Aug
30
Middle East Insurance Slowdown Sees Development of New Products
Filed Under Expat Insurance, Insurance Company, Middle East, Reinsurance, UAE Insurance, general insurance | 1 Comment
A number of financial reports released by Qatari insurance companies on Monday indicate that the country’s insurance sector may be poised to experience a significant slowdown. Five Qatari insurance companies, operating mainly in the non-life insurance market, have indicated that the sector’s total net profits have risen by only 2 percent during 2011, compared to 9 percent for the same period in 2010.
The companies, which include Qatar Islamic Insurance, Qatar General Insurance and Reinsurance, Al Khaleej Takaful, Qatar Insurance, and Doha Insurance, saw the sector’s net profit for January – June 2011 reach QR 545.96 million (US$ 149.91 million), compared to the QR 537.11 million (US$ 147.48 million) in profits seen for the same reporting period in 2010. The data on the general profitability of these five Qatari insurance companies was released by Qatar Exchange data.
One of the primary reasons cited by the insurers with regards to the lower than expected profits in the first half of 2011 is due to the rise in premiums yielded to reinsurance companies. Reinsurance premium yielding has risen by 8 percent for Qatar’s insurance companies in 2011, with three companies actually yielding more than 55 percent of total written premiums to reinsurers. With the levels of premiums being yielded to reinsurers outstripping the total growth in premium revenue for the market, profits have inevitably come in at lower than expected levels.
Profit growth for the first half of 2011 for the five companies, compared to the same period in 2010, stood at:
Qatar Islamic Insurance: 1.83 percent growth in 2011, up from 0.43 percent in 2010.
Qatar General Insurance and Reinsurance: 1.83 percent growth in 2011, up from -7.31 percent in 2010.
Al Khaleej Takaful: 11.29 percent growth in 2011, down from 46.85 percent in 2010.
Qatar Insurance: 10.74 percent growth in 2011, down from 65.77 percent in 2010.
Doha Insurance: -8.80 percent growth in 2011, down from 60.55 percent in 2010.
While the slowdown of the non-life insurance sector in Qatar does not pose major concerns at present, it has highlighted the need to create innovative policies with which to cover underserved segments of the Middle Eastern insurance market.
One company taking notice from the Qatari slowdown is the Dubai Islamic Insurance and Reinsurance Company, also known as Aman, which is headquartered in Dubai, UAE. Aman’s CEO, Hussein Al Meeza, announced the creation of two new types of protection policy which would focus on affording medical cover to Indian expatriates working in the United Arab Emirates.
The Indian Expatriate Medical Insurance plans from Aman are being run in conjunction with ICICI Lombard, one of India’s leading insurance companies. On creating the plans, Hussein Al Meeza said;
“If you check the structure of the population in the UAE and what relation it has with Emiratis, they are our partners; they are our brothers. They are also the people who (are) behind all the work that has been done here. The relationship that we have with the Indian population was not (built) today or yesterday. Also, we have (an agreement) with ICICI Lombard, which is one of the top names in the Indian market.”
Mr Hussein went on to say;
“Europeans already have the culture of insurance. They have very advanced products. We are looking to see where the opportunities are to provide services. We are looking at the Arab world, Pakistanis, Bangladeshis and Filipinos. It needs a background from the countries, because India has a platform for service providers… The Indian (expatriate population) is a big market and there are a lot of opportunities. Also, we got the right partner for the products.”
The policies, named “Rishtey” and “Health on Return,” aims to give Indian expatriates in the UAE a wider choice with regards to their medical cover than they have previously been afforded. The Rishtey plan would see UAE expatriate workers obtain medical insurance cover for their families in India, while the Health on Return policy would provide health insurance protection to those same expatriate workers in the event that they return to India for a short stay. Additionally, the Health on Return plan also offers the expatriate Indian workers the option of having retirement health insurance cover, creating a far more flexible and comprehensive health insurance product than any which currently cater to this niche market segment.
While a slowdown in Qatar’s general insurance market may pose a concern for the region, industry analysts are aware that there exists significant potential with regards to developing ever more unique products for the GCC insurance sector.
Insurance Companies Mentioned
Qatar Islamic Insurance
Founded in 1995, Qatar Islamic Insurance, also known as QIIC, operates a number of lines of insurance coverage. Offering insurance based on Islamic principles QIIC offers coverage for all risks from Aviation to personal protection.
Qatar General Insurance and Reinsurance
Qatar General Insurance and Reinsurance was founded in 1979, and is a Qatari national company. Qatar General Insurance and Reinsurance offers both individual and business insurance products in Qatar.
Al Khaleej Takaful
Founded in 1978, Al Khaleej Takaful operates primarily in the general insurance and reinsurance markets. Covering risks including Property, Engineering, Liability, General Accident, Marine Transit, and Marine Hull, Al Khaleej has proven time and again to be an innovative insurer.
Qatar Insurance Company
Founded in 1964, Qatar Insurance Company, also known as QIC, is Qatar’s oldest insurance provider. Operating a number of personal and business insurance products across the GCC, QIC is one of the most established insurers in Qatar.
Doha Insurance
One of the younger insurance providers in Qatar, Doha Insurance was founded in 2000. Establishing a Takaful products company in 2006, under the name Doha Takaful Insurance, Doha Insurance company offers a range of general insurance products.
Dubai Islamic Insurance and Reinsurance Company
Dubai Islamic Insurance and Reinsurance Company, also known as AMAN, was established in 2002 to provide comprehensive Islamic insurance products to residents of the UAE. Offering Motor, Home, and Medical Islamic insurance products, AMAN is one of the leading insurance providers in the UAE.
May
3
New Health Screening Requirements for Expats in UAE
Filed Under Expat Insurance, International Healthcare, UAE Insurance, Uncategorized | 3 Comments
Last Sunday, the UAE ‘s Ministerial Service Council, chaired by Shaikh Mansour Bin Zayed Al Nahyan, the Deputy Prime Minister and Minister of Presidential Affairs, announced that expatriate workers who want to work in the UAE must get medical tests done in both their home countries and in the UAE prior to receiving a work visa for the emirate.
Many expatriate workers try to cheat the system by providing a fake medical test result from their home country. The new system will curb the number of workers, who slip into the UAE work force with fake certificates, by mandating re-tests once the workers arrive in the UAE.
