The highlights of your “Health Insurance” plan The Health Insurance comes to your rescue at the time of your desperate need thereby protecting you from sudden medical emergency or any kind of illness you face. The insurance company pays for the expenses and you’re relieved of tension and worry. It provides you with a sense of security that you and your family are protected during the time of sudden medical emergency or any kind of illness you face.  Common Features of Health Insurance: • Eligibility: Anybody aged between 3 months and 65 years can take Health Insurance Policy. For buying health Insurance you need to undergo a Medical checkup after 45 years of age, but in some companies this age is extended to 55 years. • Health Insurance Coverage: It has got the following covers:Hospitalization cover: It covers for the hospitalization expenses if the insured is hospitalized for more than 24 hours. • Family Floater Plan: It is a plan where your entire family will be covered under one Premium and one cover, whenever any member of your family needs medical treatment, the Floater Plan will cover your whole Family, but it has a limit to the age for children.  • Critical Care Plan: Critical Insurance policy covers you for major illnesses and offers a lump-sum benefit on diagnosis of critical illness such as life-threatening cancer, Bypass Surgery, stroke, heart attack, kidney failure and paralysis, organ transplant etc. Different Insurance companies provide different Critical Insurance policies and coverage; some provide insurance cover against 4 major critical ailments, while some cover up to 10 ailments. Pre and Post Hospitalization Expenses. Pre existing diseases are covered after two, three or four continuous renewals depending upon company to company.  Day care medical expenses are also covered where insured is requiring less than 24 hours of hospitalization. • Pre-existing illnesses: Insurance Companies don’t cover you for the diseases which existed at the inception of the plan but some companies cover you after two, three or four continuous renewals depending upon company to company.• Personal Accident cover: It is a benefit cover or add on cover where insurer provides compensation if the person has met with an accident and has sustained a bodily injury. In case of death and Permanent total Disablement (PTD), additional compensation will be paid. • Pre and Post Hospitalization cover: Normally Health Insurance Policy covers for medical expenses incurred 30 days prior and 60 days after hospitalization. In some companies this cover can extend to 60 days prior and 90 days Post Hospitalization. • Claim Procedure: For making an insurance claim you need to contact the insurer, send a letter and do remember to keep a copy with yourself. The insurer should send you a claim form, which you should fill out completely and send it back. For planned hospitalization, please inform insurer one day before admission to the hospital and cashless facility can be availed in all network hospitals. • Cashless claim: It is one of the most convenient ways for getting claim in case of any medical emergency. You need not to spend initially and getting reimbursed later, your Medical Expenses will be directly incurred by the insurer through a TPA who will have a tie-up with the network hospitals. For this you will be issued a Health Card by the insurer, which will help you in settling your cashless claim.

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The burgeoning health insurance sector is set to see some far-reaching changes.

Specialized health insurance subsidiaries and allowing agents of one insurance company to sell health products of other general insurance companies are two of the major proposals.

A committee was set up to look into the issue of senior citizens and the health insurance sector mooted these proposals.

The Insurance Regulatory & Development Authority (IRDA) had, some time back, talked about the formulation of new regulations in health insurance in order to take it forward.

Industry sources told DNA Money that health insurance needs a special focus and it makes sense to spin the segment into a subsidiary.

This subsidiary, the committee felt, will require special skill sets like a separate CEO, dedicated marketing team, in-house third party administrators etc. While the committee has recommended this for the general insurance sector, it could, in the long run, be applicable to the life insurance sector as well.

Life insurers are in the process of unfolding health plans in close competition with the general insurance sector.

It may be recalled that Life Insurance Corporation has already floated a separate business unit for the purpose. Given that the health insurance sector has the potential to grow from the present Rs 4,000 crore to Rs 20,000 crore in five years, it makes sense to nurture this high growth segment, the committee is said to have pointed out.

In another change, the committee has felt that there should be modifications in the current restrictive agency regulations. The current regulations do not allow any agent of a company to sell products of different companies.

A change has to be brought about if health insurance products have to be popularized, it said.

Bidding for selection of health insurance provider planned by TN government

A new health insurance scheme for the Tamil Nadu State Government employees under which the assistance provided will be doubled from what the employees receive under the existing insurance scheme has been decided to be launched by the Tamil Nadu Government.

