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...

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.

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

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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.

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

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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.

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.

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

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.

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

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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

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...

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.

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

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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.

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

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...

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.

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.

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...

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

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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.

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.

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.

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'.

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

An Individual Claims History Simulation Machine

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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.

20 CFR 405.410 - Selecting claims for Decision Review Board review.

Science.gov (United States)

2010-04-01

... will not review claims based on the identity of the administrative law judge who decided the claim. (b... Decision Review Board review. (a)(1) The Board may review your claim if the administrative law judge made a decision under §§ 405.340 or 405.370 of this part, regardless of whether the administrative law judge's...

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: ...

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.

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...

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...

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

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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.

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.

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.

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...

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 ...

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

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.

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....

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.

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

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.

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.

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.

States with stronger health insurance rate review authority experienced lower premiums in the individual market in 2010-13.

Science.gov (United States)

Karaca-Mandic, Pinar; Fulton, Brent D; Hollingshead, Ann; Scheffler, Richard M

2015-08-01

States have varying degrees of review authority over health insurance carriers' rates, including prior approval authority over proposed rates and requirements for loss ratios, the proportion of premium revenues spent on medical claims. The Affordable Care Act (ACA) requires carriers in certain categories of health insurance to provide public justification for rate increases of 10 percent or more. We collected data on how states changed their rate review authority and requirements during 2010-13, the years immediately after enactment of the ACA, and we combined these data with carrier filings. We found that adjusted premiums in the individual market in states that had prior-approval authority combined with loss ratio requirements were lower in 2010-13 ($3,489) than premiums in states with no rate review authority or that had only file-and-use regulations, which gave the states no authority to block rate increases ($3,617). Adjusted premiums declined modestly in prior-approval states with loss ratio requirements, from $3,526 in 2010 to $3,452 in 2013, while premiums increased from $3,422 to $3,683 in states with no rate review authority or file-and-use regulations only. Our findings suggest that states with prior approval authority and loss ratio requirements constrained health insurance premium increases. Project HOPE—The People-to-People Health Foundation, Inc.

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

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

Dental insurance: A systematic review.

Science.gov (United States)

Garla, Bharath Kumar; Satish, G; Divya, K T

2014-12-01

To review uses of finance in dentistry. A search of 25 electronic databases and World Wide Web was conducted. Relevant journals were hand searched and further information was requested from authors. Inclusion criteria were a predefined hierarchy of evidence and objectives. Study validity was assessed with checklists. Two reviewers independently screened sources, extracted data, and assessed validity. Insurance has come of ages and has become the mainstay of payment in many developed countries. So much so that all the alternative forms of payment which originated as an alternative to fee for service now depend on insurance at one point or the other. Fee for service is still the major form of payment in many developing countries including India. It is preferred in many instances since the payment is made immediately.

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…

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.

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.

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...

[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

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.

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

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,...

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.

75 FR 71564 - Defense Federal Acquisition Regulation Supplement; Contractor Insurance/Pension Review (DFARS...

Science.gov (United States)

2010-11-24

... Federal Acquisition Regulation Supplement; Contractor Insurance/Pension Review (DFARS Case 2009-D025... conducting a Contractor Insurance/Pension Review from Procedures, Guidance, and Information (PGI) to the... This final rule relocates requirements for Contractor Insurance/ Pension Review to DFARS 242.7302 from...

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.

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...

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

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.

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.

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...

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)

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.

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

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.

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.

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.

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.

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

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 ...

32 CFR 199.7 - Claims submission, review, and payment.

Science.gov (United States)

2010-07-01

... review or audit, whether the review or audit is prospective, concurrent, or retroactive, OCHAMPUS or... preauthorization must be attached to the appropriate CHAMPUS claim. (4) Advance payment prohibited. No CHAMPUS... and supplies will be subject to utilization review and quality assurance standards, norms, and...

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...

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.

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...

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.

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.

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.

78 FR 53758 - Agency Information Collection Activities: Submission for OMB Review; Comment Request: Insurance...

Science.gov (United States)

2013-08-30

... Review; Comment Request: Insurance Sales Consumer Protections AGENCY: Federal Deposit Insurance... comment for 60 days on renewal of its Insurance Sales Consumer Protections information collection, which... Sales Consumer Protections. OMB Number: 3064-0140. Frequency of Response: Once--reviewing/updating...

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.

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.

75 FR 33237 - Defense Federal Acquisition Regulation Supplement; Contractor Insurance/Pension Review (DFARS...

Science.gov (United States)

2010-06-11

... Acquisition Regulation Supplement; Contractor Insurance/Pension Review (DFARS Case 2009-D025) AGENCY: Defense.../Pension Review from Procedures, Guidance, and Information to the Defense Acquisition Regulation Supplement..., February 23, 2006, moved requirements for Contractor Insurance/Pension Review (CIPR) from DFARS 242.7302 to...

41 CFR 301-71.200 - Who must review and sign travel claims?

Science.gov (United States)

2010-07-01

... travel claims? 301-71.200 Section 301-71.200 Public Contracts and Property Management Federal Travel Regulation System TEMPORARY DUTY (TDY) TRAVEL ALLOWANCES AGENCY RESPONSIBILITIES 71-AGENCY TRAVEL ACCOUNTABILITY REQUIREMENTS Travel Claims for Reimbursement § 301-71.200 Who must review and sign travel claims...

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...

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 ...

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.

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

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.

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.

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.

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 =…

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...

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.

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...

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 ...

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.

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.

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

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.

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.

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.

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....

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.

Cost-effectiveness of national health insurance programs in high-income countries: A systematic review.

Directory of Open Access Journals (Sweden)

Son Nghiem

Full Text Available National health insurance is now common in most developed countries. This study reviews the evidence and synthesizes the cost-effectiveness information for national health insurance or disability insurance programs across high-income countries.A literature search using health, economics and systematic review electronic databases (PubMed, Embase, Medline, Econlit, RepEc, Cochrane library and Campbell library, was conducted from April to October 2015.Two reviewers independently selected relevant studies by applying screening criteria to the title and keywords fields, followed by a detailed examination of abstracts.Studies were selected for data extraction using a quality assessment form consisting of five questions. Only studies with positive answers to all five screening questions were selected for data extraction. Data were entered into a data extraction form by one reviewer and verified by another.Data on costs and quality of life in control and treatment groups were used to draw distributions for synthesis. We chose the log-normal distribution for both cost and quality-of-life data to reflect non-negative value and high skew. The results were synthesized using a Monte Carlo simulation, with 10,000 repetitions, to estimate the overall cost-effectiveness of national health insurance programs.Four studies from the United States that examined the cost-effectiveness of national health insurance were included in the review. One study examined the effects of medical expenditure, and the remaining studies examined the cost-effectiveness of health insurance reforms. The incremental cost-effectiveness ratio (ICER ranged from US$23,000 to US$64,000 per QALY. The combined results showed that national health insurance is associated with an average incremental cost-effectiveness ratio of US$51,300 per quality-adjusted life year (QALY. Based on the standard threshold for cost-effectiveness, national insurance programs are cost-effective interventions

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...

Effects of health insurance on labour supply: A systematic review

NARCIS (Netherlands)

Quynh, Nga Le Thi; Groot, Wim; Tomini, Sonila M.; Tomini, Florian

2017-01-01

This study provides a systematic review of empirical evidence on the labour supply effects of health insurance. The outcomes in the 63 studies reviewed include labour supply in terms of hours worked and the probability of employment, self-employment and the level of economic formalisation. One of

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.

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

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

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.

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.

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.

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.

78 FR 13405 - Patient Protection and Affordable Care Act; Health Insurance Market Rules; Rate Review

Science.gov (United States)

2013-02-27

... Parts 144, 147, 150, et al. Patient Protection and Affordable Care Act; Health Insurance Market Rules... Insurance Market Rules; Rate Review AGENCY: Department of Health and Human Services. ACTION: Final rule. SUMMARY: This final rule implements provisions related to fair health insurance premiums, guaranteed...

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...

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...

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.

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.

The Educational Benefits Claimed for Physical Education and School Sport: An Academic Review

Science.gov (United States)

Bailey, Richard; Armour, Kathleen; Kirk, David; Jess, Mike; Pickup, Ian; Sandford, Rachel

2009-01-01

This academic review critically examines the theoretical and empirical bases of claims made for the educational benefits of physical education and school sport (PESS). An historical overview of the development of PESS points to the origins of claims made in four broad domains: physical, social, affective and cognitive. Analysis of the evidence…

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.

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.

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.

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

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.

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.

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...

Epidemiology of Trichomoniasis in South Korea and Increasing Trend in Incidence, Health Insurance Review and Assessment 2009-2014.

Science.gov (United States)

Joo, So-Young; Goo, Youn-Kyoung; Ryu, Jae-Sook; Lee, Sang-Eun; Lee, Won Kee; Chung, Dong-Il; Hong, Yeonchul

2016-01-01

Trichomoniasis, which is caused by Trichomonas vaginalis, is one of the most common non-viral sexually transmitted infections; however, limited population-based data are available that describe patterns and trends of the disease. We summarized insurance claims of trichomoniasis cases reported during 2009-2014 to South Korea Health Insurance Review and Assessment Service. The average annual incidence in South Korea was 276.8 persons per 100,000 population, and a substantial sex-associated variation was observed. The incidence rate among female subjects trended upward over 6 years, that is, it increased from 501 in 2009 to 625.8 in 2014 per 100,000 female population, which indicates a 25% overall increase. This trend was sharpest in the ≥60 years group of female population. However, a 66% decrease in incidence rates was observed among male subjects (23.7 in 2009 to 15.7 in 2014 per 100,000 male population). Further, substantial decrease was observed in the ≥40 years groups of male population. The incidence of trichomoniasis varied across regions and was the highest in Jeju province of South Korea. Overall, as the incidence of trichomoniasis appears to have increased in South Korea during 2009-2014, the disease burden is increasing; hence, there is a need to better understand the disease transmission.

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.

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...

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.

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.

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.

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.

Barefoot running claims and controversies: a review of the literature.

