International And Expatriate Healthcare And Insurance 2016 Sample Pages

International and expatriate healthcare and insurance 2016 SAMPLE PAGES

QATAR INSURANCE Base-Qatar HQ-Doha Overview Qatar Insurance Company (QIC) is a publicly listed composite insurer with a history of 50 years and an underwriting footprint across the Middle East, Africa and Asia.

Founded in 1964, QIC was the first domestic insurance company in the State of Qatar.

QIC is the market leader in Qatar and a dominant insurer in the GCC and MENA regions. QIC is the largest insurance company in the MENA region. It is listed on the Qatar Exchange and has a market capitalization of USD 4 billion.

Over the last 50 years, QIC has successfully transitioned from a domestic insurance company into a regional operation with companies and branches in various GCC countries and has now transformed into a group of companies with an international reach. QIC is a trusted insurance partner to businesses and individuals both locally and regionally and is now spreading its wings globally beyond the regions.

QIC International was set up in 2007 and Qatar Insurance Group was set up in 2008.Q Life and Medical Insurance Company was set up in 2011 and QIC (Europe) was set up in 2014.

Q-Life & Medical is a specialist subsidiary set up in 2011 in Qatar to offer life and health insurance.

Initially, it only offers life and group medical coverage to corporate customers.

The plan is to offer health and life cover to individuals. It aims to attain and retain customers with high-valued life & health insurance products and services .The ambition is to offer group, creditor and mortgage life insurance and health insurance. At present it only operates in Qatar. Other countries will follow.

Customer numbers QIC has thousands of individual and business customers.

Company plan QIC has ambitious plans on health insurance across several MENA countries. It is also said to be on the lookout for acquisitions in Europe.

By offering innovative solutions and quality services, will maximize value for shareholders, trusted business partners and customers while supporting development of the sector and the economy.

To maintain the drive for growth by innovation and diversification. By means of existing and new strategic alliances and partnerships, aims to create the optimum framework for continuous profitable development.

Qatar Insurance Company (QIC) Group is restructuring and reorganising its international and regional operations to achieve future strategic goals. QIC Group intends to incorporate a new holding company to manage all its international operations and companies.

QIC aims to spread across the Middle East, Africa and Asia. Qatar Insurance Company is based in Qatar but also operates in Abu Dhabi, Dubai, Kuwait and Muscat.

Financials Qatar Insurance Company (QIC) has reported a small increase in its profits in 2015 year and a large increase in gross written premiums- driven by geographical expansion.

The company made a net profit of $292 million in 2015 compared with of $282 million in 2014. The increase came from the successful diversification of the firm into new markets and lines of business.

QIC’s gross written premiums rose to $2.29 billion in 2015, compared with $1.54 billion in 2014.

2015 was marked by a sustained pace of the group’s international expansion, with 67 % of its overall gross written premiums now sourced through its international operations in Zurich, Bermuda, London and Malta.

QIC Group, with the biggest share of total GWP at 82.7%, saw its property & casualty; life & health and marine & aviation premiums expand by 63%, 31% and 2%, respectively.

Recent marketing changes Qatar Insurance Company (QIC) has rebranded itself as 'QIC Insured' for all countries, but not the group.

Recent service changes QIC has begun making personal insurance products directly available to individual customers in Qatar under the theme ‘Global Insurance – Local Assurance’. The offering includes an online platform, whereby customers can buy or manage their personal insurances (car, home, travel). Health insurance is not available yet.

Oman Qatar Insurance Company and QIC UAE both launched an online retail platform too.

Countries It writes health insurance only in Qatar at present but that will change soon.

Abu Dhabi QIC set up a branch in Abu Dhabi in 2002.

Dubai QIC set up a Dubai branch in 1968.

Kuwait QIC set up a Kuwait branch in 2004.

Malta QIC Europe Limited was set up in Malta in 2015 to write general risks across Europe.

Oman QIC set up Oman Qatar Insurance Company in Muscat in 2004.Oman Qatar Insurance Company is planning an initial public offering (IPO) on the Muscat Securities Market by the end of 2017.The company plans to offer 40% of its paid up capital to investors in line with requirements by Oman's regulatory authorities for locally incorporated insurance companies to go public.

UAE QIC set up a Dubai branch in 1968.

SIACA SAINT HONORE Base-France HQ-Paris Overview Siaca Saint Honore is one of the largest insurance brokerage and consulting group in France. It supports large and mid cap companies in the overall management of their property and personal insurance risks in France and around the world.

It designs and develops customised solutions for its corporate clients in employee benefits and international mobility.

Siaci Saint HonorĂŠ is the fifth largest insurance brokerage and consultancy group in France, which provides cover to 1.3 million individuals in France and abroad. It has 1600 employees worldwide, and has seen its revenues increasing by 10% on average per year since 2009. The firm also developed its customer portfolio and its geographic coverage by acquiring firms such as Assurance & Capital Partners and Unirisc.

It supports large and mid-cap companies in the management of their property and personal insurance risks in France and around the world. The group designs and develops customized solutions for its corporate clients from risk management consulting to the management of insurance plans.

In 2015 Siaci Saint Honore, owned by the House of Rothschild, appointed Banque Lizard to bring in new investors to help it grow the French broking group and in particular to expand the international health broker MSH International.

Edmond de Rothschild retains a 20% stake. The management team and employees hold a 15% stake. 65% was sold to French investment company Ardian bt Rothschild, Jardine Lloyd Thompson and Paris Orleans.

