Dialogue with Wang Shun, Head of ZhongAn Health Insurance Products: Exploring the Boundaries of the “Impossible Triangle” for Coverage of People with Pre-existing Conditions

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Domestic commercial health insurance is currently in an exceptionally critical deep-water zone.

According to the latest industry statistics, the number of people with illnesses and those in sub-health status in China has exceeded 400 million, with chronic disease patients making up the vast majority.

As the population aging curve continues its upward trend, the real medical payment demands of this huge group are experiencing exponential growth;

However, the long-standing reality is that these 400 million people are often ruthlessly filtered out by the "funnel" of mainstream commercial health insurance due to stringent health notification requirements.

In the past ten years or so, relying on the demographic dividends of young and healthy people, critical illness insurance and million-dollar medical insurance once saw explosive growth. However, today, the penetration rate among healthy people has nearly reached its limit, premium growth has slowed, and the market has completely entered a stage of intense competition for existing customers.

As the search for incremental growth becomes a universal question for all insurance companies, the previously considered “high-risk, hard-to-price” group of those with pre-existing conditions has been naturally pushed to the center stage.

Driving this shift is not only the market searching for itself but also clear top-down policy direction: the 2026 government work report calls for “accelerating the development of commercial health insurance,” and at the previous Central Financial Work Conference, "inclusive finance" was also formally included in the five major articles that the financial industry must address.

At the same time, the fundamental restructuring of the medical payment environment has pressed the accelerator on commercial health insurance transformation.

In recent years, reforms of medical insurance payment methods have been deepening, with DRG (Diagnosis Related Groups) and DIP (payment by disease category) now comprehensively covering public hospitals across the country. Under cost control constraints, hospitals tend to discharge patients who meet acute-phase clinical cure indicators as soon as possible to control average medical costs for single disease types.

The change in payment mechanism reshaped patients' medical seeking paths; a large number of patients in postoperative recovery or stable disease stage are now under practical pressure to move from public hospitals to outside rehabilitation facilities or home care.

All the above provides a clear entry point for commercial health insurance to engage in full course disease management and fill in payment gaps, bringing health protection for people with pre-existing conditions to the core of policy and market concerns.

But on a practical level, advancing insurance for those with pre-existing conditions is by no means easy.

In recent years, although the market has seen some non-standard insurance products targeting specific chronic diseases or relaxed underwriting criteria—and “Huiminbao” widely launched across regions has greatly lowered the insurance entry threshold—

But in terms of actual operational results, most products are still at the superficial level of “insurable.” High deductibles and harsh claims conditions still form an insurmountable gap from the “good claims” truly needed by patients.

Against this backdrop, on March 12, ZhongAn Insurance officially launched “Zhongminbao·Mid-to-High-End Medical Insurance 2026”, which for the first time covers inpatient rehabilitation costs for 16 specific diseases, offers zero deductible, and supports direct settlement within partner hospital networks.

This upgraded product directly targets three major frequent pain points of people with pre-existing conditions in real medical scenarios: small-amount hospitalization, postoperative rehabilitation, chronic disease medication.

From the publicly available guarantee terms, ZhongAn is attempting to fill current gaps in market coverage, achieving a substantial leap from pure financial compensation to refined medical services.

What kind of practical sample does this deep-water commercial exploration provide for the entire health insurance industry?

Focusing on the actuarial logic behind product iteration, the first HMO (Health Maintenance Organization) trial in the rehabilitation medical field, and the future direction of commercial health insurance, “Wallstreet CN” interviews Wang Shun, chief health insurance product officer of ZhongAn Insurance.

Actuarial Logic: Looking for the Balance in the “Impossible Triangle”

Wallstreet CN: Zhongminbao’s mid-to-high-end medical insurance features no occupational restrictions and coverage for pre-existing conditions, but in traditional health insurance pricing, “wide coverage, high guarantee, and low premium” is often considered the “impossible triangle” to achieve simultaneously.

