diagnoses of breast cancer led to a pay-out of pound464 000 ( pound673 000 after legal fees); the largest sum awarded following a delay in the diagnosis of an individual cancer was pound300 000. The subtle legal distinction between error and negligence is reviewed here. The reason why breast radiologists are more likely to be sued than any other type of British radiologist is also discussed, along with the implications for UK radiological practice, particularly in light of the recent Chief Medical Officer's report on revalidation. A method is proposed that may protect radiologists from allegations of clinical negligence in the future.

  6. Multilevel predictors of colorectal cancer testing modality among publicly and privately insured people turning 50.

    Science.gov (United States)

    Wheeler, Stephanie B; Kuo, Tzy-Mey; Meyer, Anne Marie; Martens, Christa E; Hassmiller Lich, Kristen M; Tangka, Florence K L; Richardson, Lisa C; Hall, Ingrid J; Smith, Judith Lee; Mayorga, Maria E; Brown, Paul; Crutchfield, Trisha M; Pignone, Michael P

    2017-06-01

    Understanding multilevel predictors of colorectal cancer (CRC) screening test modality can help inform screening program design and implementation. We used North Carolina Medicare, Medicaid, and private, commercially available, health plan insurance claims data from 2003 to 2008 to ascertain CRC test modality among people who received CRC screening around their 50th birthday, when guidelines recommend that screening should commence for normal risk individuals. We ascertained receipt of colonoscopy, fecal occult blood test (FOBT) and fecal immunochemical test (FIT) from billing codes. Person-level and county-level contextual variables were included in multilevel random intercepts models to understand predictors of CRC test modality, stratified by insurance type. Of 12,570 publicly-insured persons turning 50 during the study period who received CRC testing, 57% received colonoscopy, whereas 43% received FOBT/FIT, with significant regional variation. In multivariable models, females with public insurance had lower odds of colonoscopy than males (odds ratio [OR] = 0.68; p testing, 42% received colonoscopy, whereas 58% received FOBT/FIT, with significant regional variation. In multivariable models, females with private insurance had lower odds of colonoscopy than males (OR = 0.43; p < 0.05). People living 10-15 miles away from endoscopy facilities also had lower odds of colonoscopy than those living within 5 miles (OR = 0.91; p < 0.05). Both colonoscopy and FOBT/FIT are widely used in North Carolina among insured persons newly age-eligible for screening. The high level of FOBT/FIT use among privately insured persons and women suggests that renewed emphasis on FOBT/FIT as a viable screening alternative to colonoscopy may be important.

  7. Risk, Credit, and Insurance in Peru: Field Experimental Evidence

    OpenAIRE

    Galarza, Francisco

    2009-01-01

    This paper reports the results of behavioral economic experiments conducted in Peru to examine the relationship amongst risk preferences, loan take-up, and insurance purchase decisions. This area-based yield insurance can help reduce people's vulnerability to large scale covariate shocks, and can also lower the loan default probability under extreme negative covariate shocks. In a context of collateralized formal credit markets, we provide suggestive evidence that insurance may help reduce th...

  8. A Centralized Auction Mechanism for the Disability and Survivors Insurance in Chile

    Science.gov (United States)

    Reyes H., Gonzalo

    As part of the pension reform recently approved in Chile, the government introduced a centralized auction mechanism to provide the Disability and Survivors (D&S) Insurance that covers recent contributors among the more than 8 million participants in the mandatory private pension system. This paper is intended as a case study presenting the main distortions found in the decentralized operation of the system that led to this reform and the challenges faced when designing a competitive auction mechanism to be implemented jointly by the Pension Fund Managers (AFP). In a typical bilateral contract the AFP retained much of the risk and the Insurance Company acted in practice as a reinsurer. The process to hire this contract was not competitive and colligated companies ended up providing the service. Several distortions affected competition in the market through incentives to cream-skim members by AFPs (since they bear most of the risk) or efforts to block disability claims. Since the price of this insurance is hidden in the fees charged by AFPs for the administration of individual accounts and pension funds there was lack of price transparency. Since new AFPs have no history of members’ disability and mortality profile the insurance contract acted as a barrier to entry in the market of AFP services, especially when D&S insurance costs reached 50% of total costs. Cross-subsidies between members of the same AFP, inefficient risk pooling (due to pooling occurring at the AFP rather than at the system level) and regulatory arbitrage, since AFPs provided insurance not being regulated as an insurance company, were also present. A centralized auction mechanism solves these market failures, but also gives raise to new challenges, such as how to design a competitive auction that attracts participation and deters collusion. Design features that were incorporated in the regulation to tackle these issues, such as dividing coverage into predefined percentage blocks, are presented

