1.

INTRODUCTION
Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for payment. An insurer is a company selling the insurance; an insured or policyholder is the person or entity buying the insurance policy. The insurance rate is a factor used to determine the amount to be charged for a certain amount of insurance coverage, called the premium. isk management, the practice of appraising and controlling risk, has evolved as a discrete field of study and practice. The transaction involves the insured assuming a guaranteed and known relatively small loss in the form of payment to the insurer in exchange for the insurer!s promise to compensate "indemnify# the insured in the case of a large, possibly devastating loss. The insured receives a contract called the insurance policy which details the conditions and circumstances under which the insured will be compensated.

HISTORY:In India, insurance has a deep$rooted history. It finds mention in the writings of %anu "%anusmrithi#, &agnavalkya "'harmasastra# and (autilya "Arthasastra#. The writings talk in terms of pooling of resources that could be re$distributed in times of calamities such as fire, floods, epidemics and famine. This was probably a pre$cursor to modern day insurance. Ancient Indian history has preserved the earliest traces of insurance in the form of marine trade loans and carriers) contracts. Insurance in India has evolved over time heavily drawing from other countries, *ngland in particular. +,+, saw the advent of life insurance business in India with the establishment of the -riental .ife Insurance /ompany in /alcutta. This /ompany however failed in +,01. In +,23, the %adras *quitable had begun transacting life insurance business in the %adras 4residency. +,56 saw the enactment of the 7ritish Insurance Act and in the last three decades of the nineteenth century, the 7ombay %utual "+,5+#, -riental "+,51# and *mpire of India "+,35# were started in the 7ombay esidency. This era, however, was dominated by foreign insurance offices which did good business in India, namely Albert .ife Assurance, oyal Insurance, .iverpool and .ondon 8lobe Insurance and the Indian offices were up for hard competition from the foreign companies. In +3+1, the 8overnment of India started publishing returns of Insurance /ompanies in India. The Indian .ife Assurance /ompanies Act, +3+2 was the first statutory measure to regulate life business. In +32,, the Indian Insurance /ompanies Act was enacted to enable the 8overnment to collect statistical information about both life and non$life business transacted in India by Indian and foreign insurers including provident insurance societies. In +30,, with a view to protecting the interest of the Insurance public, the earlier legislation was consolidated and amended by the Insurance Act, +30, with comprehensive provisions for effective control over the activities of insurers.

The Insurance Amendment Act of +396 abolished 4rincipal Agencies. :owever, there were a large number of insurance companies and the level of competition was high. There were also allegations of unfair trade practices. The 8overnment of India, therefore, decided to nationali;e insurance business. An -rdinance was issued on +3th <anuary, +39= nationalising the .ife Insurance sector and .ife Insurance /orporation came into existence in the same year. The .I/ absorbed +91 Indian, += non$Indian insurers as also 59 provident societies>219 Indian and foreign insurers in all. The .I/ had monopoly till the late 36s when the Insurance sector was reopened to the private sector. The istor! of "eneral insurance dates back to the Industrial evolution in the west and the consequent growth of sea$faring trade and commerce in the +5 th century. It came to India as a legacy of 7ritish occupation. 8eneral Insurance in India has its roots in the establishment of Triton Insurance /ompany .td., in the year +,96 in /alcutta by the 7ritish. In +365, the Indian %ercantile Insurance .td, was set up. This was the first company to transact all classes of general insurance business.+395 saw the formation of the 8eneral Insurance /ouncil, a wing of the Insurance Associaton of India. The 8eneral Insurance /ouncil framed a code of conduct for ensuring fair conduct and sound business practices. In +3=,, the Insurance Act was amended to regulate investments and set minimum solvency margins. The Tariff Advisory /ommittee was also set up then. In +352 with the passing of the 8eneral Insurance 7usiness "?ationalisation# Act, general insurance business was nationali;ed with effect from + st <anuary, +350. +65 insurers were amalgamated and grouped into four companies, namely ?ational Insurance /ompany .td., the ?ew India Assurance /ompany .td., the -riental Insurance /ompany .td and the @nited India Insurance /ompany .td. The 8eneral Insurance /orporation of India was incorporated as a company in +35+ and it commence business on <anuary +sst +350. This millennium has seen insurance come a full circle in a Aourney extending to nearly 266 years. The process of re-o#enin" of t e sector had begun in the early +336s and the last decade and more has seen it been opened up substantially. In +330, the 8overnment set up a committee under the chairmanship of ? %alhotra, former 8overnor of 7I, to propose recommendations for reforms in the insurance sector.The obAective was to complement the reforms initiated in the financial sector. The committee submitted its report in +331 wherein , among other things, it recommended that the private sector be permitted to enter the insurance industry. They stated that foreign companies be allowed to enter by floating Indian companies, preferably a Aoint venture with Indian partners. Bollowing the recommendations of the %alhotra /ommittee report, in +333, the Insurance egulatory and 'evelopment Authority "I 'A# was constituted as an autonomous body to regulate and develop the insurance industry. The I 'A was incorporated as a statutory body in April, 2666. The key obAectives of the I 'A include promotion of competition so as to enhance customer satisfaction through increased consumer choice and lower premiums, while ensuring the financial security of the insurance market.

The I 'A opened up the market in August 2666 with the invitation for application for registrations. Boreign companies were allowed ownership of up to 2=C. The Authority has the power to frame regulations under Dection ++1A of the Insurance Act, +30, and has from 2666 onwards framed various regulations ranging from registration of companies for carrying on insurance business to protection of policyholders) interests. In 'ecember, 2666, the subsidiaries of the 8eneral Insurance /orporation of India were restructured as independent companies and at the same time 8I/ was converted into a national re$insurer. 4arliament passed a bill de$linking the four subsidiaries from 8I/ in <uly, 2662. Today there are +1 general insurance companies including the */8/ and Agriculture Insurance /orporation of India and +1 life insurance companies operating in the country. The insurance sector is a colossal one and is growing at a speedy rate of +9$26C. Together with banking services, insurance services add about 5C to the country)s 8'4. A well$developed and evolved insurance sector is a boon for economic development as it provides long$ term funds for infrastructure development at the same time strengthening the risk taking ability of the country.
I$#ortant $ilestones in t e Indian life insurance business

+3+2E The Indian .ife Assurance /ompanies Act came into force for regulating the life insurance business. +32,E The Indian Insurance /ompanies Act was enacted for enabling the government to collect statistical information on both life and non$life insurance businesses. +30,E The earlier legislation consolidated the Insurance Act with the aim of safeguarding the interests of the insuring public. +39=E 219 Indian and foreign insurers and provident societies were taken over by the central government and they got nationali;ed. .I/ was formed by an Act 4arliament, vi;. .I/ Act, +39=. It started off with a capital of s. 9 crore and that too from the 8overnment of India. The history of general insurance business in India can be traced back to Triton Insurance /ompany .td. "the first general insurance company# which was formed in the year +,96 in (olkata by the 7ritish
I$#ortant $ilestones in t e Indian "eneral insurance business

+365E The Indian %ercantile Insurance .td. was set up which was the first company of its type to transact all general insurance business. +395E 8eneral Insurance /ouncil, an arm of the Insurance Association of India, framed a code of conduct for guaranteeing fair conduct and sound business patterns. +3=,E The Insurance Act improved for regulating investments and set minimal solvency levels and the Tariff Advisory /ommittee was set up.

+352E The 8eneral Insurance 7usiness "?ationali;ation# Act, +352 nationali;ed the general insurance business in India. It was with effect from +st <anuary +350. +65 insurers integrated and grouped into four companies vi;. the ?ational Insurance /ompany .td., the ?ew India Assurance /ompany .td., the -riental Insurance /ompany .td. and the @nited India Insurance /ompany .td. 8I/ was incorporated as a company.

TY%&S O' INSUR(NC&:Any risk that can be quantified can potentially be insured. Dpecific kinds of risk that may give rise to claims are known as FperilsF. An insurance policy will set out in detail which perils are covered by the policy and which are not. 7elow are "non$ exhaustive# lists of the many different types of insurance that exist. A single policy may cover risks in one or more of the categories set out below. Bor example, auto insurance would typically cover both property risk "covering the risk of theft or damage to the car# and liability risk "covering legal claims from causing an accident#. A homeowner!s insurance policy in the @.D. typically includes property insurance covering damage to the home and the owner!s belongings, liability insurance covering certain legal claims against the owner, and even a small amount of coverage for medical expenses of guests who are inAured on the owner!s property. 7usiness insurance can be any kind of insurance that protects businesses against risks. Dome principal subtypes of business insurance are "a# the various kinds of professional liability insurance, also called professional indemnity insurance, which are discussed below under that name; and "b# the business owner!s policy "7-4#, which bundles into one policy many of the kinds of coverage that a business owner needs, in a way analogous to how homeowners insurance bundles the coverages that a homeowner needs. )ife:.ife insurance provides a monetary benefit to a decedent!s family or other designated beneficiary, and may specifically provide for income to an insured person!s family, burial, funeral and other final expenses. .ife insurance policies often allow the option of having the proceeds paid to the beneficiary either in a lump sum cash payment or an annuity. Annuities provide a stream of payments and are generally classified as insurance because they are issued by insurance companies and regulated as insurance and require the same kinds of actuarial and investment management expertise that life insurance requires. Annuities and pensions that pay a benefit for life are sometimes regarded as insurance against the possibility that a retiree will outlive his or her financial resources. In that sense, they are the complement of life insurance and, from an underwriting perspective, are the mirror image of life insurance. /ertain life insurance contracts accumulate cash values, which may be taken by the insured if the policy is surrendered or which may be borrowed against. Dome policies,

such as annuities and endowment policies, are financial instruments to accumulate or liquidate wealth when it is needed. In many countries, such as the @.D. and the @(, the tax law provides that the interest on this cash value is not taxable under certain circumstances. This leads to widespread use of life insurance as a tax$efficient method of saving as well as protection in the event of early death. In @.D., the tax on interest income on life insurance policies and annuities is generally deferred. :owever, in some cases the benefit derived from tax deferral may be offset by a low return. This depends upon the insuring company, the type of policy and other variables "mortality, market return, etc.#. %oreover, other income tax saving vehicles may be better alternatives for value accumulation.

