Health Insurance Final11

8/9/2019 Health Insurance Final11

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What is Health Insurance?

It is a contract between insurer & insuredwhere the latter is covered against healthcosts on payment of premium as per terms& conditions of the issues.

It is regulated by IRDA-Insurance RegulatoryDevelopment Authority.

Under Ministry of Finance.

Health Plans-Subscription based Medical Care.Beneficiaries-Self Help groups, factory workersRMPs, students, defence personnels & othersections of society.

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Key words in Health Insurance-

Premium- The amount need to pay in policy in orderfor insurer to take the risk of health care of the insured.

Contract- Documentary understanding of terms & conditionsbetween insurer & insured.

Sum Insured-Total amount, a policy assures as insured as a riskcoverage based on premium paid.Third party Administrator-(TPA)-Agent who takes care of hospitalbills of insured clients as there are very few insurancecompanies which deals with hospitals directly.Ex Star Health,Bajaj

Allianz.

Inadmissible-Those items not covered by medi claim insurancepolicy. Ex-Medical records, diet.

ICD & CPT-International Classification of Disease & CurrentProcedural Terminolo . C:\Documents and Settings\Administrator\My Documents\HEALTH


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Denial & Authorization-Whether TPAapproves hospitalization & estimated amount or not.

Co pay ment- In every policy there is particular % of amountneeded to pay out of whole bills.

Deductible-Amount which client has to pay before HIC starts

paying.

Diagnostic Related Groups (DRG)- Payment related topayment schedule as per govt. rule.

Charge Master-Hospital tariffs for investigation ,drugs,consultation.

Co-Insurance-Instead of paying a fixed amount policy holder

pays % of total cost.


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.Pre Authorization Form-Authorization or

permission from TPA in order to admit patient in hospital.

Capitation-Amount paid by insurer to health care provider.

Coverage Limits-Health plans with fixed health care

payments.

Out of Packet Maximums-The members obligation endswhen they reach out of pocket maximum, health plan paysthe rest.

Empanelment- Inclusion in list of treating physicians &institute.

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Health insurance typically helps a patient managehealth care costs beyond a threshold amount

through pooling . . .

As acontingentclaim

instrument,healthinsurance isan efficientway to helpindividualsprepare forhealth care

Insurer payment

(from premiumpool)

Individual

payment

Deductible Co-insured

Health care

expenditur

e

(INR)

Patient

expenditure(INR)

Stop-loss

level

SOURCE-Russell Parera National Industry Director Financial ServicesDelhi 18 October 2004


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TheWorld Health Organization has definedpossible approach to financing of health

expenditure . . . Tax-based andout-of-pocket

expenses are

direct expense

related outlays

Healthinsurance

involves a fund

pool for future

health care

External fund

sources rely ondonations,

grants

Total healthTotal health

expenditureexpenditure

PublicPublic

PrivatePrivate

SocialSocial

securitysecurity

ExternallyExternally

fundedfunded

TaxTax--fundedfunded

PrivatePrivatehealth ins.health ins.

ExternallyExternally

sourcedsourced

OutOut--ofof--

pocketpocket

Using central / stateUsing central / staterevenues for healthrevenues for health

Compulsory premiumCompulsory premium

contributions tocontributions tohealthhealth

Channeling loans,Channeling loans,grants etc. togrants etc. tohealthcarehealthcarePayments to healthPayments to healthcare providers forcare providers for

servicesservicesPremium contributionsPremium contributionstowards healthtowards healthsupportsupportChanneling donationsChanneling donationsetc. to healthcareetc. to healthcare

SOURCE-Russell Parera National Industry Director Financial Services Delhi18 October 2004


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Types of Health Insurance-

1)Fee for Service Health.

2) Managed Care Health Insurance.

Health Care is provided by-1) Health Maintenance Organization.2) Preferred Provided Organization.

Coverage of Health Insurance-Individual Health Insurance. Family Health Insurance.Students Health Insurance. Disability Insurance.

