We continue our series on UAE Medical Insurance Explained, to demystify some of the commonly used terms within Corporate Medical Insurance. By taking the time to understand the terms and how these relate to your corporate insurance policy, you can ensure that the policy is best used and set up. A good insurance broker who specliaises in group medical insurance such as Beneple should be able to assist with this also.  Further information on UAE medical insurance can also be found in part 1 of of our blog series here.

Claims Rated vs Community Rated

In the UAE, group medical insurance policies can also be either Claims Rated or Community Rated.

Claims Rated policies: 

These policies take into account the claims history of the entire group to determine the premium amount. The premium amount can be higher or lower based on the group’s overall claims history and the likelihood of future claims. Generally claims rated policies are applicable for companies with over 100 lives insured.

Community Rated policies: 

These policies do not take into account the individual claims history or demographics of group members when determining the premium amount. Instead, the premium is based on the average cost of medical claims for the entire community or region. Community Rated policies can result in a more stable premium, but they may not provide the same level of customization or pricing flexibility as Claims Rated policies. They are generally used for SME’s with less than 100 lives insured. 

Both Claims Rated and Community Rated policies have their pros and cons, and the type of policy that’s best for a group will depend on the group’s size, demographics, and needs. A qualified insurance broker such as Beneple should be able to help guide you as to which policy would be best for you. 

In Network vs Out of Network

Insurers look at health insurance claims as eithe in network claims or out of network claims. In-Network providers refer to medical providers, such as hospitals and doctors, who have contracted with the insurance company to provide services to the policyholders at discounted rates. When you visit an In-Network provider, your out-of-pocket expenses (such as deductibles, copayments, and coinsurance) are typically lower.

On the other hand, Out-of-Network providers are medical providers who do not have a contract with the insurance company. When you visit an Out-of-Network provider, you may have to pay more out of pocket and the insurance company may only cover a portion of the cost of the services received.

It is important for individuals covered under a group medical insurance plan to understand their coverage and the benefits and limitations of in-network and out-of-network providers. This can help them make informed decisions about their healthcare and avoid unexpected costs. Generally, to ensure cost containment for the medical insurance policy and future premiums, it’s advisable to stay within network wherever possible. 

Direct Billing vs Pay and Claim

Direct billing and Pay and Claim are two different methods of setting medical insurance claims in the UAE.

Direct billing refers to a service provided by medical insurance companies where medical providers are paid directly by the insurance company, without involving the policyholder in the payment process. The policyholder only needs to pay their insurance premium, and the patient may have to pay a small copayment amount (depending on the insurance terms) and the insurance company will take care of the rest.

Pay and Claim refers to a service provided by medical insurance companies where policyholders are responsible for paying their medical expenses up front and then submitting a claim to their insurance company for reimbursement. Policyholders need to provide proof of payment and documentation to support their claim, which will be reviewed by the insurance company before reimbursement.

Direct Billing is a more convenient and streamlined way of claiming medical insurance, while Pay and Claim requires policyholders to pay upfront and go through the process of submitting a claim to the insurance company.

Co-Insurance Payments

Co-insurance payment refers to a cost-sharing arrangement between employees and their employer in a group medical insurance policy. Under this arrangement, both the employees and the employer share the cost of medical expenses incurred in the event of a covered illness or injury.

For example, if an employee has a co-insurance rate of 20%, they would be responsible for paying 20% of the cost of medical treatment, while the employer would pay the remaining 80%. This can be capped to a certain rate or remain uncapped. The exact co-insurance rate can vary depending on the specific policy and employer. This cost-sharing helps to lower the overall cost of insurance premiums for both the employees and the employer.

In general, co-insurance is a common feature of group medical insurance policies in the UAE, and is designed to promote cost-effectiveness and encourage employees to be more involved in managing their own health care costs.

Employee Assistance Programs (EAP)

The Employment Assistance Program (EAP) is a benefit offered by many organizations in the UAE to provide support and resources to employees in a variety of areas. Plan typically include services such as:

  1. Counseling: Access to confidential counseling services for personal and work-related issues, including stress, mental health, and relationship problems.
  2. Legal Assistance: Legal advice and support for issues such as immigration, housing, and family law.
  3. Financial Support: Assistance with managing finances and budgeting, as well as information on debt management and savings.
  4. Health and Wellness: Information and resources on physical and mental health, including nutrition, exercise, and stress management.
  5. Work-Life Balance: Support and resources to help employees achieve a healthy balance between their work and personal lives.

The EAP is designed to help employees address a wide range of personal and work-related issues that can impact their well-being and job performance. The goal is to provide employees with the resources and support they need to be productive, engaged, and satisfied in their jobs.

If you need further assistance, please don’t hesitate to get in touch with us at Beneple and our team of qualified insurance brokers will be happy to help.