(uto insurance:Auto insurance protects you against financial loss if you have an accident. It is a contract between you and the insurance company. &ou agree to pay the premium and the insurance company agrees to pay your losses as defined in your policy. Auto insurance provides property, liability and medical coverageE +. 4roperty coverage pays for damage to or theft of your car. 2. .iability coverage pays for your legal responsibility to others for bodily inAury or property damage. 0. %edical coverage pays for the cost of treating inAuries, rehabilitation and sometimes lost wages and funeral expenses. An auto insurance policy comprises six kinds of coverage. %ost countries require you to buy some, but not all, of these coverages. If you!re financing a car, your lender may also have requirements. %ost auto policies are for six months to a year. Healt Care Insurance E$ Gith such high medical and health care costs these days, it)s hard to even think about visiting a doctor. 7ut what about an unexpected mishap or an unforeseen disability or attack, where the potential medical bills could shoot up to a skyH Ghere would you get so much money fromH These are exactly the situations where you feel you had a security, something which could come to your rescue and save you from such financial crisis. Ghile some companies do provide its employees with health insurance, for others, this is a must. *specially for the aging couples, who have a comparatively more chances of needing emergency bill money. The health insurance does it all, so that they do not have to worry for the huge payments at the last minute. A health insurance can cover all from a routine immuni;ation to a maAor illness. (ccident* Sic+ness and Une$#lo!$ent Insurance:-

'isability insurance policies provide financial support in the event the policyholder is unable to work because of disabling illness or inAury. It provides monthly support to help pay such obligations as mortgages and credit cards. 'isability overhead insurance allows business owners to cover the overhead expenses of their business while they are unable to work. Total permanent disability insurance provides benefits when a person is permanently disabled and can no longer work in their profession, often taken as an adAunct to life insurance. Gorkers! compensation insurance replaces all or part of a worker!s wages lost and accompanying medical expenses incurred because of a Aob$related inAury.

Casualt!:/asualty insurance insures against accidents, not necessarily tied to any specific property.

/rime insurance is a form of casualty insurance that covers the policyholder against losses arising from the criminal acts of third parties. Bor example, a company can obtain crime insurance to cover losses arising from theft or embe;;lement. 4olitical risk insurance is a form of casualty insurance that can be taken out by businesses with operations in countries in which there is a risk that revolution or other political conditions will result in a loss.

%ro#ert!:4roperty insurance provides protection against risks to property, such as fire, theft or weather damage. This includes speciali;ed forms of insurance such as fire insurance, flood insurance, earthquake insurance, home insurance, inland marine insurance or boiler insurance.

Automobile insurance, known in the @( as motor insurance, is probably the most common form of insurance and may cover both legal liability claims against the driver and loss of or damage to the insured!s vehicle itself. Throughout the @nited Dtates an auto insurance policy is required to legally operate a motor vehicle on public roads. In some Aurisdictions, bodily inAury compensation for automobile accident victims has been changed to a no$fault system, which reduces or eliminates the ability to sue for compensation but provides automatic eligibility for benefits. /redit card companies insure against damage on rented cars. o 'riving Dchool Insurance provides cover for any authori;ed driver whilst undergoing tuition, cover also unlike other motor policies provides cover for instructor liability where both the pupil and driving instructor are equally liable in the event of a claim. . *arthquake insurance is a form of property insurance that pays the policyholder in the event of an earthquake that causes damage to the property. %ost ordinary homeowners insurance policies do not cover earthquake damage. %ost earthquake insurance policies feature a high deductible. ates

depend on location and the probability of an earthquake, as well as the construction of the home. . Blood insurance protects against property loss due to flooding. %any insurers in the @.D. do not provide flood insurance in some portions of the country. In response to this, the federal government created the ?ational Blood Insurance 4rogram which serves as the insurer of last resort. :ome insurance or homeowners! insuranceE Dee F4roperty insuranceF. .andlord insurance is specifically designed for people who own properties which they rent out. %ost house insurance cover in the @( will not be valid if the property is rented out therefore landlords must take out this specialist form of home insurance. %arine insurance and marine cargo insurance cover the loss or damage of ships at sea or on inland waterways, and of cargo in transit, regardless of the method of transit. Ghen the owner of the cargo and the carrier are separate corporations, marine cargo insurance typically compensates the owner of cargo for losses sustained from fire, shipwreck, etc., but excludes losses that can be recovered from the carrier or the carrier!s insurance. %any marine insurance underwriters will include Ftime elementF coverage in such policies, which extends the indemnity to cover loss of profit and other business expenses attributable to the delay caused by a covered loss.

)iabilit!:.iability insurance is a very broad superset that covers legal claims against the insured. %any types of insurance include an aspect of liability coverage. Bor example, a homeowner!s insurance policy will normally include liability coverage which protects the insured in the event of a claim brought by someone who slips and falls on the property; automobile insurance also includes an aspect of liability insurance that indemnifies against the harm that a crashing car can cause to others! lives, health, or property. The protection offered by a liability insurance policy is twofoldE a legal defense in the event of a lawsuit commenced against the policyholder and indemnification "payment on behalf of the insured# with respect to a settlement or court verdict. .iability policies typically cover only the negligence of the insured, and will not apply to results of wilful or intentional acts by the insured.

4ublic liability insurance covers a business against claims should its operations inAure a member of the public or damage their property in some way. 'irectors and officers liability insurance protects an organi;ation "usually a corporation# from costs associated with litigation resulting from mistakes made by directors and officers for which they are liable. In the industry, it is usually called F'I-F for short. *nvironmental liability insurance protects the insured from bodily inAury, property damage and cleanup costs as a result of the dispersal, release or escape of pollutants. *rrors and omissions insuranceE Dee F4rofessional liability insuranceF under F.iability insuranceF. 4ri;e indemnity insurance protects the insured from giving away a large pri;e at a specific event. *xamples would include offering pri;es to contestants who

can make a half$court shot at a basketball game, or a hole$in$one at a golf tournament. 4rofessional liability insurance, also called professional indemnity insurance, protects insured professionals such as architectural corporation and medical practice against potential negligence claims made by their patientsJclients. 4rofessional liability insurance may take on different names depending on the profession. Bor example, professional liability insurance in reference to the medical profession may be called malpractice insurance. ?otaries public may take out errors and omissions insurance (E&O). -ther potential *Ipolicyholders include, for example, real estate brokers, Insurance agents, home inspectors, appraisers, and website developers.

Credit /redit insurance repays some or all of a loan when certain things happen to the borrower such as unemployment, disability, or death.

%ortgage insurance insures the lender against default by the borrower. %ortgage insurance is a form of credit insurance, although the name credit insurance more often is used to refer to policies that cover other kinds of debt. %any credit cards offer payment protection plans which are a form of credit insurance.

Ot er t!#es:

Binancial loss insurance or 7usiness Interruption Insurance protects individuals and companies against various financial risks. Bor example, a business might purchase coverage to protect it from loss of sales if a fire in a factory prevented it from carrying out its business for a time. Insurance might also cover the failure of a creditor to pay money it owes to the insured. This type of insurance is frequently referred to as Fbusiness interruption insurance.F Bidelity bonds and surety bonds are included in this category, although these products provide a benefit to a third party "the FobligeeF# in the event the insured party "usually referred to as the FobligorF# fails to perform its obligations under a contract with the obligee. 4ollution Insurance which consists of first$party coverage for contamination of insured property either by external or on$site sources. /overage for liability to third parties arising from contamination of air, water, or land due to the sudden and accidental release of ha;ardous materials from the insured site. The policy usually covers the costs of cleanup and may include coverage for releases from underground storage tanks. Intentional acts are specifically excluded. 4urchase insurance is aimed at providing protection on the products people purchase. 4urchase insurance can cover individual purchase protection, warranties, guarantees, care plans and even mobile phone insurance. Duch insurance is normally very limited in the scope of problems that are covered by the policy. Title insurance provides a guarantee that title to real property is vested in the purchaser andJor mortgagee, free and clear of liens or encumbrances. It is

usually issued in conAunction with a search of the public records performed at the time of a real estate transaction. Travel insurance is an insurance cover taken by those who travel abroad, which covers certain losses such as medical expenses, loss of personal belongings, travel delay, personal liabilities, etc.

N&&D 'OR INSUR(NC&

There may be scenarios where the loss that we would incur due to some event would be extensive and we would not be in a position to incur the losses. Day for e.g., the only earning member in the family meets with an accident and is incapacitated from going to work for = months, what would the family do for their survivalH These are the cases where Insurance comes in handy. The insured person can claim an amount corresponding to his disability osses and use the money to sustain his family until he is fit to resume his Aob.

%RINCI%)&S O' INSUR(NC&:%ain principles of InsuranceE

@tmost good faith Indemnity Dubrogation /ontribution Insurable Interest 4roximate /ause

Ut$ost ,ood 'ait

As a client it is your duty to disclose all material facts to the risk being covered. A material fact is a fact which would influence the mind of a prudent underwriter in deciding whether to accept a risk for insurance and on what terms. The duty to disclose operates at the time of inception, at renewal and at any point mid term.

