My father, 50 years old, was ill and couldn't buy proper commercial health insurance

"I don't want to buy when I can buy it, but I can't buy it when I want to." In the insurance industry, this is a commonplace absurd routine, and for Zhang Fan (pseudonym), who has experienced an unforgettable process of buying insurance, this sentence is like a mantra.

A few years ago, he wanted to buy a health insurance for his father, but he was dissuaded by various harsh terms due to some minor problems in the medical examination report.

For a long time, commercial health insurance products, including critical illness insurance and million medical insurance, have excluded the elderly and sick groups out of risk and benefit considerations. This makes those who already have a disease or show signs of illness and then want to buy insurance, often in the embarrassing situation of regret.

It's not a story of selling anxiety to sell insurance, though.

In fact, there are already some health insurance products on the market that can be insured by groups with diseases, including Huimin Insurance promoted by local governments in recent years, but due to various limitations, it cannot well meet the needs of people like Zhang Fan's father.

Due to his work, Zhang Fan has learned more about the medical and health industry. During the two sessions this year, some CPPCC members suggested promoting the innovation of inclusive insurance to meet the medical security needs of people with diseases. When he saw the news, he thought of his experience of buying insurance for his father, and the confusion of that year struck again - why is it so difficult to buy insurance after being sick?

He spoke deeply with a number of insurance industry practitioners to try to find answers. Here's his statement.

If you want to insure, you have to spend more money, and I won't buy this insurance

A friend of an insurance broker told me that Chinese always felt a health threat up close before she wanted to buy health insurance, even herself—when she was not yet in the insurance industry, a colleague fell seriously ill and was so moved that she immediately bought health insurance for her parents.

Me too. The mother was diagnosed with cancer, and after the treatment, the doctor announced: the next regular review can be done, as long as there is no recurrence within 5 years, a medical cure has been achieved. The whole family was finally freed from the heart-wrenching shadow of radiation and chemotherapy, and after that, my father was annoyed that he had not bought a health insurance for my mother, and just as a precaution, he also bought me a commercial health insurance.

I was touched to realize that my 50-year-old father needed health insurance more desperately than I did, and since he couldn't bear to buy it for himself, let me come. Who made me their only child.

It was the end of 2019, and an alumnus was working for a foreign insurance company. He told me that health insurance can be roughly divided into critical illness insurance and medical insurance, the former is a payment type insurance, after successful insurance, it will be automatically renewed every year within the agreed period, guaranteed for life, once diagnosed, the insurance company will claim the corresponding amount agreed upon when participating in the insurance, mild and moderate diseases can be paid multiple times, and do not affect the payment of severe diseases; Medical insurance is a reimbursement type insurance, after meeting the claim conditions, how much is spent in the hospital can be reimbursed according to the agreed proportion, and the maximum amount of promised insurance is mostly millions, so underwriting (that is, the process by which the insurance company determines whether the insured can purchase this insurance) is generally more stringent, and it is underwritten once a year, and the continuity is relatively poor.

Their company's health insurance products are characterized by strict underwriting of lenient payouts, and at the age of 50, the father needs to provide a medical examination report, or go to the insurance company for a medical examination as a health notice. After submitting the purchase application, you have to wait for the underwriting result, and if the underwriting is approved, the insurance contract is established, and once you need to pay in the future, it will be very convenient and fast.

"How professional!" I couldn't help but sigh. In my hometown, I have the impression that the health notification process when buying insurance often exists in name only, and insurance sales usually tell the insurer in order to make the transaction successful: "All options are checked 'no'." "And once this insurance enters the claims stage, it is the beginning of the rip-off and trouble."

This made me want to buy health insurance for my father at this foreign-owned insurance company even stronger.

Considering that my father has employee medical insurance, the fundamental purpose of buying health insurance is to prevent serious illness, combined with my income, I chose to pay 150,000 yuan of critical illness insurance, the annual premium is 9600 yuan, and you need to pay for 18 years. If the insured does not pay until his death, the insurance company will refund 150,000 yuan.

Although my father was extremely opposed, I still found his latest physical examination report, took photos one by one, uploaded it, and under the guidance of alumni, I purchased insurance step by step.

The physical examination report showed that the father's body was not very healthy, positive for Helicobacter pylori, fatty liver, liver cysts, heart block, hyperlipidemia, thyroid nodules, lung nodules... But I didn't care too much, because these symptoms are very common, except for Helicobacter pylori who is taking medicine for treatment, other abnormalities, doctors say pay attention to diet, exercise more, it's not a big deal.