  9. Consumer appeal of nutrition and health claims in three existing product concepts

    DEFF Research Database (Denmark)

    Verbeke, Wim; Scholderer, Joachim; Lähteenmäki, Liisa

    2009-01-01

    This paper reports on consumers' reactions towards calcium-enriched fruit juice, omega-3 enriched spread and fibre-enriched cereals, each with a nutrition claim, health claim and reduction of disease risk claim. Cross-sectional data were collected in April 2006 from a sample of 341 consumers...... in Belgium. Consumers' reactions to the carrier product, functional ingredient and claim combinations were assessed as perceived convincingness of the claim, credibility of the product, attractiveness of the product, and intention to buy the product, while accounting for differences in product familiarity......, attitudinal and demographic characteristics. Generally, health claims outperformed nutrition claims, and both of these claim types outperformed reduction of disease risk claims. Comparing consumer reactions across product concepts revealed clear preferences for fibre-enriched cereals as compared to the other...

  10. [Use of routine data from statutory health insurances for federal health monitoring purposes].

    Science.gov (United States)

    Ohlmeier, C; Frick, J; Prütz, F; Lampert, T; Ziese, T; Mikolajczyk, R; Garbe, E

    2014-04-01

    Federal health monitoring deals with the state of health and the health-related behavior of populations and is used to inform politics. To date, the routine data from statutory health insurances (SHI) have rarely been used for federal health monitoring purposes. SHI routine data enable analyses of disease frequency, risk factors, the course of the disease, the utilization of medical services, and mortality rates. The advantages offered by SHI routine data regarding federal health monitoring are the intersectoral perspective and the nearly complete absence of recall and selection bias in the respective population. Further, the large sample sizes and the continuous collection of the data allow reliable descriptions of the state of health of the insurants, even in cases of multiple stratification. These advantages have to be weighed against disadvantages linked to the claims nature of the data and the high administrative hurdles when requesting the use of SHI routine data. Particularly in view of the improved availability of data from all SHI insurants for research institutions in the context of the "health-care structure law", SHI routine data are an interesting data source for federal health monitoring purposes.

  11. 76 FR 71276 - Common Crop Insurance Regulations; Pecan Revenue Crop Insurance Provisions

    Science.gov (United States)

    2011-11-17

    ...-0008] RIN 0563-AC35 Common Crop Insurance Regulations; Pecan Revenue Crop Insurance Provisions AGENCY... Corporation (FCIC) proposes to amend the Common Crop Insurance Regulations, Pecan Revenue Crop Insurance... Regulations (7 CFR part 457) by revising Sec. 457.167 Pecan Revenue Crop Insurance Provisions, to be effective...

  12. Compensation claims for chiropractic in Denmark and Norway 2004-2012

    DEFF Research Database (Denmark)

    Jevne, Jørgen; Hartvigsen, Jan; Christensen, Henrik Wulff

    2014-01-01

    finalized compensation claims involving chiropractors reported to one of the two associations between 2004 and 2012 were assessed for age, gender, type of complaint, decisions and appeals. Descriptive statistics were used to describe the study population. RESULTS: 338 claims were registered in Denmark...

  13. Introducing Motivational Interviewing in a Sickness Insurance Context: Translation and Implementation Challenges.

    Science.gov (United States)

    Ståhl, Christian; Gustavsson, Maria

    2018-06-01

    Purpose Motivational interviewing (MI) is a conversational method to support clients in need of behavioral change. In an organizational reform, most Swedish sickness insurance officials were trained in MI to promote clients' return to work (RTW) after sick leave. The aim of this article is to investigate experiences of introducing MI as a tool to promote clients' RTW within a sickness insurance context, with special focus on the translation and implementation of the method. Methods A qualitative approach, comprising 69 interviews with officials, managers, and regional coordinators on two occasions. The material was analyzed through qualitative content analysis. Results Officials were positive about MI, but the application was limited to using certain tools with extensive individual variation. Officials struggled with translating MI into a sickness insurance context, where the implementation strategy largely failed to offer adequate support, due to low managerial priority, competing initiatives, and a high workload. Results of the educational intervention could therefore be seen on an individual but not an organizational level. Conclusions In order to translate MI into a sickness insurance context, training needs to be supported by organizational approaches that promote collective learning and sharing of experiences among officials. The results also illustrate how a method cannot be assumed to be implemented simply because training has been provided. Consequently, the application of the method needs to be carefully monitored in studies of interventions where MI is claimed to be used, in order to measure its effectiveness.