Inde$nit!
-n the happening of an event insured against, the Insured will be placed in the same monetary position that heJshe occupied immediately before the event taking place. In the event of a claim the insured mustE

4rove that the event occurred 4rove that a monetary loss has occurred Transfer any rights which heJshe may have for recovery from another source to the Insurer, if heJshe has been fully indemnified.

Subro"ation
The right of an insurer which has paid a claim under a policy to step into the shoes of the insured so as to exercise in his name all rights he might have with regard to the recovery of the loss which was the subAect of the relevant claim paid under the policy up to the amount of that paid claim. The insurer)s subrogation rights may be qualified in the policy. In the context of insurance subrogation is a feature of the principle of indemnity and therefore only applies to contracts of indemnity so that it does not apply to life assurance or personal accident policies. It is intended to prevent an insured recovering more than the indemnity he receives under his insurance "where that represents the full amount of his loss# and enables his insurer to recover or reduce its loss.

Contribution
The right of an insurer to call on other insurers similarly, but not necessarily equally, liable to the same insured to share the loss of an indemnity payment i.e. a travel policy may have overlapping cover with the contents section of a household policy. The principle of contribution allows the insured to make a claim against one insurer who then has the right to call on any other insurers liable for the loss to share the claim payment.

Insurable Interest
If an insured wishes to enforce a contract of insurance before the /ourts he must have an insurable interest in the subAect matter of the insurance, which is to say that he stands to benefit from its preservation and will suffer from its loss. In non$marine insurances, the insured must have insurable interest when the policy is taken out and also at the date of loss giving rise to a claim under the policy.

%ro-i$ate Cause
An insurer will only be liable to pay a claim under an insurance contract if the loss that gives rise to the claim was proximately caused by an insured peril. This means that the loss must be directly attributed to an insured peril without any break in the chain of causation.

H&()TH INSUR(NC&:Healt insurance like other forms of insurance is a form of collectivism by means of which people collectively pool their risk, in this case the risk of incurring medical expenses. The collective is usually publicly owned or else is organi;ed on a non$profit basis for the members of the pool, though in some countries health insurance pools may also be managed by for$profit companies. It is sometimes used more broadly to include insurance covering disability or long$term nursing or custodial care needs. It may be provided through a government$sponsored social insurance program, or from private insurance companies. It may be purchased on a group basis "e.g., by a firm to cover its employees# or purchased by an individual. In each case, the covered groups or individuals pay premiums or taxes to help protect themselves from unexpected healthcare expenses. Dimilar benefits paying for medical expenses may also be provided through social welfare programs funded by the government.

7y estimating the overall risk of healthcare expenses, a routine finance structure "such as a monthly premium or annual tax# can be developed, ensuring that money is available to pay for the healthcare benefits specified in the insurance agreement. The benefit is administered by a central organi;ation such as a government agency, private business, or not$for$profit entity. Definition: A policy that will pay specified sums for medical expenses or treatments. :ealth policies can offer many options and vary in their approaches to coverage.

..TH&ORY ON %RI/(TIS(TION O' H&()TH INSUR(NC&:-

%RI/(TIS(TION O' INSUR(NC&:%rivati0ation is the incidence or process of transferring ownership of a business, enterprise, agency or public service from the public sector "government# to the private sector "FbusinessF#. In a broader sense, privati;ation refers to transfer of any government function to the private sector $ including governmental functions like revenue collection and law enforcement.K+L The term Fprivati;ationF also has been used to describe two unrelated transactions. The first is a buyout, by the maAority owner, of all shares of a public corporation or holding company!s stock, privati;ing a publicly traded stock. The second is a demutuali;ation of a mutual organi;ation or cooperative to form a Aoint stock company. The privati;ation of insurance and constitution I 'A envisage improving the performance of the state insurance sector in the country by increasing benefits from competition in terms of lowered costs and increased level of consumer satisfaction. :owever, the implications of the entry of private insurance companies in health sector are not very clear. The recent policy changes will have been far reaching and would have maAor implications for the growth and development of the health sector. There are several contentious issues pertaining to development in this sector and these need critical examination. These also highlight the critical need for policy formulation and assessment. @nless privati;ation and development of health insurance is managed well it may have negative impact of health care especially to a large segment of population in the country. If it is well managed then it can improve access to care and health status in the country very rapidly. Dince the liberali;ation of the insurance industry in 2666 India has been promoting private players to enter the health insurance sector. Gith the enactment of the I 'A, the industry now has a regulatory framework to protect the interests of policy holders. This was followed by another landmark decision in 266+ establishing Third 4arty Administrators "T4As# to facilitate speedier expansion by providing an administrativeM intermediary structure to the insurance industry. There are, at present, +2 general insurance companies and 29 T4As. The total number of insurance holders is reported to be ++2 lakh with almost 36C enrolled with the four public sector insurance companies. These four companies collected a premium of s ++2,.=1 crore under %ediclaim. -f the +62 lakh enrolled by these four companies "excluding 8I/, *mployment 8uarantee /orporation, AI/.#, which are permitted to market health insurance products, %ediclaim alone accounts for 35 lakh persons, the rest being enrolled under other insurance

H&()TH INSUR(NC& 1&'OR& 1221::ealth care facilities and personnel increased substantially between the early +396s and early +3,6s, but because of fast population growth, the number of licensed medical practitioners per +6,666 individuals had fallen by the late +3,6s to three per +6,666 from the +3,+ level of four per +6,666. In +33+ there were approximately ten hospital beds per +6,666 individuals. 4rimary health centers are the cornerstone of the rural health care system. 7y +33+, India had about 22,166 primary health centers, ++,266 hospitals, and 25,166 dispensaries. These facilities are part of a tiered health care system that funnels more difficult cases into urban hospitals while attempting to provide routine medical care to the vast maAority in the countryside. 4rimary health centers and subcenters rely on trained paramedics to meet most of their needs. The main problems affecting the success of primary health centers are the predominance of clinical and curative concerns over the intended emphasis on preventive work and the reluctance of staff to work in rural areas. In addition, the integration of health services with family planning programs often causes the local population to perceive the primary health centers as hostile to their traditional preference for large families. Therefore, primary health centers often play an adversarial role in local efforts to implement national health policies. According to data provided in +3,3 by the %inistry of :ealth and Bamily Gelfare, the total number of civilian hospitals for all states and union territories combined was +6,+95. In +33+ there were a total of ,++,666 hospital and health care facilities beds. The geographical distribution of hospitals varied according to local socioeconomic conditions. In India!s most populous state, @ttar 4radesh, with a +33+ population of more than +03 million, there were 509 hospitals as of +336. In (erala, with a +33+ population of 23 million occupying an area only one$seventh the si;e of @ttar 4radesh, there were 2,690 hospitals. In light of the central government!s goal of health care for all by 2666, the uneven distribution of hospitals needs to be reexamined. 4rivate studies of India!s total number of hospitals in the early +336s were more conservative than official Indian data, estimating that in +332 there were 5,066 hospitals. -f this total, nearly 1,666 were owned and managed by central, state, or local governments Another 2,666, owned and managed by charitable trusts, received partial support from the government, and the remaining +,066 hospitals, many of which were relatively small facilities, were owned and managed by the private sector. The use of state$of$ the$art medical equipment, often imported from Gestern countries, was primarily limited to urban centers in the early +336s. A network of regional cancer diagnostic and treatment facilities was being established in the early +336s in maAor hospitals that were part of government medical colleges. 7y +332 twenty$two such centers were in operation. %ost of the +,066 private hospitals lacked sophisticated medical facilities, although in +332 approximately +2 percent possessed state$of$the$art equipment for diagnosis and treatment of all maAor diseases, including cancer. The fast pace of development of the private medical sector and the burgeoning middle class in the +336s have led to the emergence of the new concept in India of establishing hospitals and health care facilities on a for$profit basis.

7y the late +3,6s, there were approximately +2, medical colleges$$roughly three times more than in +396. These medical colleges in +3,5 accepted a combined annual class of +1,+== students. 'ata for +3,5 show that there were 026,666 registered medical practitioners and 2+3,066 registered nurses. Narious studies have shown that in both urban and rural areas people preferred to pay and seek the more sophisticated services provided by private physicians rather than use free treatment at public