Group subsidiaries and brands includeInternational health & life insurance solutions: International Administration of health & life policies in France: Viventer Insurance brokerage: Unirisc / Swiss Risk & Care Managing global programmes: JLT International Network MSH International is a subsidiary that designs and manages international healthcare solutions. It has an extensive global medical network partners over 860,000 accredited providers around the world. In Asia, the medical network covers Thailand, Singapore, Philippines, Indonesia, Malaysia, Cambodia, India, Vietnam, Japan, South Korea, Taiwan, HK and China.

Is the healthcare provider for internationally mobile individuals worldwide: * Employees of multinationals. * Employees of international organizations. * Small and medium enterprises. * Individual expatriates, students and cross-border commuters. * Local high-net-worth individuals looking for international health insurance.

Formed in 1974, it initially set out to provide support to the globally mobile employees of large French businesses through the delivery of dedicated group insurance solutions (Previnter). From 1998 onwards, with the purchase of OCIASFE, also began to offer insurance solutions to Individuals living outside their country of origin. In 2002, bought European Benefits Administrators, specialists in the third-party administration of benefit plans for internationally mobile individuals. This service was designed for international businesses and organizations with self-insured plans, insurance professionals wishing to outsource the management of their plans and local populations in countries where the healthcare system is inadequate.

It is a world leader in the design and management of international healthcare and death & disability insurance solutions for globally mobile individuals.

Customer numbers Siaci Saint Honoré provides cover to 1.3 million individuals in France and abroad on all classes of insurance MSH International manages international healthcare solutions with over 330,000 insured customers across more than 194 countries and 2000 corporate clients.

Financials Gross turnover of €259 million for 2014- an increase of 6% on 2013 (€244 million). The group has seen strong, continuous growth over 7 years • • • •

Employee Benefits and Total Rewards €75 million International healthcare solutions €56 million Property & Casualty and Marine €100 million Individual life insurance €28 million

Company plan MSH International aims to develop its MENA presence. The company plans to offer international healthcare solutions globally, particularly to French based organisations.

Buying and selling businesses In 2015 it bought ONP (Office National de Prévoyance) and its subsidiary ONPF (Office National de Prévoyance Funéraire), a firm specialized in brokerage and consulting services for group health and life insurance, death and disability coverage and funeral services in France.

Partnerships Siaci Saint Honoré and JLT continue their long-standing collaboration to work together in France and abroad.

Recent marketing changes As part of the widespread development of employee benefit systems (it partnered with Alixio, a consulting firm specializing in employment strategy, on a strategic and operational support offer dedicated to professional sectors for the implementation and follow-up of their healthcare and death & disability plans as well as the development of preventive actions for employee well-being.

Recent product changes MSH International (Canada) has launched IPMI individual expatriates: FIRST EXPAT+ aimed at US and other expatriates in Canada. * The core plan includes hospital care covered at 100%, routine healthcare (doctors’ visits, prescription drugs, etc.), legal assistance and third-party liability. * There are many options and a choice of deductibles. * 4 levels of benefits: Quartz, Pearl, Sapphire, and Diamond/ * 5 geographical zones. * On pricing there are 5-year age bands up to 65, in and out-of-network reimbursements and 4 different deductibles. * Extra cover includes emergency care outside of the subscribed geographical zone for up to 60 consecutive days.

It is available direct and via a wholesale basis to brokers in Canada.

Countries

Abu Dhabi In 2006 it created MSH Dubai in the United Arab Emirates, which covers the Middle East and Africa. Cover is underwritten by Abu Dhabi National Insurance and MSH International offers global IPNI cover for ADNIC customers.

Canada Set up in Canada in 2004 and in 2006 bought Norfolk Mobility Benefits, a Canadian company based in Calgary, employee benefit consultants in Canada and USA. This is now MSH International (Canada)-with a regional office in

Calgary and a branch office in Pickering, Ontario. It launched an IPMI plan in 2016.

China Founded in 2001, by 2003, MSH China had collaborated with reinsurers China Re to create an international plan that could be licensed and regulated by the CIRC (Chinese Insurance Regulatory Commission) in China. In 2009, Shanghai Tai Kai was purchased and renamed MSH China with responsibility for the AsiaPacific zone. Based in Shanghai it has branch offices in Beijing and Guangzhou, and service offices in Dalian, Wuhan, Shenzhen, Chengdu and Suzhou. It is the Asia Pacific HQ of MSH International.

Dubai In 2006 it created MSH Dubai in the United Arab Emirates, which covers the Middle East and Africa. It has a partnership with local insurer ADNIC. France MSH International has a regional office in Paris, and a branch office in Lyon.

Singapore MSH International has a service office in Singapore.

Switzerland MSH International has a branch office in Geneva.

Thailand MSH International opened a Thailand office in 2012 in Bangkok.

UAE In 2006 it created MSH Dubai in the United Arab Emirates, which covers the Middle East and Africa. It has a partnership with local insurer ADNIC. USA MSH International has a service office in Houston, Texas.

QATAR Full name: The State of Qatar Population 2016: 2.4 million Capital: Doha Major language: Arabic International tourists 2016 2.5 million Politics Qatar is an absolute monarchy. The al-Thani family are the rulers and there is no parliament. Qatar is the world's biggest exporter of liquefied natural gas and on a per capita basis Qataris became immensely rich because there are so few of them, just 280,000.Corruption and cronyism are rife.

Unlike most places where legislation has to go through many stages and is debated and refined- Qatar often works on: if government says this is the law then that is the law, basis. So law can be imposed almost instantly and laws and regulations can be suspended with no reason and with no reason given. This makes it dangerous for companies to do business with Qatari state or semi state bodies.

Economy Qatar is the richest country in the world, thanks to the exploitation of large oil and gas fields. The population is small. Foreigners - including labourers attracted by a construction boom - outnumber natives.

