The opportunities for private investment in healthcare facilities and services are ever increasing. Because the Government has opened the insurance sector to private companies, the availability of private health insurance is expected to increase access to private healthcare facilities for millions of families. Max Healthcare and Apollo Hospitals are examples of providers already offering services in each of the primary, secondary and tertiary sectors.

Health insurance is grossly underdeveloped in India. According to some estimates, only 3% of India’s population is covered under some form of voluntary health insurance. Thus, it presents a huge opportunity with some estimates suggesting that the potential health insurance market could be worth as much as 600 billion Rupees by year 2007.

The Insurance Regulatory and Development Authority (IRDA)

Any insurance company intending to enter the life or non-life insurance markets in India is required to have a minimum paid-up capital of 1 billion Rupees (approximately US$20.5 million). While there have been suggestions that the minimum capital requirement for specialist health players might be reduced, this has not happened yet. Foreign equity participation is also capped at 26%.

As a pre-condition for granting a license, each new insurer is required to write some health insurance business. Recently, the Insurance Regulatory and Development Authority (IRDA) have also issued regulations recognizing the third-party administrators (TPAs) in insurance business. TPAs are required to have a minimum working capital of 10 million Rupees and its senior officers are required to meet certain minimum training requirements from a recognized institution.

Providers and products

Most of the new life insurance entrants are providing health insurance benefits as riders to their base products. ICICI-Prudential Life offers surgical assistance benefit rider, whereas Allianz Bajaj Life offers hospital cash benefit rider, which is an indemnity type rider that provides reimbursement of medical hospitalizations facility. To date, many insurance companies have only offered limited benefits, primarily due to lack of data and experience of the local market and the relatively underdeveloped nature of the healthcare infrastructure in the country.

Opportunities and challenges

Given the potential size, India is one of the most promising countries in South East Asia for the development of its health insurance market.

There is a limited network of health/social security schemes such as the Employee State Insurance Scheme (ESIS), the Central Government Health Scheme (CGHS) and some community-based schemes and employer-based schemes. However even here, access and availability of health services is likely to be less than satisfactory. When combined with the relatively small proportion of people with voluntary health insurance, the number of lives covered represents at best 100 million people, about 10% of the population.

The support of the IRDA will be crucial. It is keen to see health insurance coverage grow rapidly in the country and is likely to encourage insurers and service providers in their efforts to develop the market. The challenges should however not be underestimated. Delivering healthcare to the rural Indian population where the medical infrastructure is minimal will be a significant task in itself. Even in urban areas where services can be more readily established little or no data for pricing products would remain an issue for insurers to resolve. And finally, the continuation of some less than ethical practices by some healthcare practitioners may cause concerns for the orderly development of the sector.

However despite these challenges, with around 90% of the population reliant on state hospitals or self-finance, the potential prize is great for the insurers that can capture the interest and provide relevant products and services for the Indian consumer.

Indian economy is now growing impressively. One of the areas of Indian economy that will have very fast growth is Insurance. Right now, the size of Indian insurance sector is just $10 billion and by 2010, it may become a $60 billion industry. Until now, Indian insurance sector did not see too much use of technology. However, it is going to change. Now, 3i Infotech has launched Premia Insurance Broking eXchange (IBX)which is ‘a first of its kind subscription-based internet solution for the Indian insurance industry.’

This product will help insurance companies a lot. It will save time for both the insurance company and the insurance agents. To know about it more, you can read the report of Moneycontrol.com.

The launch of Premia IBX will empower the insurance industry at large and thus provide the much needed impetus to the insurance market. 3i Infotech’s technology edge will power the insurance industry’s quest of being an interconnected and agile business community across the Insurance value chain” .

A four-day training workshop on health insurance, organised by the Government of India in association with the World Health Organisation, commenced at the State Institute of Health and Family Welfare here .

Managing director of the Punjab Health Systems Corporation (PHSC) T.R. Sarangal delivered the keynote address.

Dr Y.C. Markan, director, State Institute of Health and Family Welfare, and Dr Arjun Singh Gill, joint director, PHSC, were coordinating the programme.

Delegates from eight states were participating in the programme, at which training would be given by expert faculty members.

Sarangal said the basic concept behind this training programme was to support the states in their initiatives regarding health insurance.

Another aim was to orientate officials who were at the decision-making and managerial levels so that they could initiate, implement and monitor health insurance programme.

He added that he was confident that at the end of the course, the participants would have both knowledge and skills to manage health insurance programme.