Science.gov (United States)

Jenkins, David W; Cauthon, David J

2011-01-01

Barefoot running is slowly gaining a dedicated following. Proponents of barefoot running claim many benefits, such as improved performance and reduced injuries, whereas detractors warn of the imminent risks involved. Multiple publications were reviewed using key words. A review of the literature uncovered many studies that have looked at the barefoot condition and found notable differences in gait and other parameters. These findings, along with much anecdotal information, can lead one to extrapolate that barefoot runners should have fewer injuries, better performance, or both. Several athletic shoe companies have designed running shoes that attempt to mimic the barefoot condition and, thus, garner the purported benefits of barefoot running. Although there is no evidence that either confirms or refutes improved performance and reduced injuries in barefoot runners, many of the claimed disadvantages to barefoot running are not supported by the literature. Nonetheless, it seems that barefoot running may be an acceptable training method for athletes and coaches who understand and can minimize the risks.

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.

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.

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.

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.

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.

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.

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.)

The role of radiology in diagnostic error: a medical malpractice claims review.

Science.gov (United States)

Siegal, Dana; Stratchko, Lindsay M; DeRoo, Courtney

2017-09-26

Just as radiologic studies allow us to see past the surface to the vulnerable and broken parts of the human body, medical malpractice claims help us see past the surface of medical errors to the deeper vulnerabilities and potentially broken aspects of our healthcare delivery system. And just as the insights we gain through radiologic studies provide focus for a treatment plan for healing, so too can the analysis of malpractice claims provide insights to improve the delivery of safe patient care. We review 1325 coded claims where Radiology was the primary service provider to better understand the problems leading to patient harm, and the opportunities most likely to improve diagnostic care in the future.

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

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)

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...

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...

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

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

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

[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.

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.

A systematic review, and meta-analyses, of the impact of health-related claims on dietary choices.

Science.gov (United States)

Kaur, Asha; Scarborough, Peter; Rayner, Mike

2017-07-11

Health-related claims are statements regarding the nutritional content of a food (nutrition claims) and/or indicate that a relationship exists between a food and a health outcome (health claims). Their impact on food purchasing or consumption decisions is unclear. This systematic review measured the effect of health-related claims, on pre-packaged foods in retail settings, on adult purchasing decisions (real and perceived). In September 2016, we searched MEDLINE, EMBASE, PsychINFO, CAB abstracts, Business Source Complete, and Web of Science/Science Citation Index & Social Science Citation Index for articles in English published in peer-review journals. Studies were included if they were controlled experiments where the experimental group(s) included a health-related claim and the control group involved an identical product without a health-related claim. Included studies measured (at an individual or population level); actual or intended choice, purchases, and/or consumption. The primary outcome was product choices and purchases, the secondary outcome was food consumption and preference. Results were standardised through calculating odds ratios and 95% confidence intervals (CI) for the likelihood of choosing a product when a health-related claim was present. Results were combined in a random-effects meta-analysis. Thirty-one papers were identified, 17 of which were included for meta-analyses. Most studies were conducted in Europe (n = 17) and the USA (n = 7). Identified studies were choice experiments that measured the likelihood of a product being chosen when a claim was present compared to when a claim was not present, (n = 16), 15 studies were experiments that measured either; intent-rating scale outcomes (n = 8), consumption (n = 6), a combination of the two (n = 1), or purchase data (n = 1). Overall, 20 studies found that claims increase purchasing and/or consumption, eight studies had mixed results, and two studies found consumption

Adoption and impact of index-insurance and credit for smallholder farmers in developing countries : A systematic review

NARCIS (Netherlands)

Marr, Ana; Winkel, Anne; van Asseldonk, Marcel; Lensink, Robert; Bulte, Erwin

2016-01-01

Purpose – The purpose of this paper is to review the most recent scientific literature on the determinants explaining the demand for index-insurance, the impact of index-insurance and the existing links between insurance and credit. In this meta-analysis, the authors identify key discoveries on the

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...

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

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

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

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.

A Critical Review of the Marketing Claims of Infant Formula Products in the United States.

Science.gov (United States)

Belamarich, Peter F; Bochner, Risa E; Racine, Andrew D

2016-05-01

A highly competitive infant formula market has resulted in direct-to-consumer marketing intended to promote the sale of modified formulas that claim to ameliorate common infant feeding problems. The claims associated with these marketing campaigns are not evaluated with reference to clinical evidence by the Food and Drug Administration. We aimed to describe the language of claims made on formula labels and compare it with the evidence in systematic reviews. Of the 22 product labels we identified, 13 product labels included claims about colic and gastrointestinal symptoms. There is insufficient evidence to support the claims that removing or reducing lactose, using hydrolyzed or soy protein or adding pre-/probiotics to formula benefits infants with fussiness, gas, or colic yet claims like "soy for fussiness and gas" encourage parents who perceive their infants to be fussy to purchase modified formula. Increased regulation of infant formula claims is warranted. © The Author(s) 2015.

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....

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.

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.

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...

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.

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...

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.

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

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.

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.

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

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

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...

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...

A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects?

Science.gov (United States)

Alhassan, Robert Kaba; Nketiah-Amponsah, Edward; Arhinful, Daniel Kojo

2016-01-01

The introduction of the national health insurance scheme (NHIS) in Ghana in 2003 significantly contributed to improved health services utilization and health outcomes. However, stagnating active membership, reports of poor quality health care rendered to NHIS-insured clients and cost escalations have raised concerns on the operational and financial sustainability of the scheme. This paper reviewed peer reviewed articles and grey literature on the sustainability challenges and prospects of the NHIS in Ghana. Electronic search was done for literature published between 2003-2016 on the NHIS and its sustainability in Ghana. A total of 66 publications relevant to health insurance in Ghana and other developing countries were retrieved from Cochrane, PubMed, ScienceDirect and Googlescholar for initial screening. Out of this number, 31 eligible peer reviewed articles were selected for final review based on specific relevance to the Ghanaian context. Ability of the NHIS to continue its operations in Ghana is threatened financially and operationally by factors such as: cost escalation, possible political interference, inadequate technical capacity, spatial distribution of health facilities and health workers, inadequate monitoring mechanisms, broad benefits package, large exemption groups, inadequate client education, and limited community engagement. Moreover, poor quality care in NHIS-accredited health facilities potentially reduces clients' trust in the scheme and consequently decreases (re)enrolment rates. These sustainability challenges were reviewed and discussed in this paper. The NHIS continues to play a critical role towards attaining universal health coverage in Ghana albeit confronted by challenges that could potentially collapse the scheme. Averting this possible predicament will largely depend on concerted efforts of key stakeholders such as health insurance managers, service providers, insurance subscribers, policy makers and political actors.

A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects?

Directory of Open Access Journals (Sweden)

Robert Kaba Alhassan

Full Text Available The introduction of the national health insurance scheme (NHIS in Ghana in 2003 significantly contributed to improved health services utilization and health outcomes. However, stagnating active membership, reports of poor quality health care rendered to NHIS-insured clients and cost escalations have raised concerns on the operational and financial sustainability of the scheme. This paper reviewed peer reviewed articles and grey literature on the sustainability challenges and prospects of the NHIS in Ghana.Electronic search was done for literature published between 2003-2016 on the NHIS and its sustainability in Ghana. A total of 66 publications relevant to health insurance in Ghana and other developing countries were retrieved from Cochrane, PubMed, ScienceDirect and Googlescholar for initial screening. Out of this number, 31 eligible peer reviewed articles were selected for final review based on specific relevance to the Ghanaian context.Ability of the NHIS to continue its operations in Ghana is threatened financially and operationally by factors such as: cost escalation, possible political interference, inadequate technical capacity, spatial distribution of health facilities and health workers, inadequate monitoring mechanisms, broad benefits package, large exemption groups, inadequate client education, and limited community engagement. Moreover, poor quality care in NHIS-accredited health facilities potentially reduces clients' trust in the scheme and consequently decreases (reenrolment rates. These sustainability challenges were reviewed and discussed in this paper.The NHIS continues to play a critical role towards attaining universal health coverage in Ghana albeit confronted by challenges that could potentially collapse the scheme. Averting this possible predicament will largely depend on concerted efforts of key stakeholders such as health insurance managers, service providers, insurance subscribers, policy makers and political actors.

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...

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 ...

Disability Income Insurance

OpenAIRE

Hayhoe, Celia Ray; Smith, Mike, CPF

2009-01-01

The purpose of disability income insurance is to partially replace your income if you are unable to work because of sickness or an accident. This guide reviews the types of disability insurance, important terms and concepts and employer provided benefits.

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.

45 CFR 147.136 - Internal claims and appeals and external review processes.

Science.gov (United States)

2010-10-01

..., appropriateness, health care setting, level of care, or effectiveness of a covered benefit. (ii) The State process... pay the cost of the IRO for conducting the external review. Notwithstanding this requirement, the... not impose, for example, a $500 minimum claims threshold. (vi) The State process must allow at least...

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.

A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects?

Science.gov (United States)

Alhassan, Robert Kaba; Nketiah-Amponsah, Edward; Arhinful, Daniel Kojo

2016-01-01

Background The introduction of the national health insurance scheme (NHIS) in Ghana in 2003 significantly contributed to improved health services utilization and health outcomes. However, stagnating active membership, reports of poor quality health care rendered to NHIS-insured clients and cost escalations have raised concerns on the operational and financial sustainability of the scheme. This paper reviewed peer reviewed articles and grey literature on the sustainability challenges and prospects of the NHIS in Ghana. Methods Electronic search was done for literature published between 2003–2016 on the NHIS and its sustainability in Ghana. A total of 66 publications relevant to health insurance in Ghana and other developing countries were retrieved from Cochrane, PubMed, ScienceDirect and Googlescholar for initial screening. Out of this number, 31 eligible peer reviewed articles were selected for final review based on specific relevance to the Ghanaian context. Results Ability of the NHIS to continue its operations in Ghana is threatened financially and operationally by factors such as: cost escalation, possible political interference, inadequate technical capacity, spatial distribution of health facilities and health workers, inadequate monitoring mechanisms, broad benefits package, large exemption groups, inadequate client education, and limited community engagement. Moreover, poor quality care in NHIS-accredited health facilities potentially reduces clients’ trust in the scheme and consequently decreases (re)enrolment rates. These sustainability challenges were reviewed and discussed in this paper. Conclusions The NHIS continues to play a critical role towards attaining universal health coverage in Ghana albeit confronted by challenges that could potentially collapse the scheme. Averting this possible predicament will largely depend on concerted efforts of key stakeholders such as health insurance managers, service providers, insurance subscribers, policy

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.