With a strong existing market from business visitors, and a growing status among tourists from elsewhere in the Gulf, Qatar’s authorities are now focusing on developing a broader leisure industry. There is a huge building boom, partly connected to the next World Cup. Healthcare The standard of health care in this very rich country is good, but can be expensive. State owned public healthcare provider Hamad Medical Corporation (HMC) manages eight hospitals, incorporating five specialist hospitals and three community hospitals. It also manages the National Ambulance Service as well as home and residential care. All HMC hospitals are JCI accredited. Four new HMC hospitals are being built.

Healthcare regulation The Supreme Council of Health has launched a pilot programme for the licensing and accreditation of healthcare facilities in the country as part of its National Programme for Licensing and Accreditation of Healthcare Facilities.

The full new programme of licensing and accreditation of healthcare facilities will begin from March 2016. Qatar has set up a centre for licensing and accreditation.

The pilot programme will assess and find out how the system can be applicable in Qatar.

The programme has two components. One is the licensing of the facility and the second one is the accreditation. If a facility needs to go through the accreditation, it should be licensed and therefore both are integrated components. The accreditation and licensing programme focuses on quality of the services and safety of the patients. The whole programme has been developed in accordance international practices. The new programme is part of the National Health Strategy and will aim for accreditation by ISQua. All healthcare facilities, both public and private, will have to undergo the whole programme.

Healthcare for expatriates HMC has embarked on an ambitious expansion programme of hospital building.

A plan for expatriates to be mostly banned from state hospitals and hived off to less well funded and provided special hospitals only for expatriates is on the way.

It seems that these hospitals are not for professional expatriates, but just for the labouring classes. A new workers-only HMC health centre in Mesaimeer will be followed by three new specialist hospitals for expatriate labourers in the Industrial Area, Mesaieed Industrial City and Ras Laffan in 2016.

State health insurance In a sudden shock move, the government shut down the national health insurance scheme at the end of 2015- basically telling locals that they must buy private care and/or private insurance.

The compulsory Social Medical Insurance scheme (Seha) only covered Qataris.

The first phase, launched in July 2013, covered Qatari females aged 12 and above. The second phase launched in April 2014 included all Qatari citizens.

Cover for Qataris was underwritten by Seha and administered by the National Health Insurance Company. Every treatment under Seha was offered at the same price in hospitals and clinics. Each package of treatment or illnesses had a specific price. Seha set prices, not the providers.

The government decided to end the current health insurance service provided through the National Health Insurance Company (NHIC) and entrust it with private insurance companies from 31-12-2015.

Citizens who were admitted in private hospitals before the cut-off date (31 December 2015) will continue to get insurance cover until they are discharged after completing the required treatment.

Qatari nationals could access medical treatment at a range of private clinics, hospitals, health centres, opticians and other service providers across the country that had signed on to take part in the system. The government picked up the bill for Qataris. With medical treatment given more than 1 million times under Seha, and an estimated Qatari population of around 300,000, this equates to more than three visits per person.

In the 15 months from August 2013, Seha paid out QAR1.3 billion (US$357 million) for patient care. Before Seha, Qataris could only get free treatment at a limited number of state-run hospitals and clinics. But many went to private hospitals and clinics under Seha.

The Council have not given any believable reason for suddenly abandoning their own citizens. Although less affected by falling oil prices than others, Qatar is being cautious on spending. Qatar expects the first budget deficit in 15 years, in 2016-despite cancellation of major projects. The most likely reason is that Qataris and hospitals were taking serious liberties with the system to make as much money as possible from it.

The company managing Seha, the National Health Insurance Company (NHIC) was closed down in 2016.

State health insurance reform Health insurance services for citizens will be provided without any additional burden on them, and the Supreme Council of Health plans to agree with a company or more from the private sector health insurance companies to provide health insurance services to citizens-by June 2016.

There was no thought as to what would happen while Qataris looked for cover, or what happens if they are in the middle of treatment or have planned treatment for 2016.

Tenders from health insurers will be invited during February. The assessment of bids, selection of the insurers and signing of contracts will be completed in May. The Council did not specify any interim health insurance arrangement for citizens in the intervening period until 1 June. Qataris’ have been told that Seha or the government will not pay for medical bills from January 2016.

It was a gut reaction from a government used to instant decisions- so instead of trying to solve the problems they tried to dump the problem on the market.

For insurers it may be good news and other states may take the view that trying to manage a national scheme is hard work so making health insurance compulsory is a lot easier.

Any individual health insurer seeking to take the whole scheme must be very wary of a government that treats contracts and laws as moveable feasts- and there will inevitably be hands held out for a bribe or three. It now looks likely that a range of insurers will offer cover- for one company the risk is far too high.

A major reason for NHIC problems is that hospitals and doctors saw it as a cash cow for fraud and overcharging- and this problem will remain for health insurers.

That the government expects insurers to queue up to replace Seha shows devastating arrogance for a deal that will be hard to make any money from.

Compulsory health insurance reform The provision of health insurance will be linked to the issuance and renewal of employee’s residence visas. So employers will not be able to obtain residence visas for expatriate employees until such health cover is in place once The third phase will make it compulsory for all expatriates to have health insurances, from a yet to be announced date in 2016 or 2017.

The new options have not been agreed but may only be offered by private health insurers on a strictly controlled basis.

There will be three approved packages*White- collar workers *Blue-collar workers *Domestic help.

How these are defined is still in the melting pot. Cover will apply to families of workers too.

Employers will pay the cost of insurance for their employees and their dependents- the cost for either cannot be deducted from their salaries.

Employers must actually offer health insurance, as they are not allowed to offer cash to employees to buy their own cover.