  14. BenefitClaimWebServiceBean/BenefitClaimWebService

    Data.gov (United States)

    Department of Veterans Affairs — A formal or informal request for a type of monetary or non-monetary benefit. This service provides benefit claims and benefit claim special issues data, allows the...

  15. 78 FR 32709 - Open Meeting of the Federal Advisory Committee on Insurance

    Science.gov (United States)

    2013-05-31

    ... impact of global demographics on the insurance industry; receive a report on regulatory developments... DEPARTMENT OF THE TREASURY Open Meeting of the Federal Advisory Committee on Insurance AGENCY... announces that the Department of the Treasury's Federal Advisory Committee on Insurance will convene a...

  16. Rules regarding the health insurance premium tax credit. Final and temporary regulations.

    Science.gov (United States)

    2014-07-28

    This document contains final and temporary regulations relating to the health insurance premium tax credit enacted by the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, as amended by the Medicare and Medicaid Extenders Act of 2010, the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011, and the Department of Defense and Full-Year Continuing Appropriations Act of 2011 and the 3% Withholding Repeal and Job Creation Act. These regulations affect individuals who enroll in qualified health plans through Affordable Insurance Exchanges (Exchanges) and claim the premium tax credit, and Exchanges that make qualified health plans available to individuals. The text of the temporary regulations in this document also serves as the text of proposed regulations set forth in a notice of proposed rulemaking (REG-104579-13) on this subject in the Proposed Rules section in this issue of the Federal Register.

  17. 25 CFR 103.37 - What must the lender do to collect payment under its loan guaranty certificate or loan insurance...

    Science.gov (United States)

    2010-04-01

    ... collateral securing the loan under § 103.36(d)(2), and has a residual loss after doing so, it must send BIA... principal collateral securing the loan; or (iii) One hundred eighty calendar days after the date of the default. (b) For insured loans, after liquidating all loan collateral, the lender must submit a claim for...

  18. Expanding insurance coverage through tax credits, consumer choice, and market enhancements: the American Medical Association proposal for health insurance reform.

    Science.gov (United States)

    Palmisano, Donald J; Emmons, David W; Wozniak, Gregory D

    2004-05-12

    Recent reports showing an increase in the number of uninsured individuals in the United States have given heightened attention to increasing health insurance coverage. The American Medical Association (AMA) has proposed a system of tax credits for the purchase of individually owned health insurance and enhancements to individual and group health insurance markets as a means of expanding coverage. Individually owned insurance would enable people to maintain coverage without disruption to existing patient-physician relationships, regardless of changes in employers or in work status. The AMA's plan would empower individuals to choose their health plan and give patients and their physicians more control over health care choices. Employers could continue to offer employment-based coverage, but employees would not be limited to the health plans offered by their employer. With a tax credit large enough to make coverage affordable and the ability to choose their own coverage, consumers would dramatically transform the individual and group health insurance markets. Health insurers would respond to the demands of individual consumers and be more cautious about increasing premiums. Insurers would also tailor benefit packages and develop new forms of coverage to better match the preferences of individuals and families. The AMA supports the development of new health insurance markets through legislative and regulatory changes to foster a wider array of high-quality, affordable plans.

  19. Do self-insurance and disability insurance prevent consumption loss on disability?

    OpenAIRE

    Steffan G. Ball; Hamish W. Low

    2009-01-01

    In this paper we show the extent to which public insurance and self-insurance mitigate the cost of health shocks that limit the ability to work. We use consumption data from the UK to estimate the insurance provided by the government disability programme and account for the effectiveness of alternative self-insurance mechanisms. Individuals with a work-limiting health condition, but in receipt of disability insurance, have 7 percent lower consumption than those without such a condition. Self-...

