Policy insights from health insurance stakeholders

Adding my thoughts to this forum piece by Dr Ng Chee Kuan: Integrated Shield Plans (ISP) should be held to greater accountability above usual commercial insurance products, to ensure the interests of policy holders, particularly in access to care. This is because they are fundamentally taking on the role of Medishield Life - Singapore's national health insurance plan. Many insurers have also been leveraging on the positioning of 'Medisave approved' ISPs to sell their products. This means ISP payors cannot just take a pure commercial view in changing terms and access as policy holders buy into ISP as a lifelong commitment and protection. An example is how policyholders buy into ISPs to gain access to private hospital care but are informed years later that access comes with conditions and limitations. Due consideration must always be given to the original benefit assumptions on which plans were sold to restrict overly drastic changes to terms and access down the road in favour of commercial interests. In the pre 3rd party payor era, the original arrangement would have been that individuals pay directly to healthcare providers and they also select what access they want and price tag they will pay for. The introduction of insurers, ie 3rd party payors into the scene serves to riskpool and protect individuals but it should not totally take away patient voice and choice. What this means is that we need stronger patient consultations behind any scheme changes, and even to play a role in the governance of such products. ISP insurers should also be better stewards, on behalf of patients, to develop better reimbursement approaches- this means paying for value and outcomes, instead of just fee-for-service. A poor reimbursement approach can incentivise more and unnecessary interventions and may itself lead to the non-sustainable nature of such products. In our current system, insurers can just pass on such risks and losses back to policyholders in the form of premium hikes, but that does not align well with the stewardship role that policyholders expect them to play. For healthcare to be sustainable, we need to shift from being volume based to value focused. This may require a more sophisticated way to reimburse based on clinically reported outcome measures (CROMs), patient reported outcomes measures (PROMS), patient reported experience measures (PREMs). ISP payors have a key role, together with providers and regulators, to build a private healthcare system that serves patients and policyholders well, for whom we all exist to serve.

Singapore’s upcoming parliamentary debate on Integrated Shield Plan (IP) rider changes goes to the heart of a difficult but necessary trade-off in healthcare financing. On one hand, rising premiums and private healthcare costs are clearly unsustainable. Insurance designs that eliminate almost all out-of-pocket expenses weaken price signals and encourage higher utilisation. This is not about bad faith by patients. It is about incentives. When the marginal cost of care approaches zero, claims rise, premiums follow, and affordability for the wider risk pool steadily erodes. On the other hand, MPs are right to ask how families will cope if deductibles and co-payments become unaffordable at moments of medical stress. Sustainability cannot come at the expense of dignity or access. Cost sharing may be economically sound, but if poorly calibrated, it risks discouraging timely care, worsening health outcomes, or imposing sudden cash-flow shocks on households least able to absorb them. This debate is often framed as a matter of individual consumer choice. In reality, it produces systemic effects. Highly comprehensive riders may feel rational for one household, but collectively they drive higher utilisation, push up costs across the system, and increase pressure on public healthcare resources. The policy question is therefore not whether cost sharing should exist, but how much risk should be socialised, how much should remain visible, and how those boundaries are enforced fairly. Affordability must also be understood more broadly than premiums alone. It includes whether families can manage sudden deductibles, whether sufficient buffers and safety nets exist, and whether support mechanisms are well targeted rather than blunt. Cost sharing works only when paired with safeguards that recognise uneven financial resilience across households. At its core, this debate is a reminder that healthcare financing is a shared responsibility. Patients, insurers, providers, and policymakers all shape outcomes through incentives and expectations. Parliament’s discussion is therefore not just about insurance riders, but about fairness, resilience, and how we design systems that remain compassionate, credible, and sustainable over the long term. What do you think?

Every day, I come across policyholders venting on social media—not out of anger, but out of sheer helplessness. We buy insurance to protect our families from the unexpected. Yet, disputes between hospitals, TPAs, and insurers are steadily eroding trust. Yesterday I saw a Beshak.org Insurance discussion on premium hikes triggered by new health conditions discovered after purchase. For clarity: new illnesses that arise post-issuance shouldn’t become a reason to cancel a policy or load premiums at renewal unless there was proven non-disclosure or fraud. This is what the ecosystem needs to uphold—consistency and fairness. On the claims side, “reasonable & customary” deductions are often used to trim payouts. The clause is permitted, but insurers must evidence that the hospital’s charges are above what’s customary—otherwise, the cut isn’t fair. Policyholders deserve transparent, line-by-line explanations—not jargon. IRDAI has also tightened service timelines—cashless pre-auth decisions within about an hour and discharge approvals within 3 hours—so patients aren’t left waiting in distress. Let’s make sure these timelines are honoured at the bedside, not just on paper. And remember, with the newer health rules, the moratorium period has been reduced to 5 years—keep your policy active, and after five claim-free years (barring fraud), old non-disclosure disputes shouldn’t haunt you. This change was meant to reduce long-running uncertainty for families. My ask to the ecosystem: Put patients first at the hospital desk—explain what’s payable, what isn’t, and why, in simple language. Stop email ping-pong between hospital, TPA, and insurer. Create a single triage desk with accountable ownership. Publish anonymised claim-deduction benchmarks so everyone knows what “customary” actually means. Proactively educate customers at admission on room-rent caps, sub-limits, and documentation—before a deduction appears. Policyholders don’t need sympathy—they need clarity, fairness, and timely decisions. Let’s rebuild trust, one transparent claim at a time. #knowyourpolicy #insurancesamadhan #policyholder #polifyx #healthclaims #claimrejection #IRDAI