The original rules said that employers could opt to provide more than the basic packages but it is not known if this will now apply.

Cover for expatriates will probably be provided by private insurance companies on a competitive basis. But insurers have to offer cover that is equivalent to the specified packages. As yet it is not clear if insurers will have the price set by the authorities, whether they can offer more than the minimum package, or if they are allowed choice on who they can accept or the terms they offer.

The plan was that by 2017 all private health insurers must stop offering any private health insurance other than the compulsory schemes-but this plan is on hold too.

By early 2016 it had been clear that the whole scheme and plan on health insurance had been put on hold -as the governments finds that insurers are not as keen as jumping in to replace Seha as was expected, insurers want more control over acceptance, cover, pricing and claims. With NHIC closed, the government has no fall back bargaining position Compulsory health insurance price controls The Health Insurance Law provides that health insurance premiums shall be set without discrimination in respect of age, gender, previous health status or any other risk factors. This is on both basic and top up covers.

On compulsory health insurance the cost of treatment for each disease is fixed according to a package and all hospitals and clinics affiliated to the insurance system must offer the services at the same price. The costs are set by the Supreme Council of Health and not by the service providers. Two independent advisory bodies that are recognised internationally prepare the price schedule.

A Supreme Council of Health committee will set the packages, determine the price of each and set acceptance rules. So unless insurers can negotiate a compromise, they will lose control of cover, price and acceptance.

Compulsory travel health insurance Insurance for visitors is compulsory so that all travellers need to prove that they have travel health insurance to cover emergency services only. Visitors will be responsible for their own health insurance premiums for the duration of their stay in Qatar and this will be paid as part of the visa application process. Pre-bought cover from any insurer is not accepted, as cover from Seha is built into the visa.

There is nothing to stop people buying their own travel insurance, but they still have to pay for the Seha cover. But with the National Health Insurance Company (NHIC) -the government-owned entity that managed and operated Seha, the national health insurance scheme in the State of Qatar, closed down in 2016, it is now unclear how people can buy cover and even if this law is operational or suspended, Health insurance regulation Health insurers must be based inside Qatar and be licensed by the competent governmental authority in Qatar. Thus, in addition to licensing by the Supreme Council of Health (SCH) any health insurance provider also has to be licensed by the Qatar Central Bank (QCB).

Health insurance providers cannot manage or run, either solely or jointly, any healthcare services inside Qatar.

Health insurance regulation reform By 2017 all private health insurers must stop offering any private health insurance other than the compulsory schemes, was the plan, but that is now on hold.

Number of locals living overseas Qatar used to send many students abroad to study in the USA or UK but now many colleges have set up locally. This also leads to fewer Qataris living overseas.

Insurance for locals overseas No scheme.

Number of expatriates 85% of the working population is expatriate and 70% of the total population is expatriate; some professionals but mostly low paid domestic and manual workers.

Expatriate workers outnumber Qataris by six to one.

There has been huge controversy in 2013 and 2014 with prove claims that contractors and subcontractors have treated low paid expatriate workers as slaves by holding back wages, holding on to passports, and charging them massively for poor food and accommodation.

The government have denied that this is on any scale but have been unable to cover up the hundreds of workers that have died building stadia for the World Cup – and as the contractors are linked to the political elite, very little is done to prosecute offenders or do anything. Sadly this is linked to the Qatari belief that they are above menial work and that inferior races do not have to be treated as equals.

Where expatriates come from 15,000 British nationals live in Qatar and they are mostly professionals or skilled workers. Most manual and construction workers come from poor Asian countries.

Attitude to expatriates The government of Qatar encourages foreign investment, particularly in joint ventures with Qatari partners. Qataris welcome foreigners with business expertise and knowledge .The number of international firms in Qatar continue to increase.

There is, however, a definite and pronounced bias among Qataris in favour of Qatari firms and ventures with Qatari participation. This bias also prevails within the workplace, where the owner or most senior person in a company will be a Qatari. Qataris hold managerial positions and other Arabs, including many Palestinians, plus expatriate British and other Westerners.

The Advisory Council is working on a draft law on regulating the entry and exit of expatriates and their residency.

Qatar has a new residency law from October 2016 replacing the Kafala (sponsorship) system with a contract-based system that will help in regulating the entry and exit of the expatriates. As per the new labour rules, all expatriate workers will have to sign job contracts with their employers and no exit permit from the sponsor will be required for them to leave the country. Under the sweeping reforms, the expatriate workers will get to keep the passports themselves. Those employers who are found violating the rules will be slapped with a fine of QR10, 000 to QR25, 000 ($2743 to $6860) for each passport. The new law also permits expatriate workers to change jobs subject to conditions.

Requirements for expatriates Work permits for Qatar are known as Work Residence Permits. Expats need to have found a job and a local employer to act as their sponsor before they apply for a work residence permit.

Advice to expatriates Although a relatively liberal country, there are cultural problems to watch out for and for some Qataris all expat workers are second-class citizens.

Companies based in Qatar QIC International health insurers/ brokers activity

Aetna Aetna has been appointed by the National Health Insurance Company (NHIC) of Qatar to support development of its capabilities for disease management and advanced analytic reporting. Aetna has been named one of two exclusive subcontractors.

Allianz Allianz Worldwide Care has had a local office in Doha in Qatar since 2012.

Cigna Cigna has an alliance with Saudi Arabian Insurance Company covering Qatar.

Daman Daman National Health Insurance, where Munich Re has a 20% stake- started its Qatar business in July 2011 as the country’s only specialist health insurer servicing small- and medium-sized enterprises, corporate clients and government customers.