  20. ARCO and Sun agree to settle Iranian claims

    International Nuclear Information System (INIS)

    Anon.

    1992-01-01

    This paper reports that ARCO and Sun Co. Inc. have agreed to separate settlements totaling almost $261 million that resolve their claims over oil field assets expropriated by Iran in 1978--80. The agreements are subject to approval by the Iran-U.S. claims tribunal at The Hague. The tribunal was set up in 1981 to resolve foreign claims to assets nationalized by the government of Ayatollah Khomeini following the fall of the Shah of Iran as a result of the 1978-79 Iranian revolution. The settlements are seen as the latest steps Iran has taken to normalize relations with the U.S., notably through petroleum related deals

  1. INSURANCE MARKET. GENERAL CONSIDERATIONS OF INSURANCES IN ROMANIA

    Directory of Open Access Journals (Sweden)

    MARINEL NEDELUŢ

    2013-10-01

    Full Text Available Insurance is a contract made by a company or society, or by the state, to provide a guarantee for loss, damage, illness, death etc in return for regular payments. In other words it is a means by which one pays a relatively small known cost for protection against an uncertain and much larger cost. Still, this contract (insurance policy makes it possible for the insured to cover only losses that are measurable in terms of money and caused strictly by hazardous events, independent from own doing. If no such events should happen, the benefits won’t exist in a tangible, material form, but will take the shape of security against ruin. Since the insurance industry has developed more during the last decade due to the powerful players that have entered the market, the services provided by the insurance companies, and not only their products have evolved a lot in order to meet the requirements of the consumers, and to make them familiar with this type of investments. Therefore all the means of advertising became essential in this process of implementation and familiarization with this area of activity: mass-media advertising, insurance brokerage companies, the internet are all parts of this process.

  2. Athabasca Chipewyan First Nation inquiry : report on WAC Bennett Dam and damage to Indian Reserve no. 201 claim

    International Nuclear Information System (INIS)

    1998-03-01

    Aspects of a claim regarding the WAC Bennett Dam in British Columbia and damage to Indian Reserve 201 are discussed. An inquiry was held to determine whether the Crown owes an outstanding obligation to the Athabasca Chipewyan First Nation regarding damages sustained on their reserve as a result of the construction and operation of the dam. The claim alleges that the drying out of the Peace-Athabasca Delta severely affected the First Nation's treaty rights to hunt, trap and fish for food in the area. It was noted that the dam was constructed in the early 1960s before the establishment of mandatory environmental assessment procedures which are in place today to ensure that projects comply with certain safeguards and minimum standards. In 1971, the Peace-Athabasca Delta Project Group (PADPG) was established to review and to assess the environmental damage caused by the dam. The group was also advised to implement a strategy to mitigate the ongoing environmental deterioration in the Delta. It was concluded that Canada breached its statutory and fiduciary obligations to the Athabasca Chipewyan First nation by failing to take reasonable measures to prevent, to mitigate, or to seek compensation for unjustified infringement on its treaty rights and for environmental damages to IR 201. In this report the Commission recommends that the claim by the Athabasca Chipewyan First Nation be accepted for negotiation under Canada's specific claims policy. figs

  3. Life Insurance Contribution, Insurance Development and Economic Growth in China

    Directory of Open Access Journals (Sweden)

    Wang Ying

    2017-07-01

    Full Text Available Under L-type economy, remodelling the growth power in the medium and long term is essential. The insurance industry during the 13th Five-year Plan period has been given a heavy expectation on promoting economic quality and upgrading economic efficiency, so it will try to accelerate its innovation and development process which serves national needs, market demand and people's requirements. Referring to the previous researches of Solow and Zhang and measuring Capital Stock and Total Factor Productivity independently, the paper analyses the inherent correlation between insurance (including life insurance and non-life insurance and economic growth, reveals the contribution law of the insurance development in economic growth in the short and long term from both economic scale and quality respectively. It also shows enlightenments on policy decision for insurance industry, thus helps economic stability under the downturn periods.