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.

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.)

[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.

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

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)

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/.

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

The Association of State Rate Review Authority with Health Insurance Premiums.

Science.gov (United States)

Ticse, Caroline

2015-10-01

Key findings. (1) Adjusted premiums in the individual market in states with prior approval authority combined with loss ratio requirements were lower in 2010-2013 than premiums in states with no rate review authority or file-and-use regulations only. (2) Adjusted premiums declined modestly in prior approval states while premiums increased in states with no rate review authority or with file-and-use regulations only. (3) The findings suggest that states with prior approval authority and loss ratio requirements constrained increases in health insurance premiums.

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.

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.

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

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.

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.

Price-Anderson Act: Congressional review begins

International Nuclear Information System (INIS)

Anon.

1984-01-01

Every 10 years Congress reviews, amends, and extends the Price-Anderson Act of 1957, which was designed to encourage the new nuclear industry by guaranteeing insurance beyond the level provided by private insurers. The Nuclear Regulatory Commission is recommending five congressional actions for the 1987 extension: reauthorization, replacement of the absolute insurance limitation with an annual limitation of liability, raising the retrospective premium per reactor per incident from $5 million to $10 million, raising the statute of limitations on claims for 20 to 30 years, and retaining current language dealing with extraordinary events. Two bills, H.R. 421 and H.R. 3277, were introduced with provisions that broaden the opportunity for victims compensation and eliminate the subsidy aspect. Hearings began in July, with reactions from the National Taxpayers Union and Nuclear insurance underwriters in conflict over the limitations on liability. DOE and DOE contractors urge continuation of the Price-Anderson limitation

Clinical negligence in foot and ankle surgery: A 17-year review of claims to the NHS Litigation Authority.

Science.gov (United States)

Ring, J; Talbot, C L; Clough, T M

2014-11-01

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012. A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed. During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million. There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement. Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice. ©2014 The British Editorial Society of Bone & Joint Surgery.

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.

The role of micro health insurance in providing financial risk protection in developing countries--a systematic review.

Science.gov (United States)

Habib, Shifa Salman; Perveen, Shagufta; Khuwaja, Hussain Maqbool Ahmed

2016-03-22

Out of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI) has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting. We conducted a systematic search for published literature using the search terms "Community based health insurance AND developing countries", "Micro health insurance AND developing countries", "Mutual health insurance AND developing countries", "mutual OR micro OR community based health insurance" "Health insurance AND impact AND poor" "Health insurance AND financial protection" and "mutual health organizations" on three databases, Pubmed, Google Scholar and Science Direct (Elsevier). Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization. Twenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa). Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure, household borrowings and poverty. MHI also had a positive safeguarding effect on

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

Contending Claims to Causality: A Critical Review of Mediation Research in HRD

Science.gov (United States)

Ghosh, Rajashi; Jacobson, Seth

2016-01-01

Purpose: The purpose of this paper is to conduct a critical review of the mediation studies published in the field of Human Resource Development (HRD) to discern if the study designs, the nature of data collection and the choice of statistical methods justify the causal claims made in those studies. Design/methodology/approach: This paper conducts…

Differences in price elasticities of demand for health insurance: a systematic review.

Science.gov (United States)

Pendzialek, Jonas B; Simic, Dusan; Stock, Stephanie

2016-01-01

Many health insurance systems apply managed competition principles to control costs and quality of health care. Besides other factors, managed competition relies on a sufficient price-elastic demand. This paper presents a systematic review of empirical studies on price elasticity of demand for health insurance. The objective was to identify the differing international ranges of price elasticity and to find socio-economic as well as setting-oriented factors that influence price elasticity. Relevant literature for the topic was identified through a two-step identification process including a systematic search in appropriate databases and further searches within the references of the results. A total of 45 studies from countries such as the USA, Germany, the Netherlands, and Switzerland were found. Clear differences in price elasticity by countries were identified. While empirical studies showed a range between -0.2 and -1.0 for optional primary health insurance in the US, higher price elasticities between -0.6 and -4.2 for Germany and around -2 for Switzerland were calculated for mandatory primary health insurance. Dutch studies found price elasticities below -0.5. In consideration of all relevant studies, age and poorer health status were identified to decrease price elasticity. Other socio-economic factors had an unclear impact or too limited evidence. Premium level, range of premiums, homogeneity of benefits/coverage and degree of forced decision were found to have a major influence on price elasticity in their settings. Further influence was found from supplementary insurance and premium-dependent employer contribution.

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...

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...

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.

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.

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

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.

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

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.

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

Claim Assessment Profile: A Method for Capturing Healthcare Evidence in the Scientific Evaluation and Review of Claims in Health Care (SEaRCH).

Science.gov (United States)

Hilton, Lara; Jonas, Wayne B

2017-02-01

Grounding health claims in an evidence base is essential for determining safety and effectiveness. However, it is not appropriate to evaluate all healthcare claims with the same methods. "Gold standard" randomized controlled trials may skip over important qualitative and observational data about use, benefits, side effects, and preferences, issues especially salient in research on complementary and integrative health (CIH) practices. This gap has prompted a move toward studying treatments in their naturalistic settings. In the 1990s, a program initiated under the National Institutes of Health was designed to provide an outreach to CIH practices for assessing the feasibility of conducting retrospective or prospective evaluations. The Claim Assessment Profile further develops this approach, within the framework of Samueli Institute's Scientific Evaluation and Review of Claims in Health Care (SEaRCH) method. The goals of a Claim Assessment Profile are to clarify the elements that constitute a practice, define key outcomes, and create an explanatory model of these impacts. The main objective is to determine readiness and capacity of a practice to engage in evaluation of effectiveness. This approach is informed by a variety of rapid assessment and stakeholder-driven methods. Site visits, structured qualitative interviews, surveys, and observational data on implementation provide descriptive data about the practice. Logic modeling defines inputs, processes, and outcome variables; Path modeling defines an analytic map to explore. The Claim Assessment Profile is a rapid assessment of the evaluability of a healthcare practice. The method was developed for use on CIH practices but has also been applied in resilience research and may be applied beyond the healthcare sector. Findings are meant to provide sufficient data to improve decision-making for stakeholders. This method provides an important first step for moving existing promising yet untested practices into

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.

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.

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...

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...

[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.

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.

44 CFR 63.16 - Review of State application by the Federal Insurance Administrator.

Science.gov (United States)

2010-10-01

... for eligibility and indicate in what respects the State program and/or data base fails to comply with... 44 Emergency Management and Assistance 1 2010-10-01 2010-10-01 false Review of State application... FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY INSURANCE AND HAZARD MITIGATION...

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

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...

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

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.

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.

Radiation injury claims: an overview and update

International Nuclear Information System (INIS)

Schaffer, W.G.

1984-01-01

The author reviews the radiation injury claims problem and summarizes the legal framework in which the claims are presently brought. Two cases are reviewed in which the decisions are troubling. The implications of these decisions are discussed in the overall radiation injury claims problem. The author notes that in the largest radiation injury case tried in the United States, the court was unable to resolve the claims within the confines of the existing law. The disregard for established norms of adjudication and the resultant decline in predictability of outcome portends grave consequences, not only for the nuclear industry but for other industries involved with potentially toxic substances

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

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.

Nuclear insurance fire risk

International Nuclear Information System (INIS)

Dressler, E.G.

2001-01-01

Nuclear facilities operate under the constant risk that radioactive materials could be accidentally released off-site and cause injuries to people or damages to the property of others. Management of this nuclear risk, therefore, is very important to nuclear operators, financial stakeholders and the general public. Operators of these facilities normally retain a portion of this risk and transfer the remainder to others through an insurance mechanism. Since the nuclear loss exposure could be very high, insurers usually assess their risk first-hand by sending insurance engineers to conduct a nuclear insurance inspection. Because a serious fire can greatly increase the probability of an off-site release of radiation, fire safety should be included in the nuclear insurance inspection. This paper reviews essential elements of a facility's fire safety program as a key factor in underwriting nuclear third-party liability insurance. (author)

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.

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).

76 FR 40451 - Agency Information Collection (Application for Ordinary Life Insurance) Activity Under OMB Review

Science.gov (United States)

2011-07-08

... reduced automatically by one-half from its present face value on the day before a policyholder's 65th and... (Application for Ordinary Life Insurance) Activity Under OMB Review AGENCY: Veterans Benefits Administration...) of 1995 [[Page 40452

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 CFR 405.510 - Claims remanded by a Federal court.

Science.gov (United States)

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Claims remanded by a Federal court. 405.510 Section 405.510 Employees' Benefits SOCIAL SECURITY ADMINISTRATION ADMINISTRATIVE REVIEW PROCESS FOR ADJUDICATING INITIAL DISABILITY CLAIMS Judicial Review § 405.510 Claims remanded by a Federal court. When a...

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

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.

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.

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.

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...

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.

The role of micro health insurance in providing financial risk protection in developing countries- a systematic review

Directory of Open Access Journals (Sweden)

Shifa Salman Habib

2016-03-01

Full Text Available Abstract Background Out of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting. Methods We conducted a systematic search for published literature using the search terms “Community based health insurance AND developing countries”, “Micro health insurance AND developing countries”, “Mutual health insurance AND developing countries”, “mutual OR micro OR community based health insurance” “Health insurance AND impact AND poor” “Health insurance AND financial protection” and “mutual health organizations” on three databases, Pubmed, Google Scholar and Science Direct (Elsevier. Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization. Results Twenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa. Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure

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

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.

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...

Impact of Publicly Financed Health Insurance Schemes on Healthcare Utilization and Financial Risk Protection in India: A Systematic Review.

