On the surface, it is a specific drug group medical insurance, but in fact, it purchases drugs at a discounted price through the insurance channel.
This "pseudo-insurance" has been targeted by regulation.
The Property Insurance Department of the China Banking and Insurance Regulatory Commission recently issued the "Notice on Problems and Related Risks in the Short-term Health Insurance Business of Some Property Insurance Companies" (hereinafter referred to as the "Notice"), which directly refers to this kind of "underwriting customers by means of specific drug group medical insurance". The insurance alienation model of late-stage drug treatment expenses due to confirmed diseases requires property insurance companies to conduct self-inspection in a timely manner.
"This model usually involves insurance companies, insurance third-party platforms, pharmaceutical companies, health technology companies, etc. The insurance company is not limited to one or two companies doing this, but because it covers the medical expenses related to diagnosed diseases, it does not It is a real insurance product. At present, this product has been suspended. I believe this will promote the compliance and innovation of medical insurance.” A property insurance company person told the first financial reporter.
It's called insurance, but it's actually buying medicine
Statistics released by the China Banking and Insurance Regulatory Commission show that in the first half of this year, the premium income of property insurance companies' health insurance (both short-term health insurance) reached 11.56 billion yuan, a year-on-year increase of 15.4%, "leading the rise" among the main insurance types of property and casualty insurance companies. The growth rate is significantly higher than the overall business growth rate of property insurance companies (9.4%), and it is also higher than the overall industry-wide health insurance premium growth rate (4%).
However, among the strong short-term health insurance, there are some non-compliant "pseudo-insurance".
According to the above-mentioned "Notice", recently, during the daily supervision and off-site monitoring of the short-term health insurance business of some companies, the Property and Casualty Insurance Department of the China Banking and Insurance Regulatory Commission and relevant bureaus of the China Banking and Insurance Regulatory Commission found that the short-term health insurance business of some companies has grown rapidly, and Basically focus on the same business model.
Specifically, in the process of cooperating with relevant business clusters with affiliated companies of Internet hospitals, health technology companies, and insurance brokerage companies, some companies use specific drug group medical insurance to cover customers' later-stage drug treatment costs for diagnosed diseases.
And in the actual business underwriting, the company caters to the needs of the business model by setting the waiting period to 0 days and setting the insurance liability termination condition to one-time payment. , and the company did not participate in mastering the core risk management links, and the business continued to lose money.
The basis of insurance is the law of large numbers. An insurance contract is a typical fortune-telling contract, that is, a contract in which whether one party performs its obligations depends on the occurrence of accidental events.
The effect of such a contract is that there is uncertainty in the contract.
In the above model, the insurance covers the follow-up drug expenses for the customer's diagnosed disease, and there is no waiting period, which obviously does not meet the basic characteristics of insurance.
This is considered by the China Banking and Insurance Regulatory Commission as an alienation of insurance.
According to the "Notice", in the above business, some insurance companies use short-term health insurance products to actually bear the medical expenses of confirmed customers with a certain frequency of occurrence and a certain degree of loss through cooperation with relevant institutions, alienating the insurance business and making insurance possible. When an event becomes an inevitable event, two major risks will arise: First, the company underwrites certain medical expenses, which does not conform to basic insurance principles such as the law of large numbers and the principle of good luck, and cannot pass the major risk test; second, the company risks There is a lack of management and control. The core links such as front-end underwriting and back-end claim settlement are all controlled by relevant institutions. Insurance companies do not have independent pricing power, nor do they substantially participate in risk management, so they cannot reflect the basic functions of insurance operation and management of risks.
The trouble caused by "only premium theory"
In fact, this kind of "medical insurance" is extremely popular on some insurance third-party platforms, and serves the medication needs of sick people as a selling point.
However, due to factors such as the high risk of the sick body itself and the difficulty of obtaining disease-related data, the insurance of the sick body has always been a difficulty in the insurance industry. Commercial insurance almost always has measures such as reducing the coverage, excluding risks related to known diseases, and increasing premiums.
The specific drug group medical insurance mentioned in the "Notice" is obviously very different.
According to the analysis of the above-mentioned people, in this business model, insurance has actually become a channel, and the sick people are often covered by some expensive special drugs, while commercial insurance has become a promotional packaging method for pharmaceutical companies to provide preferential treatment to patients. Third-party platforms or insurance intermediaries that are related or closely cooperated with pharmaceutical companies operate to compensate customers for drug discounts in the form of group insurance indemnities, and third-party platforms or insurance intermediaries collect service fees.
"Insurance premium income is similar to drug price" in the "Circular" can reveal the essence of "pharmaceutical premiums become insurance premiums".
However, judging from the content of the "Notice", insurance companies are in a state of continuous loss in this business. Why do many property and casualty insurance companies still rush to it?
According to the analysis of the above-mentioned people, a large part of the reason why insurance companies join this model is actually to impact the scale of premiums.
"Insurers don't take insurance risks in this model, just to make premiums look better. Under the market-oriented reform of auto insurance, property and casualty insurance companies have begun to focus on non-automotive fields, and health insurance is one of the important tracks." At present, most property insurance companies have carried out short-term health insurance business, and the overall compensation is not high, so it has become an important profit point, and this is also an area with very fierce market competition.
However, the above method of "drinking doves to quench thirst" is obviously not advisable.
"Under this model, insurance companies know that they will continue to lose money, but it is obviously not conducive to the stable development of the company. At the same time, from a larger perspective, it is also not conducive to the development of the industry. On the one hand, it will affect the public's correct understanding of health insurance. On the one hand, it will also affect the market situation of normal insurance types." The above-mentioned person said.
The "Notice" stated that in response to the above problems, the Property and Casualty Insurance Department of the China Banking and Insurance Regulatory Commission will take regulatory measures against relevant companies with relevant banking and insurance regulatory bureaus, and at the same time strictly order all property and casualty insurance companies to investigate short-term health insurance business in a timely manner. Principles of insurance, short-term health insurance business that loses the possibility of insurance”, and requires companies to submit self-inspection and rectification reports before August 19.
Author: Yang Qianwen