  4. INSURANCE INTERMEDIARIES

    Directory of Open Access Journals (Sweden)

    Andreea Stoican

    2013-11-01

    Full Text Available The actual Civil code regulates for the first time in the Romanian legislation the intermediation contract, until its entering into force existing multiple situations that lent themselves to this legal operation, but did not benefit of such particular legal rules. Yet, the case law has shown that the situations that arise in the activity of the legal or natural persons are much more complex, this leading, in time, to the reglementation of such particular rules. Such a case is that found in the matter of insurance contracts, the position of the insurance intermediaries being regulated especially by Law no. 32/2000, according to which they represent the natural or legal persons authorized in the conditions of the above mentioned legal document, that perform intermediation activities in the insurance field, in exchange of a remuneration, as well as the intermediaries from the EU member states that perform such an activity on the Romanian territory, in accordance with the freedom in performing services. Therefore, the present paper aims to analyze the conclusion of such insurance contracts and to underline the particular position of the insurance brokers, having the following structure: 1 Introduction; 2 The reglementation of the intermediation contract/brokerage agreement in the Romanian Law; 3 The importance of the intermediaries in the insurance contracts; 4 The conclusion of the insurance contracts; 5 Conclusions.

  5. MARKETING OF INSURANCE PRODUCTS BY THE NATIONAL INSURANCE COMPANY LIMITED, RAJAPALAYAM

    OpenAIRE

    Dr. H. Christy Cynthia; Dr. T. Jebasheela; V. Maheswari

    2017-01-01

    Insurance is a way of reducing uncertainty of occurrence of an event. Insurance is an investment. Its basic purpose is to derive plans to counteract the financial consequences of unfavorable events. Insurance is a social device for eliminating or reducing the cost to society to certain types of risks. Insurance is essentially a co-operative endeavor. It is the function of the insurance to protect the few against the heavy financial impact of anticipated misfortunes by spreading losses among m...

  6. [Occupational health services as the insurance product and insurance economic instruments].

    Science.gov (United States)

    Rydlewska-Liszkowska, Izabela

    2014-01-01

    One of the most controversial issues in restructuring the Polish health insurance system is the implementation of private voluntary insurance and creation within it a new insurance product known as occupational health services (OHS). In this article some opportunities and dilemmas likely to be faced by providers and employers/employees, when contracting with insurance institutions, are considered as a contribution to the discussion on private insurance in Poland. The basic question is how private insurance institutions could influence the promotion of different preventive activities at the company level by motivating both OHS providers and employers. The descriptive qualitative method has been applied in the analysis of legal acts, scientific publications selected according to keywords (Pubmed), documents and expert evaluations and research project results. Taking into account the experiences of European countries, described in publications, international experts' opinions and results of research projects the solution proposed in Poland could be possible under the following several prerequisites: inclusion of a full scope of occupational health services into the insurance product, constant supervision of occupational medicine professionals, monitoring of the health care quality and the relations between private insurers and OHS provider and implementation of the economic incentives scheme to ensure an adequate position of OHS providers on the market. The proposed reconstruction of the health insurance system, comprising undoubtedly positive elements, may entail some threats in the area of health, organization and economy. Private voluntary health insurance implementation requires precisely defined solutions concerning the scope of insurance product, motivation scheme and information system.

  7. BUSINESS PROCESS MANAGEMENT IN INSURANCE CASE OF JADRANSKO INSURANCE COMPANY

    OpenAIRE

    Sanja Coric; Danijel Bara

    2014-01-01

    Selling insurance products in conditions of today’s modern technological solutions is faced with numerous challenges. Business processes in insurance as well as the results of these business processes are the real interface to policyholders. Modeling and analysis of business process in insurance ensure organizations to focus on the customer and increase the efficiency and quality of work. Managing critical business processes in every single organization, likewise in insurance is a key factor ...

  8. Motor Third Party Liability Insurance in Russia: Gaining Competitive Advantage

    OpenAIRE

    Rogozin, Konstantin

    2006-01-01

    The report identifies which factors of service-based offerings are of utmost importance for customers, considers the areas of MTPL insurance that may contain a potential sources for differentiation, and stresses importance of knowing customer needs and requirements. This report should assist the insurance company to categorise and systematise relevant information so as to develop a product position, which may give a competitive advantage.

