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health insurance in India

Health insurance in India is a growing segment of India's economy. The Indian health system is
one of the largest in the world, with the number of people it concerns: nearly 1.3 billion potential
beneficiaries. The health industry in India has rapidly become one of the most important sectors in
the country in terms of income and job creation. In 2018, one hundred million Indian households
(500 million people) do not benefit from health coverage. In 2011, 3.9%[1] of India's gross domestic
product was spent in the health sector. According to the World Health Organization (WHO), this is
among the lowest of the BRICS (Brazil, Russia, India, China, South Africa) economies. Policies are
available that offer both individual and family cover. Out of this 3.9%, health insurance accounts for
5-10% of expenditure, employers account for around 9% while personal expenditure amounts to an
astounding 82%.[2] In the year 2016, the NSSO released the report “Key Indicators of Social
Consumption in India: Health” based on its 71st round of surveys. The survey carried out in the year
2014 found out that, more than 80% of Indians are not covered under any health insurance plan, and
only 18% (government funded 12%) of the urban population and 14% (government funded 13%) of
the rural population was covered under any form of health insurance.[3]
For the financial year 2014-15, Health Insurance premium was ₹20,440.

Health Insurance Coverage in India:Stats from NSSO survey

Contents

 1Presentation
 2History
 3Structure and organisation
 4Types of policies
o 4.1The main publicly funded health insurance schemes
 4.1.1Plans funded by central government
 4.1.2Federally funded schemes
 5Key aspects of health insurance
o 5.1Payment options
o 5.2Cost and duration
 6Tax benefits
 7References

Presentation[edit]
The health situation and the provision of services vary considerably from one State to another.
Although public health services in principle provide free basic health care to all, the care provided by
most state health systems suffers from inadequate resources and poor management. As a result,
the majority of the population turns to private health services that offer more expensive care and of
very unequal quality.
In India, the health system mixes public and private providers. Public health facilities - local clinics
providing basic care, regional hospitals, national hospitals - are funded by the federal states and the
federal state and managed by the state authorities.
Public health services differ greatly from one federated state to another. In some states such
as Tamil Nadu or Kerala, public health facilities play their role as the first stage of the care journey,
but, outside of these few states, the public sector does not reach the goal to provide the basic health
needs of the population.
India's public health expenditures are lower than those of other middle-income countries. In 2012,
they accounted for 4% of GDP, which is half as much as in China with 5.1%. In terms of public
health spending per capita, India ranks 184th out of 191 countries in 2012. Patients' remaining costs
represent about 58% of the total.[4] The remaining costs borne by the patient represent an increasing
share of the household budget, from 5% of this budget in 2000 to over 11% in 2004-2005.[5] On
average, the remaining costs of poor households as a result of hospitalization accounted for 140% of
their annual income in rural areas and 90% in urban areas.
This financial burden has been one of the main reasons for the introduction of health insurance
covering the hospital costs of the poorest.

History[edit]
Launched in 1986,[6] the health insurance industry has grown significantly mainly due to liberalization
of economy and general awareness. According to the World Bank, by 2010, more than 25%[7] of
India's population had access to some form of health insurance. There are standalone health
insurers along with government sponsored health insurance providers. Until recently, to improve the
awareness and reduce the procrastination for buying health insurance, the General Insurance
Corporation of India and the Insurance Regulatory and Development Authority (IRDA) had
launched[8] an awareness campaign for all segments of the population.
Launched in 2007, the National Health Insurance Program (Rashtriya Swasthya Bima Yojana-
RSBY) is led by the Ministry of Health and was adopted by 29 states in 2014. It is funded 75% by the
government and 25% by the states. The worker and 4 of his dependents benefit from health
insurance if they are not covered by any system and live below the poverty line. RSBY beneficiaries
are required to pay an annual registration fee of INR 30 for hospital coverage up to INR 30,000 per
year per family.
September 25th, 2018, the Indian government announced the launch of a new health insurance for
the poorest citizens. Indian Prime Minister, Narendra Modi announced that the new system is
expected to reach more than 500 million people and is called "Modicare". The reform is still in
progress and aims to install universal social security in the country.