H&()TH INSUR(NC& SINC& 1221:I? *D4-?D* to a fiscal and balance of payments crisis in +33+, India launched a programme of economic policy reforms. The programme, consisting of stabili;ations$ cum$structural adAustment measures, was put in place with a view to attain macroeconomic stability and higher rates of economic growth. Dome rethinking on economic policy had begun in the early +3,6s, by when the limitations of the earlier strategy based upon import substitution, public sector dominance and extensive government control over private sector activity had become evident, but the policy response was limited only to liberali;ing particular aspects of the control system. 7y contrast, the reforms in the +336s in the industrial, trade, and financial sectors, among others, were much wider and deeper. As a consequence, they have contributed more meaningfully in attaining higher rates of growth. India has gone through the first decade of her reform process. :ence, an assessment of what has been achieved so far and what remains on the reform agenda is in order. Bour different governments were in office during the +336s > the /ongress government which initiated the reforms in +33+, the @nited Bront coalition "+33=$3,# which continued the process, the 7<4$led coalition which took office in %arch +33, and then again the 7<4$led ?ational 'emocratic Alliance "?'A# in -ctober +333 till date. In short, it seems that India!s political system is more than ever in consensus about the basic direction of reforms. The new experience of successful coalition governments in India has been ideal for democratic governance, balancing divergent views and accommodating regional and sectoral interests more effectively. This has imparted some degree of stability and consistency in economic policymaking. In broad terms, we are firmly of the view that the current decade is going to be India!s decade of development and that the country is on its way to sustaining a period of high economic growth, say, 5$, per cent per annum. Dince India!s economic reforms were launched in +33+, the Indian economy has sustained an annual average growth rate of over = per cent. In 2660$61, 8'4 growth is expected to be around 5.9 per cent. India!s foreign exchange reserves have crossed O+66 billion. The current account deficit turned into a surplus over the last four years. This was achieved through non$

debt creating flows, so that India!s external debt has remained virtually static in nominal terms. The debt servicing and debt 8'4 ratios have fallen sharply. In fact, India is now repaying foreign debt ahead of schedule. India is becoming a production base and an export hub for diverse goods, from agricultural products to automobile components to high$end services. Indian firms are now part of global production chains > importing sub$assemblies, adding value to them and re$exporting them. Taking advantage of its pool of high$quality scientific talent, international corporations have established large I' centres in India. All these strengths have resulted in a greater integration of the Indian economy with the world economy. Trade has risen from 2+ per cent to 00 per cent of India!s 8'4 in a decade. India!s strong economic growth is succeeding in bringing people out of poverty, nevertheless the country still has a long way to go before it can eradicate poverty. :owever, it increasingly appears that the ingredients of rapid poverty eradication are falling into place. Brom roads to telecommunication, the country is seeing the beginning of a qualitative change and growth in infrastructure. Dince April 2660, India has been adding nearly 2 million mobile connections every month. The enormous successes of India!s IT professionals and the new successes of IT$enabled services have been made possible by the fact that the data and voice carrying capacity in India today has been enhanced dramatically. India is meeting almost 56 per cent demand of the worldwide business process outsourcing "74-#. -perating through satellite links, Indian programmers are providing IT support to @D and *uropean firms in areas ranging from software development and maintenance, back$office operations, data transcription and transmission, telemarketing, and other related areas. In the last year or so, @D and *uropean firms in the health, insurance and banking sectors, to mention a few, are also increasingly resorting to the 74- route to cut their costs. In India, unlike in /hina and the 4hilippines, 74- is sought after not Aust on cost considerations, but for better quality as well. As far as 74- in India is concerned, firms go there for cost, and stay there for quality. The federal government has launched an ambitious proAect for a highways network, which is linking the country!s maAor metropolitan centres and is providing improved connectivity to India!s rural areas. These roads can already be seen transforming the Indian economy. Dimilarly, in terms of federal support for primary schools under the PDarva Diksha Abhiyan! "literacy for all# scheme, which was put in place in ?ovember 2666 to attain universal primary literacy by the year 26+6, large sums of federal money is being invested in, among other things, constructing new school buildings, upgrading facilities in existing schools, recruiting and training teachers and revising syllabi.

-utlook E$ %- * than a decade of opening of the economy has produced new dynamism, most dramatically in the information technology sector, but in others as well. The new technologies "especially information technology and biotechnology# give new opportunities for economic and social development. The reforms implemented so far have helped India attain =$plus per cent growth, however should India be able to implement these remaining reforms and re$orient governmental spending away from inessential expenditures and towards high priority areas of health, education and infrastructure development, then it is very likely that it would attain and sustain even higher rates of economic growth. If India does grow consistently at around 5$, per cent per year, this is likely to push up its domestic savings in the next few years. 7esides, stronger growth should attract more foreign savings, especially foreign direct investment, and thus raise the overall investment rate.

N&&D 'OR H&()TH INSUR(NC& IN INDI( ::ealth insurance means the financial protection against health risks. The need of health insurance arises when there are long bills to be paid in case of an unexpected event. It helps when there is shortage of funds for the medical treatment. -ne can get the medical and financial protection in such a situation. Apollo %unich, a Aoint venture between the Apollo 8roup of :ospitals and %unich health, is a pure health insurance company that works using the expertise of its partners, who are leaders in their respective fields. Its products are intelligently designed looking into the healthcare needs of one and all in India. The health insurance provides coverage against spiraling medical costs and guarantees you secured future. In addition, Apollo %unich plans not only provide coverage to Qcurative) needs but also to Qpreventive) needs so that clients can get the complete health cover. Bor this purpose, Apollo %unich offers three value$added services along with each product. These are cashless hospitali;ation, healthline and health risk assessment tool. Apollo %unich plans incorporate several unique features such as life$long renewal, portability etc. so that the health needs of all individuals can be considered.

R&CO33&DI(TION S&CTOR:-

1Y

CO33ITT&&

ON

INSUR(NC&

Although Indian markets were privati;ed and opened up to foreign companies in a ?umber of sectors in +33+, insurance remained out of bounds on both counts. The 8overnment wanted to proceed with caution. Gith pressure from the opposition, the

8overnment "at the time, dominated by the /ongress 4arty# decided to set up a committee headed by %r. . ?. %alhotra "the then 8overnor of the eserve 7ank of India#. The formation of the %alhotra /ommittee in +330 initiated reforms in the Indian insurance sector. The aim of the %alhotra /ommittee was to assess the functionality of the Indian insurance sector. This committee was also in charge of recommending the future path of insurance in India.The %alhotra /ommittee attempted to improve various aspects of the insurance sector, making them more appropriate and effective for the Indian market. The recommendations of the committee put stress on offering operational autonomy to the insurance service providers and also suggested forming an independent regulatory body.The Insurance egulatory and 'evelopment Authority Act of +333 brought about several crucial policy changes in the insurance sector of India. It led to the formation of the Insurance egulatory and 'evelopment Authority "I 'A# in 2666. The goals of the I 'A are to safeguard the interests of insurance policyholders, as well as to initiate different policy measures to help sustain growth in the Indian insurance sector. The Authority has notified 25 egulations on various issues which include egistration of Insurers, egulation on insurance agents, Dolvency %argin, e$ insurance, -bligation of Insurers to ural and Docial sector, Investment and Accounting 4rocedure, 4rotection of policy holders! interest etc. Applications were invited by the Authority with effect from +9th August, 2666 for issue of the /ertificate of egistration to both life and non$life insurers. The Authority has its :ead Ruarter at :yderabad. 'etailed information on I 'A is available at their web$ site. .iberali;ation of the Indian insurance market was recommended in a report released in +331 by the %alhotra /ommittee, indicating that the market should be opened to private$sector competition, and ultimately, foreign private$sector competition. It also investigated the level of satisfaction of the customers of the .I/. /uriously, the level of customer satisfaction seemed to be high. The union of the .I/ made political capital out of this finding T e follo4in" are t e #ur#oses of t e co$$ittee. To suggest the structure of the insurance industry, to assess the strengths and weaknesses of insurance companies in terms of the obAectives of creating an efficient and viable insurance industry, to have a ide coverage of insurance services, to have a variety of insurance products with a high quality service, and to develop an effective instrument for mobili;ation of financial resources for development. To make recommendations for changing the structure of the insurance industry, for changing the general policy framework etc. To take specific suggestions regarding .I/ and 8I/ with a view to improve the functioning of.I/ and 8I/.

To make recommendations on regulation and supervision of the insurance sector in India. To make recommendations on the role and functioning of surveyors, intermediaries like agents etc. in the insurance sector. To make recommendations on any other matter which are relevant for development of the insurance industry in IndiaH

T e co$$ittee $ade a nu$ber of i$#ortant and far-reac in" reco$$endations. The .I/ should be selective in the recruitment of .I/ agents. Train these people after the identification of training needs. The committee suggested that the Bederation of Insurance Institute, %umbai should start new courses and diploma courses for intermediaries of the insurance sector It suggested that settlement of claims were to be done within a specific time framewithout delay. The committee has several recommendations on product pricing,vigilance, systems and procedures, improving customer service and use of technology. It also made a number of recommendations to alter the existing structure of the .I/and the 8I/. The committee insisted that the insurance companies should pay special attention to the rural insurance business.. The committee suggested somenorms relating to promoters) equity and equity capital by foreign companies, etc. %rotection of t e interest of #olic! olders: I 'A has the responsibility of protecting the interest of insurance policyholders. Towards achieving this obAective, the Authority has taken the following stepsE I 'A has notified 4rotection of 4olicyholders Interest egulations 266+ to provide forE policy proposal documents in easily understandable language; claims procedure in both life and non$life; setting up of grievance redressal machinery; speedy settlement of claims; and policyholders! servicing. The egulation also provides for payment of interest by insurers for the delay in settlement of claim. The insurers are required to maintain solvency margins so that they are in a position to meet their obligations towards policyholders with regard to payment of claims. It is obligatory on the part of the insurance companies to disclose clearly the benefits, terms and conditions under the policy. The advertisements issued by the insurers should not mislead the public. All insurers are required to set up proper grievance redress machinery in their head office and at their other offices. The Authority takes up with the insurers any complaint received from the policyholders in connection with services provided by them under the insurance contract.