The advent of Third Party Administrators (TPAs) is expected to play an important role in health insurance market in ensuring better services to policyholders. In addition, their presence is expected to address the cost and quality issues of the vast private healthcare providers in India.

However, the insurance sector still faces the challenge of effectively institutionalizing the services of the TPA. A lot needs to be done in this direction. Towards this the present paper describes the findings of a survey study, which was carried out with the objective to ascertain the experiences and challenges perceived by hospitals and policyholders in availing services of TPA in Ahmedabad, Gujarat.

The major findings from the study are: (i) low awareness among policyholders about the existence of TPA; policyholders mostly rely on their insurance agents; (ii) policyholders have very little knowledge about the empanelled hospitals for cashless hospitalization services; (iii) TPAs insist on standardization of fee structure of medical services/procedures across providers; (iv) healthcare providers do experience substantial delays in settling of their claims by the TPAs; (v) hospital administrators perceive significant burden in terms of effort and expenditure after introduction of TPA and (vi) no substantial increase in patient turnover after empanelling with TPAs.

However, there is an indication that hospital administrators foresee business potential in their association with TPA in the long run. There is a clear indication from the study that the regulatory body needs to focus on developing mechanisms, which would help TPAs to strengthen their human capital and ensure smooth delivery of TPA services in an emerging health insurance market.

Doctors’ sharing the risk in health insurance makes it a win -win situation for all!

In India a doctor’s crucial role is to diagnose

1. Diagnosis is of two types:

a) The Doctor’s analysis of the patient’s reports.
b) The Doctor’s perception of the patient’s symptoms.

The formidable factor is that there is an acute shortage of doctors in this country.

Could we ensure high quality in the doctor’s diagnosis if he is made responsible for his own feelings?

The point is this: When a doctor consults, he is doing a risk-free business. No one can hold him responsible for his failures.

Its like the McKinsey who told Rahul Bajaj not to launch Bajaj Pulsar, or AT Kearney who told Jagdish Khattar that they should get out of the small car business by 2002, or the famous McKinsey recommendation to Tata Steel that they should get out of the steel business by 2000, as the prices are going to go down on a spiral. As we all know, Tata Steel is on the verge of becoming the fifth largest steel producer in the world.

IBM often gets into a profit sharing agreement with a client. If they believe that their solution is going to give savings of 10% of operating costs to the client, their payment for the deal could be half of that savings (apart from a fixed payment).

A consulting assignment is more about the paper. It’s about the change management, the implementation, and the sustainability of the assignment.

Then why should the doctors get away by talking through their hats and giving any recommendation they want. They need to share the risk, either mentally or monetarily.

For example, you could say, that hospitals could integrate with Health Insurance companies. This means that if the doctor does not take care of the patient, and provide him the most cost effective solution, the attached health insurance company would suffer. This would put a driver on the doctor to keep the costs down, hence reducing the risk factor, reducing the premium for users, and making it a win-win situation for all.

Athena-health has recently opened a corporate innovation center in Chennai, India American based organizations, Athena-health has recently opened a corporate innovation center in Indian city Chennai for medical practices that provides online revenue management cycle services to enhance their BPO capabilities through Software Development related work, and the story is according to co founder or CEO of company. An organization is looking forward for recruitment of more than 50 professionals’ that will include 20 in software development and other 20 for analysis. So, the center is expected to add process engineering places and software development, as well as by taking ownership for both of the underlying technologies and Offshore Outsourcing relationship. With the system of Perot it has contact for more than four years, and 310 personnel working for conversion of insurance related documents to E-form. The organizations are going to look for expanding near by 500 employees within one year. With the figure of 95 per cent in medical bills for the American are paid by their government or from insurance firms, so we can say that it is acting as a bridging link between insurance organizations doctors. An organization is catering less than 7000 physicians, it collects 1.6 billion dollar on behalf of its customer every year that is out of $600 billion of total collection.

Protest against Bush’s Veto of Childrens’ Health Care Bill

With no media looking on, Pres. Bush today used his veto power (for only the 4th time since taking office), to veto bi-partisan legislation that would have expanded the SCHIP program to provide health care for poor children.

His reason? The plan will take customers away from private insurance companies. Bush’s solution for the uninsured? “Just go to an emergency room!”

Since Rep. Randy Kuhl (R-Fairport) is set to side with Pres. Bush on this disgraceful veto, a protest was held at 5 p.m. Thursday, Oct. 4, across from Rep. Kuhl’s Fairport Office (Kennelley Park Gazebo, 33 South Main St., Fairport).

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FACTS:
*12% of American children have NO health insurance coverage at all.