Structure and organisation[edit]


The Indian social protection scheme covers insured persons against risks related to old age,
invalidity, death, but also sickness and maternity, unemployment and finally accident at work and
occupational diseases
This social protection scheme is not universal and provides only limited coverage, targeting mainly
organized sector's workers constituting less than 10% of the population in India. All risks are placed
under the supervision of the Ministry of Labour and Employment.
Social security and health insurance is defined by 5 main texts in India:
The Employees' State Insurance Act, 1948;
Employees' Provident Funds & Miscellaneous Provisions Act, 1952;
The Employees (Workmen's) Compensation Act, 1923;
The Maternity Benefit Act, 1961;
The Payment of Gratuity Act, 1972;
Social security benefits are mainly managed by: Employees' State Insurance Corporation (ESIC)
and Employees' Provident Fund Organisation (EPFO)

Types of policies[edit]
Health insurance in India typically pays for only inpatient hospitalization and for treatment at
hospitals in India. Outpatient services were not payable under health policies in India. The first
health policies in India were Mediclaim Policies. In Year 2000, Government of India liberalized
insurance and allowed private players into the insurance sector. The advent of private insurers in
India saw the introduction of many innovative products like family floater plans, top-up plans, critical
illness plans, hospital cash and top up policies.
The health insurance sector hovers around 10% in density calculations. One of the main reasons for
the low penetration and coverage of health insurance is the lack of competition in the sector. IRDA
which is responsible for insurance policies in India can create health circles, similar to telecom
circles to promote competition.[9]
In principle, government health services are available to all citizens under the tax-financed public
system. In practice, bottlenecks in accessing such services compel households to seek private care,
resulting in high out-of-pocket payments.
Health insurance plans in India today can be broadly classified into these categories:

 Hospitalization
Hospitalization plans are indemnity plans that pay cost of
hospitalization and medical costs of the insured subject to the
sum insured. The sum insured can be applied on a per member
basis in case of individual health policies or on a floater basis in
case of family floater policies. In case of floater policies the sum
insured can be utilized by any of the members insured under the
plan. These policies do not normally pay any cash benefit. In
addition to hospitalization benefits, specific policies may offer a
number of additional benefits like maternity and newborn
coverage, day care procedures for specific procedures, pre- and
post-hospitalization care, domiciliary benefits where patients
cannot be moved to a hospital, daily cash, and convalescence.
There is another type of hospitalization policy called a top-up
policy. Top up policies have a high deductible typically set a
level of existing cover. This policy is targeted at people who
have some amount of insurance from their employer. If the
employer provided cover is not enough people can supplement
their cover with the top-up policy. However, this is subject to
deduction on every claim reported for every member on the final
amount payable.

 Family Floater Health Insurance:


Family health insurance plan covers entire family in one health
insurance plan. It works under assumption that not all member
of a family will suffer from illness in one time. It covers hospital
expense which can be pre and post. Most of health insurance
companies in India offering family insurance have good network
of hospitals to benefit the insurer in time of emergency.

 Pre-Existing Disease Cover Plans:


It offers covers against disease that policyholder had before
buying health policy. Pre-Existing Disease Cover Plans offers
cover against pre-existing disease e.g. diabetes, kidney failure
and many more. After Waiting period of 2 to 4 years it gives all
covers to insurer.

 Senior Citizen Health Insurance:


As name suggest These kind of health insurance plans are for
older people in the family. It provide covers and protection from
health issues during old age. According to IRDA guidelines,
each insurer should provide cover up to the age of 65 years.

 Maternity Health Insurance:


Maternity health insurance ensures coverage for maternity and
other additional expenses. It takes care of both pre and post
natal care, baby delivery (either normal or caesarean). Like
Other Insurance, The maternity insurance provider have wide
range of network hospitals and takes care of ambulance
expense.
These services are supervised by the Maternity Benefit Act. The
Maternity Benefit Act applies to women who do not work in an
establishment covered by the ESI but who are employed in
factories, mines, circuses, plantations, shops or other
establishments employing at least 10 persons. Also covered are
women working in an establishment covered by the ESI, but
whose salary exceeds the ceiling of subjection.
Since 2010, the Indira Gandhi Matritva Sahyog Yojana (IGMSY)
program, run by the Ministry of Women and Child Development,
has been set up in some districts (52 in 2017). This program is
intended for pregnant women aged 19 or over, during their first
2 completed pregnancies (viable child). The benefit consists of a
total amount of 6000 INR paid in 3 installments, subject to
having performed the obligatory medical examinations for the
mother and the child:

 at the end of the 2nd trimester of pregnancy


 at birth
 to 6 months of the child

 Hospital daily cash benefit


plans:
Daily cash benefits is a defined benefit policy that pays a
defined sum of money for every day of hospitalization. The
payments for a defined number of days in the policy year and
may be subject to a deductible of few days.
 Critical illness plans:
These are benefit based policies which pay a lumpsum (fixed)
benefit amount on diagnosis of covered critical illness and
medical procedures. These illness are generally specific and
high severity and low frequency in nature that cost high when
compared to day to day medical / treatment need. e.g. heart
attack, cancer, stroke etc. Now some insurers have come up
with option of staggered payment of claims in combination to
upfront lumpsum payment.

 Pro active plans:


Some companies like Cigna TTK offer Pro active living
programs. These are designed keeping in mind the Indian
market and provide assistance based on medical, behavioural
and lifestyle factors associated with chronic conditions. These
services aim to help customers understand and manage their
health better.