Moreover, my father did not suffer from diabetes and high blood pressure – alumni had reminded me that at my father's age, diabetes and high blood pressure were almost absolute contraindications to insurance.

But reality hit me hard. A few days later, the alumni told me that the underwriting results were in, and the father could cover them, but the organs that were currently in problem would be "excluded." In the vernacular, if the father currently has a minor problem with these organs, if there is a serious illness in the future, the insurance company will not pay for it. In addition, after comprehensive assessment, the insurance company determined that the father needed to bear a higher risk, that is, to add money, so that the annual premium was about 20,000 yuan.

It was like a basin of cold water poured head-on, and I couldn't accept or understand the result at all. How to describe the mood at that time, dazed, sad, and a little angry.

"The doctors say there is nothing wrong with these diseases?" My tone was questioning.

"A lot of people have this misconception because the standards of insurance companies are not the same as those of doctors." The alumnus said, "Think about it, the doctor tells the patient that there is nothing big now, and if something happens in the future, will the doctor be responsible for the patient's medical expenses?" No. Once the insurance company underwrites, if the patient becomes ill later, the insurance company has to pay real money, so it will definitely control the risk more strictly than the doctor. ”

But his explanation could not convince me at all, and after careful calculation, the annual premium of about 20,000 yuan multiplied by 18 years of payment is far more than the 150,000 yuan that can be paid after being diagnosed with a serious illness. Moreover, the father's stomach, thyroid, heart, liver, and lungs are all excluded, how much probability can there be of serious illness? What is the point of buying this insurance?

After thinking about it for a night, I withdrew my critical illness insurance.

Chicken rib-like "sickness insurance"

I didn't mean to be angry with alumni, but now that I think about it, we're just in different positions. Different understandings of risk may be an eternal barrier between policyholders and insurance companies.

As I learned more about the medical industry, I understood more about the experience of buying insurance. The first recommended group of health insurance is healthy people, which is called "standard body" in the industry. However, if the insurer is not so healthy and is on the verge of reaching the level of disease, such as borderline hypertension, small nodules with low risk levels, it can be classified as "non-standard". Further, it is the "sick body" of the father.

Since 2020, many places across the country have vigorously promoted Huimin insurance, without any health notice, and there is no waiting period, which means that people with pre-existing conditions can also be insured, compared with the previous commercial health insurance to keep the elderly and sick groups out, which is a big progress, but it is still not a real sense of sick body insurance, because there are insurable and non-compensable, compensation ratio discount and other issues.

From the perspective of policyholders, the target customer group of real sick body insurance should be positioned as "sick body". For example, diabetes insurance, which had previously been conceptualized. Patients with new diabetes can purchase this insurance and receive benefits if their diabetes progresses to an end stage, such as retinopathy.

A domestic first-line insurance company has done market research on this product, and Wang Yuan (pseudonym), deputy general manager of the company's health insurance department, is a little crying and laughing: "Newly diagnosed diabetic patients are very confident, thinking that they can never develop to the terminal stage, buying this kind of insurance is equivalent to throwing money, even our own colleagues are not willing to buy it." ”

He mentioned that another reason for the lack of attractiveness points to the lack of data, resulting in the lack of sophisticated product design for sickness insurance.

As an endocrine disease, diabetes will affect multiple organs such as the eyes, kidneys, and heart in the later stage, causing a variety of diseases. From the initial diagnosis to the development of the terminal stage, how many people have which complications after 1 year of illness, how many people have what complications after 3 years, if you can grasp these data, you can measure the proportion of various complications, insurance products will include all diseases that may be caused by diabetes into the scope of coverage, which may be more attractive to the target population.

A number of industry insiders told me that in fact, before Huimin Insurance, sickness insurance had long existed in the industry, mostly single-disease insurance similar to diabetes insurance, but the sales were very bad.

"A fatal problem is the difficulty of pinpointing the target customer segment." Wu Qi (pseudonym), head of an insurance service operator, said, "For example, if we distribute leaflets on the road to promote the hepatitis B virus, 10 people will notice, but there may not be one hepatitis B virus carrier." ”

Only hospitals are the best places to sell sickness insurance, but insurance sales are a commercial practice, and selling insurance in hospitals can never seem to be carried out with great fanfare.

Second, even if hospitals are willing to open their arms to insurance sales, no one is really motivated to do it.