  9. Impact of community-based health insurance in rural India on self-medication & financial protection of the insured

    Directory of Open Access Journals (Sweden)

    David M Dror

    2016-01-01

    Full Text Available Background & objectives: The evidence-base of the impact of community-based health insurance (CBHI on access to healthcare and financial protection in India is weak. We investigated the impact of CBHI in rural Uttar Pradesh and Bihar s0 tates of India on insured households′ self-medication and financial position. Methods: Data originated from (i household surveys, and (ii the Management Information System of each CBHI. Study design was "staggered implementation" cluster randomized controlled trial with enrollment of one-third of the treatment group in each of the years 2011, 2012 and 2013. Around 40-50 per cent of the households that were offered to enroll joined. The benefits-packages covered outpatient care in all three locations and in-patient care in two locations. To overcome self-selection enrollment bias, we constructed comparable control and treatment groups using Kernel Propensity Score Matching (K-PSM. To quantify impact, both difference-in-difference (DiD, and conditional-DiD (combined K-PSM with DiD were used to assess robustness of results. Results: Post-intervention (2013, self-medication was less practiced by insured HHs. Fewer insured households than uninsured households reported borrowing to finance care for non-hospitalization events. Being insured for two years also improved the HH′s location along the income distribution, namely insured HHs were more likely to experience income quintile-upgrade in one location, and less likely to experience a quintile-downgrade in two locations. Interpretation & conclusions: The realized benefits of insurance included better access to healthcare, reduced financial risks and improved economic mobility, suggesting that in our context health insurance creates welfare gains. These findings have implications for theoretical, ethical, policy and practice considerations.

  10. Exclusion from the Health Insurance Scheme

    CERN Multimedia

    2003-01-01

    A CERN pensioner, member of the Organization's Health Insurance Scheme (CHIS), recently provided fake documents in support of claims for medical expenses, in order to receive unjustified reimbursement from the CHIS. The Administrator of the CHIS, UNIQA, suspected a case of fraud: Accordingly, an investigation and interview of the person concerned was carried out and brought the Organization to the conclusion that fraud had actually taken place. Consequently and in accordance with Article VIII 3.12 of the CHIS Rules, it was decided to exclude this member permanently from the CHIS. The Organization takes the opportunity to remind Scheme members that any fraud or attempt to fraud established within the framework of the CHIS exposes them to: - disciplinary action, according to the Staff Rules and Regulations, for CERN members of the personnel; - definitive exclusion from the CHIS for members affiliated on a voluntary basis. Human Resources Division Tel. 73635

  11. Predicting hurricane wind damage by claim payout based on Hurricane Ike in Texas

    Directory of Open Access Journals (Sweden)

    Ji-Myong Kim

    2016-09-01

    Full Text Available The increasing occurrence of natural disasters and their related damage have led to a growing demand for models that predict financial loss. Although considerable research on the financial losses related to natural disasters has found significant predictors, there has been a lack of comprehensive study that addresses the relationship among vulnerabilities, natural disasters, and the economic losses of individual buildings. This study identifies the vulnerability indicators for hurricanes to establish a metric to predict the related financial loss. We classify hurricane-prone areas by highlighting the spatial distribution of losses and vulnerabilities. This study used a Geographical Information System (GIS to combine and produce spatial data and a multiple regression method to establish a wind damage prediction model. As the dependent variable, we used the value of the Texas Windstorm Insurance Association (TWIA claim payout divided by the appraised values of the buildings to predict real economic loss. As independent variables, we selected a hurricane indicator and built environment vulnerability indicators. The model we developed can be used by government agencies and insurance companies to predict hurricane wind damage.

  12. Nuclear Insurance Subsidies Cost from Post-Fukushima Accounting Based on Media Sources

    Directory of Open Access Journals (Sweden)

    John J. Laureto

    2016-12-01

    Full Text Available Quantification of nuclear liability insurance is difficult without arbitrary liability caps; however, post-mortem calculations can be used to calculate insurance costs. This study analyzes the Fukushima (Daiichi nuclear power plant disaster to quantify the cost per unit electricity ($/kWh of nuclear energy from the lifetime of the plant after accounting for the true cost of the liability needed to cover the damages from the nuclear disaster determined from news reports. These costs are then compared to the cost of electricity currently paid by Japanese consumers, and then are aggregated to determine the indirect subsidy for nuclear power providers in both Japan and the USA. The results show that the reported costs of the Fukushima nuclear disaster are $20–525 billion, which results in a real insurance cost from the lifetime of electricity produced at the plants between $0.22–5.78/kWh. These values are far higher than the current insurance costs by Japanese law of $0.01/kWh and even the total costs consumers pay for electricity. Although the spread in the input costs is large and the reported metrics are incomplete, the nuclear insurance subsidy is clearly substantial in Japan and in the USA. Ideally, energy sources should be economically sustainable without the need for a government insurance subsidy. For the electricity market to function effectively and efficiently in all other countries using nuclear power, the insurance costs should be reported accurately and included in nuclear electricity costs without arbitrary government liability caps.