%RO1)&3S '(C&D 1Y H&()TH INSUR(NC&:The main problems affecting the success of primary health centers are the predominance of clinical and curative concerns over the intended emphasis on preventive work and the reluctance of staff to work in rural areas. In addition, the integration of health services with family planning programs often causes the local population to perceive the primary health centers as hostile to their traditional preference for large families. Therefore, primary health centers often play an adversarial role in local efforts to implement national health policies. According to data provided in +3,3 by the %inistry of :ealth and Bamily Gelfare, the total number of civilian hospitals for all states and union territories combined was +6,+95. In +33+ there was a total of ,++,666 hospital and health care facilities beds. The geographical distribution of hospitals varied according to local socioeconomic conditions. In India!s most populous state, @ttar 4radesh, with a +33+ population of more than +03 million, there were 509 hospitals as of +336. In (erala, with a +33+ population of 23 million occupying an area only one$seventh the si;e of @ttar 4radesh, there were 2,690 hospitals. In light of the central government!s goal of health care for all by 2666, the uneven distribution of hospitals needs to be reexamined. 4rivate studies of India!s total number of hospitals in the early +336s were more conservative than official Indian data, estimating that in +332 there were 5,066 hospitals. -f this total, nearly 1,666 were owned and managed by central, state, or local governments. Another 2,666, owned and managed by charitable trusts, received partial support from the government, and the remaining +,066 hospitals, many of which were relatively small facilities, were owned and managed by the private sector. The use of state$of$ the$art medical equipment, often imported from Gestern countries, was primarily limited to urban centers in the early +336s. A network of regional cancer diagnostic and treatment facilities was being established in the early +336s in maAor hospitals that were part of government medical colleges. 7y +332 twenty$two such centers were in operation. %ost of the +,066 private hospitals lacked sophisticated medical facilities, although in +332 approximately +2 percent possessed state$of$the$art equipment for diagnosis and treatment of all maAor diseases, including cancer. The fast pace of development of the private medical sector and the burgeoning middle class in the +336s have led to the emergence of the new concept in India of establishing hospitals and health care facilities on a for$profit basis. 7y the late +3,6s, there were approximately +2, medical colleges$$roughly three times more than in +396. These medical colleges in +3,5 accepted a combined annual class of +1,+== students. 'ata for +3,5 show that there were 026,666 registered medical practitioners and 2+3,066 registered nurses. Narious studies have shown that in both urban and rural areas people preferred to pay and seek the more sophisticated services provided by private physicians rather than use free treatment at public health centers.

%ROC&SS O' H&()TH INSUR(NC&:A health insurance policy is a contract between an insurance company and an individual or his sponsor "e.g. an employer#. The contract can be renewable annually

or monthly. The type and amount of health care costs that will be covered by the health insurance company are specified in advance, in the member contract or F*vidence of /overageF booklet. The individual insured person!s obligations may take several formsE

%re$iu$: The amount the policy$holder or his sponsor "e.g. an employer# pays to the health plan each month to purchase health coverage. Deductible: The amount that the insured must pay out$of$pocket before the health insurer pays its share. Bor example, a policy$holder might have to pay a O966 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor!s visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care. Co-#a!$ent: The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service. Bor example, an insured person might pay a O19 co$payment for a doctor!s visit, or to obtain a prescription. A co$payment must be paid each time a particular service is obtained. Coinsurance: Instead of, or in addition to, paying a fixed amount up front "a co$payment#, the co$insurance is a percentage of the total cost that insured person may also pay. Bor example, the member might have to pay 26C of the cost of a surgery over and above a co$payment, while the insurance company pays the other ,6C. If there is an upper limit on coinsurance, the policy$holder could end up owing very little, or a great deal, depending on the actual costs of the services they obtain. &-clusions: ?ot all services are covered. The insured person is generally expected to pay the full cost of non$covered services out of their own pocket. Covera"e li$its: Dome health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan!s maximum payment for a specific service. In addition, some insurance company schemes have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy$holder must pay all remaining costs. Out-of-#oc+et $a-i$u$s: Dimilar to coverage limits, except that in this case, the insured person!s payment obligation ends when they reach the out$of$ pocket maximum, and the health company pays all further covered costs. -ut$ of$pocket maximums can be limited to a specific benefit category "such as prescription drugs# or can apply to all coverage provided during a specific benefit year. Ca#itation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer. In-Net4or+ %rovider: "@.D. term# A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or co$payments, or additional benefits, to a plan member to see an in$network provider. 8enerally, providers in network are providers who have a contract with the insurer to accept rates further discounted from the Fusual and customaryF charges the insurer pays to out$of$network providers. %rior (ut ori0ation: A certification or authori;ation that an insurer provides prior to medical service occurring. -btaining an authori;ation means that the

insurer is obligated to pay for the service, assuming it matches what was authori;ed. %any smaller, routine services do not require authori;ation.K3L &-#lanation of 1enefits: A document sent by an insurer to a patient explaining what was covered for a medical service, and how they arrived at the payment amount and patient responsibility amount.K+6L

4rescription drug plans are a form of insurance offered through some employer benefit plans in the @.D., where the patient pays a copayment and the prescription drug insurance part or all of the balance for drugs covered in the formulary of the plan. Dome, if not most, health care providers in the @nited Dtates will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn!t pay. The insurance company pays out of network providers according to Freasonable and customaryF charges, which may be less than the provider!s usual fee. The provider may also have a separate contract with the insurer to accept what amounts to a discounted rate or capitation to the provider!s standard charges. It generally costs the patient less to use an in$network provider.

DOCU3&NTS 'OR T(5IN, H&()TH INSUR(NC& (R& (S 'O))O6S:'or Healt Insurance All documentation must be included for the application to be considered complete. Applicant ?ame Application 'ate %ROO' O' ID&NTITY7D(T& O' 1IRTH (ND R&SID&NC&: &ou must show -?* of the documents listed in both categories to see if you are eligible for health insurance. 'iscuss this with the person helping you with your application. 4hotocopies are acceptable. ID&NTITY7D(T& O' 1IRTH R&SID&NCY7HO3& (DDR&SS 'rivers licenseJ-fficial 4hoto identification I' card with address 4assport 4ostmarked envelope, postcard, or maga;ine label with name and date 7irth certificate 'rivers license issued within past = months 7aptismalJother religious certificate @tility bill "gas, electric, cable#, bank statement, or correspondence from a government agency which contains name and home address -fficial Dchool records "not a 4.-. 7ox#Adoption records .etterJleaseJrent receipt with home address from landlord -fficial :ospitalJdoctor birth records 4roperty tax records or mortgage statement ?aturali;ation certificate %arriage records

%ROO' O' CURR&NT INCO3&: &ou must provide a letter, written statement, or copy of check or stubs, from the employer, person or agency providing the income. Dubmit all that apply. 4rovide the most recent proof of income before taxes. The proof must be dated, include the employees name and show gross income for the pay period. DOCU3&NT(TION CH&C5)IST 'or Healt Insurance D&%&ND&NT C(R& COSTS: Gritten statement from day care center or other childJadult care provider /anceled checks or receipts %ROO' O' H&()TH INSUR(NC&: Insurance policy /ertificate of Insurance Insurance card Termination .etter -ther

RO)& O' DI''&R&NT R&,U)(TOR:The government has established Insurance egulatory and 'evelopment Authority "I 'A# which is the statutory body for regulation of the whole insurance industry. They would be granting licenses to private companies and will regulate the insurance business. As the health insurance is in its very early phase, the role of I 'A will be very crucial. They have to ensure that the sector develops rapidly and the benefit of the insurance goes to the consumers. 7ut it has to guard against the ill effects of private insurance. The main danger in the health insurance business we see is that the private companies will cover the risk of middle class who can afford to pay high premiums. @nregulated reimbursement of medical costs by the insurance companies will push up the prices of private care. Do large section of India!s population who are not insured will be at a relative disadvantage as they will, in future, have to pay much more for the private care. Thus checking increase in the costs of medical care will be very important role of the I 'A. Decondly, I 'A will need to evolve mechanisms by which it puts some kind of statue in place that private insurance companies do not skim the market by focusing on rich and upper$ class clients and in the process neglect a maAor section of India!s population. They must ensure that companies develop products for such poorer segments of the community and possibly build an element of cross$subsidy for them. 8overnment companies can take the lead in this matter and cataly;e new products for the poor and lower middle class as they have done in the past. Thirdly the regulators should also encourage ?8-s, /o$operatives and other collectives to inter into the health insurance business and develop products for the poor as well as for the middle class employed in the services sector such as education, transportation, retailing etc and the self employed. This could be run as no$profit$no loss basis similar to the scheme pioneered by Indian %edical Association for its members. Dpecial licenses will have to be given to ?8- for this purpose without insisting on the minimum capital norms, which are for commercial insurance companies.

IRD( ,UID&)IN&SS 'OR H&)TH INSUR(NC&:I 'A guidelines issued also make it clear that the renewal of a health insurance policy cannot be reAected on arbitrary grounds. As per I 'A, the only exception for reAection of a health policy renewal could be fraud or misrepresentation of facts. ?*G 8@I'*.I?*D issued by the Insurance egulatory and 'evelopment Authority "I 'A#, on Thursday "April 2#, made it mandatory for an insurance company to renew a health insurance policy, irrespective of the payments already made out in claims. These new rules will come in handy for the old and those with medical conditions as they faced a lot of problem while renewing their health policies. I 'A has made it clear that delays of up to +9 days from the renewal date will also need to be condoned by the insurers and they have to cover benefits given for pre$ existing diseases. T e ne4 "uidelines s all be a##licable fro$ 8une 1* .992. I 'A guidelines issued today also make it clear that the renewal of a health insurance policy cannot be reAected on arbitrary grounds. As per I 'A, the only exception for reAection of a health policy renewal could be fraud or misrepresentation of facts. I 'A also stated that a customer should not be compelled or forced to shift from one health insurance policy to another insurance product, except where the policy was being upgraded or discontinued with permission from the authority. It has also asked the insurance companies to provide complete details about terms of renewing a health policy. I 'A said that the purpose of these guidelines was to enable the consumer to take an informed decision. The regulatory body also told the insurance companies to state in clear terms if there are any changes in the payment of premium by the consumer.