 Disease specific
special plans:
Some companies offer specially designed disease specific plans
like Dengue Care. These are designed keeping in mind the
growing occurrence of viral diseases like Dengue in India which
has become a cause of concern and thus provide assistance
based on medical needs, behavioural and lifestyle factors
associated with such conditions. These plans aim to help
customers manage their unexpected health expenses better and
at a very minimal cost.
The main
publicly
funded health
insurance
schemes[edit]
Plans funded by
central
government[edit]

 ESI scheme:
This scheme
covers
organized
private sector
workers,
which is about
55 million
people.

 Central
Government
Insurance
Scheme: This
scheme
covers central
government
agents and
retirees, i.e.
about 3
million people.

 RSBY: this
scheme
covers
families below
the poverty
line of about
40 million
families.
Federally funded
schemes[edit]

 Andhra
Pradesh: This
scheme
covers
families below
the poverty
line or with
annual
income below
INR 75,000. It
represents 70
million
beneficiaries.
 Tamil Nadu:
This scheme
finances
families below
the poverty
line or with
annual
income below
INR 72,000,
which
represents
about 40
million
beneficiaries.
 Karnataka:
this scheme
covers
members of
rural
cooperatives,
more than 3
million people.

Key aspects
of health
insurance[ed
it]
Payment
options[edit]

 Direct
Payment or
Cashless
Facility:
Under this
facility, the
person does
not need to
pay the
hospital as
the insurer
pays directly
to the
hospital.
Under the
cashless
scheme, the
policyholder
and all those
who are
mentioned in
the policy can
undertake
treatment
from those
hospitals
approved by
the insurer.
 Reimbursem
ent at the
end of the
hospital stay:
After staying
for the
duration of the
treatment, the
patient can
take a
reimbursemen
t from the
insurer for the
treatment that
is covered
under the
policy
undertaken.
Cost and
duration[edit]

 Policy price
range:
Insurance
companies
offer health
insurance
from a sum
insured
of ₹5000/-
[10]
for micro-
insurance
policies to a
higher sum
insured of ₹50
lacs and
above. The
common
insurance
policies for
health
insurance are
usually
available
from ₹1 lac
to ₹5 lacs.
 Duration:
Health
insurance
policies
offered by
non-life
insurance
companies
usually last for
a period of
one year. Life
insurance
companies
offer policies
for a period of
several years.
Tax
benefits[edit]
Under Section
80D of the
Income-tax
Act the insured
person who takes
out the policy can
claim for tax
deductions.[11]
₹25,000 for self,
spouse and
dependent
children.
₹50,000/- for
parents.

References[
edit]

1. ^ "WHO
South-East
Asia
Region:
India
statistics
summary
(2002 -
present)".
World
Health
Organizati
on.
Retrieved
13
January 20
14.
2. ^ http://ww
w.cppr.in/a
rticle/healt
h-
insurance-
and-
telecom-
markets-a-
comparativ
e-study/
3. ^ Ambrish
Singh .
Current
Situation of
Health
Care
Coverage
in India,
ISPOR,
News
Across
Asia,
Volume 5
Number 1
April–July
2016.
Available
at: https://
www.ispor.
org/consort
iums/asia/
NewsAcro
ssAsia_Sp
ring2016.p
df
4. ^ "Études
économiqu
es de
l'OCDE :
Inde
2007". Étu
des
économiqu
es de
l'OCDE :
Inde.
2008-11-
26. doi:10.
1787/eco_
surveys-
ind-2007-
fr. ISSN 22
23-5108.
5. ^ Ladusing
h,
Laishram;
Pandey,
Anamika
(2013-05-
23). "High
inpatient
care cost
of dying in
India". Jour
nal of
Public
Health. 21
(5): 435–
443. doi:10
.1007/s103
89-013-
0572-
9. ISSN 09
43-1853.
6. ^ "4 factors
that
impacted
health
insurance
industry in
2013". Fin
ancial
Express.
30
December
2013.
Retrieved
13
January 20
14.
7. ^ "Govern
ment-
Sponsored
Health
Insurance
in India:
Are You
Covered?".
World
Bank.
Retrieved
13
January 20
14.
8. ^ "4 factors
that
impacted
health
insurance
industry in
2013". Fin
ancial
Express.
30
December
2013.
Retrieved
13
January 20
14.
9. ^ http://ww
w.cppr.in/a
rticle/healt
h-
insurance-
and-
telecom-
markets-a-
comparativ
e-study/
10. ^ "Handbo
ok on
Health
Insurance"
(PDF).
Insurance
Regulatory
and
Developm
ent
Authority.
Retrieved
13
January 20
14.
11. ^ "Section
80D
provides
tax
benefits for
mediclaim
premium".
Live Mint.
24 June
2013.
Retrieved
13
January 20
14.
Categories:
 Health insurance
in India
 1986
establishments in
India
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What is private health insurance?