Front-line insurance salesmen/brokers often do not have a base salary, and their income comes entirely from the commission of the policy. "A medical insurance that sells for several hundred yuan, the commission given to us may be ten yuan, twenty yuan, the express data fee at the time of claim settlement is not enough, the price of single-disease with sick body insurance and medical insurance are in the same range, and even given away in the early years, the commission is not high." One salesperson said, "Critical illness insurance has higher premiums and higher commissions for us, but the cost of sickness and weight sickness insurance is higher than that of ordinary critical illness insurance, and the protection liability is weaker." ”

More importantly, the claim cost of medical insurance with sick body is high, and there are great hidden dangers in the case of customers who do not trust and do not make health notifications, "We are still mainly healthy people." ”

It may be a way to let the staff who work in the hospital help with the marketing, but there is a risk of non-compliance - as early as 2008, the former Department of Medical Administration of the Ministry of Health issued a circular prohibiting all types of medical institutions at all levels and their medical staff from advertising, promoting and selling insurance products through medical services, and prohibiting them from accepting gifts from insurance product operators to promote products. In 2021, the National Health Commission issued the "Nine Guidelines for the Honest Practice of Medical Institution Staff", which once again emphasized that it is strictly forbidden to promote goods or services to patients and seek personal gain.

"From the perspective of the market, it is always difficult to land with sickness insurance." The insurance salesman asserted.

The precise push of Internet insurance intermediaries can play a certain role in locating target customer groups, which is why insurance companies are keen to cooperate with them with disease insurance, but the lack of effective risk control means is destined to be unsolvable.

Wu Qi gave an example that 780% of the liver cirrhosis caused by hepatitis B has the possibility of transforming into liver cancer, but under the existing medical level, as long as hepatitis B virus carriers take antiviral drugs on time, liver cirrhosis can be avoided. "However, insurance companies are afraid to protect hepatitis B carriers against liver cancer, because compliance management can't keep up - how do you know if he is taking his medicine on time and in the right amount?" It can't be managed. ”

The consequence of the lack of effective risk control is the soaring probability of risk events, and insurance companies must ultimately aim for profit, and risk avoidance is their consistent pursuit. So there are some pure flickering insurance with disease on the market, Wu Qi told me, such as some anti-XX cancer recurrence insurance, industry insiders carefully look at the terms can find that as long as it is a XX cancer patient who meets the insurance conditions, there is basically no possibility of recurrence.

There is demand in the market, insurance companies are motivated, and then what?

From another perspective, if I were an insurance practitioner, I could fully understand the dilemma they face when it comes to insurance with sickness.

However, from the demand side, according to statistics, the number of chronic diseases in mainland China has reached 400 million, and the incidence of people over 65 years old exceeds 60%. For people over 55 years old who suffer from chronic diseases such as diabetes and high blood pressure, there are few types of health insurance to choose from. I don't know how to understand that this huge group, which has the highest health risks, the heaviest disease burden, and relatively weak ability to earn labor income due to physical reasons, does not have adequate medical coverage.

Ran Wei, a partner of Waterdrop, has publicly stated that users who consult or try to purchase various health insurance products on the Waterdrop Insurance platform, but cannot be insured due to physical reasons, are close to tens of millions.

It stands to reason that this should be an opportunity for insurance companies. As Wang Yuan said, "It must be a hit." ”

However, this optimistic judgment of the market has been questioned by first-tier insurance brokers. Insurance broker Pu Yan (pseudonym) told me that Chinese people's insurance awareness is still very poor, "A person's body is priceless, but many people have no sense of risk at all, and 300 yuan a year of medical insurance or even 100 yuan of inclusive insurance are not willing to buy." Everyone is betting on probability, or luck, and that kind of serious illness will definitely not be my turn. But the fact is that every day someone in the circle of friends forwards the link of the water drop chip. ”

When Huimin Insurance was hot, she suggested that some friends in her hometown buy one, "that is, a meal money thing", but she did not expect that her friends did not know about Huimin Insurance at all, and did not buy it in the end.

I think it is mainly because the vast majority of people already have basic medical insurance, and when they do not have major diseases, basic medical insurance is basically enough, so there is no incentive to buy other insurance.

Some people will compare car insurance and critical illness insurance, which is also commercial insurance, and the premium is high, in 2020, China's total car insurance premium income exceeded 800 billion yuan, and critical illness insurance was less than 500 billion. Is the body less expensive than the car gold? Not necessarily. First, the ability of people with cars to pay is relatively stronger; Second, traffic accidents may cause damage to the personal and property of third parties. Another point is that car insurance claims are not as complicated as health insurance, and it is relatively difficult to encounter the situation of "this does not pay, that does not pay".