'&(TUR&S O' H&()TH INSUR(NC&:Brom the above discussion, five features that characteri;e the health insurance system in India emergeE +. 7y and large, the system offers traditional indemnity, under which the insured first pay the amount and then seek reimbursement. @nder indemnity, all known diseases or health conditions are excluded and therefore such policies typically have a large number of exclusions. This also means that those most in need of insurance, i.e. the sick, get excluded for any financial risk protection against the diseases they are suffering from. 2. It is a fee$for$service$based payment system. Duch a system of payment is advantageous for the provider since he bears no risk for the prices he can charge for

services rendered by him. /ombined with the asymmetry in information, such a system usually entails increased costs. 0. 4olicies provide a ceiling of the assured sum. Duch a system, and that too within a fee$for$service payment system, results in shortchanging the insured as he gets less value for money, as the provider and the insurer have no obligations to provide quality care andJor over provideJover charge services so long as the amounts are within the assured amount of the insurance policy. 1. The system is based on risk$rated premiums. This again puts the risk on the insured as the premium is fixed in accordance with the health status and age. @nder such a system, women in the reproductive age group, the old, the poor and the ill get to pay higher amounts and are discriminated against. 9. The system is voluntary, making it difficult to form viable risk pools for keeping premiums low.

1&N&'ITS O' H&()TH INSUR(NC&:The benefits of group health care insuranceE$ S No # !sical e-a$inations In a group health policy, the insurance company insures all members of the group, regardless of current physical health and prior health history. The only condition is that the group members apply for insurance within a specified eligibility period. This is an advantage for people with chronic health conditions, who would probably be unable to get individual insurance. S C ea#er t an individual insurance As one policy is issued for the entire group, the initial costs are much lower than the costs of issuing a separate policy to each person. 8roup health care insurance is also less risky for insurers, as the risk is spread out among a larger number of people. It is also more affordable as the employer usually pays some part or all of, the group insurance premium. :owever, the downside to group coverage is that you do not get a customi;ed health care policy. Gith group insurance, the provisions of the policy are negotiated between the insurer and main policy owner. &ou may not have the freedom to have provisions included or excluded, and your deductible amount and co$payment percentage are determined in advance.

(D/(NT(,&S O' H&()TH INSUR(NC&:Individual health care insurance covers medical expenses of a single person or a family. @nlike in group insurance, here you have to purchase the individual insurance directly from an insurance company. Ghen applying for individual insurance, the insurer first evaluates how much of risk you present, by conducting a physical exam and a thorough medical history check. &our risk determines whether you can qualify for healthcare insurance and how much it will cost.

T e advanta"es of individual ealt care insurance :S Custo$i0ed ealt care: :er you have direct control over your policy and its benefits, unlike in group coverage. &ou can negotiate to have certain provisions included or excluded in your policy, and you can choose your deductible amount and co$payments. S C oosin" !our doctor:-Delecting a health care provider including doctors is another advantage of an individual health care policy. The biggest disadvantage is the price. Individual policies can be very expensive, especially if you have high risk potential or pre$existing health problems. 7efore issuing an individual health care insurance policy, the insurance company usually runs a background check on your personal health history. It is unwise to try to hide any pre$existing conditions from your insurer. The main advantages of health insurance areE

'ecreasing of medical costs *asy access to routine medical checkups and health care eduction of trips) costs to specialist doctors The possibility of hospitali;ation and treatment

R&(SONS 'OR %OOR %&NTR(TION O' H&()TH INSUR(NC&:4enetration of health insurance has been slow and halting, despite the Qhuge market) estimated to range between s5.9M26 crores. Dome reasons that explain for the slow expansion of health insurance in the country are as followsE 1. )ac+ of re"ulations and control on #rovider be aviour The unregulated environment and a near total absence of any form of control over providers regarding quality, cost or2,2 Binancing and 'elivery of :ealth /are Dervices in India data$sharing, makes it difficult for proper underwriting and actuarial premium setting. This puts the entire risk on the insurer as there could be the problems of moral ha;ard and induced demand. %ost insurance companies are therefore wary about selling health insurance as they do not have the data, the expertise and the power to regulate the providers. Geak monitoring systems for checking fraud or manipulation by clients and providers, add to the problem. .. Unaffordable #re$iu$s and i" clai$ ratios Increased use of services and high claim ratios only result in higher premiums. The insurance agencies in the face of poor information also tend to overestimate the risk and fix high premiums. 7esides, the administrative costs are also high over 06C, i.e. +9C commission to agent; 9.9C administrative fee to T4A; own administrative cost

26C, etc. 4atients also experience problems in getting their reimbursements including long delays to partial reimbursements. :. Reluctance of t e ealt insurance co$#anies to #ro$ote t eir #roducts and lac+ of innovation Apart from high claim ratios, the non$exclusivity of health insurance as a product is another reason. In India, an insurance company cannot sell non$life as well as life insurance products. Dince insurance against fire or natural disaster or theft is far more profitable, insurance companies tend to compete by adding low incentive such as premium health insurance products to important clients, cross$subsidi;ing the resultant losses. Gith a view to get the non$life accounts, insurance companies tend to provide health insurance coverat unviable premiums. Thus, there is total lack of any effort to promote health insurance through campaigns regarding the benefits of health insurance and lack of innovation to make the policies suitable to the needs of the people. ;. Too $an! e-clusions and ad$inistrative #rocedures Apart from delays in settlement of claims, non$transparent procedures make it difficult for the insured to know about their entitlements, because of which the insurer is able to, on one stratagem or the other, reduce the claim amount, thus demotivatingthe insured and deepening mistrust. The benefit package also needs to be modified to suit the needs of the insured. *xclusions go against the logic of covering health risks, though, there can be a system where the existing conditions can be excluded for a time period>one or two years but not forever. 7esides, the systems entail equity implications. <. Inade=uate su##l! of services There is an acute shortage of supply of services in rural areas. ?ot only is there non$ availability of hospitals for simple surgeries, but several parts of the country have barely one or two hospitals with specialist services. %any centres have no cardio$ logistsor orthopaedicians for several non$communicable diseases that are expensive to treat and can be catastrophic. If we take the number of beds as a proxy for availability of institutional care, the variance is high with (erala having 2= beds per+666popu$ lation compared with 2.9 in %adhya 4radesh. >. Co-variants ris+s :igh prevalence levels of risks that could affect a maAority of the people at the same time could make the enterprise unviable as there would be no gains in forming large pools. The result could be higher premiums. In India this is an important factor due to the large load of communicable diseases. A study of claims "7hat 2662# found that 22C of total claims were for communicable diseases.

SCH&3&S UND&R H&()TH INSUR(NC&:T e e-istin" sc e$es can be cate"ori0ed as: "+# Noluntary health insurance schemes or private$for$profit schemes; "2# *mployer$based schemes; "0# Insurance offered by ?8-s J community based health insurance, and "1# %andatory health insurance schemes or government run schemes

"?amely *DID, /8:D#. /oluntar! ealt insurance sc e$es or #rivate-for-#rofit sc e$es:In private insurance, buyers are willing to pay premium to an insurance company that pools people with similar risks and insures them for health expenses. The key distinction is that the premiums are set at a level, which provides a profit to third party and provider institutions. 4remiums are based on an assessment of the risk status of the consumer "or of the group of employees# and the level of benefits provided, rather than as a proportion of the consumer)s income. In the public sector, the 8eneral Insurance /orporation "8I/# and its four subsidiary companies "?ational Insurance /orporation, ?ew India Assurance /ompany, -riental Insurance /ompany and @nited Insurance /ompany# and the .ife Insurance /orporation ".I/# of India provide voluntary insurance schemes. There are exclusions and pre$existing disease clauses. 4remiums are calculated based on age and the sum insured, which in turn varies from s +9 666 to s 9 66 666. In +339J3= about half a million %ediclaim policies were issued with about +., million beneficiaries"(rause 4atrick 2666#. Another scheme, namely the Jan Arogya Bima policy specifically targets the poor population groups. It also covers reimbursement of hospitali;ation costs up to s 9 666 annually for an individual premium of s +66 a year. The same exclusion mechanisms apply for this scheme as those under the %edi$claim policy. A family discount of 06C is granted, but there is no group 'iscount or agent commission. :owever, like the %ediclaim, this policy too has had only limited success. The Jan Arogya Bima Dcheme had only covered 166 666 individuals by +335. Self-&$#lo!ed 6o$en?s (ssociation @S&6(A* ,uBaratE This scheme established in +332, provides health, life and assets insurance to women working in the informal sector and their families. The enrolment in the year 2662 was 30 666. This scheme operates in collaboration with the ?ational Insurance /ompany "?I/#. @nder D*GA)s most popular policy, a premium of s ,9 per individual is paid by the woman for life, health and assets insurance. At an additional payment of s 99, her husband too can be covered. s 26 per member is then paid to the ?ational Insurance /ompany "?I/# which provides coverage to a maximum of s 2 666 per person per year for hospitali;ation. After being hospitali;ed at a hospital of one)s choice "public or private#, the insurance claim is submitted to D*GA. The responsibility for enrolment of members, for processing and approving of claims rests with D*GA. ?I/ in turn receives premiums from D*GA annually and pays them a lumpsum on a monthly basis for all claims reimbursed. Social Insurance or $andator! ealt insurance sc e$es or "overn$ent run sc e$es @na$el! t e &SIS* C,HSA Docial insurance is an earmarked fund set up by government with explicit benefits in return for payment. It is usually compulsory for certain groups in the population and the premiums are determined by income "and hence ability to pay# rather than related to health risk. The benefit packages are standardi;ed and contributions are earmarked for spending on health services The government$run schemes include the /entral