Science.gov (United States)

Prinja, Shankar; Chauhan, Akashdeep Singh; Karan, Anup; Kaur, Gunjeet; Kumar, Rajesh

2017-01-01

Several publicly financed health insurance schemes have been launched in India with the aim of providing universalizing health coverage (UHC). In this paper, we report the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Empirical research studies focussing on the impact or evaluation of publicly financed health insurance schemes in India were searched on PubMed, Google scholar, Ovid, Scopus, Embase and relevant websites. The studies were selected based on two stage screening PRISMA guidelines in which two researchers independently assessed the suitability and quality of the studies. The studies included in the review were divided into two groups i.e., with and without a comparison group. To assess the impact on utilization, OOP expenditure and health indicators, only the studies with a comparison group were reviewed. Out of 1265 articles screened after initial search, 43 studies were found eligible and reviewed in full text, finally yielding 14 studies which had a comparator group in their evaluation design. All the studies (n-7) focussing on utilization showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. About 70% studies (n-5) studies with a strong design and assessing financial risk protection showed no impact in reduction of OOP expenditures, while remaining 30% of evaluations (n-2), which particularly evaluated state sponsored health insurance schemes, reported a decline in OOP expenditure among the enrolled households. One study which evaluated impact on health outcome showed reduction in mortality among enrolled as compared to non-enrolled households, from conditions covered by the insurance scheme. While utilization of healthcare did improve among those enrolled in the scheme, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or

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.

Claims in civil engineering contracts

CERN Document Server

Speirs, N A

1999-01-01

This paper considers claims arising during civil engineering construction contracts. The meaning of the word 'claim' is considered and its possible implications for additional cost and time to completion. The conditions of the construction contract selected will influence the risk apportionment between contractor and client and the price offered by the contractor for the work. Competitive bidding constraints and profit margins in the construction industry, however, may also influence the price offered. This in turn can influence the likelihood of claims arising. The client from his point of view is concerned to complete the work within an agreed time and budget. The circumstances under which claims may arise are reviewed in relation to typical conditions of contract. These circumstances are then related to the CERN LHC civil works. Ways of avoiding claims, where this is possible, are considered. Finally, the means of evaluation of claims and their settlement are considered.

Towards Actualizing the Value Potential of Korea Health Insurance Review and Assessment (HIRA) Data as a Resource for Health Research: Strengths, Limitations, Applications, and Strategies for Optimal Use of HIRA Data.

Science.gov (United States)

Kim, Jee Ae; Yoon, Seokjun; Kim, Log Young; Kim, Dong Sook

2017-05-01

Health Insurance and Review Assessment (HIRA) in South Korea, also called National Health Insurance (NHI) data, is a repository of claims data collected in the process of reimbursing healthcare providers. Under the universal coverage system, having fee-for-services covering all citizens in South Korea, HIRA contains comprehensive and rich information pertaining to healthcare services such as treatments, pharmaceuticals, procedures, and diagnoses for almost 50 million beneficiaries. This corpus of HIRA data, which constitutes a large repository of data in the healthcare sector, has enormous potential to create value in several ways: enhancing the efficiency of the healthcare delivery system without compromising quality of care; adding supporting evidence for a given intervention; and providing the information needed to prevent (or monitor) adverse events. In order to actualize this potential, HIRA data need to actively be utilized for research. Thus understanding this data would greatly enhance this potential. We introduce HIRA data as an important source for health research and provide guidelines for researchers who are currently utilizing HIRA, or interested in doing so, to answer their research questions. We present the characteristics and structure of HIRA data. We discuss strengths and limitations that should be considered in conducting research with HIRA data and suggest strategies for optimal utilization of HIRA data by reviewing published research using HIRA data. © 2017 The Korean Academy of Medical Sciences.

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.

Insurance Regulation: The NAIC Accreditation Program Can be Improved

National Research Council Canada - National Science Library

DIngell, John

2001-01-01

... environment of the insurance industry and insurance regulation. In addition, it has revised the way accreditation reviews are performed and scored and has improved training for members of review teams.

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.

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

28 CFR 543.32 - Processing the claim.

Science.gov (United States)

2010-07-01

..., Central Office for their review. (f) Will appreciation or depreciation be considered? Yes. Staff will consider appreciation or depreciation of lost or damaged property in settling a claim. (g) If my claim is...

Optimal non-linear health insurance.

Science.gov (United States)

Blomqvist, A

1997-06-01

Most theoretical and empirical work on efficient health insurance has been based on models with linear insurance schedules (a constant co-insurance parameter). In this paper, dynamic optimization techniques are used to analyse the properties of optimal non-linear insurance schedules in a model similar to one originally considered by Spence and Zeckhauser (American Economic Review, 1971, 61, 380-387) and reminiscent of those that have been used in the literature on optimal income taxation. The results of a preliminary numerical example suggest that the welfare losses from the implicit subsidy to employer-financed health insurance under US tax law may be a good deal smaller than previously estimated using linear models.

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.

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.

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

76 FR 71993 - Extension of Agency Information Collection Activity Under OMB Review: TSA Claims Management Program

Science.gov (United States)

2011-11-21

... Information Collection Activity Under OMB Review: TSA Claims Management Program AGENCY: Transportation... Security Administration (TSA) has forwarded the Information Collection Request (ICR), Office of Management... the nature of the information collection and its expected burden. TSA published a Federal Register...

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.

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)

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

77 FR 3482 - Agency Information Collection Activities: Submission for OMB Review; Comment Request, National...

Science.gov (United States)

2012-01-24

... Insurance Claims Appeals Process. Type of Collection: Revision of a currently approved information collection. OMB Number: 1660-0095. Abstract: The process requires policyholders to submit a written appeal to..., National Flood Insurance Claims Appeals Process AGENCY: Federal Emergency Management Agency, DHS. ACTION...

Chiropractic claims in the English-speaking world.

Science.gov (United States)

Ernst, Edzard; Gilbey, Andrew

2010-04-09

Some chiropractors and their associations claim that chiropractic is effective for conditions that lack sound supporting evidence or scientific rationale. This study therefore sought to determine the frequency of World Wide Web claims of chiropractors and their associations to treat, asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound evidence), and lower back pain (supported by some evidence). A review of 200 chiropractor websites and 9 chiropractic associations' World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States was conducted between 1 October 2008 and 26 November 2008. The outcome measure was claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment. We found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were made about asthma, ear infection/earache/otitis media, neck pain, The majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.

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.

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.

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.

28 CFR 104.31 - Procedure for claims evaluation.

Science.gov (United States)

2010-07-01

... COMPENSATION FUND OF 2001 Claim Intake, Assistance, and Review Procedures § 104.31 Procedure for claims..., described herein as “Track A” and “Track B,” selected by the claimant on the Personal Injury Compensation Form or Death Compensation Form. (1) Procedure for Track A. The Claims Evaluator shall determine...

20 CFR 410.705 - Duplicate claims.

Science.gov (United States)

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Duplicate claims. 410.705 Section 410.705 Employees' Benefits SOCIAL SECURITY ADMINISTRATION FEDERAL COAL MINE HEALTH AND SAFETY ACT OF 1969, TITLE IV-BLACK LUNG BENEFITS (1969- ) Rules for the Review of Denied and Pending Claims Under the Black Lung...

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...

Psychotherapy for depression in claimants receiving wage replacement benefits: review of the evidence.

Science.gov (United States)

Ebrahim, Shanil

2014-01-01

To review the evidence on the provision of psychotherapy for claimants who are suffering from depression and receiving wage replacement benefits. A literature review was performed using PubMed and EMBASE. Results from three studies are discussed. The first is a systematic review and individual patient data meta-analysis of randomized controlled trials to assess the relative effectiveness of cognitive behavioral therapy (CBT) for depression in patients receiving disability benefits. A non-significant trend showed that the effect of CBT was greater in patients receiving benefits (34 patients) than those not receiving disability benefits (193 patients) on the Beck Depression Inventory; mean difference (95% confidence interval [CI]) = -4.46 (-12.21 to 3.30). The second study is an analysis of a large insurance administrative database consisting of 10,338 long-term disability claims for depression. Receipt of psychotherapy was associated with faster claim closure (hazard ratio = 1.42; 95% CI = 1.33 to 1.52). The third study evaluated the effectiveness of standard CBT vs work-focused CBT in 168 employees with common mental health problems (depression, anxiety and adjustment disorders). Employees receiving work-focused CBT returned to work 65 days earlier on average than those receiving standard CBT. Limited evidence shows that psychotherapy is effective in claimants suffering from depression who are in receipt of wage replacement benefits. At this time, clinicians and insurers should continue to recommend psychotherapy as a treatment management strategy for claimants with depression. Larger comparative trials, conducted in collaboration with disability insurers, will lead to increased confidence in estimates.

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.

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...

Health Insurance Rate Review Fact Sheet

Data.gov (United States)

U.S. Department of Health & Human Services — The Affordable Care Act is bringing an unprecedented level of scrutiny and transparency to health insurance rate increases. The Act ensures that, in any State, any...

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.

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.

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...

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

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.

Insurance requirements and practices of Ethiopia's construction sector

African Journals Online (AJOL)

The principles of insurance and types of insurance policies in construCtion industry in general is discussed. The status of consultants and contractors in Ethiopian construction sector is briefly reviewed. Questionnaires were designed to preliminary assess whether relevant insurance policies are bought by contracting and ...

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.

Systematic Review of Willingness to Pay for Health Insurance in Low and Middle Income Countries.

Science.gov (United States)

Nosratnejad, Shirin; Rashidian, Arash; Dror, David Mark

2016-01-01

Access to healthcare is mostly contingent on out-of-pocket spending (OOPS) by health seekers, particularly in low- and middle-income countries (LMICs). This would require many LMICs to raise enough funds to achieve universal health insurance coverage. But, are individuals or households willing to pay for health insurance, and how much? What factors positively affect WTP for health insurance? We wanted to examine the evidence for this, through a review of the literature. We systematically searched databases up to February 2016 and included studies of individual or household WTP for health insurance. Two authors appraised the identified studies. We estimated the WTP as a percentage of GDP per capita, and adjusted net national income per capita of each country. We used meta-analysis to calculate WTP means and confidence intervals, and vote-counting to identify the variables that more often affected WTP. 16 studies (21 articles) from ten countries met the inclusion criteria. The mean WTP of individuals was 1.18% of GDP per capita and 1.39% of adjusted net national income per capita. The corresponding figures for households were 1.82% and 2.16%, respectively. Increases in family size, education level and income were consistently correlated with higher WTP for insurance, and increases in age were correlated with reduced WTP. The WTP for healthcare insurance among rural households in LMICs was just below 2% of the GPD per capita. The findings demonstrate that in moving towards universal health coverage in LMICs, governments should not rely on households' premiums as a major financing source and should increase their fiscal capacity for an equitable health care system using other sources.

