VHI policies and programs - Insurance

7.5.2. VHI policies and programs

Under US law, the licensed form is actually medical insurance, implemented in two forms: compulsory and voluntary. Therefore, United States insurers have only general licensed VHI rules, which are specified by each insurance organization in private VHI programs. These individual programs can be called VHI types.

Types of VHI are distinguished depending on the consequences of the onset of the disease, both economic and medical-rehabilitation, the volume of insurance coverage, the type of insurance tariff, the degree of supplementing the CHI system. As types of LCA, its typical conditions differing in a number of important parameters of the insurance coverage are considered (Table 7.11).

Table 7.11. Classification of VHI species

Insurance coverage options

Types of VHI

Economic consequences for the insured

o Insurance of costs associated with treatment, restoration of health

o Insurance of loss of income caused by the onset of the disease

Medico-rehabilitation types and methods of necessary treatment

o Outpatient treatment and home (family) doctor

o Inpatient treatment

o Dental care

o Specialized diagnosis of diseases

o Drug acquisition

o Prosthetics

o Acquisition of glasses, contact lenses

o Costs related to pregnancy and childbirth

o Service costs and patient care costs

The volume of insurance coverage

o Full insurance of medical expenses (outpatient and inpatient treatment)

o Partial insurance of medical expenses (either for outpatient treatment, or for inpatient, or for specialized treatment (dentistry, spa treatment, etc.) at the option of the insured)

o Expense insurance for only one risk

Type of applied insurance rates

o Total (combined) tariff

o According to the tariff with the insurer's own participation

o For a tariff with an insurer liability limit

o With dynamic tariffs

Combination with OMS

o Additional Private Health Insurance

o Self-Employed Private Health Insurance

Daily Payment Insurance

o Insurance of daily payments when you stay in a hospital

o Daily allowance for day sickness insurance

o Daily allowance insurance for days in need of care

The set of guarantees for voluntary health insurance is different for individual insurance companies, depending on which VHI programs they work with. Therefore, it is customary to allocate basic types of health insurance and additional types (options). The first include the insurance of outpatient and inpatient medical expenses. These guarantees compensate for the cost of treatment required for life. Additional types include insurance that cover the costs of treatment-related services or specialized medical care, such as dentistry, obstetrics, prosthetics, and some others.

<?> Tariffication VHI is one of the most subjective among personal insurance types, as the need for health services is determined not only by critical health problems, but also by the need for diagnostics, prevention, services of medical specialists, the presence of chronic diseases, etc., which significantly reduces the risk nature of this insurance. It is accepted to allocate deposit and risk LCA.

VHI Deposit Agreement assumes the provision of medical services, at the cost of an equal net premium paid. In this case, the insurer does not risk anything, and the policyholder makes full use of the premiums paid. It is used for collective insurance at the expense of the employer. In this case, there is a tax saving on income tax, compulsory insurance contributions to extra-budgetary funds and income tax. It is more profitable for an employer to conclude an LCA deposit agreement than to pay for the provision of medical services to its employees directly through medical institutions.

The VHI contract assumes guarantees above the insurance premium and is structured as any insurance contract, indicating the sum insured. However, the tariffs for such a contract are very high - for individual insurers they make up to 75% of the sum insured, and for collective agreements where there is an additional diversification of risk, up to 25-30%.

Therefore, insurers use different options for tariffing VHI to make the contract the most economical and at the same time attractive to the insured. Full-fare insurance involves covering all costs for outpatient and (or) inpatient treatment, including additional fees for selected options. Insurance on the basis of the insurer's own participation assumes a franchise, depending on which medical expenses are covered either starting from the agreed amount in the contract, or starting from a certain day of incapacity, or with each insurance the policyholder independently pays for the part of the costs incurred for treatment agreed with the insurer. Tariffs with liability limits allow the insurer to limit his participation in covering the medical expenses of the insured amount for which the insured is able to pay the premium and which corresponds to his needs. Limit of liability can be established in three ways:

- the amount of insurance cover is agreed for the year within which the insurer makes payment of the medical expenses of the insured (according to the formula: all expenses are covered, but not more than X den per year);