A relief to all class of employees:

While marginally increasing the monthly subscription the employees pay for the health insurance cover the new scheme, will bring those employees receiving non-standard scales of pay and also employees of the local bodies, PSUs, statutory boards and state government universities under health insurance cover.

The Government has planned to invite competitive bidding for selection of the health insurance provider.

Lacunae in the existing scheme:

· Under the present Tamil Nadu Government Employees Health Fund Scheme providing coverage to the government employees and their family members, a monthly subscription of Rs 10 was collected and assistance to the extent of 75 per cent of the expenses or Rs 1 lakh whichever was less was granted to the eligible applicants.

· It has been represented to the Government that the cap of Rs 1 lakh was insufficient to meet the medical expenses of major ailments such as cancer and congenital heart disease.

· The employees were deprived of getting further assistance under the scheme during the rest of their service after availing the maximum amount of Rs 1 lakh.

· Employees also found it difficult to meet the cost of treatment themselves first before applying for reimbursement under the insurance scheme.

· In certain areas the employees/their dependents had to travel long distances for treatment due to lack of approved institutions nearby.

· The existing insurance scheme also left out employees of PSUs, local bodies, state government universities and statutory boards and some major ailments were out of coverage.

Mr Gnanadesikan said the State Government has now decided to implement a new health insurance scheme to ‘provide for comprehensive healthcare assistance to the employees with a wider scope of coverage’. (Contd)

New India Assurance will shortly launch a special health insurance product for senior citizens.

Unique features: The period for which the pre-existing disease clause is applicable is four years“ under most health insurance policies. Under this new plan it has been reduced to 18 months, especially for senior citizens. · By paying a simple 10 per cent loading on the premium, persons suffering from hypertension and diabetes can also avail themselves of New India’s new scheme.· Persons between 60 and 80 years after a pre-acceptance health check-up are eligible for the scheme. · For a cover of Rs 1 lakh to Rs 1.5 lakh the premium under the plan ranges from Rs 4,000 to Rs 6,600. · By paying an extra 10 per cent in premium policyholders between 80 and 85 can renew their plan while those between 86 and 90 will have to chip in an extra 20 per cent. Compulsory Co-payments in the case of claimThe insured has to make a compulsory co-payment of 10 per cent in the case of a claim under this scheme and the policyholders can opt for increasing the co-payment of a claim to 20 per cent for a 10 per cent discount in the premium Sub limits that are woven into the policy· For instance, if a person is hospitalized, not more than 1 per cent of the sum assured can be spent on the room rent per day and not more than 2 per cent per day on the rent for the Intensive Care Unit. · An overall limit of 25 per cent of the sum assured has been fixed per illness for rent charges.· The policy also fixes a limit of 25 per cent of the sum assured on the fees of the surgeon or anesthetist and 50 per cent of the sum assured on services like blood, oxygen and X-rays, among others.

An elderly man about to receive anesthesia is on the operating table awaiting surgery. He insisted that his son, a renowned surgeon should only perform the operation.

The old man signalled to speak to his son.
“Yes, Dad, what is it?” asked the son

“Don’t be jittery, son, perform your best, and do never forget if it fails, if something should happen to me, your mother will live with you and your wife the rest of her days”

When You’re 50…plus

1. People can call also call at 7 p.m. and ask, “Did I wake you?”
2. Hijackers are least bothered about you.
3. In a prisoner situation you are likely to be released first.
4. You can eat dinner at 5 p.m.
5. You enjoy hearing about other people’s surgeries.
6. Speed limits are no more a challenge.
7. You are no more pestered with “Insurance Investigations”
8. You are free to sing with the elevator music.
9. Your eyes won’t get worse.
10.Your investment in health insurance is finally beginning to pay off.

The Employees State Insurance Scheme was the result of the enactment of the Employees State Insurance Act in 1948. The employees are protected against loss of wages due to inability to work due to sickness, maternity, disability and death due to employment injury in this scheme. The scheme offers health education, preventive care, medical and cash benefits. The employees and their family members are provided with medical care without fee for service. The insurance cover is extended to employees working in all non-power using factories with 20 or more persons though the ESIS scheme originally, covered all power-using non-seasonal factories employing 10 or more people. Service establishments like road transport, cinema houses, shops, restaurants, hotels and newspapers printing are now covered while persons working in mines and plantations, or an organization offering health benefits as good as or better than ESIS, are specifically excluded. For enrolment in the ESIS the monthly wage limit is Rs. 6 500 with a prepayment contribution in the form of a payroll tax of 1.75% by employees.