Munich Daman National Health Insurance, where Munich Re has a 20% stake- started its Qatar business in July 2011 as the country’s only specialist health insurer servicing small- and medium-sized enterprises, corporate clients and government customers.

New India New India seeks to open a branch here nib nib has a partnership to offer health insurance to Qatari students in Australia.

Oman Insurance OIC has a branch in Doha.

Saico Cigna has an alliance with Saudi Arabian Insurance Company covering Qatar.

State Life State Life has offices in Qatar. It only offers health cover as an add-on to life cover. This supplementary cover provides benefits in case of hospitalization of the life insured, in State Life’s approved hospitals, as a result of sickness or accident.

INDONESIA Full name: Republic of Indonesia Population 2016: 255.7 million Capital: Jakarta Major languages: Javanese, Sudanese, 300 regional languages International tourists 2015 9.5 million Politics Spread across a chain of thousands of islands between Asia and Australia, Indonesia has the world's largest Muslim population. Ethnically it is highly diverse, with more than 300 local languages. The people range from rural huntergatherers to a modern urban elite. Since 1998, when long-standing authoritarian ruler General Suharto stepped down, Indonesia’s people have enjoyed a widening range of political freedoms, and participation in the political process is high. Joko Widodo won a tight race for the presidency in 2014, pledging to end corruption and promote economic reform.

Economy Indonesia's economy is now one of the best performing in the region, but corruption and red tape are rampant. Indonesia desperately needs more roads, ports and highways to see its economy reach its full potential. The increasingly modern and diversified economy has recovered from the global recession. Often forgotten is Indonesia’s geographic diversity - the country spans across nearly 17,000 islands.

Healthcare The general standard and availability of healthcare in Indonesia is poor.

Differences and inequalities exist between rural and urban health care access; figures show that two thirds of Indonesia’s doctors are based in Java, though one of the government’s aims is to get more doctors out to rural areas.

Of the total 2,414 hospitals in Indonesia, only 121 are internationally accredited.

The Indonesian Commission for Hospital Accreditation (KARS) accredits 1400; KARS is ISQua accredited, and hospitals are inspected every three years.

Healthcare reform With Indonesia’s new universal health care programme expected to put pressure on the public hospital system, investors are looking to develop private sector medical facilities as an alternative for the growing middle class.

Under the government scheme, all Indonesians will have some form of health coverage by 2019, up from around 50% at present. The system will provide insurance to millions who lack access to employer-sponsored plans and cannot

afford private coverage, but it is also likely to stretch capacity at state hospitals and clinics. Initial trials of the comprehensive scheme in Jakarta saw sharp increases in the numbers of patients attending government facilities, many of whom were visiting the hospital for the first time.

Most hospital expansion will come from private players and private public partnerships while government focuses on expanding access in rural areas and in primary care. Universal healthcare JKN will give more locals access to healthcare The demand for hospital beds, especially outside the greater Jakarta area, cannot be addressed by public hospitals alone so private hospitals will expand beyond the key cities to capture the new and growing catchment areas.

There are 73 major private hospitals in Indonesia. Of these 42 are in Greater Jakarta. Greater Jakarta is still the most attractive destination; the highest potential growth is seen in Tier 2 cities Makassar, Pekanbaru and Balikpapan.

Increasingly friendly foreign investment policies and the huge opportunity in healthcare will attract non-conventional players into healthcare. Specialist hospital services are now open for 70 % ASEAN ownership -this opens the hospital business market for partnerships with groups in ASEAN countries. And healthcare groups plan to build many new hospitals in the next few years.

Indonesia is planning to phase- in the world’s largest single-payer health care insurance programme up to 2019. Under the new system, the government is committed to providing universal health care to all, though employers and wealthier citizens are obliged to pay their own premiums.

Indonesia’s government will pay to provide medically necessary treatment for the poor. Wealthier citizens are obliged to pay 5 % of their monthly income and can opt to increase their cover with private insurance.

There is disagreement over how many people will qualify for 100 % government coverage and how many are wealthy enough to pay into the program. An income threshold has not been announced. Just over one third of people are expected to qualify for the full subsidy.

To encourage foreign investment new rules are being drafted to allow overseas companies to own up to 67% of local healthcare businesses.

State health insurance BPJS Health runs universal health insurance JKN .It is a stripped-down no choice, no frills policy mainly to cover infectious diseases and expensive surgery.

Those earning wages from private companies or the state pay a fixed premium; employers pay a contribution, and the state pays a contribution for its workers.

Others regarded as self employed, business owners or informal workers (a unique Indonesian classification) pay their own premiums. All have a government subsidy.

Under the scheme, beneficiaries are required to pay monthly premiums; those living in poor households have their premiums subsidized by the government.

BPJS holders who want to enjoy class I services at hospitals must pay Rp 59,500 ($4.60) as monthly premium. Those who want class II services pay Rp 42,500 per month, while those who can only afford class III services pay Rp 25,500 per month.

BPJS clients from poor households who qualify for government assistance receive a subsidy of only Rp 19,225 toward their monthly premiums.

Now more than 150 million people are enrolled, and the organisation the government created to run it, BPJS Kesehatan, is struggling to attract those who are used to a simpler process under private self-paid insurance. The numbers include 90 million where the government effectively pays the premium and 11 million where the employer fully or partially pays the premium.

Companies must register their employees and the number will be 168 million people by 2016.

BPJS social health insurance covers civil servants and their dependents – about 6% of the population.

Regulators are far from happy with the performance of BPJS- so much so that they refused to allow price increases in 2016.