* The U.S. (the richest nation in the world) ranks 37th in the world for infant mortality.

* One-in-five U.S. jobs do not provide health insurance, a pension, or wages high enough to support a family.

* For a family of 4, one year of health insurance costs an average of $11,000.

* Over 1/2 of all bankruptcy filings in 2001 were a result of medical expenses.

* With the same money we’re spending to fund operations for 41 days in Iraq, we could provide health insurance for ten million kids in America for a full year!

* Between 2000 – 2004, the annual profits of insurance corporations doubled while health insurers raised premiums 59%.

* Average pay for the five top executives at [the top] health insurers almost doubled during this same time period to $3 million a year.

Diabetes: A rising phenomenon in India A research confirms that in a little over a decade from now, chronic diseases like diabetes, hypertension, cancer and AIDS would account for over 65% of deaths in India compared to 53% in 2005. By 2020, chronic diseases are expected to claim 7.63 million lives in India, compared to 3.78 million in 1990,. India that is already home to the largest number of diabetes patients is projected to have 30 million diabetics by 2020, of which 6.6 million or 22% would suffer from complications such as diabetic nephropathy. Doctors blame sedentary lifestyle, lack of physical activity, obesity, stress and consumption of a diet rich in fat and sugar for the high incidence. Similarly, stress both at work and at home is going to take a further toll with the number of people suffering from hypertension estimated to rise 213.5 million in 2025, compared to 118.2 million in 2000 representing an 80% rise in a span of a quarter century.  A recent study had estimated that nearly 11% of India’s urban population and 3% of rural population above the age of 15 have diabetes. The World Health Organization estimates that mortality from diabetes and heart disease cost India about $210 billion every year and is expected to increase to $335 billion in the next 10 years. These estimates are based on lost productivity, resulting primarily from premature death.  Focus shift by the Indian government: While traditionally the government’s focus was on combating infectious diseases, it has now decided to address the issues related to chronic or lifestyle diseases, along with private sector.  By 2010, an additional 4.5 lakh hospital beds will be required, the study adds. Today, the value of the healthcare sector is over $34 billion, translating to roughly 6% of GDP and the sector is projected to grow to nearly $40 billion by 2012.  While the government is drawing up plans to build at least half-a-dozen AIIMS-like multi-speciality hospitals, the study said, the government was expected to chip in with only 15-20% of the investment requirement.   Lack of  health insurance the fundamental factor: There are however significant challenges that need to be addressed. The lack of adequate healthcare insurance for a vast number of people is a fundamental problem. Currently 11% of the population has any form of health insurance coverage but with growing public-private partnership in this sector, many more people can be brought under insurance coverage

After showing their Insurance card or policy copies the Policyholder can be hospitalized in emergency and are supposed to fill an undertaking form at the emergency reception.

They should complete pre-authorizations formality filled by the concerned doctor.

TPA will issue an authorization letter for the coverage as per the policy to the concerned hospital. The answer will come from TPA in the form of authorization letter.

· Policy holder can directly approach the hospital Admission Counter for admission with the ID Card and one copy of the authorization letter will be given to the Admission / IP billing counter.
· Hospital will extend cashless treatment to the policyholder up to the authorized amount.
· In case the authorized limit get exhausted get in touch with Insurance helpdesk.
· At the time of discharge, policyholder has to inform the Insurance desk & is supposed to sign the claim form.

Important note : Insurance help desk is only helping you to get your claim processed by TPA. In the event of the cashless authorization request being rejected by TPA, the patient has to pay the bill to the hospital and try to claim the expenses subsequently from the Insurance company or TPA.

Do’s

1. Obtain pre – authorization form from Insurance Helpdesk 3 – 4 days prior to the
admission for planned hospitalization.
2. Pre – authorization form is to be filled in by treating doctor.
3. Check about the pre – authorization approval at the Insurance helpdesk within next 24hrs.
4. You can avail cashless treatment at the hospital after receipt of written authorization from TPA for the covered.
5. Leave back all the original documents and signed claim form with the hospital at the time of discharge.
6. Contact local TPA office in case of any query.
7. Make payment to the hospital for the expenditure over and above the TPA approved limit and for the treatment not covered under the package.

Don’ts

1. Don’t insist upon admission at the hospital merely for investigation, evaluation or Health check – up, as these are not approved by TPAs.
2. Don’t insist on admission on cashless basis at the Hospital without obtaining the
pre –authorization approval from TPA.
3. Don’t carry back any original documents at the time of discharge from the hospital,
if your cashless hospitalization is approved by the TPA.
4. Don’t forget to sign the claim form.