The amazing success of Yeshasvini Trust, Karnataka was possible through a tight partnership with the Karnataka Department of Cooperation, which launched “The Yeshasvini Cooperative Farmers Health Scheme” a young, but incredibly successful microinsurance scheme in Karnataka.

Initiated in 2003 with 1.6 million insured right away, it covered 2.2 million lives in its second year of operation, but in the third year it dropped to 1.45 million members after doubling the premium.

Cooperative societies were encouraged to market the product actively with the department using its influence positively. Members were convinced to join the scheme while some of them were enrolled straightaway.

Karuna Trust a Karnataka based NGO that has been working successfully on health and development issues for nearly two decades. For its target population the Karuna trust decided to implement a pilot health insurance scheme in a partnership with the United Nations Development Programme (UNDP),

In designing a health insurance product that complements the public healthcare infrastructure the Karuna Trust, the non-governmental organization (NGO) were pioneers in collaborating with the state-owned National Insurance Company (NIC)

Acting as an agent for NIC the Karuna Trust promoted the insurance product that compensates the insured for the loss of income in case of hospitalization at a public health facility.
Furthermore, to supply medicines that are unavailable in public facilities a drug fund was set up and people belonging to the poverty line received treatment through public health facilities free-of-charge. Between the public infrastructure and the insurance scheme a tight network has evolved that has resulted in efficient services for the poor.

Health insurance is recommended as a measure to protect households from catastrophic health expenditure (CHE). An “Annual hospital expenditure greater than 10% of annual income,” means they have experienced CHE.
Individual households finance more than 72% of health expenditure in India at the time of illness through out-of-pocket (OOP) payments.

This is a highly regressive way of financing health care and sometimes leads to impoverishment. Two Indian community health insurance (CHI) schemes, ACCORD and SEWA, provide health insurance cover for the indigenous population in Tamil Nadu and Gujarat.

Both cover hospitalizations expenses, but only upto a maximum limit of US$23 and US$45, respectively.

There were a total of 683 and 3152 hospital admissions at ACCORD and SEWA, respectively. In the absence of the CHI scheme, all of the patients at ACCORD and SEWA would have had to pay OOP for their hospitalization. With the CHI scheme, 67% and 34% of patients did not have to make any out-of-pocket (OOP) payment for their hospital expenses at ACCORD and SEWA, respectively.

Both CHI schemes halved the number of households that would have experienced CHE by covering hospital costs. However, despite this, 4% and 23% of households with admissions still experienced CHE at ACCORD and SEWA, respectively. This was related to the following conditions: low annual income, benefit packages with low maximum limits, exclusion of some conditions from the benefit package, and use of the private sector for admissions.

Conclusion

CHI appears to be effective at halving the incidence of CHE among hospitalized patients. Improving the design of the CHI schemes, especially by increasing the upper limits of benefit packages, minimizing exclusions and controlling costs, could further enhance this protection.

Around 40 micro health insurance schemes covering several million clients are active in India and the numbers are on the rise. India clearly emerges as the world’s leader in the development of low-cost health insurance through micro health insurance units for poor and for rural population-segments.

Micro health insurance schemes, which are non-commercial and mutual, are striking because the members can retain part of their profits. It is also an efficient way to cut down free riding, moral hazards and adverse selection as well as keeps a check on insurance frauds.

As the package required by the rural poor was not met by the commercial insurance companies there was an understandable reluctance among rural communities and the poor to add to profits of commercial insurance companies. This factor enabled the existing micro health insurance schemes to run their own independent insurance and cater to the burgeoning needs of India’s rural poor.

The significant factor is the modus operandi of the schemes’ which involves the clients in some important aspects of the business cycle. Greater, cheaper and better information flows, which can be used to augment broad-based affiliation and renewal, and also monitor outlier utilization was feasible due to the prevalent intensive contacts among community members.