Small Business Health Plans. Low Cost Insurance.International Health Insurance. Medical Savings Plan.Injury Plan. Travel Insurance.Group Health Insurance. Crop Insurance.


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Issues relating Health Insurance in Medical

Institute - ABCDE..Analysis-MOUS Memorandum Of Understanding.

Balancing-Terms, condition, Time of settlement of Bills.

Consensus Building.Drafting/Developing- Final agreement.

Executing.

Empanelment.Regular Auditing of bills & validity of claims.

Timely payments of claims.


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Community based health Insurance-

Ambulatory & Inpatient care.MODELS

1) Provider model-Usually NGO, Hospital health insurance forcommunity around it. Annual payment given to provide-annual

health checkup, discounted OPD & IPD facilities. Ex-StudentHealth Homes in Calcutta, VHS Chennai.

2) Insurer Model-Insurer collects money from community &purchase health service for it. Ex. Spandan in A.P.

3) Linked Model-NGO intermediately between Target population& insurance company. Ex-SEWA Health Insurance by ICICI-Lombard for females.


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Health Insurance in India-It is infantile stage.Limited Coverage (10% of pop.)Lack of uniform schemes.Very less amount spent on health as compared toother countries.(32 $ p.c ,5.3 % GDP.)Insurance is not attractive due to lot of exclusions inmedical bills.

Lack of uniform CPT & DRG leading to discrepancy inbilling.Govt. of KA,TN,M.P. are promoting micro insurance.


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The proportion of insurance in health care

financing in India is extremely low . . .

Public spending

in health care

is very low at

17% and the

National

Health Policy

has

recognized

this

More than 86% of

healthcare

financing isthrough

unplanned

for, non-

contributory

spending

%

1 %

ource of finance Means of finance

86% from

out-of-

pocket

expenses

83% from

private

sector

spending

Health care financing in India

2002, %

Source:WHO. CII-McKinsey. 2003.


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Health Insurance for HIV +VE

Pilot project in Karnataka by Programme Director of Population ServiceInternational ,in collaboration with Star Health , Allied Insurance Company &

KNP.

Rs-30,000insurance cover for 250 HIV +ve Rs -15,000 assistance forhospitalization & family following demise.

Health Insurance for Urban Dwellers

For 55 million slum dwellers in 489 cities-Under National Urban HealthMission for 100,000 population .Insurance cover of Rs-40-50,000. Bypremium of 600/person/annually. CASHLESS PAYMENT directly to hospital.

H:\Now, health insurance for urban slum dwellers.htmH:\First health insurance policy for HIV launched- Insurance ne.htm

Universal Health Insurance Scheme-In 2004, MOF, UHIS for BPL families, Premium of Rs200/individual,Rs-

300/5 member family,Rs-400/7 member family.


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Benefits in Health Insurance-

Excellent viable alternative to provide huge sum of money inurgent medical needs. Ex Traumas.

Even on long time payment of small sums, one time largepayments can be avoided.

Low premiums are affordable, not the large bills.

HI is a future payment of Medical Expenditure.

Few HIC also covers HIV.

More efficient & transparent than Public Health Care Systemas expected..


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Mal Practices in Health Insurance

1)Adverse Selection.

2)Moral Hazard.

3)Dictate terms to hospital.

4)Can reject claims even on receiving PAF.

5)Denial of claims on reasonable/unreasonable grounds.

6)Less the pay, More they keep. Lack of transparency in terms &conditions.

7)Un necessary delay In settlement of bills.

8)Interference with length of stay, medical procedure interventions, &

freedom of physicians.

9)Frauds by TPA & HIC.

10)Over billing

11)No coverage for Pre-existing conditions Ex- alcoholism, HIV. etc.


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Scope for Improvement

Integration of Insurance &health Care provision.

Care Oriented Health Insurance.

Generous Health Insurance for more sick individuals.

Appropriate Health infrastructure is an essential, & isrequired to health care reforms.

Focus on health as against finances.

Centralized database, HI experience statistics.

Insurance approach must be designed around differentsegment of population as per its mindset of population.


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THANKS.

Health Insurance Final11

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