How did ZhongAn balance this contradiction in the actuarial logic and data model underlying its 2026 upgrade?

Wang Shun: The biggest pain point for commercial medical insurance handling people with pre-existing conditions is the lack of reliable long-term, large-scale data. Traditional actuarial models rely mostly on static morbidity tables for healthy people, and simply applying them to the pre-existing-condition group would easily result in huge payout deviations.

The “impossible triangle” is a static model preset in actuarial practice, but insurance products require continuous exploration, verification, and refinement in real operation across large user bases.

Over the past three years, Zhongminbao has accumulated massive and solid claims experience data during actual operation.

Analyzing this real medical behavior, we found some that matched product design expectations, but also exposed some long-tail risks and adverse selection deviations beyond expectations. The essence of commercial insurance is mutual assistance. If short-term arbitrage by a minority is left unchecked, it will ultimately harm the long-term interests of the majority of clients.

Therefore, the 2026 iteration of Zhongminbao’s mid-to-high-end insurance did not blindly pursue scale, but instead adopted more restrained and refined actuarial strategies.

The upgrade expands advantageous coverage but also adds highly targeted risk-prevention exclusion clauses. This refined adjustment ensures both horizontal fairness and vertical sustainability of product rates, thus providing stable long-term protection for long-term clients.

Wallstreet CN: What specific risk control details reflect these "restraint adjustments"?

Wang Shun: For example, we excluded high-risk conditions such as Grade 4 or above nodules and lung nodules over 8mm;

Extended waiting periods for general pre-existing conditions and lowered first-year claims ratios for elective surgery diseases like stones, polyps, and benign tumors for new policyholders.

Wallstreet CN: What’s the reason or basis for actively implementing these “subtractions”?

Wang Shun: When we find original designs unfavorable to the majority of clients, we revise them in iterations.

From clinical medical data, the probability of lung nodules turning into malignant tumors and incurring high surgical costs in the short term is very high; including them in coverage would cause severe adverse selection and push up overall pool costs.

Extending waiting periods is also because we observed in real claims that many users would purchase insurance with pre-existing conditions, wait out a very short period, then undergo non-emergency surgeries like gallbladder removal or polyp excision.

After removing these, the saved payout resources have been distributed to loyal clients seeking long-term health coverage.

Wallstreet CN: Please elaborate on the “addition” aspect of the new product; what upgrades and innovations are offered in daily high-frequency medical scenarios?

Wang Shun: We raised the payout ratio for general medical (non-critical illness) expenses in the 0–20,000 yuan range from 50% to a substantial 60%.

Previously, million-dollar medical insurance often had deductibles of 10,000 yuan or more, preventing reimbursement of numerous small hospitalization expenses. Raising the payout ratio in the low deductible bracket directly and greatly increases actual claim amounts.

Furthermore, one of the most significant long-term burdens for people with pre-existing conditions is chronic disease medication.

Zhongminbao’s mid-to-high-end 2026 upgrade makes original imported chronic disease medication a mandatory coverage, providing an exclusive 5,000 yuan annual limit, with a payout ratio up to 60% and zero deductible.

We benchmarked mainstream e-commerce platforms’ drug pricing, combined online consultations and home drug delivery, substantially lowering the threshold for patients to access high-quality, cost-effective original drugs.

Rehabilitation Breakthrough: Reconstructing the HMO Cost Control Loop under the DRG Model

Wallstreet CN: The most innovative part of this upgrade is covering the rehabilitation phase under high-level guarantees, with reimbursement ratios up to 100% for certain diseases.

In the past, rehabilitation medicine has always been an untouchable "forbidden zone" for commercial medical insurance; including high-value rehabilitation in coverage, poses a huge cost control challenge to insurance companies.

As the product manager, how do you see the role of insurance companies in the full medical rehabilitation process?

Wang Shun: Adding rehabilitation coverage is a direct response to current changes in medical payment systems.

