R ITIKAJAIN NIKITA KEJRIWAL

PROLOY PAUL ANKUR CHOUDHARY

NIKESH PODDAR
 H ISTORY OF HEALTH
INSURANCE

÷ In mid 80͛s most of the hospitals in India were

government owned and treatment was free of cost
÷ With the advent of Private Medical Care the need for
Health Insurance was felt and various Insurance
Companies (New India Assurance, National Insurance
Company, Oriental Insurance & United Insurance
Company) introduced Mediclaim Insurance as a product
÷ On August 15, 2007 Prime Minister had announced Rs
2000 Crores for Health Insurance for poor citizens and
the impact of the same is being seen by us in the form of
success of RSBY (Rashtriya Swasth Bima Yojna ).
 C ONTD «
In 2001 with entry of various private Insurance companies now the
customers have choice of buying this insurance from 21 Insurance companies
÷ 1. Apollo DKV Insurance Company Limited.
÷ 2. Bajaj Allianz General Insurance Company Limited
÷ 3. Bharti AXA General Insurance Company Limited
÷ 4. Cholamandalam MS General Insurance Company Limited
÷ 5. Future Generali India Insurance Company Limited
÷ 6. HDFC General Insurance Company Ltd.
÷ 7. ICICI Lombard General Insurance Limited.
÷ 8. IFFCO Tokio General Insurance Company Limited
÷ 9. Max Bupa Health Insurance Company Limited
÷ 10. National Insurance Company Limited
W HAT IS HEALTH INSURANCE ?

A health insurance policy is a contract between an

insurer and an individual or group, in which the
insurer agrees to provide specified health insurance
at an agreed-upon price ( the premium)
 W HY IS H EALTH I NSURANCE
IMPORTANT ?
· Rising medical costs

· Sharing of health related risk

· Uncertain hospital bills

· Expensive/quality health care services

· Money value ʹ Sick Vs Healthy

· Family health insurance

· Tax benefit

· Productivity of workforce

· Removes some of the burden from the state

· Keeping pace with the customer needs while achieving

profitability
H EALTH I NSURANCE ² S COPE

÷ Medical tourism on the rise

÷ Healthcare infrastructure expansion

÷ Increasing burden of new diseases and health

risks and neglect of preventive and primary care
and public health functions due to under
funding of the government health care.
 W HAT DOES HEALTH
INSURANCE COVER ?

÷ In general, it offsets the cost of doctor bills,

surgery, hospital, laboratory and x-ray fees and
pharmacy costs.

÷ In some cases, it will cover specific needs like

long-term care, vision care, or dental care
 TYPES OF HEALTH
INSURANCE
÷ Individual Health Insurance

÷ Group Health Insurance

÷ Small Business Health Insurance

÷ Travelers Health Insurance

÷ Self Employed Health Insurance

÷ Medicare Health Insurance

÷ Medicaid Health Insurance

÷ Catastrophic Health Insurance

÷ Private Health Insurance

÷ Long Term Health Insurance

÷ Disability Health Insurance

 T YPES OF I NSURANCE
C OVERAGE

÷ Managed Care

i) Preferred Provider Organizations (PPOs)

ii) Health Maintenance Organizations (HMOs)

÷ Fee-for-Service / Indemnity Plans

÷ Point-of-Service Plan
 M ANAGED CARE

÷ Managed Care plans provide care at the lowest,

͚out-of-pocket͛ expense.

÷ In order to keep the coverage affordable, these

plans have rules which must be followed.

÷ Patients are encouraged to stay within the

plan͛s network of providers and healthcare
facilities.

÷ Two types of Managed Care plans are HMOs

and PPOs
 P REFERRED P ROVIDER
O RGANIZATION (PPO)

÷ PPO plans give the patient more flexibility.

÷ The patient can see any doctor in the network

without getting approval. This includes
specialists.

÷ The PPO patient is able to seek care outside of

the network, but the insurance benefit is
reduced, and the out-of-pocket expense
increases.

÷ Refer to individual policies for details.

 H EALTH M AINTENANCE
O RGANIZATION (HMO)

÷ A primary care provider is designated. This

provider may act as a gatekeeper managing the
course of your healthcare treatment.

÷ HMO patients are required to see in-network

providers, and use in-network healthcare
facilities (except in cases of emergency).
 F EE - FOR -S ERVICE
(I NDEMNITY ) P LANS

÷ Private indemnity or ͞fee-for-service͟ insurance can be

obtained by individuals on their own, or through
groups, such as employers or associations.
÷ These plans generally offer the freedom to choose your
own healthcare providers including specialists and
hospitals.
÷ The medical costs are split between the insurance
company and the subscriber. Each pays a fixed
percentage of the medical costs.
÷ These plans have set maximum ͞out-of-pocket
expenses͟
÷ the subscriber will have to pay.
 P OINT- OF -S ERVICE P LANS

÷ Point-of-service plans blend elements of

managed care and indemnity plans.

÷ Every plan is different, so choose carefully!

÷ Read the fine print and understand the

terminology.
HEALTH INSURANCE SCHEMES

÷ Œ


 


   

 

 
 


 
 


÷ Government or State Based System.
÷ Market ʹ Based System.
÷ Employer Provided Insurance System.
÷ Member Organization based System.
 C ONT.

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 H EALTH I NSURANCE P OLICY
IN I NDIA DOES NOT C OVER

÷ Treatment of illness at home by consulting

doctor in your locality or even in a hospital is
not covered. This means Cold, Cough, Flu, Viral
fever, Malaria, TB etc. are not covered as these
are generally treated at home. If viral fever
touches 104 degrees F and patient has to be
admitted into a hospital (for more than 24
hours) then this will be covered and payment
will be made by the Insurance company.
Treatment of illness at home by consulting
doctor in your locality or even in a hospital is
not covered
 P RE - REQUISITES CONDITIONS
OF H EALTH I NSURANCE

Rule applies with respect to Health Insurance to be

purchased from an Insurance Company.

÷ Filled up proposal form submitted to the Insurance

Company.
÷ Receipt received from Insurance Company.
÷ Any correspondence received or sent to the Insurance
Company.
÷ Any correspondence received or sent to the TPA.
÷ Photocopy of ID Card.
÷ Insurance policy received from Insurance Company.
 C LAIM PROCEDURE

Claim has to be lodged when these documents are to be

submitted along with other applications:

÷ All Prescriptions from Doctors/Medical Consultants,

÷ All Health checkups reports

÷ X Rays,

÷ All Pathological tests reports,

÷ Receipts of Doctors/bills from Chemists.

If original documents are to be submitted to insurance office

for reimbursement then photocopies of the same should be
filed in this file.
 C ONT.
In Case bills/receipts are taken and put in file then you can
include these in the claim document being submit to
insurance Company. In the event of claim not being
accepted in full

÷ If the insured has to take up the matter with higher

authorities in Insurance Company.

÷ If the insured has to take up the matter with authorities

like Consumer Forum then the whole case will be
argued on the basis of these documents only.