8overnment :ealth Dcheme "/8:D# and the *mployees Dtate Insurance Dcheme "*DID#. Insurance offered b! N,Os 7 co$$unit!-based ealt insurance /ommunity$based funds refer to schemes where members prepay a set amount each year for specified services. The premia are usually flat rate "not income$related# and therefore not progressive. %aking profit is not the purpose of these funds, but rather improving access to services. -ften there is a problem with adverse selection because of a large number of high$risk members, since premiums are not based on assessment of individual risk status. *xemptions may be adopted as a means of assisting the poor, but this will also have adverse effect on the ability of the insurance fund to meet the cost of benefits. /ommunity$based schemes are typically targeted at poorer populations living in communities, in which they are involved in defining contribution level and collecting mechanisms, defining the content of the benefit package, and J or allocating the schemes, financial resources Duch schemes are generally run by trust hospitals or nongovernmental organi;ations "?8-s#. The benefits offered are mainly in terms of preventive care, though ambulatory and in$patient care is also covered. Duch schemes tend to be financed through patient collection, government grants and donations. Increasingly in India, /7:I schemes are negotiating with the for$profit insurers for the purchase of custom designed group insurance policies. :owever, the coverage of such schemes is low, covering about 06$96 million indicates that many community$ based insurance schemes suffer from poor design and management, fail to include the poorest$of$the poor, have low membership and require extensive financial support. -ther issues relate to sustainability and replication of such schemes. Central ,overn$ent Healt Sc e$e @C,HSA Dince +391, all employees of the /entral 8overnment "present and retired#; some autonomous and semi$government organi;ations, %4s, Audges, freedom fighters and Aournalists are covered under the /entral 8overnment :ealth Dcheme "/8:D#. This scheme was designed to replace the cumbersome and expensive system of reimbursements (GOI, !!"). It aims at providing comprehensive medical care to the /entral 8overnment employees and the benefits offered include all outpatient facilities, and preventive and promotive care in dispensaries. Inpatient facilities in government hospitals and approved private hospitals are also covered. This scheme is mainly funded through /entral 8overnment funds, with premiums ranging from s +9 to s +96 per month based on salary scales. The coverage of this scheme has grown substantially with provision for the non$allopathic systems of medicine as well as for allopathy. 7eneficiaries at this moment are around 102 666, spread across 22 cities. The /8:D has been critici;ed from the point of view of quality and accessibility. Dubscribers have complained of high out$of$pocket expenses due to slow reimbursement and incomplete coverage for private health care "as only ,6C of cost is reimbursed if referral is made to private facility when such facilities are not available with the /8:D#. &$#lo!ee and State Insurance Sc e$e @&SISA

The enactment of the *mployees Dtate Insurance Act in +31, led to formulation of the *mployees Dtate Insurance Dcheme. This scheme provides protection to employees against loss of wages due to inability to work due to sickness, maternity, disability and death due to employment inAury. It offers medical and cash benefits, preventive and promotive care and health education. %edical care is also provided to employees and their family members without fee for service. -riginally, the *DID scheme covered all power$using non$seasonal factories employing +6 or more people. .ater, it was extended to cover employees working in all non$power using factories with 26 or more persons. Ghile persons working in mines and plantations, or an organi;ation offering health benefits as good as or better than *DID, are specifically excluded. Dervice establishments like shops, hotels, restaurants, cinema houses, road transport and news papers printing are now covered. The monthly wage limit for enrolment in the *DID is s. = 966, with a prepayment contribution in the form of a payroll tax of +.59C by employees, 1.59C of employees! wages to be paid by the employers, and +2.9C of the total expenses are borne by the state governments. The number of beneficiaries is over 00 million spread over =26 *DI centres across states. @nder the *DID, there were +29 hospitals, 12 annexes and + 196 dispensaries with over 20 666 beds facilities. The scheme is managed and financed by the *mployees Dtate Insurance /orporation "a public undertaking# through the state governments, with total expenditure of s 0 066 million or s 166J$ per capita insured person. The *DID programme has attracted considerable criticism. A report based on patient surveys conducted in 8uAarat found that over half of those covered did not seek care from *DID facilities. @nsatisfactory nature of *DID services, low quality drugs, long waiting periods, impudent behaviour of personnel, lack of interest or low interest on part of employees and low awareness of *DI procedures, were some of the reasons cited.

Healt insurance initiatives b! State ,overn$ents In the recent past, various state governments have begun health insurance initiatives. Bor instance, the Andhra 4radesh government is implementing the Aarogya aksha Dcheme since 2666, with a view to increase the utili;ation of permanent methods of family planning by covering the health risks of the acceptors. All people living below the poverty line and those who accept permanent methods of family planning are eligible to be covered under this scheme. The 8overnment of Andhra 4radesh pays a premium of s 59 per acceptor. The benefits to be availed of, include hospitali;ation costs up to s.1666 per year for the acceptor and for his J her two children for a total period of five years from date of the family planning operation. The coverage is for common illnesses and accident insurance benefits are also offered. The hospital bill is directly reimbursed by the Insurance /ompany, namely the ?ew India Assurance /ompany. The 8overnment of 8oa along with the ?ew India Assurance /ompany in +3,, developed a medical reimbursement mechanism. This scheme can be availed by all permanent residents of 8oa with an income below s 96 666 per annum for hospitali;ation care, which is not available within the government system. The non$ availability of services requires certification from the hospital 'ean or 'irector :ealth Dervices. The overall limit is s 06 666 for the insured person for a period of one year.The aim of the proAect was to develop and test a model of community health financing suited for rural community, thereby increasing the access to medical care of

the poor. The beneficiaries include the entire population of these blocks. The premium is s 06 per person per year, with the 8overnment of (arnataka subsidi;ing the premium of those below poverty line and those belonging to Dcheduled /astesJ Dcheduled Tribes. This premium entitles them to hospitali;ation coverage in the government hospitals up to a maximum of s 2 966 per year, including hospitali;ation for common illnesses, ambulance charges, loss of wages at s. 96 per day as well as drug expenses at s 96 per day. eimbursements are made to an insurance fund which has been set up by the ?8- J 4 I with the support of @?'4. The 8overnment of (erala is planning to launch a pilot proAect of health insurance for the 06C families living below the poverty line. The scheme would be associated with a government insurance company. /urrently, negotiations are under way with the I A to seek service tax exemption. The proposed premium is s 296 plus 9C tax. The maximum benefit per family would be s 26 666. The amount for the premium would be recovered from the drug budget " s +66#, the 4 I " s +66# and from the beneficiary " s =2.96# while the benefits available would include cover for hospitali;ation, deliveries involving surgical procedures "either to the mother or the newborn#. Instead of payment by the beneficiary, Dmart /ard facility would be offered. This scheme would be applicable in 2+= government hospitals.

TY%&S O' H&()TH INSUR(NC&:A quality healthcare is a challenging process. It!s a critical issue whose importance is recogni;ed in all the aspects of a society. 7efore opting for health insurance plan, the need is to make a good research because both private players and government organi;ations are competing with each other in order to attract the maximum customers, thus creating an overall confusion with a wide range of plans. :ealth insurance estimates the overall risk involved in healthcare expenses and develops a routine finance structure of monthly premium and annual tax, ensuring that the money will be made available as per the insurance agreement. 8enerally, people of higher age prefer these plans. 7ut it is also important for younger generation to start planning for their future in order to lead a financially secure life in the later years. There are different types of health insurance plans ,rou# Insurance %lan 8roup insurance offers medical insurance to the groups like employees of a company, members of an association or a co$operative society and so on. Individual Insurance %lan Individual insurance caters to the special needs of the individuals. 4remium is comparatively high for this kind of insurance. 'loater Insurance %lan Bloater plan can be availed individually or by all the members of the family. It provides single premium for the entire family

:ealth insurance plans can be furthe categori;ed asE

%ed claim 4olicy 4ersonal Accident $ Individual 4ersonal Accident $ Bamily Insurance for 8roup Accident <an Arogya 7ima 4olicy 7havishya Arogya 4olicy "Insurance for senior citi;ens# Traffic Accident 4olicy -verseas %ed claim 4olicy

Ho4 to Save 3one! on Healt Insurance

:ealth insurance premiums are becoming a larger and larger portion of the typical /olorado family)s budget. Bor most, the rate of increase is not sustainable > but what do you doH It would be unwise to go without health insurance coverage, but something has got to change. :ere are five steps that you can take to save money on your health insurance premiums "andJor reduce other health$related expenses#E Ste# 1 /onsider taking a prudent risk by going with a higher deductible health plan. 'oing so can save you hundreds "or even thousands# of dollars per year. *very dollar saved can pay Tfirst dollarU benefits "i.e. co$pays andJor deductibles# if needed. And, if you don)t need to spend it on health care, it is pure savings. In addition, the purchasing power of these saved dollars is increased by 16C to 96C if the savings is invested "passes through# a tax advantaged account such as an Ste# . /onsider participating in your employer)s health insurance plan if you are eligible. As a general rule, employers in /olorado are required to subsidi;e Temployee onlyU premiums by at least 96C. This, combined with the fact that you can pay your portion of the premium with pre$tax dollars via payroll deduction, results in a net price that generally can)t be beat in the individual health insurance market. I%4- TA?T ?-T*E Always seek out professional advice before ditching your individual health plan for group coverage. There are some circumstances where the individual coverage may be better for you even if it is more expensive "in the short term#. Also, while it may be cheaper for you to hop on your employer)s plan, many times purchasing individual health insurance for your dependents is a better value. Ste# : I have already hinted at this twiceVmake sure that you are being Ttax smartU when considering your health insurance options. If you are an individual looking for private insurance, consider an :DA 4lan "a less expensive, high deductible plan combined with a tax advantage savings account#. If you get your health insurance through your employer, make sure that you are paying your portion of premiums with pre$tax

dollars via payroll deduction. Ghile this doesn)t really save you money on your health insurance premiums directly, it does reduce your tax burden increasing your take home pay. If your employer does not offer Tpre$tax deductionsU tell them to call us because these Tpre$tax plansU save them money tooW Ste# ; If you have maintenance prescriptions, consider buying them through your insurance company)s mail order pharmacy. %ost mail order pharmacies will permit you to purchase a 36$day supply of your prescription medications for the same co$pay you would pay for a 06$day supply at a traditional pharmacy. %ost doctors are familiar with this process and are more than happy to accommodate you by writing a modified prescription. In addition, always remember to ask your doctor about generic alternatives "most plans have lower co$pays for generic drugs vs. brand names#. Ste# < If you have a life or limb threatening inAury, by all means, go to the emergency room "* #. 7ut for other milder conditions, avoid the * if you can. %ost * docs will tell you that as many as 59C of the cases they see could have been handled by a less expensive urgent care center instead. The co$pays for emergency rooms can be 2$9 times as expensive as an urgent care clinic. In addition, * s will always prioriti;e cases "as they well should# which could mean for long waits for patients with milder conditions.