The Ministerial Service Council has ordered the Ministry of Health to prepare and implement the legislations necessary to put the new system into effect. Expatriate workers, who bring communicable diseases into the UAE, have been a long-term issue for the council.
Another challenge that the council fights in preventing expatriate workers with communicable diseases from entering the country is internal corruption. Recently eight people, an Emirati health official, her uncle, and six others, were accused of accepting bribes and forging health certificates for individuals with infectious diseases.
The 25-year old Emirati woman, who worked for the Dubai Health Authority (DHA), is charged with accepting 30,000 Dhs ($8,167 USD) in bribe from her 42-year old Indian uncle to forge and issue health certificates to expatriate workers who have communicable diseases.
The uncle owns a typing center, which he is accused of working out of to distribute clean medical certificates to people with infectious diseases, ranging from hepatitis to Acquired Immuno-Deficiency Syndrome (AIDS). Prosecutors claimed that the 25-year old niece would abuse her authority and position to stamp certificates with a free-of-communicable-diseases stamp during her night shift.
Another two DHA clerks, a 28-year old Iranian and a 30-year old Indian, are also charged for accepting 45,000 Dhs ($12,251 USD) from four Pakistani workers to forge similar health certificates.
As of Monday, the Emirati woman has pleaded not guilty before the Dubai Court of First Instance. Her uncle also pleaded not guilty as he defended himself in the courtroom, which was presided by Judge Hamad Abdul Latif Abdul Jaward.
The 28-year old Iranian, 30-year old Indian, and one of the four Pakistani workers have too pleaded not guilty, while the other three Pakistani workers were not present for Monday’s trial.
An Emirati second lieutenant testified that the Dubai Police’s CID was informed that an Asian suspect was responsible for forging health certificates at one of the DHA’s fitness centers. He also notes, “We arrested the uncle who ran a typing center. During interrogation, he admitted that he collected from one of the Pakistani workers applications for individuals with infectious diseases and needed to renew their residence permits or have one issued.” The lieutenant also claimed that the uncle would charge around 500 Dhs to 1,000 Dhs ($136 to $272 USD) per application.
He goes on to say, “We detained one of the Pakistani individuals, who immediately admitted the two clerks, who worked in fitness centers, used to issue for him the forged certificates.”
Prosecution records showed that the confession was confirmed by another one of the Pakistani workers after he was arrested.
Although the new system cannot prevent DHA health officials from forging health certificates, it can deter expatriate workers who have infectious diseases from coming into the country with false test results and help relieve the pressure on the UAE healthcare system.
Any expatriate who wishes to work and live in the UAE is required to get a health check to see if he or she has HIV/AIDS, syphilis, or pulmonary TB. Housemaids and nannies will also be subjected to a pregnancy test, while kindergarten school employees, barber shop, health club, and restaurant workers will also have to test for hepatitis B.
The Ministerial Service Council hopes that the new system will lessen the stress and expenses on the UAE healthcare system, which has to treat all patients with communicable diseases before deporting them. The number of people waiting to get tested is also expected to drop as expatriate workers will be deterred from trying to get into the country with faked test results. DHA clinics have been so busy recently that some have suffered a breakdown in services.
May
3
Many Expat Residents No Longer Able to Afford Rising Healthcare Costs in Dubai
Filed Under Expat Insurance, Health Insurance, Healthcare, Medical Insurance, Middle East, UAE Insurance | 5 Comments
In Dubai, public healthcare costs are rising at a significant rate, which has become a major concern for expatriates, especially those without private health insurance.
Dubai residents can apply for health cards that are supposed to grant them access to public health facilities at a discounted rate. However, with the rising costs of treatment, those health cards essentially offer no discounts now. Treatment costs in government hospitals are now about the same as those of private hospitals, with a consultation costing around 250 Dhs to 400 Dhs (US$ 75 to US$ 120), and a one night stay in the Intensive Care Unit costing around 3100 Dhs (US$ 845).
There has been discussion of passing a legislation that would make health insurance mandatory for all expatriate employees that would be paid for partially by their employers. Abu Dhabi currently already has a similar law in place, which has led to around 98 percent of workers being insured. However, after years of talks in Dubai, expat residents are still waiting to see whether a mandatory health insurance scheme materializes.
To exacerbate the situation, the Dubai Health Authority (DHA) has recently announced that they will start charging expatriate patients for chemotherapy sessions. This announcement was made 2 weeks ago, and is due to be in effect in 1 week.
A staff from the Oncology Department of Dubai Hospital announced, “From May 3rd, patients will have to pay for their chemotherapy injections, the cost of which will depend on the medications.”
The vast majority of expat residents will not be able to afford these costs out-of-pocket. One session of chemotherapy can cost around 8000 Dhs (US$ 2,177), and around 14 – 16 treatments are needed in one year.
Many physicians, authorities, and patients have criticized the DHA for the short notice that it gave patients, and the lack of consideration for patients who have already begun a course of treatment and cannot afford to stop.
For many expat patients, they cannot wait to go back to their home country to seek treatment because it may take a while for the paperwork to be processed before they can start receiving treatment. The delay in treatment can drastically change the outcome of their recovery. It is also too late for these expat cancer patients to apply for and get private health insurance because no private insurer will agree to cover cancer treatment costs once the patient already has cancer.
Other costs, aside from chemotherapy, are also on the rise. Expats, B. Joseph and his wife, had a baby in Dubai in 2000, said, “We paid just Dh 100 for the delivery then. The health card is of no use now” Eleven years later, they have to pay 12,000 Dhs (US$ 3,266) for the same delivery package.
A DHA representative stated, “The card has no specific benefits. It only gives you access to government hospitals and clinics.”
Currently, treatment is still free for Emirati nationals. Emergency treatment for expats is also free until the patient’s condition stabilizes. At that point, they will be billed for all other treatment received outside of the emergency ward.
For example, an Arab woman, who was stabbed during a robbery, was billed 285,000 Dhs (US$ 77,589) for her treatment costs after her situation stabilized. She cannot afford the bill, and felt that the burden of the bill should not be on her. She complained to the Dubai Police Chief Lieutenant General Dahi Khalfan Tamin, and has started a discussion in the Emirate about who should be responsible for treatment costs for crime and traffic accident victims.