Systematic Review of Willingness to Pay for Health Insurance in Low and Middle Income Countries.

Directory of Open Access Journals (Sweden)

Shirin Nosratnejad

Full Text Available Access to healthcare is mostly contingent on out-of-pocket spending (OOPS by health seekers, particularly in low- and middle-income countries (LMICs. This would require many LMICs to raise enough funds to achieve universal health insurance coverage. But, are individuals or households willing to pay for health insurance, and how much? What factors positively affect WTP for health insurance? We wanted to examine the evidence for this, through a review of the literature.We systematically searched databases up to February 2016 and included studies of individual or household WTP for health insurance. Two authors appraised the identified studies. We estimated the WTP as a percentage of GDP per capita, and adjusted net national income per capita of each country. We used meta-analysis to calculate WTP means and confidence intervals, and vote-counting to identify the variables that more often affected WTP.16 studies (21 articles from ten countries met the inclusion criteria. The mean WTP of individuals was 1.18% of GDP per capita and 1.39% of adjusted net national income per capita. The corresponding figures for households were 1.82% and 2.16%, respectively. Increases in family size, education level and income were consistently correlated with higher WTP for insurance, and increases in age were correlated with reduced WTP.The WTP for healthcare insurance among rural households in LMICs was just below 2% of the GPD per capita. The findings demonstrate that in moving towards universal health coverage in LMICs, governments should not rely on households' premiums as a major financing source and should increase their fiscal capacity for an equitable health care system using other sources.

Outlier detection in healthcare fraud: A case study in the Medicaid dental domain

NARCIS (Netherlands)

van Capelleveen, Guido Cornelis; Poel, Mannes; Mueller, Roland; Thornton, Dallas; van Hillegersberg, Jos

Health care insurance fraud is a pressing problem, causing substantial and increasing costs in medical insurance programs. Due to large amounts of claims submitted, estimated at 5 billion per day, review of individual claims or providers is a difficult task. This encourages the employment of

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.

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.

Effect of Health Insurance on the Use and Provision of Maternal Health Services and Maternal and Neonatal Health Outcomes: A Systematic Review

Science.gov (United States)

Peterson, Lauren A.; Hatt, Laurel E.

2013-01-01

Financial barriers can affect timely access to maternal health services. Health insurance can influence the use and quality of these services and potentially improve maternal and neonatal health outcomes. We conducted a systematic review of the evidence on health insurance and its effects on the use and provision of maternal health services and on maternal and neonatal health outcomes in middle- and low-income countries. Studies were identified through a literature search in key databases and consultation with experts in healthcare financing and maternal health. Twenty-nine articles met the review criteria of focusing on health insurance and its effect on the use or quality of maternal health services, or maternal and neonatal health outcomes. Sixteen studies assessed demand-side effects of insurance, eight focused on supply-side effects, and the remainder addressed both. Geographically, the studies provided evidence from sub-Saharan Africa (n=11), Asia (n=9), Latin America (n=8), and Turkey. The studies included examples from national or social insurance schemes (n=7), government-run public health insurance schemes (n=4), community-based health insurance schemes (n=11), and private insurance (n=3). Half of the studies used econometric analyses while the remaining provided descriptive statistics or qualitative results. There is relatively consistent evidence that health insurance is positively correlated with the use of maternal health services. Only four studies used methods that can establish this causal relationship. Six studies presented suggestive evidence of overprovision of caesarean sections in response to providers’ payment incentives through health insurance. Few studies focused on the relationship between health insurance and the quality of maternal health services or maternal and neonatal health outcomes. The available evidence on the quality and health outcomes is inconclusive, given the differences in measurement, contradictory findings, and

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.

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…

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.

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.

Neonatal hypoglycaemia: learning from claims

OpenAIRE

Hawdon, Jane M; Beer, Jeanette; Sharp, Deborah; Upton, Michele

2016-01-01

Objectives Neonatal hypoglycaemia is a potential cause of neonatal morbidity, and on rare but tragic occasions causes long-term neurodevelopmental harm with consequent emotional and practical costs for the family. The organisational cost to the NHS includes the cost of successful litigation claims. The purpose of the review was to identify themes that could alert clinicians to common pitfalls and thus improve patient safety. Design The NHS Litigation Authority (NHS LA) Claims Management Syste...

[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.

ANALISA HUKUM ATAS PENOLAKAN KLAIM ASURANSI KESEHATAN DALAM KASUS ANTARA HANDOYO DENGAN PERUSAHAAN ASURANSI ALLIANZ

Directory of Open Access Journals (Sweden)

Dwi Tatak Subagiyo

2012-09-01

Full Text Available This research was intended to review and analyze the claim refusal by PT Alianz to Handoyo which is legally justified, it was also intended to analyze the remedy done by Handoyo to get the claim for his loss. Based on this research conclusions, claim refusal by PT Allianz which is filled by Handoyo was not justified by law, because PT Allianz doesn’t admit the related insurance policy. In has been clearly stated in the substance of the related insurance policy that the loss was guaranteed by the insurance company. It means that non disclosure of facts was included a loss that is guaranteed by the insurance as stated in the insurance policy, and therefore PT Allianz can’t use it as a basis to deny the insured claim. Secondly, Handoyo’s remedy was to peacefully resolve the issue of the claim refusal by PT Allianz, because PT Allianz can not unilaterally did the policy cancellation, because it has been tied to an insurance agreement with Handoyo and the agreement meets the terms and conditions of insurance agreements, besides, Handoyo also imposes the PT Allianz to pay the insurance claims along with the cost replacement, damages and interest.

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...

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.

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.

[Quality Assurance in Sociomedical Evaluation by Peer Review: A Pilot Project of the German Statutory Pension Insurance].

Science.gov (United States)

Strahl, A; Gerlich, C; Wolf, H-D; Gehrke, J; Müller-Garnn, A; Vogel, H

2016-03-01

The sociomedical evaluation by the German Pension Insurance serves the purpose of determining entitlement to disability pensions. A quality assurance concept for the sociomedical evaluation was developed, which is based on a peer Review process. Peer review is an established process of external quality assurance in health care. The review is based on a hierarchically constructed manual that was evaluated in this pilot project. The database consists of 260 medical reports for disability pension of 12 pension insurance agencies. 771 reviews from 19 peers were included in the evaluation of the inter-rater reliability. Kendall's coefficient of concordance W for more than 2 raters is used as primary measure of inter-rater reliability. Reliability appeared to be heterogeneous. Kendalls W varies for the particular criteria from 0.09 to 0.88 and reached for primary criterion reproducibility a value of 0.37. The reliability of the manual seemed acceptable in the context of existing research data and is in line with existing peer review research outcomes. Nevertheless, the concordance is limited and requires optimisation. Starting points for improvement can be seen in a systematic training and regular user meetings of the peers involved. © Georg Thieme Verlag KG Stuttgart · New York.

The plaintiff's two-sided mouth: defeating ADA claims based on inconsistent positions taken by the plaintiff on other claims.

Science.gov (United States)

Connell, D S

1996-01-01

In the typical ADA claim, the plaintiff will claim that he or she has a disability but is nevertheless able to perform the essential functions of his or her job. This position is often in direct conflict with other non-ADA claims that the plaintiff has made or is making, where the plaintiff is claiming total disability and/or that he or she is unable to work. This article examines these phenomena, reviews the numerous recent cases that have found for employers based on these inconsistent positions of the plaintiff, and explains how employers can be develop and present this defense.

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

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...

Insurance of liability for the transport of nuclear materials

International Nuclear Information System (INIS)

Deprimoz, J.

1975-01-01

The legal principle governing civil liability for damage involving nuclear substances in course of carriage are summarized, and the main aspects of the French nuclear insurance market are analysed. The financial capacity of insurance and the role of the Atomic Pool as an aid in this respect as well as its use as a mechanism for reinsurance are also discussed. As regards the insured party, cases are reviewed where the principle of the sole liability of the operator is inapplicable. Arguments are put forward demonstrating that acknowledgement of a plurality of insured persons would not necessarily lead to an increase of insurance costs. Finally, a review is made of the nature and extent of the damage covered according to whether such damage is caused to persons or property [fr

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.

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)

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.

Empirical Musicology Review: Serialist Claims versus Sonic Reality

Directory of Open Access Journals (Sweden)

William Thomson

2010-08-01

Full Text Available This study examines the descriptive mores of Serialism, as found in writings of leading American academics of the past half-century. A serious gap is revealed, especially between claims made for structural conditions rooted in dodecaphonic procedures and the actual kinetics of music as heard. Curious (and debilitating ambiguities and dead ends are noted in terms used to define critical perceptual conditions in such music; some claims of significance for features of 12- tone rows in certain works are revealed as wholly irrelevant to music as sonic event. Most prominent of the writings discussed are those of Milton Babbitt, Allen Forte and David Lewin.

Sport-related concussions in New Zealand: a review of 10 years of Accident Compensation Corporation moderate to severe claims and costs.

Science.gov (United States)

King, Doug; Gissane, Conor; Brughelli, Matt; Hume, Patria A; Harawira, Joseph

2014-05-01

This paper provides an overview of the epidemiology of sport-related concussion and associated costs in New Zealand requiring medical treatment from 2001 to 2011 in seven sports codes. A retrospective review of injury entitlement claims by seven sports from 2001 to 2011. Data were analyzed by sporting code, age, ethnicity, gender and year of competition for total and moderate-to-severe (MSC) Accident Compensation Corporation (ACC) claims and costs. A total of 20,902 claims costing $NZD 16,546,026 were recorded over the study period of which 1330 (6.4%) were MSC claims. The mean yearly number and costs of MSC claims were 133 ± 36 and $1,303,942 ± 378,949. Rugby union had the highest number of MSC claims per year (38; 95% CI 36-41 per 1000 MSC claims). New Zealand Māori recorded the highest total ($6,000,759) and mean cost ($21,120) per MSC claim. Although MSC injury claims were only 6.4% of total claims, they accounted for 79.1% of total costs indicating that although the majority of sport-related concussions may be minor in severity, the related economic costs associated with more serious sport-related concussion can be high. The finding that rugby union recorded the most MSC claims in the current study was not unexpected. Of concern is that rugby league recorded a low number of MSC claims but the highest mean cost per claim. Due to the high mean cost per concussion, and the high total and mean cost for New Zealand Māori, further investigation is warranted. Copyright © 2013 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

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.