Medical insurance companies and TPAs are operating under immense financial pressure driven by rising medical inflation, overutilization by some providers, high cost innovative treatments, and escalating operational costs. Yet, despite these challenges, they’re still expected to keep insurance premiums affordable to remain competitive in an already saturated market. The result? ➡️ Tighter controls on claims. ➡️ Higher rejection rates. ➡️ Dissatisfied policyholders and frustrated providers. ➡️ And ultimately, payers suffering continued financial losses. This cycle is unsustainable. If it continues, it will impact not only payer profitability, but also access, quality, and long-term market stability. So how do we solve this? I believe the answer lies in collaboration and regulatory guidance: 🔹 Providers need to focus on evidence-based, value-driven care rather than volume-driven utilization. 🔹 Payers must invest in smarter analytics, fraud-waste-abuse controls, and clearer communication with stakeholders. 🔹 Policyholders should be educated and empowered to use their benefits responsibly. 🔹 Regulators must step in to ensure fairness, transparency, and sustainability across the entire ecosystem. A balanced market is only possible when all stakeholders work together, not in silos, not in competition, but in alignment. #HealthInsurance #UAEHealthcare #MedicalInsurance #TPA #HealthcareEconomics #HealthTech #InsuranceInnovation #HealthcareSustainability #MedicalInflation #HealthcareProviders #Payers #Regulation #HealthPolicy #ValueBasedCare #HealthcareChallenges #InsuranceMarket

When premiums rise faster than trust, insurance stops being protection and starts becoming a problem. India’s insurance sector is quietly but critically strained. In a recent review meeting, Finance Ministry raised alarm over three festering issues: Aggressive hikes in health insurance premiums. Poor claims settlement practices. And Governance lapses especially among standalone health insurers. These aren’t isolated glitches. They signal a system under deep structural stress. Health insurance premiums have surged over 15% in many cases this year. For middle income families and senior citizens, this price hike is an exit point. Impact is already visible. India’s insurance penetration has dropped from 4.2% to 4%. In a country where risk protection is still a luxury, that’s not just a warning sign, it’s a siren. Beneath the surface, there’s a force few talk about openly: private equity. With short return horizons of 5 to 7 years, many PE backed insurers are pressured to chase valuations over values. Pricing is increasingly dictated by investor timelines, not public good. Result? Policyholders are paying more for less peace of mind. Claims, too, have become a credibility minefield. Delays, disputes, and unresolved grievances eat away at the very promise of insurance. If we cannot offer dignity in someone’s most vulnerable moment, no regulatory metric can compensate for that moral failure. IRDAI’s recent move to cap premium hikes for senior citizens at 10% per year is a welcome gesture, but gestures don’t fix broken systems. What we need is structural reform: Transparent governance Pricing strategies that prioritize sustainability over exit multiples And Grievance mechanisms that treat people as humans not just policy IDs. Insurance is not about policies. It’s about people. And right now, people are walking away not from a company, but from the idea that they’ll be protected when it matters most. This is concerning. Because in a country where risk is constant, trust should be the only thing that compounds. Refer attached article for detailed insights.⬇️ #Insurance #HealthInsurance #InsuranceReform #CustomerTrust

Medical innovation and unmet needs are moving faster than most health systems can fund – and patients are the ones facing the gap. At Simon-Kucher's Southeast Asia Innovative Financing Roundtable, one theme was clear: if we don’t tackle affordability head-on, equitable and sustainable access remains theoretical. Private health insurance will never be the answer for everyone, but it can be a powerful part of the solution – if we reimagine how it works for all stakeholders involved. Some of the most valuable ideas from the discussion: ♦️ Design coverage along the full patient journey – from prevention and screening to diagnosis, treatment, and follow-up ♦️ Use modular, disease-specific products that reflect real needs ♦️ Share and use data to price fairly and sustainably ♦️ Spread financial risk across the ecosystem – governments, insurers, pharma, providers, and patients Ultimately, equitable access is about more than pricing and reimbursement decisions. It’s about intentionally designing financing models that reduce the financial strain on patients while keeping systems sustainable. We captured these insights – and practical design principles for private health insurance partnerships – in our new blog based: 🔗 skp.link/nrnt Thanks again to all who participated!