The DHA has responded to criticisms of cost cutting measures and rising costs by saying, “As a vital service provider, we take into account ethical and moral requirements. We are always aware that the field involves the life and death of patients and keep in mind the oath all doctors have taken – to treat all patients no matter what race, religion, or social standing – leading to the fact that all patients coming to the hospitals, especially emergency cases, need to be treated immediately regardless of their capability of paying or not. However, taking into account the rapid increase in the population of Dubai and the spiraling costs in running health organizations, there should be a mechanism in place to at least cover the costs of such services.”
He goes on to add, “We believe that most of the issues, if not all, will be resolved with the introduction of a universal mandatory health insurance scheme, whereby every resident of Dubai is covered for certain health services. Dubai is moving forward in that direction.”
However, many Dubai expat residents are skeptical about whether the scheme will ever come into effect. The DHA has said in the past that the scheme was originally to be introduced in January 2009.
According to a month-long Dubai Household Health Survey performed by the DHA, 75 percent of workers in Dubai have no health insurance. This creates a chain of consequences that results in reduced interest and investment in Dubai healthcare services as well as escalating bills.
Dr. Haider Al Yousuf, Director of Health Funding at the DHA said, “Limited access reduces utilization; this does not provide enough volume to maintain a high quality of services provided, allow specialized centers of excellence nor promote medical tourism.”
Ram Lachhan Raj, a laundry worker, ran up a bill of 44,000 Dhs (US$ 11,978) in one week after he was diagnosed with leukemia and renal failure. Neither him nor his employer can afford the costs.
“As good residents, we would like to pay, but just cannot afford it,” said Somsun S, a small business owner, who is left with a bill of 45,000 Dhs (US$ 12,250), after an employee was paralyzed after a fall.
In the past, hospitals have been understanding and have waived the bills for many people. NGOs and other organizations have contributed to treatment costs, but this solution is no longer sustainable as the amounts involved have become much too high.
Patients and hospitals are also trying to organize charity drives by holding garage sales and markets to raise money for patients who cannot afford the costs, but many experts believe that the only permanent solution is mandatory insurance.
Others have pointed out that it is not as simple as passing a law that makes health insurance mandatory. Albert Rodrigues, the Managing Director of Millenium Insurance Brokers noted, “It is not easy. The challenge for the health authorities is to find the right formula that would satisfy all the stakeholders – medical providers, employers, insurance companies, and the general public who include both Emiratis and expatriates. Most employers do not have the margins to cater to the new equipment”
Deteriorating economic conditions are another contributing factor to the delay in implementing the mandatory health insurance scheme. Sanjay Tolani, Director of Goodwill Insurance Brokers expressed, “After the financial crisis, some multinationals have sized down employee covers, while others have begun to share premium costs with the employees.” Tolani also said that to compromise, many large employers have opted for Health Management Offices (HMOS), where employees can have discounts at a network of predetermined clinics and doctors.
Until employers, health authorities, and insurance companies reach a deal, the situation continues to worsen with hospital bills continuing to escalate.
According to the World Health Organization (WHO), the UAE expenditure on health per capita is 3,607 Dhs (US$ 982). Comparatively, this is much lower than many Western countries. However, since the UAE is a tax-free country, medical care costs are becoming more difficult for the government to carry entirely on their own.
Apr
19
A+ International Insurance May Not Offer Renewals
Filed Under CIGNA, Expat Insurance, Health Insurance, Insurance Company, International Healthcare, Medical Insurance, Switzerland, Vanbreda | 2 Comments
It has emerged within international private medical insurance industry that A+ International Insurance may not offer policyholders the option of renewing their medical insurance policies in the future.
A+ International Insurance’s decision to not offer clients a renewal on their IPMI policies may be due to Cigna’s purchase of Van Breda International; Van Breda International was integral to A+ International’s plan offerings and policy administration.
Cigna, a leading US based international insurance provider, purchased Vanbreda International in August 2010 in order to access the Belgian insurer’s international reach.
A+ International’s partnership with Vanbreda International is through Justitia NV. Justitia, an independent insurance company within the Vanbreda Group of companies, is responsible for underwriting A+ International’s international health insurance plans.
Justitia NV generated premium collections of EUR 18.5 million (US$ 26.3 million) in 2008.
While A+ is a relatively new entry to the global health insurance market, the company does have a significant number of policyholders worldwide; the potential denial of renewal terms to existing customers may leave a substantial number of consumers without adequate medical insurance coverage.
A+ policyholders are advised to contact the company, or their intermediary, in order to understand their health insurance options in the event that they are not offered a renewal of their current policy.
At present there has been no official confirmation from A+ International Insurance regarding future business, but policyholders who have contacted the company have been informed that there may not be renewal terms on their policies.
Apr
6
Kuwait National Healthcare System Transition Underway
Filed Under Expat Insurance, Health Insurance, Medical Insurance | Leave a Comment
Kuwait’s national healthcare system is set to undergo substantial reform and transformation in the next 3 to 4 years under the new Kuwait Health Assurance Company (KHAC), affecting both nationals and expatriates who look for health coverage options in the country. Kuwait is looking to evolve its health services policy from a welfare state into a ‘healthcare business.’
KHAC was established in 2010 by Ministerial Resolution 586 to develop a comprehensive public-private enterprise tasked with improving the healthcare sector in Kuwait and to guarantee high quality medical services for residents. The expansion of the Kuwaiti health system would be financed through the implementation of a new private medical insurance system issued through the company brand. KHAC plans on eventually enacting Law 1/1999, which instructs Kuwait to begin incorporating an integrated universal medical security system that would cover expatriates and ultimately extend services for all residents. KHAC also wants to provide substantial support in the development of the Kuwaiti private healthcare industry and to promote their individual medical services through proactive participation within the health development company.
Speaking at a press conference held for potential investors, Mohammad Al-Munifi, KHAC Chairman, explained the strategy of the new organization: “We have a vision for synergy and cooperation between the private and government sectors. By letting the private sector manage such a project, we expect an efficient health care system in Kuwait and a better experience for patients.”
The Kuwait Health Assurance Company has a capital sum of KD318 million (US$ 1.15 billion). The company is operating as a partnership between the Kuwait Investment Authority (KIA), the Ministry of Health and the private healthcare sector, with 26 percent of the ownership share to be auctioned off to a strategic partner. The KIA is largely in charge for the administration and auctioning of new shares in KHAC.