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.

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...

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

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.

Does a Claims Diagnosis of Autism Mean a True Case?

Science.gov (United States)

Burke, James P.; Jain, Anjali; Yang, Wenya; Kelly, Jonathan P.; Kaiser, Marygrace; Becker, Laura; Lawer, Lindsay; Newschaffer, Craig J.

2014-01-01

The purpose of this study was to validate autism spectrum disorder cases identified through claims-based case identification algorithms against a clinical review of medical charts. Charts were reviewed for 432 children who fell into one of the three following groups: (a) more than or equal to two claims with an autism spectrum disorder diagnosis…

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.

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

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.

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.

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

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.

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.

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...

Influence of awareness on the usage of motor third party insurance ...

African Journals Online (AJOL)

a case study of Kampala district. ... informants (insurers, insurance regulators as well as enforcers – traffic police officers); and carried out desk review of motor third party insurance ... enormous negative economic impact on individuals, fam-.

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.

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.

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.

[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...

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

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.

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...

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...

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...

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.

Consumer and product-specific characteristics influencing the effect of nutrition, health and risk reduction claims on preferences and purchase behavior - A systematic review.

Science.gov (United States)

Steinhauser, Johann; Hamm, Ulrich

2018-08-01

The research on nutrition, health, and risk reduction claims (NHR claims) shows a lack of consensus as to whether these claims have a positive or negative effect on consumer's preferences and purchase behavior. This issue has been highlighted by many authors. Therefore, a comprehensive literature review was performed to find reasons for contradictory results. First, a theoretical framework was developed which divided the determinants of the effects of NHR claims on consumers' preferences and purchase behavior into consumer and product-specific characteristics. Additionally, a categorization for the different NHR claim types was constructed to make the studies comparable. Afterwards, the scientific literature from the 1980s until May 2017 was scanned and 66 articles were found to be relevant. Consumer-specific characteristics such as nutrition knowledge, health motivation, familiarity, and socio-demographic characteristics were found to influence the NHR claim effect. Important product-specific characteristics were the perceived healthiness of the food product, the interaction between the product and the nutrient in the NHR claim, and the interaction between the claimed benefit and the NHR claim type. The consumer's nutrition knowledge and the product's perceived healthiness were deemed to be the most promising determinants for further investigation. Copyright © 2018 Elsevier Ltd. All rights reserved.

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

Operating room fires: a closed claims analysis.

Science.gov (United States)

Mehta, Sonya P; Bhananker, Sanjay M; Posner, Karen L; Domino, Karen B

2013-05-01

To assess patterns of injury and liability associated with operating room (OR) fires, closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1985 were reviewed. All claims related to fires in the OR were compared with nonfire-related surgical anesthesia claims. An analysis of fire-related claims was performed to identify causative factors. There were 103 OR fire claims (1.9% of 5,297 surgical claims). Electrocautery was the ignition source in 90% of fire claims. OR fire claims more frequently involved older outpatients compared with other surgical anesthesia claims (P fire claims (P fires (n = 93) increased over time (P fires occurred during head, neck, or upper chest procedures (high-fire-risk procedures). Oxygen served as the oxidizer in 95% of electrocautery-induced OR fires (84% with open delivery system). Most electrocautery-induced fires (n = 75, 81%) occurred during monitored anesthesia care. Oxygen was administered via an open delivery system in all high-risk procedures during monitored anesthesia care. In contrast, alcohol-containing prep solutions and volatile compounds were present in only 15% of OR fires during monitored anesthesia care. Electrocautery-induced fires during monitored anesthesia care were the most common cause of OR fires claims. Recognition of the fire triad (oxidizer, fuel, and ignition source), particularly the critical role of supplemental oxygen by an open delivery system during use of the electrocautery, is crucial to prevent OR fires. Continuing education and communication among OR personnel along with fire prevention protocols in high-fire-risk procedures may reduce the occurrence of OR fires.

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

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

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.

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

Legislations and policies to expand mental health and substance abuse benefits in health insurance plans: a community guide systematic economic review.

Science.gov (United States)

Jacob, Verughese; Qu, Shuli; Chattopadhyay, Sajal; Sipe, Theresa Ann; Knopf, John A; Goetzel, Ron Z; Finnie, Ramona; Thota, Anilkrishna B

2015-03-01

Health insurance plans have historically limited the benefits for mental health and substance abuse (MH/SA) services compared to benefits for physical health services. In recent years, legislative and policy initiatives in the U.S. have been taken to expand MH/SA health insurance benefits and achieve parity with physical health benefits. The relevance of these legislations for international audiences is also explored, particularly for the European context. This paper reviews the evidence of costs and economic benefits of legislative or policy interventions to expand MH/SA health insurance benefits in the U.S. The objectives are to assess the economic value of the interventions by comparing societal cost to societal benefits, and to determine impact on costs to insurance plans resulting from expansion of these benefits. The search for economic evidence covered literature published from January 1950 to March 2011 and included evaluations of federal and state laws or rules that expanded MH/SA benefits as well as voluntary actions by large employers. Two economists screened and abstracted the economic evidence of MH/SA benefits legislation based on standard economic and actuarial concepts and methods. The economic review included 12 studies: eleven provided evidence on cost impact to health plans, and one estimated the effect on suicides. There was insufficient evidence to determine if the intervention was cost-effective or cost-saving. However, the evidence indicates that MH/SA benefits expansion did not lead to any substantial increase in costs to insurance plans, measured as a percentage of insurance premiums. This review is unable to determine the overall economic value of policies that expanded MH/SA insurance benefits due to lack of cost-effectiveness and cost-benefit studies, predominantly due to the lack of evaluations of morbidity and mortality outcomes. This may be remedied in time when long-term MH/SA patient-level data becomes available to researchers. A

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.

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.

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.

Validity of claims made in weight management research: a narrative review of dietetic articles

Directory of Open Access Journals (Sweden)

Aphramor Lucy

2010-07-01

Full Text Available Abstract Background The best available evidence demonstrates that conventional weight management has a high long-term failure rate. The ethical implications of continued reliance on an energy deficit approach to weight management are under-explored. Methods A narrative literature review of journal articles in The Journal of Human Nutrition and Dietetics from 2004 to 2008. Results Although the energy deficit approach to weight management has a high long-term failure rate it continues to dominate research in the field. In the current research agenda, controversies and complexities in the evidence base are inadequately discussed, and claims about the likely success of weight management misrepresent available evidence. Conclusions Dietetic literature on weight management fails to meet the standards of evidence based medicine. Research in the field is characterised by speculative claims that fail to accurately represent the available data. There is a corresponding lack of debate on the ethical implications of continuing to promote ineffective treatment regimes and little research into alternative non-weight centred approaches. An alternative health at every size approach is recommended.

Private health insurance: implications for developing countries.

Science.gov (United States)

Sekhri, Neelam; Savedoff, William

2005-02-01

Private health insurance is playing an increasing role in both high- and low-income countries, yet is poorly understood by researchers and policy-makers. This paper shows that the distinction between private and public health insurance is often exaggerated since well regulated private insurance markets share many features with public insurance systems. It notes that private health insurance preceded many modern social insurance systems in western Europe, allowing these countries to develop the mechanisms, institutions and capacities that subsequently made it possible to provide universal access to health care. We also review international experiences with private insurance, demonstrating that its role is not restricted to any particular region or level of national income. The seven countries that finance more than 20% of their health care via private health insurance are Brazil, Chile, Namibia, South Africa, the United States, Uruguay and Zimbabwe. In each case, private health insurance provides primary financial protection for workers and their families while public health-care funds are targeted to programmes covering poor and vulnerable populations. We make recommendations for policy in developing countries, arguing that private health insurance cannot be ignored. Instead, it can be harnessed to serve the public interest if governments implement effective regulations and focus public funds on programmes for those who are poor and vulnerable. It can also be used as a transitional form of health insurance to develop experience with insurance institutions while the public sector increases its own capacity to manage and finance health-care coverage.

Competition in hospital and health insurance markets: a review and research agenda.

Science.gov (United States)

Morrisey, M A

2001-04-01

To review the empirical literature on the effects of selective contracting and hospital competition on hospital prices, travel distance, services, and quality; to review the effects of managed care penetration and competition on health insurance premiums; and to identify areas for further research. Selective contracting has allowed managed care plans to obtain lower prices from hospitals. This finding is generalizable beyond California and is stronger when there is more competition in the hospital market. Travel distances to hospitals of admission have not increased as a result of managed care. Evidence on the diffusion of technology in hospitals and the extent to which hospitals have specialized as a result of managed care is mixed. Little research on the effects on quality has been undertaken, but preliminary evidence suggests that hospital quality has not declined and may have improved. Actual mergers in the hospital market have not affected hospital prices. Much less research has been focused on managed care markets. Greater market penetration and greater competition among managed care plans are associated with lower managed care premiums. Greater HMO penetration appears to be much more effective than PPO penetration in leading to lower premiums. While workers are willing to change plans when faced with higher out-of-pocket premiums, there is little evidence of the willingness of employers to switch plan offerings. Preliminary evidence suggests that greater managed care penetration has led to lower overall employer premiums, but the results differ substantially between employers with and without a self-insured plan. Much more research is needed to examine all aspects of managed care markets. In hospital markets, particular attention should be focused on the effects on quality and technology diffusion.

10 CFR 765.21 - Procedures for processing reimbursement claims.

Science.gov (United States)

2010-01-01

... Department shall complete a final review of all relevant information prior to making a reimbursement decision... 10 Energy 4 2010-01-01 2010-01-01 false Procedures for processing reimbursement claims. 765.21... AND THORIUM PROCESSING SITES Procedures for Submitting and Processing Reimbursement Claims § 765.21...

