آسیب شناسی نرخ گذاری بیمه های درمان گروهی (مقاله علمی وزارت علوم)
درجه علمی: نشریه علمی (وزارت علوم)
آرشیو
چکیده
دو عامل اصلی باعث افزایش ضریب خسارت بیمه درمان می شود. اول، تعیین نرخ های غیرفنی حق بیمه به دلیل کم بودن حق بیمه های دریافتی یا کاهش قیمت در بازار بیمه تکمیلی درمان و دوم، هزینه های بالای بیمه درمانی که می تواند دلایل مختلفی داشته باشد. از چالش های خسارت بالای بیمه درمان در ایران در رابطه با قیمت گذاری می توان به عدم توانایی شرکت های بیمه در افزایش حق بیمه متناسب با افزایش تعرفه ها و غیر واقعی بودن حق بیمه در بیمه های درمان اشاره کرد. در واقع، قیمت ها باید هزینه های واقعی را منعکس کنند و اهداف نظام ارائه بیمه های درمان گسترده تر را در نظر بگیرند. در این راستا، شناسایی آسیب های نرخ گذاری بیمه های درمان گروهی اهمیت فراوانی پیدا می کند. روش تحقیق، از نوع آمیخته (کمی-کیفی) بوده، داده های تحقیق با استفاده از مطالعه کتابخانه ای و مصاحبه گردآوری شد. جامعه تحقیق را مدیران و متخصصین درمان در صنعت بیمه کشور تشکیل داده که به روش نمونه گیری گلوله برفی با سؤالات باز تا رسیدن به اشباع نظری مصاحبه شد. بر اساس نتایج تحقیق، عمده چالش ها را می توان در سه دسته ارزیابی ریسک، برگزاری مناقصه و رقابت کاذب و قانونی و مقرراتی قرار داد که از این میان، نرخ شکنی شرکت های بیمه و ارائه نرخ های غیرفنی جهت جذب سهم بیشتر در بازار، سهم بالایی در چالش های مطروحه دارد. صنعت بیمه برای رفع چالش ها در بخش رگولاتوری، نهاد نظارتی می تواند سامانه ثبت مناقصات بزرگ را راه اندازی کند و تمامی درخواست های بیمه گذاران را بر اساس پوشش هایی که در آیین نامه ۹۹ شورای عالی بیمه ارائه می شود، نرخ های شرکت های بیمه را به منظور اطمینان از مناسب بودن نرخ ها ارزیابی کند. لذا نهاد ناظر می تواند سالانه نرخ هایی را حداقل نرخ پایه در بیمه های درمان گروهی تعیین و شرکت های بیمه را ملزم به اعمال این کف نرخ کند. در بخش ارزیابی ریسک، بیمه گران می توانند پایگاه های اطلاعاتی را برای نظارت بر رفتار بیمه گذاران خود تقویت کرده و پایه های ریسک را برای ارزیابی دقیق ریسک شناسایی و اعمال کنند.Pathology of group health insurance rating
IntroductionGroup health insurance pricing is a key component in purchasing these products; in this way, if the price set for group health coverage is too high, it can easily dissuade policyholders from staying with that company, and if it is too low, it can make it difficult for insurance companies to fulfill their obligations. Preliminary investigations have shown that two main factors cause the increase of the loss ratio of health insurance. First, the determination of non-technical premium rates due to the low premiums received or price reduction in the supplementary health insurance market and secondly, the high medical insurance costs which can be due to several reasons. Among the challenges of high health insurance losses in Iran related to pricing, we can mention the inability of insurance companies to increase insurance premiums in proportion to the increase in tariffs and the unrealistic premiums in health insurances. In fact, prices should reflect real costs and take into account the goals of the broader health insurance system. In this regard, considering that group health insurances are always among the loss-making fields in the Iran's insurance industry and have a high loss ratio in the insurance industry, it is very important to identify the challenges of group health insurance rating, which will be discussed in this paper.Methodology The research method used is of a mixture type (qualitative-quantitative), which research data was collected using library study and interview. The statistical population of the research includes managers and health insurance specialists in the Iran's insurance industry, who were interviewed by snowball sampling and semi-structured interviews until theoretical saturation was reached. In this research, firstly, insurance companies were identified based on the share of the country's health insurance market and health portfolio, and leading companies in the field of health were identified, and interviews were conducted with the health managers and deputy directors of these companies, and then, academic experts in this field were also interviewed. In the next step, the interviewees were asked to introduce the managers/specialists of health who are proficient and experienced in the field of issuing group health insurances. Research team also interviewed the second group of sample members, and the sampling continued until theoretical saturation of the interviews. In order to reach the saturation point, the field study should continue until no new evidence is obtained from the data in the qualitative research process. In this research, this method was also used and after the interviews reached the point of saturation and no new code was received in the subject, two more interviews were conducted to ensure theoretical saturation. After conducting interviews, relevant texts were implemented and words, sentences and concepts were identified and summarized in the form of open coding method. Then, the counted codes were re-examined and after reducing categories, removing duplicate categories and merging smaller categories into bigger ones, they were defined as main categories and analyzed.Results and Discussion Based on the results of the research, the main challenges that can be posed in the pricing of group health insurance can be placed in three categories: risk assessment (such as the use of traditional methods and non-compliance with actuarial principles, non-proportion of insurance premiums with services and tariffs and their full price, freedom of action of insurance companies, etc.), holding tenders and false competition (such as the disproportion of insurance premiums with competitive items in the market, price cutting and unhealthy competition, focusing on attracting portfolios instead of focusing on providing appropriate services, etc.) and legal and regulatory (such as non-enforceability of some by-laws, lack of proper monitoring of group medical insurance rates, etc.), among which, insurance companies' dumping and providing non-technical rates to attract customers has a high share in these challenges.Conclusion In order to solve the existing challenges in this field, the insurance industry can use different solutions. In the regulatory sector, the supervisory body can set up a system for registering large tenders and evaluate all the requests of the policyholders based on the coverages that can be provided in Regulation no. 99 of the Supreme Insurance Council and on the other hand, evaluate the rates provided by the insurance companies in order to ensure the appropriateness of the rates. In this regard, the supervisory body can annually set rates as the minimum base rate in group health insurance and oblige insurance companies to apply this rate floor. In the risk assessment section, insurers can strengthen the databases to monitor the insurance behavior of their policyholders and identify and apply risk bases for accurate risk assessment.
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