Gender Inequity in Utilisation of Publicly Funded Health Insurance Schemes- Findings based on insurance data from a Southern Indian State

While Publicly Funded Health Insurance Schemes (PFHIS) can be an effective strategy to achieve Universal Health Coverage by offering financial protection, the extent to which they facilitate gender equity has been less explored. Women constitute one of the main vulnerable groups owing to a combination of health and economic vulnerabilities to access inpatient care services. Gender health equity requires that healthcare resources, such as PFHIS effectively reach women. This study investigates the gender differences in utilisation of Chief Ministers’ Comprehensive Health Insurance Scheme (CMCHIS) by looking at a large volume of claims data covering 2012 to 2014 in the southern Indian state, Tamil Nadu. Previous studies indicate that women in the state had a higher hospitalisation rate than men and are entitled equally to CMCHIS. By disaggregating the data on number of beneficiaries, claim status, average and total claim value, type of procedures based on gender on a random selection of 230265 cases, the paper points out that women’s utilization of CMCHIS is significantly lesser than men. Women constitute only 36% of all beneficiaries and received only half of the total claim value disbursed through the scheme. This pro-male bias was found to be statistically significant and consistent across the scheme years, age group and type of procedures. The study concludes that the gender inequity in utilization of CMCHIS is conspicuous and needs immediate attention from policy makers and administrators. With recent inclusion of COVID19 testing and treatment under PFHIS, the paper urges for further research lest more women are left behind.

Determining Critical Yield Index of Area Yield Insurance based on Basis Risk Constraint

Area yield index insurance at district level faces heterogeneous basis risk due to geographical conditions which implies to obtain unprecise critical index . Clustering and zone-based area yield scheme can reduce heterogeneous basis risk that leads to determine the suitable alternative for . On the previous research, we have obtained 7 clusters and 2 level of paddy productivity based on clustering assumption from primary data in Java. The suitable clustering assumption for calculating is cluster based assumption, which gives the homogeneous paddy productivity under 7 clusters in Java. Therefore, our goal is to develop area yield index at district level (cluster based) with minimize basis risk at certain constraints for paddy farmer productivity in Java Indonesia. There are some methods for calculating such as mean, median, winsor mean, one sigma, two sigma and (first quartile) method on the basis risk constraints using confusion matrix. Furthermore, two basis risk constraints are the difference between overpayment and shortfall is not extremely far, and total basis risk does not exceed 20% of its total claim occurrence. Two sigma method has the lowest basis risk, overpayment, and shortfall, but it has lowest pure premium, small probability of claim, and low range of claim. Hence, we consider to use (first quartile) method as alternative and suitable method to calculate that satisfied two basis risk constraints. In conclusion, our research provides analytical calculation for area yield index at district level with pure premium as Rp 152,151 using ( method), which is sufficient to cover the total claim and consistent with the simulation.

Claim Amount Forecasting and Pricing of Automobile Insurance Based on the BP Neural Network

The BP neural network model is a hot issue in recent academic research, and it has been successfully applied to many other fields, but few researchers apply the BP neural network model to the field of automobile insurance. The main method that has been used in the prediction of the total claim amount in automobile insurance is the generalized linear model, where the BP neural network model could provide a different approach to estimate the total claim loss. This paper uses a genetic algorithm to optimize the structure of the BP neural network at first, and the calculation speed is significantly improved. At the same time, by considering the overfitting problem, an early stop method is introduced to avoid the overfitting problem. In the model, a three-layer BP neural network model, which includes the input layer, hidden layer, and output layer, is trained. With consideration of various factors, a total claim amount prediction model is established, and the trained BP neural network model is used to predict the total claim amount of automobile insurance based on the data of the training set. The results show that the accuracy of the prediction by using the BP neural network model to both the data of Shandong Province and to the data of six cities is over 95%. Then, the predicted total claim amount is used to calculate premiums for five cities in Shandong Province according to credibility theory. The results show that the average premium of the five cities is slightly higher than the actual claim amount of the city. The combination of BP neural network and credibility theory can perform accurate claim amount estimation and pricing for automobile insurance, which can effectively improve the current situation of the automobile insurance business and promote the development of insurance industry.

