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The Pattern of Risk Assessment of Fetal Anomaly Coverage of Supplementary Insurance in the Iranian Insurance Industry: Grounded Theory Approach
Aram Kaykhosravi, Mehrdad Hosseini Shakib, Mitra Montazerlotf,
Volume 6, Issue 3 (12-2023)
Abstract
Introduction: Risk assessment is one of the important issues in insurance industry that can lead to better performance of insurance companies. The aim of this study is to provide a risk assessment model for the coverage of fetal malformations of supplementary insurance in the Iranian insurance industry in order to identify the effective factors and the extent of the impact of each with a mixed approach.
Methods: This research is exploratory-descriptive based on the way of data collection and is developmental-applied in terms of purpose. The qualitative section was conducted with in-depth interviews with 14 insurance industry experts and specialized physicians using the data method of the foundation in three stages of open coding, axial coding, and selective coding in MAXQDA software. In the quantitative section, the data collected using a questionnaire from 67 insurance industry experts were measured by the structural equation modeling method using SMART-PLS software. The reliability and validity of the quantitative method were calculated and confirmed using Cronbach's alpha coefficient and confirmatory factor analysis, respectively.
Results: In the qualitative section, six main factors including parental characteristics, insured group characteristics, environmental factors, scientific and technological factors, cultural and social factors, and factors related to the insurance industry were identified, and 36 indicators as factors affecting risk of coverage fetal malformations insurance. Findings showed that 32 indicators out of 36 indicators are statistically confirmed and all six identified factors have a positive and significant effect on fetal malformations.
Conclusion: The results confirm that the insured group characteristics have the greatest impact on the risk of insurance coverage for fetal malformations. Therefore, in order to cover the mentioned risk, insurance companies should pay special attention to the indicators of education, geographical status, demographic composition, and gender composition of the members of the insurance group.

Classification and Rating of Health Insureds Using Risk Matrix Approach
Mojtaba Abed, Amirteymor Payandeh Najafabadi,
Volume 7, Issue 3 (12-2024)
Abstract
Introduction: One of the most important pillars of improving healthcare services is the state of supplementary medical insurances, which increase people's access to healthcare. The accurate and scientific assessment of the risks of issuing a medical insurance policy is one of the most sensitive and important stages of risk assessment, and performing it leads to the identification of high-risk customers and the determination of the health insurance policy rate, in accordance with the customers' risk. Therefore, the present study aimed to classify and rate health insurance beneficiaries using a risk matrix approach.
Methods: In order to assess the risk of insured persons, a two-step model has been presented along with the risk assessment matrix approach, which can be used to classify the insureds into different risk classes. For this purpose, in the first step, the probability of claiming damages using logistic regression based on age, gender and geographical location risk factors are predicted and in the next step the severity of the damage is predicted using quantile regression.
Results: Finally a risk assessment model is presented with a risk matrix approach, which presents three risk class; critical (R_1), moderate (R_2) and acceptable (R_3) risk class.
Conclusion: Using the results of the risk matrix approach, insurance premiums have been determined for the insurance policies according to their risk class. This can help increase people's satisfaction, move towards justice, achieve fair insurance premiums, expand the security environment, and take a scientific look at the country's insurance industry.

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