  13. Insurance of nuclear risk

    International Nuclear Information System (INIS)

    Lacroix, M.

    1976-01-01

    Insurance for large nuclear installations covers mainly four types of risk: third party liability which in accordance with the nuclear conventions, is borne by a nuclear operator following an incident occurring in his installation or during transport of nuclear substances; material damage to the installation itself, which precisely is not covered by third party liability insurance; machinery breakdown, i.e. accidental damage or interruption of operation. Only the first category must be insured. In view of the magnitude of the risk, nuclear insurance resorts to co-insurance and reinsurance techniques which results in a special organisation of the nuclear insurance market, based on national nuclear insurance pools and on the Standing Committee on Atomic Risk of the European Insurance Committee. Conferences of the chairmen of nuclear insurance pools are convened regularly at a worldwide level. (NEA) [fr

  14. Improvement of life insurance-related accounting opera-tions within the New Economy

    Directory of Open Access Journals (Sweden)

    Marinică DOBRIN

    2010-06-01

    Full Text Available This paper outlines the life insurance-related accounting operations, in consideration to the harmonization of the Romanian legislation with the International Financial Reporting Standards. The main accounting operations specific to the life insurance sector include: accounting of revenues and expenses derived from life insurance operations (recording the premiums written, recording the payment of insurance premiums, termination of insurance policy, recording the compensation expenses, accounting of operations related to the setting up and using the technical reserves for life insurance (general principles, accounting of premium reserves, accounting of loss reserve, accounting of the reserve for benefits and discounts, accounting of mathematical reserve, accounting of other life insurance-related technical reserves.

  15. Should the District Courts Have Jurisdiction Over Pre-Award Contract Claims? A Claim for the Claims Court

    National Research Council Canada - National Science Library

    Short, John J

    1987-01-01

    This thesis briefly examines the jurisdiction of the federal district courts and the United States Court of Claims over pre-award contract claims before the Federal Courts Improvement Act of October 1...

  16. Everyday Citizenship: Identity Claims and Their Reception

    Directory of Open Access Journals (Sweden)

    Nick Hopkins

    2015-10-01

    Full Text Available Citizenship involves being able to speak and be heard as a member of the community. This can be a formal right (e.g., a right to vote. It can also be something experienced in everyday life. However, the criteria for being judged a fellow member of the community are multiple and accorded different weights by different people. Thus, although one may self-define alongside one’s fellows, the degree to which these others reciprocate depends on the weight they give to various membership criteria. This suggests we approach everyday community membership in terms of an identity claims-making process in which first, an individual claims membership through invoking certain criteria of belonging, and second, others evaluate that claim. Pursuing this logic we report three experiments investigating the reception of such identity-claims. Study 1 showed that in Scotland a claim to membership of the national ingroup was accepted more if couched in terms of place of birth and ancestry rather than just in terms of one’s subjective identification. Studies 2 and 3 showed that this differential acceptance mattered for the claimant’s ability to be heard as a community member. We discuss the implications of these studies for the conceptualization of community membership and the realization of everyday citizenship rights.

  17. THE MODEL OF INTERACTION BETWEEN INSURANCE INTERMEDIARIES AND INSURANCE COMPANIES IN THE ASSURANCE OF SUSTAINABLE DEVELOPMENT OF THE INSURANCE MARKET

    Directory of Open Access Journals (Sweden)