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

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

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.

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.

The Role of Public Health Insurance in Reducing Child Poverty.

Science.gov (United States)

Wherry, Laura R; Kenney, Genevieve M; Sommers, Benjamin D

2016-04-01

Over the past 30 years, there have been major expansions in public health insurance for low-income children in the United States through Medicaid, the Children's Health Insurance Program (CHIP), and other state-based efforts. In addition, many low-income parents have gained Medicaid coverage since 2014 under the Affordable Care Act. Most of the research to date on health insurance coverage among low-income populations has focused on its effect on health care utilization and health outcomes, with much less attention to the financial protection it offers families. We review a growing body of evidence that public health insurance provides important financial benefits to low-income families. Expansions in public health insurance for low-income children and adults are associated with reduced out of pocket medical spending, increased financial stability, and improved material well-being for families. We also review the potential poverty-reducing effects of public health insurance coverage. When out of pocket medical expenses are taken into account in defining the poverty rate, Medicaid plays a significant role in decreasing poverty for many children and families. In addition, public health insurance programs connect families to other social supports such as food assistance programs that also help reduce poverty. We conclude by reviewing emerging evidence that access to public health insurance in childhood has long-term effects for health and economic outcomes in adulthood. Exposure to Medicaid and CHIP during childhood has been linked to decreased mortality and fewer chronic health conditions, better educational attainment, and less reliance on government support later in life. In sum, the nation's public health insurance programs have many important short- and long-term poverty-reducing benefits for low-income families with children. Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

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.

ECONOMIC NATURE OF THE FINANCIAL REGULATION OF INSURANCE MARKET

Directory of Open Access Journals (Sweden)

L. Shirinyan

2013-07-01

Full Text Available Author made critical review of researches and found out the existance of the problem of determination and differentiation in a scientific literature the concepts “financial regulation of the insurance market”, “government financial regulation of the insurance market” and “government regulation of the insurance market”. It is offered the consideration of the insurance market from positions of analysis of the complex systems as being the component part of the greater system. It is disclosured the economic nature and determined the mentioned notions.

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...

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.

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

Exposure as Duration and Distance in Telematics Motor Insurance Using Generalized Additive Models

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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.

48 CFR 1652.204-72 - Filing health benefit claims/court review of disputed claims.

Science.gov (United States)

2010-10-01

... beyond his or her control from making the request within the time limit. (2) The Carrier has 30 days... information is required to make a decision on the claim; (iii) Specify the time limit (60 days after the date... that time and give a written notice of its decision to the covered individual and to the Carrier. (f...

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

Subverting Risk Attachment as Consideration for Insurance Contracts: Kansas City College of Osteopathic Medicine v. Employers' Surplus Lines Insurance Co.

Science.gov (United States)

Sweeney, Patricia J.

1980-01-01

Legal implications and court rulings are reviewed for a case in which a medical college requested a premium refund and cancellation of the bond. It is concluded that the court decision in favor of the insurance company was inappropriate and tends to undermine insurance law. (Journal availibility: Boston U. School of Law, Boston, MA 02215) (MSE)

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

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.

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

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

Good Faith in Life Insurance Contract by Indonesian Court

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Mokhamad Khoirul Huda

2017-03-01

Full Text Available This paper reviews both the interpretation of good faith and its implementation by the Court in terms of life insurance contracts. The principle of good faith in life insurance contracts was under the provision of the Article 251 Wet Boek van Kophandel which assigned the obligation of good faith on the insured. Based on the context of its historical and systematical interpretation, the obligation of good faith should be on both sides, the insurer and the insured. The insured had an obligation to inform any material facts and the insurer had to investigate those all facts. Until recent days, however, judges in all levels of Court did not have any shared and full understanding on the interpretation of good faith in life insurance contracts. As the result, many Courts were frequently inconsistent with each other. Hence, the sense of fairness the people perceived from the court verdict was not achieved.

Promoting universal financial protection: health insurance for the poor in Georgia--a case study.

Science.gov (United States)

Zoidze, Akaki; Rukhazde, Natia; Chkhatarashvili, Ketevan; Gotsadze, George

2013-11-15

The present study focuses on the program "Medical Insurance for the Poor (MIP)" in Georgia. Under this program, the government purchased coverage from private insurance companies for vulnerable households identified through a means testing system, targeting up to 23% of the total population. The benefit package included outpatient and inpatient services with no co-payments, but had only limited outpatient drug benefits. This paper presents the results of the study on the impact of MIP on access to health services and financial protection of the MIP-targeted and general population. With a holistic case study design, the study employed a range of quantitative and qualitative methods. The methods included document review and secondary analysis of the data obtained through the nationwide household health expenditure and utilisation surveys 2007-2010 using the difference-in-differences method. The study findings showed that MIP had a positive impact in terms of reduced expenditure for inpatient services and total household health care costs, and there was a higher probability of receiving free outpatient benefits among the MIP-insured. However, MIP insurance had almost no effect on health services utilisation and the households' expenditure on outpatient drugs, including for those with MIP insurance, due to limited drug benefits in the package and a low claims ratio. In summary, the extended MIP coverage and increased financial access provided by the program, most likely due to the exclusion of outpatient drug coverage from the benefit package and possibly due to improper utilisation management by private insurance companies, were not able to reverse adverse effects of economic slow-down and escalating health expenditure. MIP has only cushioned the negative impact for the poorest by decreasing the poor/rich gradient in the rates of catastrophic health expenditure. The recent governmental decision on major expansion of MIP coverage and inclusion of additional drug

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.

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

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

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.

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...

Deposit insurance reform; or, deregulation is the cart, not the horse

OpenAIRE

John H. Kareken

1990-01-01

This paper, originally published in the spring 1983 Quarterly Review, explains why flat-rate deposit insurance gives financial intermediaries an incentive to take on too much risk. It also discusses the purposes of deposit insurance and some ways reforms might serve those purposes. Three possible reforms are discussed: abolishing the insurance and requiring depository institutions to either hold safe assets or mark to market, reducing the deposit ceilings for insurance, and risk-adjusting the...

Insurance Coverage Policies for Personalized Medicine

Directory of Open Access Journals (Sweden)

Andrew Hresko

2012-10-01

Full Text Available Adoption of personalized medicine in practice has been slow, in part due to the lack of evidence of clinical benefit provided by these technologies. Coverage by insurers is a critical step in achieving widespread adoption of personalized medicine. Insurers consider a variety of factors when formulating medical coverage policies for personalized medicine, including the overall strength of evidence for a test, availability of clinical guidelines and health technology assessments by independent organizations. In this study, we reviewed coverage policies of the largest U.S. insurers for genomic (disease-related and pharmacogenetic (PGx tests to determine the extent that these tests were covered and the evidence basis for the coverage decisions. We identified 41 coverage policies for 49 unique testing: 22 tests for disease diagnosis, prognosis and risk and 27 PGx tests. Fifty percent (or less of the tests reviewed were covered by insurers. Lack of evidence of clinical utility appears to be a major factor in decisions of non-coverage. The inclusion of PGx information in drug package inserts appears to be a common theme of PGx tests that are covered. This analysis highlights the variability of coverage determinations and factors considered, suggesting that the adoption of personal medicine will affected by numerous factors, but will continue to be slowed due to lack of demonstrated clinical benefit.

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,

A systematic review of validated methods to capture acute bronchospasm using administrative or claims data.

Science.gov (United States)

Sharifi, Mona; Krishanswami, Shanthi; McPheeters, Melissa L

2013-12-30

To identify and assess billing, procedural, or diagnosis code, or pharmacy claim-based algorithms used to identify acute bronchospasm in administrative and claims databases. We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to bronchospasm, wheeze and acute asthma. We also searched the reference lists of included studies. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria. Two reviewers independently extracted data regarding participant and algorithm characteristics. Our searches identified 677 citations of which 38 met our inclusion criteria. In these 38 studies, the most commonly used ICD-9 code was 493.x. Only 3 studies reported any validation methods for the identification of bronchospasm, wheeze or acute asthma in administrative and claims databases; all were among pediatric populations and only 2 offered any validation statistics. Some of the outcome definitions utilized were heterogeneous and included other disease based diagnoses, such as bronchiolitis and pneumonia, which are typically of an infectious etiology. One study offered the validation of algorithms utilizing Emergency Department triage chief complaint codes to diagnose acute asthma exacerbations with ICD-9 786.07 (wheezing) revealing the highest sensitivity (56%), specificity (97%), PPV (93.5%) and NPV (76%). There is a paucity of studies reporting rigorous methods to validate algorithms for the identification of bronchospasm in administrative data. The scant validated data available are limited in their generalizability to broad-based populations. Copyright © 2013 Elsevier Ltd. All rights reserved.

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.

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...

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.

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.

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.

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.

The EU health claim regulation in international comparison

DEFF Research Database (Denmark)

Aschemann-Witzel, Jessica

2011-01-01

Nutrition and health claims are voluntary claims on food indicating favourable nutritional content or health benefits of the food. Nutrition and health claims on food are increasingly regulated in the world market. This process is accompanied by intensive stakeholder discussions on the possible...... impact on consumer protection and food marketing effectiveness. This article reviews literature on regulations in the major food markets in comparison with the EU regulation. The focus is on identifying characteristics of regulations that are expected to have an impact on consumer protection and food...... marketing. The EU regulation is regarded as focusing relatively strongly on precaution and consumer understanding. The extent to which this hampers food innovations is in dispute. It is suggested that using marketing measures in favour of scientifically approved claims as well as stakeholder cooperation...

Economic Effects of Legislations and Policies to Expand Mental Health and Substance Abuse Benefits in Health Insurance Plans: A Community Guide Systematic Review

Science.gov (United States)

Jacob, Verughese; Qu, Shuli; Chattopadhyay, Sajal; Sipe, Theresa Ann; Knopf, John A.; Goetzel, Ron Z.; Finnie, Ramona; Thota, Anilkrishna B.