STUDY OF CLAIMS FOR COMPENSATION OF DAMAGE TO CORAL REEF ECOSYSTEM DUE TO VESSEL GROUNDED IN THE WATERS AREA OF CILIK ISLAND, KARIMUNJAWA SUBDISTRICT, JEPARA REGENCY, CENTRAL JAVA PROVINCE

The purpose of this research is to conduct a claim of compensation claim for damage to the coral reef ecosystem as a vessel grounded in the waters of Cilik island, Karimunjawa Subdistrict, Jepara Regency, Central Java Province. The research method of this study conducted using survey and case of study. The analyses used by this study was economic valuation of ecosystem services loss, cost of coral reef restoration and cost of verification and dispute resolution. The result of this study showed that the total claim of compensation amounted IDR 3,067,031,155.96 (USD 227,466.52) for compensating the area of coral reef damage 111.69 square meters, i.e. IDR 635,525,318.46 for losing of coral reef ecosystem services, IDR 2,181,505,837.50 for cost of coral reef restoration, and IDR 250,000,000.00 for verification and dispute resettlement cost. This claim of compensation delivered as an effort to force the responsibility of the vessel owner and to restore the area of coral reef damage in the future.

Evaluation of claim submission and returning for BPJS inpatient services: a case study of hospital X in 2017

Latar belakang: Keterlambatan dan ketidaklengkapan pengajuan klaim menyebabkan keterlambatan pembayaran klaim yang akan berdampak pada arus kas rumah sakit (RS). Artikel ini bertujuan untuk menilai pengajuan dan pengembalian klaim pada pelayanan rawat inap pasien BPJS. Metode: Penelitian potong lintang dengan desain studi kasus. Sumber data menggunakan data pengajuan dan pengembalian klaim rawat inap pasien BPJS periode Januari-Juni 2017. Data dianalisis secara deskriptif. Hasil: Frekuensi pengajuan klaim rawat inap terbanyak 17 kali dan terendah 13 kali dalam sebulan, yang berarti RS mengajukan klaim ke BPJS hampir setiap 2-3 hari sekali.Dari 11,945 berkas klaim, sebanyak 3,013 (25,2%) berkas klaim dikembalikan ke RS oleh BPJS. Nilai klaim yang diajukan untuk 11,945 berkas adalah Rp. 146,967,494,700, sedangkan nilai klaim dari berkas yang dikembalikan sebesar Rp. 45,150,888,100-. Alasan berkas dikembaliakn antara lain masalah administrasi, ketidaklengkapan resume medis, pemeriksaan penunjang, konfirmasi koding, tidak layak, pinjam status, dan TXT yang tidak terbaca. Penyebab paling banyak berkas dikembalikan adalah konfirmasi koding (42,4%) dan ketidaklengkapan resume medis (30,3%). Kesimpulan: Tampaknya RS tidak pernah mengalami keterlambatan dalam pengajuan klaim, namun berkas klaim yang dikembalikan BPJS masih banyak, yang utamanya disebabkan oleh permasalahan koding dan ketidaklengkapan resume medis. Kata kunci: Penilaian, klaim, pengajuan, pengembalian. Abstract Background: Incomplete and late claim submission may result in the delay of claim payment. The impact of late payment will certainly disrupt the cash flow of the hospital. This study aims to evaluate the claim submission and returning for BPJS inpatient services. Methods: This was cross sectional study with a case study design approach. The source of data used was submission and returned claim data from hospital financing department during the period of January to June 2017. The data were analyzed descriptively. Results: The highest frequency for inpatients claim submission was 17 times and the lowest was 13 times. The hospital submit the claim file almost every 2-3 days. Of the 11.945 inpatient claims, as many as 3.013 claim files were returned by BPJS. The total claim amounts of 11,945 files was Rp. 146.967.494.700,- and, the total amount of returned claim was Rp. 45.150.888.100,-. The reasons of claim returned including administrative completeness, incomplete summary discharge , confirmation of coding, inappropriate files, unreadable TXT in BPJS application and supporting examination. The most common causes of claim files returned was confirmation of coding (42.4%) and incompleteness of discharge summary (30.3%). Conclusion: The hospital was never late in submitting claim documents but the claim returned by BPJS were still high. The most common causes of claim returned to the hospital was coding confirmation and incompleteness of discharge summary. Keywords: Evaluation, claim, submission, returning