Moreover by reducing moral hazards, adverse selection and free riding, rural communities in India in turn reduced the costs of health insurance and thereby paved the way for a health cover for all the rural communities.

Nandakumar Rajeshirke was suspicious of health insurance when he first heard about the idea three years ago. He had trouble understanding why it made sense to gamble on an unforeseen illness or accident when there was no guarantee he would ever see any money in return.

But his insurance provider, a network of nongovernmental organizations called UpLift India Association, had already earned his trust by supplying him with reliable microcredit to fund his stone carving business in the city of Pune. Mr. Rajeshirke decided to buy coverage for his whole family at 50 rupees ($1.10) per person annually and renewed the plan for several years in a row.

In 2005, his gamble paid off. Rajeshirke’s wife needed a hysterectomy, a procedure that would normally cost 20,000 rupees ($446), one-third of his yearly salary.

“Without insurance,” he says, “I would have had to sell some things from my house or get a loan from someone at high rates.” Instead of facing financial ruin, he paid 6,000 rupees ($134) total and had help navigating the long process through diagnosis, surgery, and medication.

Such plans, known as micro health insurance, are gathering momentum in regions of Asia and Africa that lack public health strategies. These nonprofit programs aim to provide quality healthcare at low premiums on a community-level scale. The idea is that, with creative planning, the poor can benefit from the same protections against risk as the rich.

India is a world leader in this emerging field, with 5 to 10 million people enrolled in micro health insurance nationwide. Fewer than 10 percent of India’s 1.1 billion people have any sort of health insurance, much of which covers only government employees. Poor people usually work in informal jobs or are self-employed, so they are extremely unlikely to be included in employment-related plans.

In its very first year of operations, The Star Health and Allied Insurance Company is confident of securing Rs 80-crore premium income. Within 45 days of operation, the company has opened 57 offices and plans 28 more before the middle of next month. Writing 30 lakh health policies in the current year is not a big deal, according to the company’s Managing Director, Mr. V. Jagannathan. So far, the company has earned a premium income of Rs 4 crore.

Star Health is capitalized at Rs 105 crore and has a non-life insurance licence. However, the company intends to focus on health insurance because “there is lot of money in it”. Barely about 10 per cent of the Indian health insurance potential has been tapped, Mr Jagannathan, formerly chairman and managing director of the public sector United India Insurance, told journalists here on Tuesday.

Health premium in the country is of the order of Rs 1,750 crore, but there is a lot to be done. Importantly, the growth in health premium does not depend on how well the economy is doing, he pointed out.

But is health insurance not risky? Mr Jagannathan replied that health insurers faced risks from two areas — high claims due to sickness and high claims owing to unnecessary tests or fraudulently inflated bills.

Star Health, Mr Jagannathan said, had safeguards against both. A screening system ensures that persons who are already sick do not get cover.

Star Health has an overriding protection, through a reinsurance arrangement with General Insurance Corporation. All claims beyond the claims ratio of 90 per cent will be picked up by GIC. “No other insurer has this comfort in India,” Mr Jagannathan said.

Star Health intends to introduce overseas mediclaim and personal accident policies. Munich Re has been hired as the settlement agency.

In private insurance, buyers are willing to pay premium to an insurance company that pools people with similar risks and insures them for health expenses. The key distinction is that the premiums are set at a level, which provides a profit to third party and provider institutions. Premiums are based on an assessment of the risk status of the consumer (or of the group of employees) and the level of benefits provided, rather than as a proportion of the consumer’s income.

In the public sector, the General Insurance Corporation (GIC) and its four subsidiary companies (National Insurance Corporation, New India Assurance Company, Oriental Insurance Company and United Insurance Company) and the Life Insurance Corporation (LIC) of India provide voluntary insurance schemes.