    Nataliia Kudriavska

    2017-11-01

    Full Text Available The purpose of this paper is the investigation of the model of interaction between insurance intermediaries and insurance companies in the assurance of sustainable development of the insurance market. The methodology is based on the new studies and books. It is underlined the importance of potency and effectiveness of this model, its influence on the insurance market stability. It is analysed the European experience and specific of Ukrainian insurance market. The main ways for improving its model and ways of its practical realization are characterized. Results. The problems that exist in the broker market in general are connected with an ineffective state policy. In particular, we can say about the absence of many laws, acts, resolutions, which explain what a broker have to do in case of different problems with insurance companies, another brokers and clients. At the same time, the problem of distrust to national brokers exists. It provokes a decline of the demand for their services and so on. However, it is possible to solve these problems. Practical implications. For this, it is necessary to do some acts. The first one is to implement resolutions that regulate relationships between insurance brokers and insurance companies, clearly regulate the model of its interaction. This model affects the stability of the insurance market in general. The second is to find methods of solving problems of the increase in insurance culture of the population (for example, by the way of advertisement. The third one is to solve problems connected with the appearance of foreign brokers in the insurance market of Ukraine. Actually, the Ukrainian market of insurance brokers is not developed enough. That is why it needs big changes and reforms. Value/originality. Among alternatives of the strategic development of insurance, the method of quick liberalization and gradual development is distinguished. According to the liberal way, it is possible to transfer to the

  18. Acceptability of, and willingness to pay for, community health insurance in rural India.

    Science.gov (United States)

    Jain, Ankit; Swetha, Selva; Johar, Zeena; Raghavan, Ramesh

    2014-09-01

    To understand the acceptability of, and willingness to pay for, community health insurance coverage among residents of rural India. We conducted a mixed methods study of 33 respondents located in 8 villages in southern India. Interview domains focused on health-seeking behaviors of the family for primary healthcare, household expenditures on primary healthcare, interest in pre-paid health insurance, and willingness to pay for such a product. Most respondents reported that they would seek care only when symptoms were manifest; only 6 respondents recognized the importance of preventative services. None reported impoverishment due to health expenditures. Few viewed health insurance as necessary either because they did not wish to be early adopters, because they had alternate sources of financial support, or because of concerns with the design of insurance coverage or the provider. Those who were interested reported being willing to pay Rs. 1500 ($27) as the modal annual insurance premium. Penetration of community health insurance programs in rural India will require education of the consumer base, careful attention to premium rate setting, and deeper understanding of social networks that may act as financial substitutes for health insurance. Copyright © 2013 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. All rights reserved.

  19. Availability of Insurance Linkage Programs in U.S. Emergency Departments

    Directory of Open Access Journals (Sweden)

    Mia Kanak

    2014-07-01

    Full Text Available Introduction: As millions of uninsured citizens who use emergency department (ED services are now eligible for health insurance under the Affordable Care Act, the ED is ideally situated to facilitate linkage to insurance. Forty percent of U.S. EDs report having an insurance linkage program. This is the first national study to examine the characteristics of EDs that offer or do not offer these programs. Methods: This was a secondary analysis of data from the National Survey for Preventive Health Services in U.S. EDs conducted in 2008-09. We compared EDs with and without insurance programs across demographic and operational factors using univariate analysis. We then tested our hypotheses using multivariable logistic regression. We also further examined program capacity and priority among the sub-group of EDs with no insurance linkage program. Results: After adjustment, ED-insurance linkage programs were more likely to be located in the West (RR= 2.06, 95% CI = 1.33 – 2.72. The proportion of uninsured patients in an ED, teaching hospital status, and public ownership status were not associated with insurance linkage availability. EDs with linkage programs also offer more preventive services (RR = 1.87, 95% CI = 1.37–2.35 and have greater social worker availability (RR = 1.71, 95% CI = 1.12–2.33 than those who do not. Four of five EDs with a patient mix of ≥25% uninsured and no insurance linkage program reported that they could not offer a program with existing staff and funding. Conclusion: Availability of insurance linkage programs in the ED is not associated with the proportion of uninsured patients served by an ED. Policy or hospital-based interventions to increase insurance linkage should first target the 27% of EDs with high rates of uninsured patients that lack adequate program capacity. Further research on barriers to implementation and cost effectiveness may help to facilitate increased adoption of insurance linkage programs. [West J

  20. 41 CFR 60-741.25 - Health insurance, life insurance and other benefit plans.

    Science.gov (United States)

    2010-07-01

    ... 41 Public Contracts and Property Management 1 2010-07-01 2010-07-01 true Health insurance, life insurance and other benefit plans. 60-741.25 Section 60-741.25 Public Contracts and Property Management... Health insurance, life insurance and other benefit plans. (a) An insurer, hospital, or medical service...