State health insurance reform Indonesia is planning to phase in the world’s largest single-payer health care insurance programme up to 2019. Under the new system, the government is committed to providing universal health care to all, though employers and wealthier citizens are obliged to pay their own premiums.

By 2019 it be mandatory for all Indonesians when the population is predicted to reach 300 million.

Indonesian health insurers want to be able to offer private top ups to the state scheme.

Private health insurance

Those not covered by government schemes pay for health insurance themselves privately, and foreign residents are included here. Less than 4% actually pay to buy their own private health insurance. At present PMI is not available-only health cash plans that require upfront funding.

In 2015 state owned Bank Mandiri completed the acquisition of Mandiri InHealth from BPJS, increasing ownership from 60% to 80%. Mandiri Inhealth expects to increase premium revenue to Rp 2.6 trillion in 2015 from Rp 1.4 trillion as of 2014. 65% of all business is health insurance mostly from group company health insurance. It plans to boost its non-health business, especially credit life insurance.

Private health insurance reform Insurers are working on bundling health insurance with hospital expenses and health check ups, together in a bundle with disability benefits and additional services for the elderly such as home care services with mobile nurses.

Health insurance regulation In 2013 Indonesia passed new insurance laws with a new super-regulator controlling insurers and banks with new rules in governance that aim to bring more foreign insurers onshore. Insurers cannot open overseas branches, but must establish companies locally.

Indonesia's 2014 insurance law clears up uncertainty over the strategic direction of regulation. It is unlikely to discourage future M&A activity involving international insurers, although it adds some restrictions to foreign investment in the sector.

The new law provides greater clarity on regulations and the government's policy focus with regards to the industry, replacing the much broader and more general terms written into the previous insurance law passed in 1992.

The law has tightened up the requirements for the 20% Indonesian shareholding, closing some loopholes that had enabled higher foreign stakes. Language allowing for "Indonesian legal entities" to qualify as Indonesian shareholders, even if the entity was wholly owned by foreign citizens, has been removed from the new legislation. This would affect joint ventures fully controlled by foreign investors that are operating in Indonesia. Foreign firms operating under such parameters will have five years to ensure their holdings meet the 80% limit.

Foreign insurers can own up to 80% of a local insurer. Maintaining the 80% limit provides a clear indication that the government remains open to foreign investment in the insurance sector.

Health insurance regulation reform The 80% cap on foreign investments in Indonesian insurers remains in place, despite earlier speculation that this might be reduced.

Number of locals living overseas Many Indonesians go abroad as students or labourers. Most of them settled in Malaysia, UAE, South Korea, Japan, Singapore, Netherlands, United States, and Australia.

Official estimates say between 2 and 6 million Indonesians live overseas, but the higher figures include second and third generations.

There are over a million in Malaysia, 200,000 in Saudi Arabia and 150,000 in the UAE. There are about 36,000 Indonesian citizens in the State of Qatar.

Even though there has been an increase in the number of Indonesians coming to Oman since 2013, in 2013, the number of Indonesians in Oman was 28,548, and by 2014 it had declined to 35,738 and 33651 by 2015.

According to the Indonesian Embassy in Singapore, as of 2010 there were 180.000 Indonesian citizens in Singapore. 80.000 as domestic helpers, 10.000 as sailors, and the rest are either students or professionals. But the number can be higher as registering residence is not compulsory for Indonesians, so it could be up to 200.000. Singaporean citizens of Indonesian descent make the bulk of the Malay population in Singapore.

Indonesia was the colony of the Netherlands. Indonesian students study in the Netherlands. There are 20,000 in Japan.

Insurance for locals overseas No scheme known.

Number of expatriates The 2010 Indonesian census includes millions of ethnic minorities who have lived in Indonesia for generations, but have not changed their citizenship to Indonesian.

The number of expatriates working in Indonesia has declined in recent years.

Based on data from the Ministry of Manpower & Transmigration in 2014 there were 68,957 expatriates working in Indonesia in 2013, and this fell to 65,000 in 2014. The main reason for this falling number is tighter government policy to stop a foreigner blocking an Indonesian (possessing equal skills) from employment.

Number of expatriates working in Indonesia2011 77,307 2012 72,427 2013 68,957 2014 65,000

Where expatriates come from Based on data from the Ministry of Manpower & Transmigration in 2014Number of foreign workers: * China 14,371 * Japan 11,081 * South Korea 9075 * India 6047 * Malaysia 4962 Attitude to expatriates Indonesia is looking at finding more ways to ensure that qualified locals land jobs that would otherwise go to foreigners .It has listed 19 jobs that foreign professionals are barred from taking up. The aim is to get employers to consider an Indonesian candidate before a foreign one, especially for professional and managerial posts. It plans to extend this amid concerns that locals are being passed over for foreigners.

Indonesia still welcomes foreign professionals who can offer valuable know-how and contribute to the local economy, but it has also been introducing measures gradually to help locals land better-paid jobs.

The number of foreigners issued work permits remains high because foreign investors like to bring in their own people to run companies. Indonesia accepts it is a tricky problem as if they clamp down too heavily on foreign workers there is a risk that overseas investors will either move companies away or not bring in new investment.

Law number 13 of 2003 regarding Manpower (Labour Law) and its implementing regulations are setting stringent restrictions to companies employing foreign workers (expatriates). A sole proprietorship is prohibited to employ foreign workers.

The following companies are allowed to hire foreign workers: *Government agencies, international agencies, foreign missions. *Foreign trade representative offices, representative offices of foreign companies, representative offices of foreign news. *Foreign private companies. *Legal entities established under the laws of Indonesia or foreign business undertaking registered at authorized institutions in Indonesia. *Social, religious, educational and cultural institutions. *Impresario service businesses.

