Risk segmentation in Chilean social health insurance

Purpose: The objective of this study is to identify how risk and social variables are likely to be impacted by an increase in private sector participation in health insurance provision. The study focuses on the Chilean health insurance industry, traditionally dominated by the public sector. Design/methodology/approach: Predictive risk modelling is conducted using a database containing over 250,000 health insurance policy records provided by the Superintendence of Health of Chile. Findings: Although perceived with suspicion in some circles, risk segmentation serves as a rational approach to risk management from a resource perspective. The variables that have considerable impact on insurance claims include the number of dependents, gender, wages and the duration a claimant has been a customer. Practical implications: As shown in the case study, to ensure that social benefits are realised, increased private sector participation in health insurance must be augmented by regulatory oversight and vigilance. Originality/value: As it is clear that a "community-rated" health insurance provision philosophy impacts on insurance firm's ability to charge "market" prices for insurance provision, the authors explore whether risk segmentation is a feasible means of predicting insurance claim behaviour in Chile's private health insurance industry.