2015-01-01

Background Health insurance plans have historically limited the benefits for mental health and substance abuse (MH/SA) services compared to benefits for physical health services. In recent years, legislative and policy initiatives in the U.S. have been taken to expand MH/SA health insurance benefits and achieve parity with physical health benefits. The relevance of these legislations for international audiences is also explored, particularly for the European context. Aims of the Study This paper reviews the evidence of costs and economic benefits of legislative or policy interventions to expand MH/SA health insurance benefits in the U.S. The objectives are to assess the economic value of the interventions by comparing societal cost to societal benefits, and to determine impact on costs to insurance plans resulting from expansion of these benefits. Methods The search for economic evidence covered literature published from January 1950 to March 2011 and included evaluations of federal and state laws or rules that expanded MH/SA benefits as well as voluntary actions by large employers. Two economists screened and abstracted the economic evidence of MH/SA benefits legislation based on standard economic and actuarial concepts and methods. Results The economic review included 12 studies: eleven provided evidence on cost impact to health plans, and one estimated the effect on suicides. There was insufficient evidence to determine if the intervention was cost-effective or cost-saving. However, the evidence indicates that MH/SA benefits expansion did not lead to any substantial increase in costs to insurance plans, measured as a percentage of insurance premiums. Discussion and Limitations This review is unable to determine the overall economic value of policies that expand MH/SA insurance benefits due to lack of cost-effectiveness and cost-benefit studies, predominantly due to the lack of evaluations of morbidity and mortality outcomes. This may be remedied in time when

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...

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.

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.

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.

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.

Insurability of Cyber Risk: An Empirical Analysis

OpenAIRE

Biener, Christian; Eling, Martin; Wirfs, Jan Hendrik

2015-01-01

This paper discusses the adequacy of insurance for managing cyber risk. To this end, we extract 994 cases of cyber losses from an operational risk database and analyse their statistical properties. Based on the empirical results and recent literature, we investigate the insurability of cyber risk by systematically reviewing the set of criteria introduced by Berliner (1982). Our findings emphasise the distinct characteristics of cyber risks compared with other operational risks and bring to li...

Efficiency concept and investigations in insurance industry: A survey

Directory of Open Access Journals (Sweden)

Bilel Jarraya

2013-01-01

Full Text Available Most recent studies are based on benchmarking analysis allowing the measure of company efficiency relatively to a reference performance. Benchmarking is a helpful tool to analyze and promote efficiency in insurance companies. The fast development of X-efficiency notion makes traditional performance measures (ROA, ROE, etc. obsolete. Indeed, various methods have been used, various input-output measures have been proposed and various research fields have been explored in insurance company investigation. So, after reviewing most known efficiency concepts and their definitions, this section explores the literature review of two principal points of discussion: the first point is focused on the different used techniques to measure efficiency, including the developed approaches to define inputs, outputs and their prices. The second point represents an overview of efficiency investigations in insurance industry.

Effects of School-Based Educational Interventions for Enhancing Adolescents Abilities in Critical Appraisal of Health Claims: A Systematic Review.

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Lena V Nordheim

Full Text Available Adolescents are frequent media users who access health claims from various sources. The plethora of conflicting, pseudo-scientific, and often misleading health claims in popular media makes critical appraisal of health claims an essential ability. Schools play an important role in educating youth to critically appraise health claims. The objective of this systematic review was to evaluate the effects of school-based educational interventions for enhancing adolescents' abilities in critically appraising health claims.We searched MEDLINE, Embase, PsycINFO, AMED, Cinahl, Teachers Reference Centre, LISTA, ERIC, Sociological Abstracts, Social Services Abstracts, The Cochrane Library, Science Citation Index Expanded, Social Sciences Citation Index, and sources of grey literature. Studies that evaluated school-based educational interventions to improve adolescents' critical appraisal ability for health claims through advancing the students' knowledge about science were included. Eligible study designs were randomised and non-randomised controlled trials, and interrupted time series. Two authors independently selected studies, extracted data, and assessed risk of bias in included studies. Due to heterogeneity in interventions and inadequate reporting of results, we performed a descriptive synthesis of studies. We used GRADE (Grading of Recommendations, Assessment, Development, and Evaluation to assess the certainty of the evidence.Eight studies were included: two compared different teaching modalities, while the others compared educational interventions to instruction as usual. Studies mostly reported positive short-term effects on critical appraisal-related knowledge and skills in favour of the educational interventions. However, the certainty of the evidence for all comparisons and outcomes was very low.Educational interventions in schools may have beneficial short-term effects on knowledge and skills relevant to the critical appraisal of health

Effects of School-Based Educational Interventions for Enhancing Adolescents Abilities in Critical Appraisal of Health Claims: A Systematic Review.

Science.gov (United States)

Nordheim, Lena V; Gundersen, Malene W; Espehaug, Birgitte; Guttersrud, Øystein; Flottorp, Signe

2016-01-01

Adolescents are frequent media users who access health claims from various sources. The plethora of conflicting, pseudo-scientific, and often misleading health claims in popular media makes critical appraisal of health claims an essential ability. Schools play an important role in educating youth to critically appraise health claims. The objective of this systematic review was to evaluate the effects of school-based educational interventions for enhancing adolescents' abilities in critically appraising health claims. We searched MEDLINE, Embase, PsycINFO, AMED, Cinahl, Teachers Reference Centre, LISTA, ERIC, Sociological Abstracts, Social Services Abstracts, The Cochrane Library, Science Citation Index Expanded, Social Sciences Citation Index, and sources of grey literature. Studies that evaluated school-based educational interventions to improve adolescents' critical appraisal ability for health claims through advancing the students' knowledge about science were included. Eligible study designs were randomised and non-randomised controlled trials, and interrupted time series. Two authors independently selected studies, extracted data, and assessed risk of bias in included studies. Due to heterogeneity in interventions and inadequate reporting of results, we performed a descriptive synthesis of studies. We used GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) to assess the certainty of the evidence. Eight studies were included: two compared different teaching modalities, while the others compared educational interventions to instruction as usual. Studies mostly reported positive short-term effects on critical appraisal-related knowledge and skills in favour of the educational interventions. However, the certainty of the evidence for all comparisons and outcomes was very low. Educational interventions in schools may have beneficial short-term effects on knowledge and skills relevant to the critical appraisal of health claims. The small

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.

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

Legal liability and claims for the hotel industry

OpenAIRE

Dimcho Todorov

2017-01-01

The paper presents a review of various aspects of legal liability and claims to hotel management arising in the hotel industry in the context of the legal framework and possible legal consequences for hotels and other types of commercial accommodation establishments. The main reasons for accidents' occurrence in the hotel industry are chronologically traced. Possible claims to the hotel management are also presented in detail. The problem with workplace discrimination, which is considered as ...

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.

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.

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). ...

Scientific Evaluation and Review of Claims in Health Care (SEaRCH): A Streamlined, Systematic, Phased Approach for Determining "What Works" in Healthcare.

Science.gov (United States)

Jonas, Wayne B; Crawford, Cindy; Hilton, Lara; Elfenbaum, Pamela

2017-01-01

Answering the question of "what works" in healthcare can be complex and requires the careful design and sequential application of systematic methodologies. Over the last decade, the Samueli Institute has, along with multiple partners, developed a streamlined, systematic, phased approach to this process called the Scientific Evaluation and Review of Claims in Health Care (SEaRCH™). The SEaRCH process provides an approach for rigorously, efficiently, and transparently making evidence-based decisions about healthcare claims in research and practice with minimal bias. SEaRCH uses three methods combined in a coordinated fashion to help determine what works in healthcare. The first, the Claims Assessment Profile (CAP), seeks to clarify the healthcare claim and question, and its ability to be evaluated in the context of its delivery. The second method, the Rapid Evidence Assessment of the Literature (REAL © ), is a streamlined, systematic review process conducted to determine the quantity, quality, and strength of evidence and risk/benefit for the treatment. The third method involves the structured use of expert panels (EPs). There are several types of EPs, depending on the purpose and need. Together, these three methods-CAP, REAL, and EP-can be integrated into a strategic approach to help answer the question "what works in healthcare?" and what it means in a comprehensive way. SEaRCH is a systematic, rigorous approach for evaluating healthcare claims of therapies, practices, programs, or products in an efficient and stepwise fashion. It provides an iterative, protocol-driven process that is customized to the intervention, consumer, and context. Multiple communities, including those involved in health service and policy, can benefit from this organized framework, assuring that evidence-based principles determine which healthcare practices with the greatest promise are used for improving the public's health and wellness.

The insurance of industrial risks at home and abroad

International Nuclear Information System (INIS)

Braun, H.

1976-01-01

For more than 85 years now, the Allianz has followed the trend of development in industry from both the technological and economic aspects. This contribution furnishes a review - in summarised form - of the types of insurance of significance for industry, with particular reference to the insurance requirements of the German export industry. (orig.) [de

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.

INSTITUTIONAL SUPPORT SOSIAL INSURANCE AGAINST OCCUPATIONAL ACCIDENTS IN UKRAINE

Directory of Open Access Journals (Sweden)

O. Gamankova

2015-04-01

Full Text Available The paper deals with the peculiarities of formation of relationships in the reform of social security. Examines institutional support provided social insurance accidents with the latest trends reform of the sector. The study notes that the organization of social security is lost insurance principle, the general principles of the Social Insurance Institute, added other excess principles that form the basis for misappropriation of funds and various abuses. These problems are urgent and require research. The paper reviews the basic principles to achieve the optimal balance of economic and social needs of providing social protection of citizens of Ukraine. The results emphasize the need for heightened security procedures for consolidation of compulsory state social insurance against industrial accidents and the State Mandatory Social Insurance against disability.

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

A review of health, planning, insurance and property value issues related to active solar heating systems

International Nuclear Information System (INIS)

Sadler, R.; Spencer, L.; Digby, G.; Battye, L.

1996-01-01

The research reported here considers the potential health risks, local authority planning implications, insurance and property value aspects of solar water heating systems. The United Kingdom market for this technology is also discussed. Methodologies employed, including literature reviews, telephone and postal survey and re-analysis of a 1995 survey, are explained. No major problems are identified in any of the target areas although recommendations for water temperature management and coordinated local authority policies on renewable energy are given. (UK)

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...

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.

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.

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)

Employee Satisfaction Survey on the Life Insurance Industry