It is true that commercial health insurance is different from basic medical insurance, and even different from Huimin insurance, which is strongly supported by the government, and is not mandatory and inclusive, and must be considered for costs and benefits. Especially for sickness insurance with a higher loss ratio, the requirements for risk control are also higher. However, unlike the medical insurance department, commercial insurance institutions can use rich administrative means to achieve cost control goals.

"Lack of data" is a difficulty that the industry repeatedly mentions when talking about the development of sickness insurance. This is due to the medical and health system, where the mainland's disease and medication data are in the hands of medical institutions and medical insurance departments, and the degree of participation in commercial insurance is quite limited, and the proportion of medical expenses paid is also low (currently about 5%). Therefore, it is difficult for commercial insurance market entities to obtain detailed data on the medical treatment and course of the disease.

In Wu Qi's view, this does not seem to be entirely the case. Taking a health insurance product that sold 40 million orders as an example, if you calculate it with a 30% loss ratio, it is the disease data of 12 million people - why the insurer is sick, whether he has treatment, how effective the treatment is, etc. - but the insurance company "ignores" the data in front of them, and the number of data entered into the system, statistics and analysis is 0.

"As long as a product doesn't exceed the actuarial claim cost ratio, the company can make a profit, and even if the task is completed, they have little incentive to collect and organize data." Wu Qi said.

Although the current market supply and demand are full of contradictions and confusion, Wang Yuan is still optimistic about the prospects of sick body insurance. He believes that with the increase of the concentration of the health insurance market and the rapid popularization of Internet health insurance, the industry competition has become more and more intense, coupled with the rapid expansion of the elderly and chronic disease groups, the increase of traditional health insurance products has been limited. Even for the sake of sustained profitability, insurance companies need to lay out new business growth points.

Pu Yan also clearly remembers that before the landing of the "Specification for the Use of Disease Definitions for Critical Illness Insurance (2020 Revised Edition)", the insurance industry frantically marketed, and even set off the old version of critical illness insurance "rush to stop selling" tide, "which is equivalent to this part of the demand was released in advance, and the purchase demand after that fell sharply, and now it is in a slow recovery trend." ”

Some industry experts believe that the future of sickness insurance lies in the link between insurance products and medicines.

At least for now, there is no real effective health management method, but insurance companies can perfectly avoid risks by cooperating with pharmaceutical companies.

For example, some hypertension with disease insurance, as long as the patient purchases the hypertension drugs specified in the insurance, the relevant drug costs can be reimbursed.

"The compensation rate of this kind of sickness insurance can reach 98%, 99% or even more than 100%, which is essentially to turn the patient's medical expenses into premiums." Wu Qi calculated that in 2020, China's direct medical expenditure is about 4.3 trillion yuan, of which personal expenditure is 2 trillion yuan, most of these 2 trillion are the drug costs of chronic disease patients, if which insurance company can "take" this business, casually negotiate a little discount with pharmaceutical companies, easily reap billions of premium income.

In the context of drug centralized procurement and medical insurance negotiations, some original pharmaceutical companies are also very motivated to promote this matter, such as including anti-tumor drugs that have not been collected or insured into the list of drugs that can be compensated by health insurance, so that the out-of-hospital sales of drugs can rise, and another path to achieve the sales target of pharmaceutical companies.

It seems that there is still room for development of sickness insurance. It's just that under this "insurance + medicine" model, if the loss ratio is close to or even more than 100%, and the insurance product is almost certain not profitable or even loss, it is not in line with the principle of luck. If the loss is too large, it may lead to financial risks. As far as I know, the regulatory authorities have already flashed a red light for "drug transfer insurance" last year. Therefore, further exploration is needed in the future.

In the case that basic medical insurance is not enough to cover all medical expenses, I very much hope that the insurance with sickness can be developed with the cooperation of insurance companies, medical institutions, pharmaceutical companies and other parties and the support of the government. Because there are certainly many middle-aged and elderly people like my father.

Of course, now I fully understand that insurance is a kind of risk relief, and I also accept the result that may not be used when I buy it, and it is difficult for me to understand and accept that I can't buy it when I get sick, or I can't use it when I get sick after buying it.

(Song Xinze also contributed to this article)

Tian Wei wrote for 丨

Edited by Liu Ran丨

This article was first published on the WeChat public account "Eight Points Jianwen" and may not be reproduced without authorization