The initial proponent of KHAC’s healthcare development strategy calls for the construction of three major hospitals in Ahmadi, Jahra and Farwaniya and 15 new polyclinics throughout the country within the next 3 to 4 years. These facilities will be built and operated by private companies. The Kuwaiti government is set to grant renewable 20 year leases with KHAC for the proposed locations, and has given the company a three-year grace period to obtain all necessary licenses and successfully finish the construction and equipment of all new medical buildings. Kuwaiti Health Minister, Dr Hilal Al-Sayer claimed that the project represents the biggest health development initiative in the Middle East and would provide employment opportunities for over 1400 doctors and 4000 nurses and technicians.
The development of these new facilities, providing a projected 1,600 new hospital beds in Kuwait, will help ameliorate the structural pressure the state health provider network is currently facing. Substantial population growth, especially from the growing expatriate community, coupled with increased life expectancy rates and the escalating global costs of medical treatment have placed substantial burden on the health system’s resources. Demographic forecasts will exacerbate this trend. The current population of Kuwait is 3.5 million inhabitants and is growing substantially at 6.8 percent a year. Life expectancy at birth in Kuwait has increased substantially by 20 years within the last half century, from 59.4 years in 1960 through to 78 years on average in 2008.
Kuwaiti citizens are provided with free healthcare services from the publicly run hospitals and clinics. Foreign nationals in Kuwait must obtain health insurance from the government run scheme, as per residency requirements, or through a local healthcare system provider. Expatriates are required to pay additional out-of-pocket payments towards medical costs in the Kuwait public medical facilities. The compulsory state insurance scheme does not cover private treatment or repatriation costs. The law defines an appropriate alternative private healthcare company as one providing over 900 beds across Kuwait’s governorates and as Ahmad Nossouli of the Advisory Group explains: “there are no such healthcare providing companies…we have private hospitals and clinics, but they don’t meet the minimum requirements.” The average cost of healthcare services per person in Kuwait has increased substantially in the last decade, doubling to KD 112 (US$ 404) from KD 56 (US$ 202) between the years 2002 and 2009. All these factors push people towards the state hospital system and have resulted in medical personnel and equipment shortages, overcrowding, longer waiting times for treatment and a growing dissatisfaction with the public health care sector.
KHAC Chairman Al-Munifi confirmed that the Kuwaiti system could not continue on this trajectory: “We don’t expect the government to continue spending money on healthcare for non-nationals, even for nationals – there are many indicators that suggest the government won’t be giving free healthcare and education.”
The new private health insurance scheme, provided through KHAC, would provide access to the newly constructed healthcare facilities as well as other public-private practices set up around Kuwait. The price for the annual health assurance policy for the first ten years has been set at KD130 (US$468.8) per person and KD120 (US$432.7) during the tenth year. KHAC reserves the right to increase charges in the event inflation in Kuwait exceeds six percent in the coming decade.
The establishment of KHAC is intended to diversify healthcare provision and will deliver more opportunities for the private healthcare industry in Kuwait. Al-Munifi asserted: “The private sector today provides about 10 percent of healthcare, which is a small market share. This percentage should be increased in the future through government support and providing health opportunities.” If another healthcare provider, meeting the minimum 900 bed capacity requirement, comes to market alongside KHAC, individuals will have the opportunity to choose between them. The Kuwaiti government is looking forward to foreign input on the marketplace, as Health Minister Dr Hilal Al-Sayer explains: “With this project we want a new health insurance system in Kuwait,” adding, “This will be an opportunity for the private sector to participate and be involved.”
Once the new KHAC insurance scheme is implemented, the Ministry of Health will stop issuing their health insurance certificates to foreign nationals. “In order to stamp their visas, expatriates in Kuwait must obtain insurance from the KHAC,” Chairman Al-Munifi continued “We believe that the maximum fee of KD 130 is very reasonable, considering the quality of healthcare the KHAC will provide.” The introduction of the KHAC insurance scheme will further necessitate changes in sponsorship laws for Kuwait, to ensure employment does not capriciously deduct new healthcare fees from their foreign staff.
The KHAC insurance system is not exclusively a healthcare option for expatriates as Chairman Al-Munifi notes: “Many [Kuwaiti] nationals prefer to go to private clinics instead of public clinics because of the poor quality of service at public clinics. We want to give affordable premium healthcare services to all residents of Kuwait whether nationals or non-nationals alike.”
The Kuwait Health Assurance Company is part of Kuwait’s National Development Plan (NDP). Initialized in 2010, the plan will organize several hundred development projects and initiatives in housing, transport, social services and healthcare, with total infrastructure spending expected to reach US$108 billion. The NDP is designed to promote and diversify further economic growth in Kuwait, improve the state’s general services and ensure the state remains an attractive global business center. The private sector is expected to account for almost 50 percent of the net spending set out in the project and would participate through joint stock companies and partnerships between the Kuwaiti state and multinational businesses. The increase in private and state funding resources will most likely improve the local marketplace. While the increase in oil prices has enabled Kuwait’s economy to successfully recover from the 2008-09 global economic crisis, further success and long-term growth could be determined by the successful execution of the NDP.
Apr
1
Cigna Moves Into Singapore, Adds Individual International Coverage
Filed Under CIGNA, Expat Insurance | 6 Comments
Cigna Inc, the leading international group health insurer for expatriates and other individuals traveling abroad, was today granted a license to operate in the Singapore health insurance market. The move reaffirms the company’s commitment to developing its international business for providing supplemental coverage products. The expansion of the Philadelphia-based health insurance company’s operations into Singapore means the US insurer’s global coverage network of around 900,000 hospitals, physicians and other healthcare professionals, is now working out of 28 different countries and jurisdictions.
As a fully licensed Singapore insurer, Cigna will bring their global healthcare expertise to the country. Locally-based sales and client management operations will allow the company to work more closely with Singapore businesses to develop appropriate health coverage solutions for both their domestic and international employees. Through an arrangement with Parkway Shenton, one of Singapore’s largest private medical operators, Cigna will provide customers with comfortable access to quality healthcare services at competitive prices.
Entrance into the Singaporean insurance market was a priority for Cigna. The Managing Director for the Asia Pacific Region, Ken Vaughn announced in a press statement that the new Singapore-based offices would both enable the company to respond more effectively to the local market as well as internationally: “Our expansion into Singapore demonstrates our commitment to our clients and customers in the local market and their evolving needs in the international market,” he said. The country hosts several thousand multinational companies who need coverage options for their employees, many of whom are globally mobile. The substantial local middle class population, who can well afford supplemental insurance policies, and the large expatriate workforce (estimated to be 110,000) further present avenues for growth. Mr. Vaughn further added: “Singapore is an important market for us because of its choice location within Asia and the fact that many of our clients and customers are located here.”
