长险首两年理赔风险分析——以浙江省某分公司为例

An analysis on the claim risk for long-term commercial health insurance in the first two policy years——Using a certain branch company in Zhejiang province as a case study

本文应用单因素卡方检验、线性回归分析的方法,分析认为影响长险首两年理赔发生率主要有以下五个风险因素:保额、年缴保费、非意外出险性别、出险原因和出险年限。提高体检阳性率能够明显降低长险首两年理赔发生率。建议在长险业务中要加强体检工作、强化医疗资料的审核、推进外勤核保制度,建立业务员信用制度、巩固与医疗机构合作关系,建立快速信息通道,探索费用预付制。

The paper applied the methods of One-Way ANOVA and linear-regression analysis to study on the claim risk for long-term commercial health insurance in the first two policy years. The results indicated that the claims ra- tio of long-term insurance in the first two years was mainly related to the following five risk factors： the insured a- mount, the annual premium paid, non-accidental accident gender, accident age and causes. Improving the positive rate of physical examination can significantly reduce the incidence of long-term insurance claims in the first two years. Insurers need to strengthen physical examination, enhance the audit of medical information, promote under- writing by sales agents, set up the sales agent credit system, strengthen relationship with medical institutions, create an express information channel, and explore the pre-paid system for expenses.