UNIT 3 – MEDICAL INSURANCE TYPES IN INDIA.pptx

this ppt deals with the various kinds and significance of medical insurance in India

1. UNIT 3 – SIGNIFICANCE AND KINDS OF MEDICAL INSURANCE Ms. R.Yuvanaa priyadharshini , Sol, sastra

2. HEALTH INSURANCE Health Insurance is defined as "coverage that provides for the payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment" A health insurance policy like other policies is a contract between an insurer and an individual / group in which the insurer agrees to provide specified health insurance cover at a particular "premium" subject to terms and conditions specified in the policy.

3. WHAT A HEALTH INSURANCE POLICY WOULD NORMALLY COVER? A Health Insurance Policy would normally cover expenses reasonably and necessarily incurred under the following heads in respect of each insured person subject to overall ceiling of sum insured (for all claims during one policy period). a) Room, Boarding expenses b) Nursing expenses c) Fees of surgeon, anesthetist, physician, consultants, specialists d) Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines, drugs, diagnostic materials, X-ray, Dialysis, chemotherapy, Radio therapy, cost of pacemaker, Artificial limbs, cost or organs and similar expenses.

4. HEALTH INSURANCE IN INDIA 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. 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 an awareness campaign for all segments of the population. Tax benefits : Under Section 80D of the Income tax act the insured person who takes out the policy can claim for tax deductions 25,000/- for self, spouse and dependent children. 50,000/- for parents / senior citizens

5. TYPES OF POLICIES Hospitalization Hospitalization plans are indemnity plans that pay and medical costs of the insured subject to the sum insured can be applied on a per member basis in health policies or on a floater basis in case of family. These floater policies do cash benefit. In addition to hospitalization benefits, offer a number of additional benefits like maternity coverage, day care procedures for specific procedure hospitalization care, domiciliary benefits where patient moved to a hospital, daily cash, and convalescence. There is another type of hospitalization policy called Top-up policies have a high deductible typically set at a level of existing cover. This policy is targeted at people who have some cover from their employer. If the employer provided cover people can supplement their cover with the top-up is subject to deduction on every claim reported for the final amount payable.

6. 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 a 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.

7.   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. 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.

8. 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, behavioral 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, behavioral 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.

9. EMPLOYEES STATE INSURANCE SCHEME The ESI scheme, introduced by an Act of Parliament in 1948, It has introduced for the first time in India the principle of contribution by the employer and employee. The Act besides full medical care for self and dependants , that is admissible from day one of insurable employment, the insured persons are also entitled to a variety of cash benefits in times of physical distress due to sickness, temporary or permanent disablement etc. resulting in loss of earning capacity, the confinement in respect of insured women, dependants of insured persons who die in industrial accidents or because of employment injury or occupational hazard are entitled to a monthly pension called the dependants benefit, drawing wages not exceeding 15,000 per month.

10. CENTRAL GOVERNMENT HEATH SCHEME It was first introduced in New Delhi in 1954 to provide comprehensive medical care to Central Government employees. The scheme is based on the principle of cooperative effort by the employee and the employer, to the mutual advantage of both. The medical facilities are provided through Wellness Centres (CGHS Dispensaries) Allopathic, Ayurveda, Yoga,Unani , Sidha and Homeopathic systems of medicines. The main components of the Scheme are: The dispensary services including domiciliary care F. W. & M.C.H. Services Specialists' consultation facilities both at dispensary, polyclinic and hospital level including X-Ray, ECG and Laboratory Examinations. Hospitalization Organization for the purchase, storage, distribution and supply of medicines and other requirements Health Education to beneficiaries

11. RASHTIYA SWASTHIYA BIMA YOJANA (RSBY) RSBY ( Rashtriya Swasthiya Bima Yojana) has been launched by Ministry of Labour and Employment, Government of India to provide health insurance coverage for Below Poverty Line (BPL) families. Beneficiaries under RSBY are entitled to hospitalization coverage up to 30,000/- for most of the diseases that require hospitalization. Government has even fixed the package rates for the hospitals for a large number of interventions. Pre-existing conditions are covered from day one and there is no age limit. Coverage extends to five members of the family which includes the head of household, spouse and up to three dependents. Beneficiaries need to pay only 30/- as registration fee while Central and State Government pays the premium to the insurer selected by the State Government on the basis of a competitive bidding.