Cigna’s Singapore office is also of strategic international importance due to its location in Southeast Asia. The new operations are expected to improve communication and decision-making with the company’s other branches in China and Hong Kong and strengthen Cigna’s overall capacity to handle its clientele on a global scale. The company established a presence in China in 2003 through a joint venture with China Merchants Group. Today Cigna is estimated to have around 6 million clients in the Asia Pacific Region, with South Korea currently home to the most policyholders. International business rose 33 percent to US$ 243 million and totaled 19 percent of Cigna’s adjusted earnings for 2010. Industry analysts predict Cigna’s international operations could grow to become a third of the company’s total business within the next three to five years.
Cigna has consistently been one of the most proactive American insurers looking to develop its presence in emerging Asian economies, with only Aetna Inc. also moving into China in the past few years. Both firms have been looking to increase their penetration in global insurance markets in order to offset the low growth forecast for the USA, in addition to the general unrest surrounding the 2010 US Health Reform Law, which will have a far-reaching impact on the industry and comes into effect in 2014. Many insurance companies are in fact looking to diversify and potentially become larger conglomerates to better absorb upcoming changes in the once lucrative US market.
International markets offer an enticing post-reform growth opportunity for US based insurers. As the Asian healthcare market develops, Cigna plans to be at the forefront with an aggressive strategy to take advantage of the projected increasing demand for insurance policies that will provide better coverage than the government provided coverage plans in the region. India and Turkey have been identified by Cigna CEO David Cordani at a presentation in March to investors in New York as the next priority target markets to establish company partnerships in.
In an interview, Cigna’s President of Cigna Expatriate Benefits Andrew Kielty, confirmed that work was underway for Cigna to establish an operation in India: “We are making good progress in India, but finding a long-term joint venture partner is a very delicate process and we can’t predict at this point when that will happen.”
Cigna is also interested in further growing its international business coverage options, selling expatriate healthcare products to multinational companies that are increasingly globalizing their operations. Cigna recently aquired Belgium’s Vanbreda International in 2010 to give the firm increased access to the expatriate health insurance market in Europe and Asia. In January 2011, Cigna announced its intentions to increase expatriate benefit plans through its African operations.
Cigna yesterday announced a new individual international healthcare plan, titled Cigna Global Health Options. The policy is designed for individuals who are frequent travelers and want access to a high standard of medical care wherever they are around the world. The basic policy, which is expected to cost around US$ 4,500 a year, covers hospitalization, maternity care, surgical procedures, cancer treatment and emergency services. Customers can also customize their package through purchasing any of the four additional service options including: international medical insurance plus (outpatient), international vision and dental, international health and well-being, and international emergency evacuation. Cigna Global Health Options’ clients will have access to a 24/7 customer service hotline to authorize treatment, guaranteed payment to hospitals, and handle all other customer inquiries related to the healthcare plan including claims and medical support.
Mr. Kielty explained the significance behind Cigna’s decision to launch this new product: “We are pursuing a broader market of wealthy individuals who want to seek out the best possible health care,” he added “The market for selling individual plans to expatriates is in excess of $1 billion. When you add in the broader high net-worth market, it’s hard to say how high that goes.”
This innovative plan marks Cigna’s entrance first foray into the individual consumer market, having long established itself in the expatriate insurance industry through its sale of group policies to employers. Cigna Global Health Options will prove an important benchmark in measuring the company’s growth into an even more comprehensive health insurance provider. Cigna Global Health Options is currently being marketed exclusively online but plans are underway for a more robust promotion strategy throughout 150 countries, including Cigna’s new venture in Singapore.
Insurance Companies Mentioned
CIGNA
CIGNA Health Insurance is a global health service company dedicated to helping people improve their health, well being and sense of security. CIGNA Corporation’s operating subsidiaries provide an integrated suite of medical, dental, behavioral health, pharmacy and vision care benefits, as well as group life, accident and disability insurance, to approximately 46 million people throughout the United States and around the world.
Mar
30
US Maternity Medical Tourist Situation Mirrors Hong Kong
Filed Under China, China insurance, Expat Insurance, Health Insurance, Healthcare, Hong Kong, Medical Insurance, USA Health Insurance | 1 Comment
American authorities have announced the closure of a “Maternity House” in the Californian city of San Gabriel, according to a New York Times report published March 29th, 2011. Neighborhood residents had complained repeatedly about the excessive noise coming from a local building, and the large number of pregnant women seen entering and exiting the area. Police officers and building inspectors discovered that the building was a center for Chinese medical tourists, who were using the home as a means to deliver their babies in the USA, thereby granting the child American citizenship. This situation is by no means unique to the USA as Hong Kong, for many years, has experienced a massive influx of mainland mothers looking to give birth within the city.
There are a number of reasons which can be used to explain the increase in Chinese mothers traveling abroad to give birth. One of these is with regards to the People’s Republic’s notorious “One Child Policy,” stating that Chinese nationals, within China, are only allowed to conceive, and give birth to, one Child. By going overseas to deliver, the mother is able to escape the bounds of Chinese legislation, and potentially have an additional baby upon return to her home nation.
The second reason for going overseas to give birth is more to do with having a form of “insurance” against untoward changes within the People’s Republic of China. In the case of the USA, any child born within the bounds of America’s borders automatically becomes a Citizen of the USA under the 14th amendment. Once the child is 21 years of age, they are then a full citizen of the country, and are able to petition the government to allow their parents to join them as residents of the US.
In Hong Kong this situation is paralleled, mainland mothers giving birth within the HKSAR gain their child “Right of Abode,” and consequently Permanent Residency; in addition to being granted the privilege of living in one of China’s most prosperous cities as their child’s guardian. While technically a part of China, Hong Kong operates under the “One Country, Two Systems” principal, and immigration of PRC nationals to the city is tightly controlled. By having a child in Hong Kong, the families of these children are able to ensure that they will not be deported for illegal immigration or visa over-stay infringements.