- limit amounts of coverage for certain types of medical services are established (according to the formula: a certain nosology is covered up to X den. units);

- the share of the insurer's participation in covering the medical expenses of the insured is determined (according to the formula: the insurer's costs for each insured event are compensated <% x


VHI Regulations establish general insurance conditions in which:

- object and subject of insurance, insured event;

- subjects of insurance;

- the amount of insurance coverage or the sum insured (the exceptions to coverage or events not recognized by insurance are specified). Often insurers indicate a list of specific programs - conditions on which, at the option of the insured, an agreement can be concluded;

- the insurance premium and the order of its calculation;

- the procedure for concluding and maintaining an insurance contract specifying the rights and obligations of the parties;

- the procedure and conditions for the provision of medical care and its payment.

VHI rules have methodological and organizational characteristics in comparison with other types of insurance.

1. The insured event is clearly defined - the appeal of the insured person to a medical institution (to the doctor) for medical services.

2. The insured event, as a rule, is stretched in time and is considered settled by the decision of the medical institution (doctor).

3. Insurance coverage is represented by the list of diseases and types of medical services or by the principle of "all inclusive, except ...".

4. The insurance payment is payment by the insurer of the services of a medical institution that provided medical assistance to the insured person. Settlements are conducted between the insurer and the medical institution. Sometimes the payment in the form of compensation for the cost of medicines or items necessary for the provision of medical care is made to the insured person himself after submission of prescriptions and checks.

5. The most common exceptions to insurance coverage are shown in Table. 7.12.

Table 7.12. Standard exceptions from insurance coverage by LCA

According to the US Civil Code (Chapter 48 "Insurance")

Included by the insurers in accordance with the previous US law "About health insurance in the United States"

Applied by domestic insurers additionally

The occurrence of an insured event due to the intent of the insured, the beneficiary or the insured person

Treatment was performed in medical institutions or in private practitioners who do not have a state license

Health disorders related to the commission of an intentional crime by an insured person

The impact of a nuclear explosion, radiation or radioactive contamination

Violation by the medical institution of the terms of the insurance contract (the insurer has the right not to reimburse the costs to the medical institution)

Especially dangerous infectious diseases (smallpox, plague, cholera, etc.) in case of an epidemic or state quarantine

Military actions, maneuvers or other military events

Obtaining medical services not covered by the insurance contract

According to the US Civil Code (Chapter 48 "Insurance")

Included by the insurers in accordance with the previous US law "About health insurance in the United States"

Applied by domestic insurers additionally

Civil war, popular disturbances of all kinds or strikes

Obtaining medical services in institutions not covered by the insurance contract

Attempted suicide (within two years of the contract)

Poisoning with substances (alcohol, drugs, etc.) taken for intoxication

Driving a vehicle without rights or in a state of intoxication

Health damage due to natural disasters

Since the United States does not have a long-term VHI contract (within one year), insurers often exclude expensive treatments and certain diseases from coverage (Table 7.13).

Table 7.13. Exemptions from insurance coverage of VHI for long-term and expensive types of medical services


Types of treatment

Oncological diseases

Transplantology, implantology

Congenital malformations and malformations

Application of methods of artificial circulation, coronary angiography

Venereal diseases, HIV infection




Diabetes mellitus


Serious diseases of the cardiovascular system - heart attacks, strokes


If the VHI Rules characterize the economic and legal aspects of the types of health insurance offered by the insurer, VHI programs contain:

- the list of medical services included in the insurance coverage;

- a scale of insurance amounts, within which an insurance contract can be concluded;

- Limits of the insurer's liability by types of medical services;

- options indicating the amount of the additional premium;

- scale of insurance premiums corresponding to the scale of insurance amounts;

- the list of medical institutions that serve this program;

is the period of insurance.

The insurer, using the licensed VHI Rules, develops a basic VHI Program, which serves as the basis for compiling various insurance programs for the conclusion of insurance contracts. Usually the name and summary of VHI programs are set out in the Insurance Rules as the insurance conditions offered by the insurer.

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