The Life Insurance Corporation offers Ashadeep Plan II and Jeevan Asha Plan II. The General Insurance Corporation offers Personal Accident policy, Jan Arogya policy, Raj Rajeshwari policy, Mediclaim policy, Overseas Mediclaim policy, Cancer Insurance policy, Bhavishya Arogya policy and Dreaded Disease policy (Srivastava 1999 as quoted in Bhat R & Malvankar D, 2000)

Of the various schemes offered, Mediclaim is the main product of the GIC. The Medical Insurance Scheme or Mediclaim was introduced in November 1986 and it covers individuals and groups with person’s aged 5 -80 yrs. Children (3 months – 5 yrs) are covered with their parents. This scheme provides for reimbursement of medical expenses (now offers cashless scheme) by an individual towards hospitalization and domiciliary

Social Health Insurance – Social health insurance programmes in India offer valuable lessons for policy-makers.

Hospitalization is facilitated as per the sum insured. There are exclusions and pre-existing disease clauses. Premiums are calculated based on age and the sum insured, which in turn varies from Rs 15 000 to Rs 5 00 000. In 1995/96 about half a million Mediclaim policies were issued with about 1.8 million beneficiaries (Krause Patrick 2000). The coverage for the year 2000-01 was around 7.2million.

Another scheme, namely the Jan Arogya Bima policy specifically targets the poor population groups. It also covers reimbursement of hospitalization costs up to Rs 5 000 annually for an individual premium of Rs 100 a year. The same exclusion mechanisms apply for this scheme as those under the Mediclaim policy. A family discount of 30% is granted, but there is no group discount or agent commission. However, like the

The IRDA and the advent of foreign players:

The Mediclaim, policy has had only limited success. The Jan Arogya Bima Scheme had covered only 400 000 individuals by 1997. The year 1999 marked the beginning of a new era for health insurance in the Indian context. With the passing of the Insurance Regulatory Development Authority Bill (IRDA) the insurance sector was opened to private and foreign participation, thereby paving the way for the entry of private health insurance companies. The Bill also facilitated the establishment of an authority to protect the interests of the insurance holders by regulating, promoting and ensuring orderly growth of the insurance industry. The bill allows foreign promoters to hold paid up capital of up to 26 percent in an Indian company and requires them to have a capital of Rs 100 crore along with a business plan to begin its operations. Currently, a few companies such as Bajaj Allianz, ICICI, Royal Sundaram, and Cholamandalam among others are offering health insurance schemes, which have manifold benefits.

In recent years, community health insurance (CHI) has emerged as a possible means of: (1) improving access to health care among the poor; and (2) protecting the poor from indebtedness and impoverishment resulting from medical expenditures. The World
Health Report 2000, for example, noted that prepayment schemes represent the most effective way to protect people from the costs of health care, and called for investigation into mechanisms to bring the poor into such schemes (World Health Organisation 2000).

Various other terms are used in reference to community health insurance, including: ‘micro health insurance’ [Dror et al 1999], ‘local health insurance’ [Criel 2000] and ‘mutuelles’ [Atim C 2001]. We define CHI (along the same lines as [Atim 1998]) as “any not-for-profit insurance scheme that is aimed primarily at the informal sector and formed on the basis of a collective pooling of health risks, and in which the members participate
in its management.” CHI schemes involve prepayment and the pooling of resources to cover the costs of health-related events.

Community health insurance is generally targeted at low-income populations, and the nature of the ‘communities’ around which they have evolved is quite diverse: from people living in the same town or district, to members of a work cooperative or micro-finance groups. Often, the schemes are initiated by a hospital, and targeted at residents of the surrounding area. As opposed to social health insurance, membership is almost always voluntary rather than mandatory.

It is time that there is a deep rethink on India’s healthcare system. What passes off, as a healthcare system today is a number of ill-equipped apathetic under funded government hospitals, which are hotbeds of corruption and squalor.

Being essentially free of charge, the government hospitals are unable to attract good doctors or invest in modern facilities, while attracting large numbers of poor patients. Black markets and corruption are the inevitable result.

Its time to move away from “free” medical care to a co-payment model. The health insurance system is totally isolated from hospitals and pharmacies. These have to be brought together into a coherent healthcare system – not an easy task for any country, but nevertheless one of the top social priorities for India. The involvement of the private sector into the public healthcare system will be a necessary first step.

AIDS is shocking because of sheer numbers – but there are a number of deadly diseases that diminish lives in India. Along with specific campaigns to tackle ‘branded’ diseases it is equally important to put in place a healthcare system that can take care of a billion Indians; a large number of whom earn less than one dollar a day.