However, Hong Kong, unlike the USA, has healthcare system which is predominately public in nature. While private healthcare services and hospitals do exist in the city, the majority of residents receive their medical treatment through low cost, government run healthcare facilities. With a large number of pregnant mainland mothers using the maternity facilities at public hospitals within Hong Kong there was a serious strain placed on the city’s healthcare services. In some cases Chinese mothers accounted for more than 30 per cent of all deliveries at certain hospitals within Hong Kong.
In fact, this situation progressed to such an extent in Hong Kong that in 2008 the city’s government passed legislation introducing mandatory pricing for non-resident mothers wishing to give birth in Hong Kong public hospitals. Non-resident mothers who have booked their delivery in a Hong Kong public hospital are now required to pay a minimum booking fee of HK$ 39,000 (US$ 5,005.82) for a three day, two night maternity package. Non-resident mothers who have not booked a hospital bed, in other words, walk-ins, are charged HK$ 48,000 (US$ 6,161.06). The costs here do not include any complications of pregnancy, but are only for a routine delivery, and even then represent the minimum amount that a non-resident mother can be expected to pay; for Chinese nationals this no mean sum, as the nation’s average annual income is a paltry US$4,520.
Further to this, the Hong Kong government has not made any specific legislation with regards to the city’s private maternity hospitals, where the average maternity costs for a routine delivery are in the US$ 8,500 range; a cesarean section, or c-section, at the same hospitals will typically be priced at US$ 12,838. In comparison, the USA federal average for a routine child delivery comes in at roughly US$ 7,600.
As can be seen from the costs involved, the women undertaking this Medical Maternity Tourism phenomenon are clearly not from the lowest strata of Chinese society. With Chinese companies offering one-stop maternity tourism services from between CNY 50,000 – 90,000 (US$ 7,623 – 13,721), it is evident that these women, and their families must be, at least, slightly well off.
This then poses the question of why, exactly, the rate at which Chinese mothers are traveling overseas to give birth is increasing.
In recent years the PRC’s Central Government has made extraordinary strides towards improving the standards of the nation’s healthcare system and services; going so far as to introduce a comprehensive private China health insurance system, and stepping up much needed overhauls of the country’s top hospitals. In many cases China is able to offer private medical services which are on-par with, if not exceeding, those of their western counterparts. Hospitals like Parkway Shanghai are able to deliver some of the highest standards of medical treatment within the People’s Republic of China, and while they mainly serve foreign national expatriates, do cater services to Chinese residents.
The reason for this development then cannot be the quality of care, or even the cost of treatment, as these are both adequately covered within the People’s Republic. Additionally, unlike the furor over “Anchor Babies” within the USA, the Chinese mothers in question often return home after giving birth, and are usually in possession of above average financial means.
The issue of Chinese mothers giving birth in the USA is baffling American immigration experts, who say that the women are not acting in violation of current American laws. However, as in Hong Kong, there is apparent anger towards the trend. From the New York Times story:
“These people aren’t doing anything in violation of our laws,” said Mark Krikorian, the executive director of the Center for Immigration Studies, which advocates tougher immigration controls. “But if anything, it is worse than illegal immigrants delivering a baby here. Those kids are socialized as Americans. This phenomenon of coming to the U.S. and then leaving with people who have unlimited access to come back is just ridiculous.”
While there are many women from Asian nations participating in similar activities, such as South Korea, the Philippines, and India, it is Chinese mothers who are driving the trend. Not only are these mothers driving the trend, but their actions imply long term forethought towards the question of; where is it best to deliver my child overseas?
When looking at the American medical system the first thing which is immediately apparent is the need for some form of health insurance. Medical services within the USA can be prohibitively expensive, a much publicized and debated issue, necessitating some form of comprehensive health insurance coverage. However, it is important to realize that many insurers will impose a significant waiting periods on policy benefits such as maternity coverage. In some cases, the waiting period associated with maternity can be as long as 24 months from the start of a plan, although the norm would be closer to 12.
As such, it is obvious that these “Maternity Tourists” will have been planning their delivery trip for quite some time prior to departure. However, looking at the overall situation, it becomes much more complex than it can first seem.
Of those Chinese nationals and residents who do possess a health insurance policy, the type of policy prevalent within the population is “local health insurance.” These are medical insurance plans which are designed to work solely within a specific country, in this case China. These plans will not cover the policyholder overseas; while Hong Kong is considered to be a part of China, it is technically a separate national entity, so local China health insurance will not provide cover in the city, never mind the USA. However, in the case of Hong Kong, these maternity tourists tend to cover the costs related with the birth out-of-pocket.
American health insurance would then seem like an option; however, obtaining domestic USA health insurance to cover the costs associated with the birth is also a difficult proposition for foreign nationals, as an American residential address is typically required to access a plan. Looking at the waiting periods which will be involved, the logistics here would mean that the Chinese mother would have to be “resident” in the USA for a period which far exceeds the length of stay granted by her visa. As American immigration experts have cited the legality of this type of action, this is most likely not the case.
The last proposition for insurance coverage of the birth is with regards to international health insurance plans, which provide medical protection on a global basis. However, Chinese regulations, and the restrictions put in place by many of the major insurance providers operating on the mainland, mean that unless the Chinese citizen is an expatriate residing outside of their home country, they will be unable to obtain this type of policy. Due to the fact that American immigration experts cite the fact that many, if not all, of these mothers return to China after giving birth, having been abroad on temporary tourist visas, this is most likely not the case.
At the end of the day, it is extremely difficult for these mothers to fund their maternity tourism via insurance, which lends strong weight to the fact that they are paying for their maternity services out-of-pocket. If the USA is seeking options to resolve this potentially concerning issue, a price increase, or mandatory down payment such as that in place in Hong Kong may be a solution. In 2008, the year that “maternity tourism” began making headlines in Hong Kong, there were 7,462 babies born in the USA to foreign parents. Since then, the number of maternity tourists has only increased, and as China continues to generate more wealth, is likely to continue doing so.
Mar
23
Qatar to introduce National Insurance Scheme in 3 years
Filed Under Expat Insurance, Health Insurance, Healthcare, Middle East, UAE Insurance | 1 Comment
A senior advisor from Qatar’s top health advisory body, the Supreme Council of Health, has announced that a broad national health insurance system with universal access for both citizens and visitors will be operable within the next 3 to 4 years.
