Made By : Dhruv Ajmera (4) Antriksh Bajaj (5) Suveer Malhotra (28) Kushal Mansukhani (30) Vikramaditya M (37)

Sharan Sanil (43)

 Health insurance is agreement between two entities-

insurer and insured Health insurance provides health cover or medical expenses to insured in case of hospitalization for more than 24 hours. Health insurance not only covers individual but also complete family.

 It minimizes uncertainty of both illness and cost of

treatment. Essentials of health insurance programme benefits prepayment and risk pooling. Health Insurance fund is used to finance their needs in crisis.

Providers

Payers

Employers

Patients

 Total Expenditure on health in India is nearly 6% of the entire

GDP Government spending is less than 25% against the average spending of 30-40 % in other developing countries. Indian health insurance industry stands at INR 5,125 crores with only a small Section of the total population (around 2%) being covered so far. CAGR (compound annual growth rate) of around 35 % (FY2002-08) Health Insurance industry in India is one of the fastest growing segments.

Indian health financing CHALLENGES:

Population covered under some form of Healthcare Prepayment
16 14 12 10 8 6 4 2 0 14.3
Increase in health care costs High financial burden on the poor
Percentage (%)

Need for long term and nursing care for

senior citizens
3.4 0.9 Private Social Employer Community Health Insurance Spend Insurance Insurance Healthcare Type Total 5 5
Increasing burden of new diseases and

health risks
Due to under funding, preventive and

primary
functions objectives.

care
are

and
yet

public
to meet

health
their

 Uncertain hospital

Tax benefit Productivity of

bills
Expensive/quality

workforce
Removes some of the

health care services

Money value Sick Vs

burden from the state

Keeping pace with the

Healthy
Family health

insurance

customer needs while achieving profitability

Market Size: (INR) - Crores

6000 5125 5000

4000

CAGR 35%
3000 2222 2000 1354 1000 761 1004 1732

3209

0 FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008

Market Size: (INR) - Crores

Health Insurance Plans

Community Based / Micro Insurance

Private

Social

Government Initiatives
CGHS Schemes for Government Employees
ESIS Schemes Recent Initiative - covering mass populace PAN India RSBY
With participation of health insurer Implemented in 11 states Extended to other section of populace other than BPL

State Government have also initiated several schemes where

there is participation of Insurers to run the Scheme

 Catering to Mass Population based on Income criteria Price Pre-fixed A challenge to administrator TPA working with synergies in NGOs to ensure a

successful model Subsidized schemes To be run on community based models

Health Care for Government Employees & Workers Self Funded schemes Impressive network

Covers small segment of population

Cumbersome procedure

 Significant out of pocket

Criticized for quality and

costs of treatment.
Inadequate supplies of

accessibility.
Access to specialist

medicines and equipment.

Inadequate staff and

consultants done usually without any referrals.

Long waiting periods.

conditions that are often unhygienic

 For providing financial risk

In 2004 the subsidy was

protection to the poor, the Government announced a

increased to Rs 200, Rs 300 and Rs 400 to individuals, respectively. To make the scheme more saleable, the for a floater clause that made any member of the

UHIS in 2003. Under this scheme, for a

families of five and seven,

premium of Rs 365 per year per person, Rs 548 for a

insurance companies provided

family of five and Rs 730 for a

family of seven, health care for an assured sum of family eligible as against the Mediclaim Policy which is for an individual member. Rs 30,000 was provided. BPL families were given a premium subsidy of Rs 200 p.a

 The public sector

Enrolment and very

companies find it to be potentially loss-making and do not invest in

propagating it, resulting

poor claim ratios.

Identification of the

eligible families in very low levels of awareness, reflected in the low

The procedures are

cumbersome and difficult for the poor the premium has to be paid in a lump sum.

 The initiative had the following

objectives:

The membership of these CHIs

scheme varies from 1000 to more than 20 lakh.

1. 2.

To revitalize public health systems; To decentralize decisionmaking;

Enrolment is usually facilitated by

membership of the organizations

The annual premium ranges from Rs

3.
4.

To mobilize resources to cover local operating costs;

To encourage community participation through management of services and locally generated funds To define the minimum package of essential health services.

20 to Rs 120 per individual. The unit of enrolment is an individual and the membership is voluntary in most of the schemes.

Yeshaswani, an insurance scheme

5.

for farmers, designed and implemented by the Government of Karnataka since 2002 has widespread attention.

 Started in 1999 as med claim. Ensure the user for access to

The

health care when they need it.

standard Med claim policy covers only hospital care and domiciliary hospitalization benefits.

In 2001, there were 7.8 million

Most medical conditions are

persons covered under Med claim. The subscribers are usually the middle and upper class, especially as there is a tax benefit in subscribing to Med claim.

reimbursed though there are important exclusions.

only reimbursement insurance is provided, though the companies have tried a third payment system with TPAs.

Traditionally

Individual health plan mediclaim,

Cover expenses if hospitalized for at least 24 hours. Indemnity policies, i.e., they reimburse the actual expenses

incurred up to the amount of the cover that you buy. Some of the expenses that are covered are room rent, doctors fees, anesthetists fees, cost of blood and oxygen, and operation theatre charges.

Family floater plan Fairly new entrant in the health insurance. It takes advantage of the fact that the possibility of all members of a family falling ill at the same time or within the same year is low. The entire sum insured can be availed by any or all members and is not restricted to one individual only as is the case in an individual health plan.

Daily hospital cash One can buy maximum daily covers of anything between Rs500 and Rs5000. The premium would depend on the age and amount. For stay in ICU, the amount is automatically doubled. There is usually a cap on the number of days of claim per year .

 ICICI PRUDENTIAL

LIFE- 22.1% Bajaj Allianz- 13.8% SBI Life- 9.8% Reliance Life- 8% Max New York- 8%

 Health Insurance - potential to

become a Rs.25000 crores industry by 2012.

No. of Elderly People in the Developing World will TRIPLE in 25yrs. (WHO)

In India, the no. of people above 60

yrs is about 8% today, with that no. expected to hit 21% by 2025. (Asia Insurance Review)

 Committee to formulate

Standalone health

regulations
Pure health insurance

insurance companies
Renewability Senior

products
Allowing the formation

citizens

of an stand alone health insurance company

 Creating awareness on Rights & Responsibilities Data Pool Regulator as a repository Standardization of Cost

TPAs Health Providers

Increased Tax benefit Removal of Service Tax Standardization of definition a right step ahead

Standard Pre-Existing exclusion defined w.e.f. 01/06/08

Gradation of Health service providers Pool for Senior Citizen Renewability / Portability Compulsory Health Benefits for organized sector Government role on mass healthcare initiatives

 http://www.medindia.net/slideshow/health-

insurance.asp#4 http://patientsafetyed.duhs.duke.edu/module_a/intro duction/stakeholders.html http://www.google.co.in/url?sa=t&rct=j&q=health%20 insurance%20key%20stakeholders&source=web&cd=1 &sqi=2&ved=0CFgQFjAA&url=http%3A%2F%2Fwww. assocham.org%2Fevents%2Frecent%2Fevent_310%2Fs ess3_Hemalatha_Chandrasekar.ppt&ei=17BPT8fC4XMrQehwfzNDQ&usg=AFQjCNFF2boLcmxvX9no PTl98iAdI7ZeNA&sig2=oBNR-eDBqD7RY1_aBUikbA