The term “private health insurance” simply refers to any health insurance coverage that is not
offered by a state or federal government. Instead, private health insurance is offered by a private
entity, such as an insurance company or broker.
There are a number of private health insurance options available. This can include:
 Federal or state marketplace plans
 Health insurance offered through an employer (such as a group health plan)
 Private health insurance plans offered by licensed brokers or agents
Some private health insurance plans have benefits that meet the minimum essential
coverage requirements of the Affordable Care Act (also known as Obamacare). Other types of
private health insurance options, such as short-term plans and catastrophic coverage, may offer
different benefits, but may not count as a qualified health plan under the Affordable Care Act.
Please note that not all plans available outside of the government marketplace count as
qualifying health coverage, and, up until 2018, you would have faced a tax penalty for not
meeting the requirements of the ACA if this was the only coverage you had. However, beginning
with the 2019 plan year, if you’re enrolled in a plan that doesn’t meet minimum essential
coverage standards, you will no longer face a penalty.

What is public health insurance?


Now that we’ve defined private health insurance, you may be wondering how public health
insurance works. Currently, there are only a few limited options for public health insurance in
the US. These include:
 Medicare, a federal program for adults over the age of 65 and certain disabled individuals.
 Medicaid, a state-run public health insurance program for low-income individuals.
 The Children’s Health Insurance Program (CHIP), a subset of Medicaid, which offers
subsidized low- or no-cost health insurance for children.
For people who aren’t eligible for these government programs based on income or other criteria,
there are currently no other public health insurance options. Instead, people can get the coverage
they need through private health insurance providers.

Where can I get private health insurance?


For those looking for private health insurance, there are a few options. If you don’t have
coverage through your employer or you’re self-employed, you might get private health insurance
through the federal marketplace or your state’s marketplace. Employer-sponsored plans and all
marketplace plans are required to include certain essential health benefits, such as maternity care,
mental health services, preventive care, and more.
ACA-compliant coverage is also available through licensed health insurance brokers like
eHealth. eHealth also offers other options that may offer more flexibility for those looking for
coverage over a short period or in specific situations.

Types of private insurance outside the marketplace


If you already have ACA-compliant health coverage, such as through an employer, you might be
interested in exploring other insurance options outside the marketplace.
For instance, someone who is young and healthy may want a more “bare bones” insurance
policy, such as catastrophic insurance. A catastrophic policy offers very limited coverage for
those under 30 who qualify for a “hardship exemption” and can’t afford qualified health
coverage. Catastrophic coverage covers the same essential health benefits offered through other
ACA-compliant plans, as well as some preventive services for no cost. However, you’ll need to
meet a very high deductible before the plan begins to cover costs. In 2019, all catastrophic plans
have a deductible of $7,900.
A catastrophic plan might help with high expenses from a severe illness or accidental injury.
However, it might be less helpful with routine health care, such as check ups, where you’re less
unlikely to meet the yearly deductible and could wind up with high out-of-pocket expenses. This
type of coverage could be a good fit if you know that your annual health-care costs will meet the
deductible, or if you’re generally in good health but want coverage for a worst-case scenario.
Another type of private health insurance to consider is short-term coverage. Coverage terms
depend on the state you live in. Federal laws allow short term plans to have initial terms of 364
days, with the chance to renew for up to 36 months. States are allowed to have their own laws
limiting short term plans further, so make sure to check short term laws in your state if you’re
considering this kind of coverage. These affordable private health insurance policies can be a
good fit if you only need coverage for a short period – for example, if you’re between jobs and
need insurance to bridge a coverage gap, but don’t want to pay the high premiums of a COBRA
policy.
Please note that each plan has its own terms and limitations, so be sure to check the official plan
documents to understand how that specific plan works. This article is only for general education.

What type of private insurance coverage is right for me?


While every person’s situation is different, here are some things to consider as you explore
coverage options.
One benefit of private health insurance is that certain types of coverage may be available any
time of the year, instead of only during open enrollment periods. Marketplace plans are typically
only available during Open Enrollment unless you qualify for a Special Enrollment Period. If
you do not have coverage and don’t qualify for a Special Enrollment Period, some types of
private health insurance (such as short-term plans) may help bridge the gap in the meantime.
If you opt to get insurance through a broker, such as eHealth, costs for coverage may be different
— and possibly lower — than plans offered through the marketplace. Plan types and availability
may vary by location as well.
When looking for coverage, it’s important to consider all of your private health insurance
options. A licensed insurance agent can help you find a policy that offers what you need at a
price that makes sense for your specific circumstances. If you have questions, feel free to contact
eHealth today to explore coverage choices that might fit your situation.

Find plans on eHealth starting at

$
269
per month
Zip Code
Get local prices
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