Qatar’s Supreme Council of Health (SCH) was established by an Emir decree in 2005. The Council replaced both the former National Health Authority and Ministry of Public Health of Qatar. Although the state of healthcare provision in Qatar is currently very good, there are substantial problems on the horizon. The continued evolution of hi-tech medical technology and pharmaceutical innovations coupled with increasing expectations from patients for new treatments all coupled with a growing population are putting serious stress on the financial resources and infrastructure capacity of the state’s health care sector. Currently bed occupancy rates are above average and many patients surveyed complain about waiting lines for treatment.
Assistant Secretary General for Policy, Dr Faleh Mohamed Hussain Ali, spoke to the media at the SCH headquarters on Monday:“We are drawing closer to getting the national health insurance scheme up and running and we are presently developing a plan which will lay down the upcoming implementation process in discreet and incremental stages.”
When asked whether this significant measure was introduced to close the healthcare funding gap, Dr. Faleh Ali responded: “Our aim is to present this scheme as a tool for guaranteeing quality healthcare services and not as a means only to generate revenue as there will be competitiveness between service providers to the benefits of the users.”
The status of the comprehensive health insurance legislation is progressing quickly though its formative stages. Dr. Faleh Ali added: “The draft law is ready. There are some gaps in the draft law that need to be filled, after which it will be forwarded to the Cabinet for approval.”
In accordance with the original draft law, a national statutory health insurance association will be established within the next 12 months. This body will be tasked with overseeing the compulsory health insurance scheme, collaborating closely with existing insurance companies in Qatar, handling disputes between parties, and ensuring compliance with current health promotion and policy goals. After successfully registering and maintaining accreditation with the new government body, health providers would have access to both the public and private patient networks. Exactly how this will manifest itself is yet to be worked out. Both the healthcare practices in public and private sectors as well as insurance companies’ input and co-operation will be sought out in this exchange. The SCH will continue to regulate the health system and, according to the draft law, manage the new funds allocated towards the compulsory health insurance proposal.
The new healthcare scheme will offer a minimum service package at a pre-determined affordable premium. Standards regarding quality and cost of treatment will be reviewed and made abundantly clear to both providers and patients in the public system. Certain elective procedures, such as cosmetic surgery, are not currently planned to be covered or subsidized through the new scheme. Medical fees in the private sector are also thought to be under review prior to the execution of the national insurance scheme.
The full implementation of the national health insurance scheme is projected to take three to four years. Once completed, the public insurance structure will cover all nationals and expatriates as well as visitors to Qatar. Dr. Faleh Ali explained the reason for this: “Health insurance is a social scheme, so we are going to provide minimum package to cover healthcare costs of everybody including visitors and we will ensure that the premium is also affordable.”
Dr. Faleh Ali updated the media on the direction the project was going, saying: “We have just concluded the phase one of the scheme’s time-line and plan, which included selecting the best insurance option for the country by researching the best known international and regional practices as well as held an extensive stakeholders consultation.” He then added: “We are expecting to implement the first phase of the mandatory health insurance scheme by the end of next year. It will be a pilot project, targeting particular segments of the population, which is yet to be decided.”
The pilot program will enable the SCH to micro-manage a small proportion of the potential public healthcare base, allowing them to troubleshoot any problems for the main compulsory health insurance scheme that arise.
Dr. Faleh Ali confirmed that the Supreme Council of Health is already planning further ahead: “We are in the second phase of preparations for the project which includes establishment of the Statutory Health Insurance Body” and that “[i]ntensive work in establishing all other required infrastructure and prerequisites such as quality, cost and access standards, a common coding scheme, business and IT system and communication and public relations programme of dissemination of the scheme, will soon get under way”
The Assistant Secretary General further remarked: “In three to four years we should have a scheme offering universal coverage that others will aspire to replicate.”
Mar
9
Bupa’s Results Show Strong Growth In Emerging Markets
Filed Under BUPA, Expat Insurance, Health Insurance, Medical Insurance, United Kingdom | 3 Comments
British United Provident Association (BUPA) announced results for the year ending 31st December 2010, with strong international sales contributing to a 9 percent jump in revenue to total £7.58 billion (US$12.12 billion) for the year.
However, the health insurers’ surplus before taxation expense was down by 72 percent to £118.0 million (US$188.8 million) from £416.5 million (US$666.4 million) reported in 2009, mainly due to goodwill impairments of £249.2 million (US$398.7 million).
Bupa’s overall revenue was up 9 percent compared to 2009 reaching £7.58 billion (US$12.1 billion); this reflects a 4 percent growth from organic activities and a 5 percent benefit from favourable foreign exchange movements. The key drivers for improvements in sales were Bupa’s international businesses in Asia, Latin America, Australia and Saudi Arabia; the improvements from these sources offsetting static sales in the UK, North America and Spain during 2010.
Bupa’s underlying surplus before taxation amounted to £464.9 million (US$743.8 million) representing a 9 percent improvement year-on-year primarily down to the positive performance in Australian and Asian healthcare markets.
The Bupa Health and Wellbeing UK (BHW) brand also produced sound results contributing to the health insurer’s profit margin following the restructuring of this business sector.
Bupa struggled in some established markets – particularly in the UK, US and Spain – during 2010, with new sales remaining static in line with the very tough economic conditions applicable in western hemisphere countries.
Buoyant sales in Asian, Latin American and in Middle Eastern countries, along with a new business activity in Australia, helped the company offset the loss of growth in previous dominant markets.
A key driver for Bupa’s robust international sales figures resulted from the market for expatriate health insurance. This activity strengthened in 2010 with increased mobility by expats searching for new opportunities as economic conditions deteriorated in Europe and the US causing high levels of unemployment; Bupa was able to capitalize on this trend, being one the leading insurance providers for expatriate health insurance.
In Asia, Bupa saw profitability levels increase as higher customer numbers helped revenue from international activity reach £3.39 billion (US$5.42 billion) in 2010 – up from £2.83 billion (US$ 4.52 billion) in 2009. This represented a 20 percent increase in revenue generating a business surplus of £208.9 million (US$334.2 million) in 2010.
Bupa’s fledgling operations – Bupa Arabia and Bupa Australia – have generated new customers: now there are over 1 million BUPA policyholders from the Middle Eastern operation and over 3.2 million customers in Australia. Bupa Arabia’s sales have benefited from the health insurance legislation in place in Saudi Arabia, which requires all expatriate residents in the country to hold private health insurance.
There was a notable growth in sales in Hong Kong and Thailand which saw customer numbers increased by 12 percent and 9 percent respectively. Health insurance delivered a good performance in both countries with new sales growth and high retention of existing customers.