The following companies are prohibited from hiring foreign workers: *Civil partnership. *Limited partnership. *Trade enterprise.

Foreign workers can only be employed for certain positions and they are not allowed to occupy positions that deal with personnel. Employers of foreign workers are prohibited to employ foreign workers for multiple positions in one company or to employ foreign workers that are already employed by other companies. Beside these general position restrictions, specific business fields are regulating additional restrictions.

Foreign workers can only be employed for a certain period of time. This means that based on legislation expatriates cannot become permanent employees, which has been confirmed by several court decisions.

Requirements for expatriates Indonesia's manpower laws restrict foreign hires to mostly white-collar jobs and require them to renew their work permits annually. Companies have to explain why only a foreigner can fill the job vacancy and declare what skills and expertise he has that locals do not. Employers must ensure that every foreign hire has at least two local deputies or managers to whom he can transfer his expertise or skills.

Expatriates working in Indonesia require a limited stay permit (KITAS). To obtain a limited stay permit several licenses must be arranged that include a foreign manpower utilization plan (RPTKA), a foreign manpower work permit (IMTA) and telex visa. Before being able to obtain a limited stay permit (KITAS), expatriates and their employer must have arranged all these. KITAS permits vary from 30 days to 2 years for expatriates.

Advice to expatriates Foreign residents in Indonesia are not covered by the government health schemes. Given the high cost of good medical care, particularly when in more remote areas, having international health insurance with the ability to go to another country for treatment is essential.

International health insurers/ brokers activity

Aetna PT Aetna Global Benefits Indonesia is based in Jakarta. and offers local products.

Alliance Group NowCompare launched an Indonesian version of its online expat health insurance comparison tool in 2014. The group has offices in Jakarta.

April GlobalHealth Asia launched an IPMI plan in 2015 , Mega International Healthcare underwritten by local insurer Mega Insurance (PTAsuransi Umum Mega).

Aviva Aviva Indonesia moved to tap into Indonesia’s upper-class and expatriate markets by introducing Global Health insurance in mid 2012 as the first local expat health insurance covering healthcare costs from hospitals all around the world.

Axa AXA PPP International has teamed up with fellow subsidiary AXA Asia General Insurance (AGI) to increase the volume of health business in Indonesia, where AXA has already established a presence. AXA PPP International offers international cover to global corporations seeking to cover both expatriate employees and also local national employees using a local market proposition.

Chubb In 2012 ACE bought 80% of PT Asuransi Jaya Proteksi in Indonesia. Jakartabased Asuransi Jaya Proteksi is one of Indonesia’s top insurers and offers health insurance. The ACE Dental Care Plan was rolled out to Indonesia in 2012.

Cigna PT Asuransi Cigna offers a range of health insurance products in Indonesia including PMI and health cash.

Generali Generali Indonesia offers a range of health insurances to groups, but not individuals.

Global Benefits Group GBG has a local office in Jakarta.

Jardine Expacare Mediksure plans are supported by a local claims administrator and ssistance provider Asuransi Dayin Mitra , based in Jakarta.

Pacific Cross Pacific Cross owns Pacific Cross Indonesia, rebranded in 2016 from PT Asuransi Indrapura- a leading health and travel insurer, and owns PT International Services Pacific Cross aTPA based in Jakarta.

Primary Group Now Health International opened in Indonesia in 2015 with an office in Jakarta and local underwriting partner, PT Asuransi Sompo Japan Nipponkoa Indonesia (SJNKI. Now Health International’s management consultancy is PT Kesehatan Kini Indonesia.

Healthcare research reports Frost and Sullivan Indonesia healthcare outlook 2015 Greater Jakarta remains the most promising market due to strong infrastructure support, accessibility, and the presence of major hospitals. Kalimantan and Papua also offer attractive potential.

The implementation of the Jaminan Kesehatan Nasional (JKN) insurance scheme has spiked patient volumes significantly, heightening the demand for the Economic and Social Research Institute hospital beds, medical devices, affordable medicines and diagnostic services. A few clinics in Bandung report up to a 200 % rise in patient volumes in the first 2 months after the scheme's implementation.

Indonesia's physical infrastructure is sub-standard, as the archipelagic nature of the country makes it difficult to keep the national healthcare infrastructure together. Hospitals are unevenly distributed with maximum concentration in the Java and Sumatera islands.

Private healthcare services are addressing this gap in healthcare. They help meet the needs of the rapidly growing patient pool, which is also looking for quality care.

IPMI overview INTRODUCTION INTERNATIONAL HEALTH INSURANCE FIGURES Global premium problems Premium retention in countries Premiums and local taxes Local partnerships Muddying the waters It is not health insurance HEALTH INSURANCE Compulsory health insurance Health insurance claims Health insurance for females Health insurance market potential Health insurance market size Health insurance and universal healthcare INTERNATIONAL HEALTH INSURANCE MARKET Buying the market overseas Distribution Healthcare or health insurance History Market potential Hospitals offering health insurance Numbers of insurers Systemically important insurers Insurance companies Lloyd’s of London How Lloyds’ works Lloyds’ brokers Managing general agents Third party administrators Insurance brokers Financial advisors Insurance agents Banks Health insurance trade bodies Advertising regulation Medical price comparison sites Health insurance comparison sites Micro insurance Mobile technology Private exchanges Self- insurance Smart phones Social media

Videos INTERNATIONAL HEALTH INSURANCE PRODUCTS Cover International insurance versus domestic insurance EXPATRIATE NUMBERS Expatriate figures Global number of expatriates Global population trends European population trends Global economic trends Expatriates, migrants and refugees European migration statistics Why people emigrate Global mobility Comparing where expatriates live Expatriates in the Gulf Expatriate population as % of worldwide population Expatriate or international migrant ?