12. UNIQUE FEATURES OF RSBY Empowering the beneficiary- RSBY provides the participating BPL household with freedom of choice between public and private hospitals and makes him a potential client worth attracting on account of the significant revenues that hospitals stand to earn through the scheme. Business Model for all Stakeholders- The scheme has been designed as a business model for a social sector scheme with incentives built for each stakeholder. This business model design is conducive both in terms of expansion of the scheme as well as for its long run sustainability Intermediaries- The inclusion of intermediaries such as NGOs and MFIs which have a greater stake in assisting BPL households. The intermediaries will be paid for the services they render in reaching out to the beneficiaries. Government -By paying only a maximum sum up to 750/- per family per year, the Government is able to provide access to quality health care to the below poverty line population Information Technology (IT) Safe and foolproof Portability - The key feature of RSBY is that a beneficiary who has been enrolled in a particular district will be able to use his/ her smart card in any RSBY empanelled hospital across India. Cash less and Paperless transactions

13. AYUSHMAN BHARAT YOJANA Ayushman Bharat Yojana or Pradhan Mantri Jan Arogya Yojana (PMJAY) or National Health Protection Scheme or ModiCare is a centrally sponsored scheme launched in 2018, under the Ayushman Bharat Mission of MOHFW in India. The scheme aims at making interventions in primary, secondary and tertiary care systems, covering both preventive and promotive health, to address healthcare holistically. It is an umbrella of two major health initiatives namely, Health and Wellness centres and National Health Protection Scheme (NHPS). The National Health Protection Scheme (NHPS) scheme is formed by subsuming multiple schemes including Rashtriya Swasthya Bima Yojana, Senior citizen health Insurance Scheme (SCHIS), Central Government Health Scheme (CGHS), Employees' State Insurance Scheme (ESIS) etc. Further, the National Health Policy, 2017 has envisioned Health and Wellness Centres as the foundation of India's health system which the scheme aims to establish.

14. KEY FEATURES OF PM-JAY Provides hospitalisation cover of up to 5,00,000 per entitled family per year. More than 10.74 crore poor and vulnerable families (approximately 50 crore beneficiaries) covered across the country. Entitlement based scheme. No formal enrolment process is required. Poor, deprived rural families and identified occupational category of urban workers' families as per the latest Socio-Economic Caste Census (SECC) 2011 data, both rural and urban will be covered. In addition, all enrolled families under Rashtriya Swasthaya Bima Yojana (RSBY) that do not feature in the targeted groups as per SECC data will be included as well. No cap on family size and age of members. All members of designated families get coverage; specifically, girl child and senior citizens. Covers secondary and tertiary care hospitalization. Free treatment available at all public and empanelled private hospitals. Cashless and paperless access to quality health care services. Benefits of national portability. Eligible beneficiaries can avail services across India. 1,350 medical packages covering surgery, medical and day care treatments, cost of medicines and diagnostics. All pre-existing diseases covered.

15. PUBLIC AND PRIVATE AGENCIES In a mixed economy such as India's, private companies provide a lot of different varieties of health insurances and health covers. The higher costs of the private sector, however, are out of reach of many Indians, generating demand for public health insurance in India.

16. OTHER AGENCIES Defence Personnel – have their own specific insurance policies, including in-house group insurance schemes and specialized policies from private insurers that cover high-risk activities, war-like situations, and offer benefits tailored to their lifestyle, such as flexible premiums and dedicated after-sales service. The Indian government and banking institutions also provide insurance benefits, such as group life insurance and accidental death cover, which are often deducted from salaries and are separate from standard market policies.  Army Group Insurance Fund (AGIF) : An in-house fund for the Indian Army, providing life and personal accident coverage for members.  Air Force Group Insurance Scheme : A similar in-house scheme for Air Force personnel.  Naval Group Insurance Scheme : A parallel scheme for Navy personnel.  Benefits : These schemes offer protection during war or battle, war-like situations, and even superannuation, with premium amounts and coverage varying by rank. 

17. THANK YOU