MaxBupa, the standalone Indian health insurer, was initiated by Bupa in 2010. It now has a presence in nine cities and has established a network link with over 700 hospitals across India. Bupa is in a strong position in India through their MaxBupa venture, which has already secured a sound reputation with over 27,000 customers in a market set to expand as economic conditions strengthen.
Speaking on Bupa’s 2010 results, Chief Executive, Ray King, said: ‘We achieved strong growth in our insurance businesses in Australia and Asia and increased operational efficiency in our businesses in Europe and North America, where market conditions were more challenging.”
Bupa is expecting business to grow in 2011 particularly in the expanding Asia-Pacific and Latin America regions, where there is an increasing demand for quality health insurance. The momentum within these two emerging regions and Saudi Arabia are expected to drive profits for the international health insurer and create an increasingly diversified customer base.
While growth is expected in emerging markets, Bupa is anticipating challenging conditions to continue in its traditional markets in the UK and the USA with sales likely to be inhibited as economic conditions are impacted by austerity measures being applied nationally. While unemployment numbers remain high in the UK and the USA, both individual and corporate health insurance sales are expected to be frustrated.
As global demands change, Bupa will seek to penetrate new markets and strengthen its foothold in emerging markets where a presence has been recently been established. The health insurer also plans to develop its product range and quality of service in order to promote sales growth.
The UK based health insurer took a major strategic decision in 2007 and sold its private hospital network within the UK in an ambitious step to focus on the core private health insurance and care market. The £1.44 billion (US$2.2 billion) capital generated from the sale of private hospitals was used to strengthen Bupa’s global presence which is now reaping financial benefits.
In the medium term, Bupa is planning to grow by responding to demands from highly populous emerging markets where action has been taken to establish a presence.
Bupa’s global reputation has made it one of the leading multinational health insurers and it is a strong favourite with expatriates seeking health insurance cover. This sector of business has helped Bupa to increase sales during 2010 and it is expected to be a major contributor to trading activities in 2011.
Across the group, Bupa retains a strong market position with a sound financial standing. It is, therefore, well placed to meet the prevailing challenges in 2011 including pressures arising from the spread of chronic diseases, the rise in ageing populations and changing consumer and national government expectations about the services required from companies in the health insurance and care business.
Insurance Company Mentioned:
Bupa
Bupa was established more than 60 years ago in the UK and is now has ten million customers in over 190 countries, and over 52,000 employees around the world. Bupa is a leading international healthcare provider, offering personal and corporate health insurance, workplace health services and health assessments. As a provident association Bupa has no shareholders, because of this it uses its profits to invest in healthcare and medical facilities around the world. Bupa has operations around the world, principally in the UK, Australia, Spain, New Zealand and the US, as well as Hong Kong, Thailand, Saudi Arabia, India, China and across Latin America.
Mar
1
Aetna Revamps Private Healthcare Plans
Filed Under Aetna, Expat Insurance, Health Insurance, Insurance Company | 5 Comments
Aetna the healthcare insurance specialist has launched a new suite of International Healthcare Plans (IHPs) designed to cater for expatriate employees and employing companies in order to make health benefits more accessible for members when overseas.
The Connecticut based insurer’s revamp of its healthcare insurance products is focused on giving employers and their workforce optimum flexibility in accessing healthcare benefits and the management of costs for treatment required.
The fundamental purpose of the new plans is to offer greater accessibility to healthcare, medical services and benefits for Aetna members when seeking medical care abroad. The reform of Aetna’s international health plans means that expatriate members of company based private healthcare insurance schemes will have more flexibility in obtaining medical services, including benefits covering services associated with care such as dental, maternity and the provision of pharmaceutical products as well as traditional medical treatment and emergency admittance to hospital.
The new additions to Aetna’s private plans include the revamping of health and wellness products, with 49 optional benefits available for employers to incorporate into plans which can be tailor-made to fit individual requirements. The improvements in core healthcare plans have been implemented to meet the emerging needs of members as demands change with more employee mobilization.
A key facility included in the new suite of plans is a free of charge health risk assessment – part of Aetna’s wellness package. This feature, along with other health improvement initiatives, has been included to promote the adoption of healthier lifestyles. Encouraging members of private healthcare schemes to follow procedures for healthy lifestyles has been recognized as an important tool for health insurers and employers in order to maximize productivity from employees.
The multi-national insurer identified the variation in the needs of employers and employees and has adapted plans to offer comprehensive core healthcare benefits.
Aetna’s new IHPs will mean employees now have the choice of 49 additional benefits with a range of financial limits. It has become more important for global health insurers to offer flexible plans as workers move from country-to-country as part of companies globalized trading.
Changes to Aetna’s international plans have been made to reflect cover for local niche treatments such as the application of traditional Chinese medication, which is popular with the workforce originating from the Far East.
“We recognise that employers need a comprehensive level of core health benefits and flexibility in plan design in order to meet the needs of their varied employee populations. We have redesigned our health plans to provide a richer level of base benefits to work with different budgets and included wellness features to help employees make positive changes that can lead to lasting healthy lifestyles. At the same time, we’ve provided the most flexible selection of add-ons and limits yet, so that employers can purchase the features they need to tailor benefits packages to cater for regionally diverse needs and make the most of their healthcare investments.” said Donna Otten, head of Aetna Global Benefits (AGB).
Aetna’s core health plans – IHP Essential, IHP Plus and IHP Elite – will allow additional benefits for hospice care, inoculations and vaccinations. Expatriates can also have coverage for evacuation assistance to repatriate an employee, along with emergency travel for an expatriate on compassionate grounds if a close family member is taken ill. These sort of extra benefits have been included in Aenta’s international health plans to meet the needs of expatriates who want to ensure their private healthcare policy covers any potential emergency circumstance.
The new IHPs are already available in Europe, the Middle East and Hong Kong, with plans for introduction in China, Jakarta and Singapore in the near future. The plans can also be adapted to cater for college students or government departments and other types of group activity.
Insurance Company Mentioned:
Aetna
Aetna is a leading global diversified health care benefits company head-quartered in the U.S., serving approximately 35.8 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioural health, group life and disability plans, and medical management capabilities and health care management services for Medicaid plans. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, governmental units, government-sponsored plans, labour groups and expatriates.
Join us on Google +