Refugees and expatriates Refugees Total number of non-citizens CUSTOMERS Target markets for insurers What is an expatriate?

Expatriate characteristics Expatriate salaries and benefits Buyers Generation Y High net worth How people choose international health insurance Maritime Mining Music industry NGOs Need Oil and gas Questions potential customers ask Retirees Self-employed Short assignments Short-term cover Students Target ages Teachers Wealthy expatriates Who can be covered?

Why companies buy it Why individuals buy it Why needs are changing Why not just buy cover locally Women THE PRODUCT Addiction treatment Admitted policies Budget covers Cancer Choice of cover or set packages?

Claims Compliance with local law Consumer Rights Act 2015 Co-payments Critical illness Currency Danger zones Diabetes treatment Duty of care Emergency assistance Emergency evacuation Fertility treatment Fraud Global cover Helplines Income protection International medical accreditation Medical evacuation and repatriation Medical tourism Medical travel insurance Obesity treatment Organ transplants Passive war Political risks Pricing Price regulation Pricing on group schemes red 24 Risk management Second opinion Security and travel advice Takaful Takaful health Term life Top up covers

Travel insurance Underwriting War risks Wearables GLOBAL RESEARCH ON HEATHCARE GLOBAL RESEARCH ON TRAVEL REGIONAL RESEARCH ON HEALTHCARE REGIONAL RESEARCH ON TRAVEL REGIONAL INFORMATION Africa Americas Asia Australasia Caribbean Europe Middle East GLOBAL HEALTHCARE ORGANISATIONS GLOBAL HEALTH ACCREDITION ORGANISATIONS

INTRODUCTION The globally mobile population has grown dramatically along with increased global business. There are over 55 million expatriates, and by 2020 this will be 60 million. 244 million people now live away from their country of birth.

There are many more expatriates with no health insurance, than those who have a policy - and even then many only have basic state cover. ‘International and expatriate healthcare and insurance 2016’, the latest report from insurance analyst Ian Youngman, puts the international and expatriate health insurance market in perspective and offers valuable insight into the nature of the current and future market.

This is an increasingly lucrative and expanding area for insurers and brokers, but there are many legislative pitfalls for the unwary.

The number of counties where health insurance is compulsory is growing fast, but local rules differ on whether this is by a state scheme, approved private insurers or a mix of the two. Some countries include expats while others have special rules for expatriates. Some allow top-ups but, others do not. Some allow people with IPMI to escape the compulsory rules but others do not. An increasing number have compulsory health insurance for students and/ or all visitors.

The situation is very fast moving. Insurers used to the slow speed of UK and US legislation may find it hard to grasp that in certain countries new law and rules can emerge in a matter of days.

The days of offering one policy from the USA or Europe, for any overseas country and not worrying if it meets local rules on offshore and onshore insurance are gone.

Expatriates and companies that employ them need to know the insurance laws in each country and what they can, cannot or must do. Not even the biggest multinational can steamroller their way through local law.

With the potential of domestic health insurance markets limited many health insurers and intermediaries are increasingly looking at healthcare for expatriates and locals in international markets.

The big international insurers get the most publicity but globally there are many less well-known insurance groups that now offer health insurance in several countries, while property insurers are also moving in.

Recent years has seen a flurry of mergers and takeovers so keeping up with who is who, is a moving feast.

More companies are looking to the world’s emerging markets as opportunities to expand their business. Organizations want to ensure they are looking after their people’s health and wellbeing and particularly so if they are being posted to countries around the globe. With increased risk for overseas employees and complex local legislation, companies are looking for more than simple health cover from international health care benefits providers. There are new risks such as disease and terrorism where companies are looking to insurers to offer help and protection.

More individuals are moving to another country to set up business or find a job when they get there, rather than being moved by an employer or finding a job first.

The split –by corporate need and legislation – between health insurance for the locals and for expatriates healthcare is no longer clear and many insurance plans now have to offer cover to both.

International healthcare used to be very simple; you designed one product and used it everywhere. But now there are local restrictions on who can insure, how, who and what can be insured. Some countries require insurers to have local partners while in others it can take years to get an insurance license.

The rewards for insurers and brokers are worthwhile as it often allows access to local healthcare markets, premiums can be higher than domestic business, and it reduces dependence on mature markets that may have little room for growth.

Despite the wide availability of cover, insurers agree that at between one in two and one in three expatriates has no health insurance. For insurers with restrictions on possible growth at home, international health insurance is now a must rather than just an option for major health insurers.

With fast changing markets and economies, and as businesses move into new areas, health insurers have to expand where they offer cover or lose customers.

This includes previously ignored markets in Europe, Asia, South America and African states.

But it is not as simple as just opening an office, or saying “ We will cover Mongolia from London”. Many of these places pose a significant challenge for insurance companies and require sophisticated solutions. Companies have to adjust their strategies to expatriate needs and the requirements of locals.

Then there are the laws on who can be an insurer or broker in that country, even if offering cover from overseas. Add in an increasing number of countries demanding that expatriates and students must take out state approved insurance, or prove they have international health cover .An increasing number demand that all inbound travellers have travel health insurance. Then there are places where, rules or not, the only practical way to do business is to have a local partner-or suffer obstacles at every turn.

So what used to be fairly simple business of replicating and adjusting domestic health covers for overseas markets is now hugely complex. And as specialist brokers report, no two insurers interpret the risk or regulation in any country in the same way, as there are lots of grey areas.

This report is the result of years of research and seeks to be the one� go to ‘ report that anybody interested in international health insurance needs.