Q. Who is a Third Party Administrator (TPA) & What are their functions?

A. An important link between Insurance companies policyholders & healthcare providers (Hospitals and nursing homes) is the Third Party Administrator (TPA). The TPA’s role is to provide administrative support to the insurance companies for servicing their insurance policies.

The Unique Services offered by TPA for Healthcare Provider and policyholders.

1 Easy and Cashless Hospitalization: A list of empanelled hospitals where in he/she can avail cashless hospitalization is provided for each policyholder.
2. ID card: In order to validate their Identity at the time of admission the TPA provides ID cards to all their policy holders.
3. Claims Management: TPA administers & settles claims for hospitals & policyholders on behalf of insurance companies
4. 24 hours customers help line: Through its 24 hrs call center information the TPA provides assistance regarding policyholder’s data, provider network, claim status, benefits available with existing cardholder, etc and furnishes them on request.

If you have a medical insurance please check out the following details:
• Have you received the insurance cards from Third Party Administrator? If not contact your agent or TPA.
• If you have received the Insurance ID cards check the name of the TPA before getting
hospitalized.
• If you have fresh policy / first year policy or recently got your policy renewed check with your
TPA about your policy enrollment, failure of which can result in rejection of your cashless
authorization request.
• Medical insurance do not cover your OPD consultation / procedure / investigation done before being hospitalized.
• All claims of the discharge from the hospitals will be processed by the TPA directly / or for reimbursements of all your post discharge expanses directly file all originals documents, bill, prescription in TPA.

Role of the Insurance Help Desk

1. Only policyholder’s (Those who have medical insurance) can avail the cashless service from TPA.
2. Insurance Help Desk only helps the policyholders in getting cashless approval from TPA.

Plan for planned Hospitalization

Policyholder’s collect the preauthorization form from the Insurance help desk & after
Filling and signing by the concerned doctor, submit it back to the Insurance Helpdesk at least 3- 4 days prior to hospitalization.

Many people may not realize that an affordable alternative to costly permanent life insurance policies even exists. They hear of the often steep rates that come with a permanent (or whole) life insurance policy, and think they cannot afford life insurance, and may consequently leave their loved ones uncovered. But an affordable alternative does exist, and that is term life insurance.

There are two basic types of life insurance: term life insurance, where you choose the coverage amount and length of the policy; and whole or permanent life insurance (of which there are many variations), which combines an investment product with life insurance.

Below are some of the advantages to buying term life insurance:

Whole life insurance is expensive, due mainly to its investment aspect, while term life insurance is very affordable. Whole life insurance policies often cost thousands of dollars a year, as opposed to the mere hundreds of dollars a year that the majority of term life insurance policies cost consumers.

For example, if you are a healthy, non-smoking 35 year old male, you can get 10-year, Rs 100,000 term life insurance policy for as little as a month .

Term life insurance is simple to understand, and allows for personal choice. You pay a (low) monthly premium based on the term length and amount of coverage you choose. That’s it. Simple. You can choose term lengths such as 10, 20 or 30 years, and coverage amounts anywhere from Rs100, 000 to several lakhs of rupees.

You can invest your hard-earned money yourself, rather than having an insurance company does it for you (which is what happens with whole life insurance). Insurance companies are often very conservative with how they invest your money. If you are at all savvy in investing, or good at saving, the extra money a whole life insurance policy costs may not be for you. Instead, buy a cheaper term life policy, and invest the money you saved yourself.

Term life insurance is good for short-term needs. Two good examples of this are to cover your children’s college education and to cover your mortgage. Parents could buy a policy that expires after their children graduate from college to ensure that the full education is paid for (in case anything happened to the parents). Or, the main breadwinner in a house could buy a term policy that matches the length of his or her home’s mortgage.

Here are some additional term life insurance tips:

Buy enough life insurance to meet your needs; life insurance is not the place to skimp, especially because term life insurance is so affordable.

Also, match the term to your needs. Make sure your dependents are covered until they can provide for themselves, or that your spouse is covered until retirement income becomes available.

Buy when you are healthy, and try to match your terms to when you will still be healthy. When you get into your 50s and 60s, it may be harder to find affordable term life insurance.

Don’t lie on your policy; as life insurance companies will investigate before paying. If you do not admit to a habit, behavior or health risk on your application, your beneficiaries may not receive the money after you pass away. That is the whole point of your life insurance policy, to leave money for those left behind, and it would be a shame if they didn’t receive what you had paid for because you were not truthful on your application.