By 2026, the DRG reform for payment methods has fully rolled out in all public hospitals nationwide. Under DRG, hospitals prefer to discharge patients meeting acute-phase clinical cure as early as possible for cost control.

But that does not mean the end of treatment.

For example, post-stroke patients have a six month golden period after discharge for neurological recovery—deep, professional rehabilitation intervention is crucial for their future quality of life.

Previously, commercial medical insurance rarely covered rehab due to its highly non-standardized nature and the lack of clear management norms or treatment endpoints.

We have not adopted a blanket approach, but have precisely selected specific critical illnesses such as stroke and cancer (with clear rehab needs and clinical pathways) to offer up to 1 million RMB coverage and 100% reimbursement.

Wallstreet CN: In practice, how did ZhongAn screen and integrate external medical providers to ensure service delivery?

Wang Shun: In practical implementation, we are exploring a deep partnership model similar to HMO.

We have carefully selected 33 core hospitals under two leading rehabilitation medical groups nationwide for direct connection. Unlike traditional insurance, which only reimburses after the fact with no intervention in medical processes, we intervene before patient admission.

Through collaboration with hospital professional medical teams, the insurer jointly participates in standardized, integrated rehab program development, establishing ongoing monitoring and price comparison in specific disease diagnostics, medication, and physical therapy.

Deep intervention greatly strengthens insurers' control over medical processes and overall costs, closing the service loop to benefit patients directly. In connected rehab hospitals, patients enjoy direct settlement upon discharge, without needing to pay large sums upfront, making rehab smoother.

Industry Prospects: From Payment Tool to Healthcare Service Entry

Wallstreet CN: We noticed this product offers a special medical booster pack with a 3 million RMB limit and a 20,000 RMB deductible, with a 50% payout ratio for certain diseases.

Can you break down how Zhongminbao’s mid-to-high-end medical insurance’s zero deductible and the 20,000 RMB deductible for the special pack connect in actual claims?

Wang Shun: The underlying logic for the booster pack is mainly to give consumers layered choices for medical treatment. Fees in the special departments of public hospitals often multiply those in regular departments and are not reimbursed by medical insurance.

In product liability: If clients contract critical illnesses, the main insurance enjoys zero deductible and direct access to special departments, maximizing convenience for serious patients to obtain top medical resources.

For ordinary illnesses, clients who buy the booster pack and go to special departments must bear the 20,000 RMB deductible—above that, 100% is reimbursed. If not going to special departments, the main plan covers 60% for 0-20,000 RMB, 100% above 20,000 RMB.

Through deductible lever adjustment and tiered reimbursement rates, the product meets differentiated, high-end medical needs while also effectively preventing moral hazard from special resources abuse by mild cases.

Wallstreet CN: How do you view the trends and future evolution of commercial health insurance?

Wang Shun: Overall, the shift from a passive financial payer to an active healthcare service entry is already an irreversible trend for domestic commercial health insurance.

With the population aging and normalized medical insurance cost controls, the real value of medical insurance is no longer just the probability game on actuarial charts, but rather as a solid link, using financial payment mechanisms to efficiently connect patients to high-quality, selected medical resources.

Although the industry has high consensus on this direction, under the current medical system, companies are still arduously seeking breakthroughs and profitable business models.

In future, ZhongAn will continue to build on base data accumulation from large user groups, leveraging fast iteration, and gradually improving an integrated health service loop from inpatient care to outpatient rehab, special treatment to chronic disease medication.

Only by truly engaging with the medical industry’s core can commercial health insurance find new growth in an era of stock competition.

Risk warning and disclaimerThe market involves risks; investment needs caution. This article does not constitute personal investment advice and does not take into account individual users’ specific investment goals, financial situation, or needs. Users should consider whether any opinions, viewpoints, or conclusions in this article fit their particular circumstances. Invest accordingly, at your own risk. ```