ENTERPRISE FUNCTION - Health Insurance Underwriting

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Description	EN: The  Health Insurance Underwriting function ensures the alignment of health policy issuance and claims practices with medical risk, cost control, and member satisfaction. It leverages policy and claims management capabilities to deliver compliant, equitable, and responsive healthcare coverage. FR: La fonction  Production/exploitation assurance santé veille à ce que les pratiques d'émission et de remboursement des polices d'assurance maladie soient conformes aux risques médicaux, à la maîtrise des coûts et à la satisfaction des assurés. Elle exploite les capacités de gestion des polices et des sinistres pour offrir une couverture santé conforme, équitable et réactive.
Name (FR)	Production/exploitation assurance santé
Related Capability Maps	Health Insurance Policy Services    Health Insurance Claims Services
Packaging Library	Insurance

FULFILLED CAPABILITIES

•    Health Insurance Claims Services

  The  Health Insurance Claims Services group all specific capabilities related to fraud prevention, recovery, complaints handling, and settlement of health insurance claims.

  •    Complaints Handling & Monitoring (*)

    Involves tracking and updating claims while ensuring clear communication with the insured. The goal is to resolve claims promptly and transparently, ensuring customer satisfaction.

  •    Fraud Prevention (*)

    Aims to detect and prevent fraud by analyzing claims and verifying information. The service includes using detection tools to identify irregularities. The expected result is to reduce fraud-related losses, maintaining process integrity.

  •    Health Insurance Claims Settlement

    Enables the finalization of indemnity payments after claim assessment and validation of amounts owed. The service includes communication with the insured and execution of payments. The expected result is to effectively close claims files with prompt and contract-compliant payments.

    •    Disability and Incapacity Benefits

      Involves paying daily allowances or lump sums in the event of work incapacity or disability. This includes analyzing incapacity conditions and processing payments. The expected result is timely and appropriate financial support for insured individuals who are incapacitated or disabled.

    •    Funeral Expenses

      Involves paying benefits to cover funeral expenses in the event of a death claim. This includes validating expenses and executing payments. The expected result is a prompt and accurate settlement of funeral costs, ensuring respect for the deceased's wishes.

    •    Insured’s Share

      Amount remaining payable by the insured after applying coverage limits, ceilings, and contractual deductibles.
      

    •    Medical Expense Reimbursement

      Involves reimbursing medical expenses and treatments according to the terms of health insurance contracts. This includes verifying costs and ensuring compliance with policy rules. The expected result is fast and accurate reimbursement, improving insureds' satisfaction.

  •    Recovery & Subrogation (*)

    Involves recovering amounts owed from third parties responsible for claims, such as other insurers. The service includes analyzing recovery opportunities and necessary legal steps. The expected result is to recover owed funds, thus reducing the insurer's claim costs.

•    Health Insurance Policy Services

   Health Insurance Policy Services group all specific capabilities related to the administration and monitoring of health insurance policies and the oversight of insured portfolios.

  •    Health Insurance Policy Administration & Monitoring

    Oversee and coordinate all actions related to the lifecycle of insurance contracts, from implementation to renewal, ensuring regulatory compliance, policyholder satisfaction, and continuous alignment between coverage, risks, and client expectations.

    •    Active Health Coverage Adjustment

      Adjust the maximum reimbursement limits of health insurance contracts based on insureds' needs. This includes tailoring coverage ceilings to match benefits and guarantees. The expected outcome is adequate coverage while maintaining the insurer’s financial balance.

    •    Contractual Rights Administration (*)

      Encompasses all operational activities aimed at managing, monitoring, and updating the rights and obligations of stakeholders (insurer, policyholder, beneficiaries) throughout the life of the contract.

  •    Insured Portfolio Management (*)

    Analyze, monitor, and optimize insured portfolios to ensure a balance between profitability and risk exposure.

    •    Insurance Product Profitability

      Assess the financial performance of insurance products by analyzing loss ratios and technical margins.

    •    Monitoring of Solvency Reserves

      Involves monitoring and adjusting technical reserves to ensure the insurer’s ability to meet future obligations in compliance with regulatory requirements.

MAP VIEW