On the total claim amount for marked Poisson cluster models

We study the asymptotic distribution of the total claim amount for marked Poisson cluster models. The marks determine the size and other characteristics of the individual claims and potentially influence the arrival rate of future claims. We find sufficient conditions under which the total claim amount satisfies the central limit theorem or, alternatively, tends in distribution to an infinite-variance stable random variable. We discuss several Poisson cluster models in detail, paying special attention to the marked Hawkes process as our key example.

ANALISA ASPEK-ASPEK DALAM PROSEDUR CHANGE ORDER PADA PROYEK KONSTRUKSI

Change order merupakan perubahan kondisi kontrak yang mengubah harga, dan schedule proyek. Penelitian sebelumnya menunjukan claim change order mencapai 50% dari keseluruhan claim, dimana 76% diantaranya merupakan change order lisan dan separuhnya mengalami kegagalan claim. Tujuan penelitian adalah mengetahui berbagai aspek dalam prosedur change order. Metode penelitian yaitu dengan membuat kuesioner berdasarkan literatur terhadap “frekuensi kejadian” dan “tingkat kepentingan”. Data dianalisa deskriptif untuk mendalami kondisi proyek dan literatur beserta penyebabnya secara mendalam, yang kemudian dilakukan analisa perbedaan kontraktor dan MK melalui uji T-Test. Berdasarkan analisa diketahui saat identifikasi, change order diprakarsai owner, kontraktor, MK dengan site instruction, selanjutnya kontraktor harus mengajukan proposal gambar, spesifikasi, harga, dokumentasi. Selanjutnya owner akan mengevaluasi harga satuan dan mengukur volume bersih berdasar perubahan gambar. Pada tahapan approval, owner memberikan tanda tangan berdasarkan harga yang disetujui. Payment dilakukan dengan invoice terpisah sesuai progress change order beserta biaya tidak langsung, sedangkan tambahan waktu diberikan dalam hari kalender Change orders are changes in contract conditions change prices, and the project schedule. Previous research shows change order claims reaches 50% of total claim, where 76% given in verbal, and half have failed. The research objective is to determine the various aspects of the change order procedure. The research method is to create a questionnaire based on the literature of the "frequency of occurrence" and "level of interest". Data were analyzed descriptively to explore the conditions of the project and literature and how it happens, analyzed the differences contractors and MK through T-Test. Based on the analysis found that identification phase, change orders initiated by the owner, the contractor, MK with site instruction, then the contractor must submit a proposal drawings, specifications, price, documentation. Next phase, owner will evaluate the unit price and measuring the net volume based on changes drawing. At approval phase, owner provides a signature based on the agreed price. Payment is done by a separate invoice based on progress including indirect costs, while additional time is given in calendar days.

Claim Settlement of Life Insures in Nepal

Claim management has been vital area of the life insurance business. Life insurance of Nepal seems still in infant stage; however the success of life insurance companies may largely depend upon the claim management. This paper has attempted to state and analyze five years’ status of the performance of claim settlement made by life insurers especially on the basis of total claim received; claim paid and claim outstanding aspects. This paper describes the status of current situation of claim settlement in life insurance market. The literature review indentified the lapses and gaps of the claim settlement in Nepalese Life Insurance Companies. The study concludes that present claim settlement status of Nepal has been seen in growing stage of development in terms of total claim. Some of the life insurers have made tremendous improvement in paying claim in the range of 90.96% to 98.49%. Some life insurers established earlier have not demonstrated well performance in settling claim and some newly set companies have made satisfactory growth. Janapriya Journal of Interdisciplinary Studies, Vol. 5 (December 2016), page: 27-43