TY%&S O' RIS5 IN/O)/&D I H&()TH INSUR(NC&:The si;e of the company, type of industry, type of organi;ational structure, capitali;ation, geographical area, management team, degree of experience and expertise in the targeted business, capitali;ation, competitive environment and many other factors can have a bearing on the risk environment for the company. The business owners should address such issues in their business and strategic analyses of the company)s situation. A few of the potential operational risks are as followsE +. isk of 4roperty 'amage 2. isk of Inventory .oss or 'amage "through spoilage, etc.# 0. isk of .oss from *mployee Theft 1. isk from Narious .iabilities "including inAuries to customers or to others# 9. isk from *rrors and -missions .iabilities =.7usiness interruption isks -ther risks involve the business)s employees and may call for optional or mandatory

insurance coverageE +. Gorker)s compensation 2. @nemployment 0. *mployee benefits

:. 'R(UDS (ND SC(3S IN H&()TH INSUR(NC& S&CTOR:'R(UDS:An insurance claim prepared with the intention to deceive, conceal or distort relevant information that eventually accounts for health care benefits for an individual or a particular group is defined as fraudulent health insurance claim. Brauds can be committed by anybody M either by a policyholder, a healthcare provider or even its employees. Brauds committed by a policyholder could consist of members that are not eligible, concealment of age, concealment of pre$existing diseases, failure to report any vital information, providing false information regarding self or any other family member, failure in disclosing previously settled or reAected claims, frauds in physician)s prescriptions, false documents, false bills, exaggerated claims etc Brauds by :ealthcare 4rovider or its employees include preparation of bogus claims by fake physicians, billing for products or services not rendered, exaggerated claims submission, billing prepared for higher level of services, modifications or alterations made in submission of claims, change in diagnosis of the patient, fake documentation, and fraud committed by the employees of a hospital or any other healthcare products in order to make a quick buck.Braudulent and dishonest claims are a maAor morale and a moral ha;ard not only for the insurance industry but even for the entire nation)s economy. /oncrete proof as evidence including documentation, statements made by the policyholder and his family members and even neighbors are taken into consideration. &ssential Co$#onents of 'raud:The essential components of fraud include intention to deceive, derive benefits from Insurance industry, preparation of exaggerated or inflated claims or medical bills and malafide intention to induce the firm to pay more than it otherwise would. 'evising innovative methods and tactics including pressure tactics, favoritism, nepotism etc form a part of fraud which is a ha;ard growing by leaps and bounds since the last

decade.To establish that a fraud has been committed requires furnishing of relevant proof. An in$depth analysis of the policyholder)s intention may also be taken into consideration.

SC(3S:An Indian American has been sentenced to ,+ months in prison and asked to pay @D' 3.5 million in restitution along with his accomplices for his role in the @D' +, million health insurance scam. Duresh /hand, 1=, had pleaded guilty on Deptember 2, 2663, to one count of conspiracy to commit healthcare fraud and one count of conspiracy to launder money in %edicare Braud Dcheme. The 'epartment of <ustice and :ealth and :uman Dervices said between <anuary 2660 and %arch 2665, /hand and his co$conspirators submitted claims to the %edicare programme totaling more than @D' +, million for physical and occupational therapy services that were never provided. %edicare actually paid approximately @D' ,.9 million on those claims, a statement said. According to court documents, /hand owned and controlled a company operating in Garren called /ontinental ehab Dervices Inc "/ D#, which purported to provide physical and occupational therapy services to %edicare beneficiaries. :e later started another corporation at the same address in Garren called 4acific %anagement Dervices Inc "4%#, which also purported to provide physical and occupational therapy services to %edicare beneficiaries. /hand admitted that, beginning around <anuary 2660, he and his associates at / D, and later 4%, began to create fictitious therapy files, appearing to document physical and occupational therapy services provided to %edicare beneficiaries, when in fact no such services were provided. The fictitious services reflected in the files were billed to %edicare through sham %edicare providers controlled by /hand and two of his co$ conspirators. In his plea, /hand admitted that in order to create the fictitious therapy files, he and his co$conspirators recruited and paid cash kickbacks and other inducements to %edicare beneficiaries, in exchange for the beneficiaries) %edicare numbers and signatures on documents falsely indicating that they had visited / D or 4% for the purpose of receiving physical or occupational therapy. /hand acknowledged recruiting hundreds of %edicare beneficiaries for this purpose, and paying them for their signatures with cash and prescriptions for controlled substances, including Nicodin, Xanax and Doma. /hand and his co$conspirators obtained the prescriptions for these drugs from co$conspirator physician <ose /astro$ amire;, who prescribed controlled substances for beneficiaries he had never seen, for the purpose of recruiting those beneficiaries into the scheme. /hand also prepared fictitious therapy prescriptions and other documents, which when signed by /astro$ amire;, falsely indicated he had ordered and monitored physical or occupational therapy services that were provided to the %edicare beneficiaries. To complete the

fictitious files, /hand admitted that he and his co$conspirators obtained signatures from licensed physical or occupational therapists on Fprogress notesF and other documents in the therapy files, falsely indicating that the therapists had provided therapy services to the %edicare beneficiaries on those dates. /hand recruited a number of licensed physical and occupational therapists into the scheme, and paid these therapists a set fee per file that they helped falsify.

%R&/&NTION O' 'R(UDS (ND SC(3S:It has been observed that frauds pertaining to health insurance usually possess some sort of common trends or patterns. There are certain parameters that can be employed as a trigger to detect false claims or practices which have been enlisted belowE Insurance frauds usually have common profile and pattern. There are certain parameters which can be used as a trigger to detect or analyse fraudulent claims or practices. They are as followsE

Treatment costs are usually on the higher side as compared to the etiology. /ostlier investigations are more. 'iagnosis of the ailment and the investigations done are not much related to each other. 'uration of stay in the hospital is more at times. 4ost$operative histopathology reports are not available "surgical cases#. 'ocumentations are usually in order. %ore member re$imbursement claims from the partner providers of the T4A and insurance companies. In most fraudulent claims, the treating doctor, agents, ailments are the same. %edicine bills in serial order. 4atient residence and the hospital, chemist address, are not geographically same. Braud claimers are usually short term policy holders with lower sum insured. :igher per$patient cost. *xcessive per$doctor patients. :igher per$patient average visit numbers. :igher per$patient average medical tests. Bluctuating monthly claims of the providers.

;. (%O))O 3UNICH H&()TH INSUR(NC&

INTRODUCTION:The word !Apollo! and quality healthcare go together. It is a fact that is reiterated by the global healthcare experts and international accreditation. The Asia!s largest healthcare group, the Apollo 8roup of :ospitals has Aoined hands with %unich :ealth *urope!s leading re$insurers to form Apollo %unich :ealth Insurance /ompany. It is because of their partners that Apollo %unich :ealth says, TGe know :ealth. Ge know InsuranceU. 7oth these leaders work together to be the trusted partner in positive health and to provide innovative healthcare solutions to individuals. They work collectively on the philosophy of !.et!s @ncomplicated! to help Indian citi;ens to access quality care Apollo %unich :ealth Insurance /o. .td. is the new name for Apollo '(N Insurance /o. .td. The new name was officially announced today as the company embarks on the new re$branding exercise after receiving the required shareholder and regulatory approvals to change its name. The announcement of the !Apollo %unich! name is a significant milestone as the company is set to scale its business to garner a si;able share of the growing market for health insurance. :eadquartered in 8urgaon with an expanding national presence, Apollo %unich is a Aoint venture between Asia)s largest integrated healthcare provider, The Apollo :ospitals 8roup, and 8ermany based %unich e)s newest business segment, %unich :ealth.

S()I&NT '&(TUR&S:+. 4olicy is issued for a period of one year for an individual andJor family. 2. In a Bloater policy the entire family can be covered. As per the Terms and /onditions the family comprises of spouse, dependent children and dependent

parents. 0. Individuals from the age of 9 years onwards are covered under this policy. A child can be covered from the 3+st day provided if both parents are covered under this particular policy. The upper age limit for availing the *asy health insurance is 96 years. 1. easonable premium rates Tax implications under section ,6 ' of Income Tax Act. 4olicy holder can opt for the sum insured during the /ritical Illness 9. /ritical Illness cover pay the specific amount, only ifE +. A policy holder is diagnosed against the mentioned /ritical Illness during a policy period 2. :eJshe survives for at least 06 days after the start of diagnosis. 'iseases coveredE /ancer, Birst :eart Attack, Dtroke, 4aralysis, /oronary artery surgery, (idney failure, multiple sclerosis and maAor organ transplantation. 7ut, there is no payment made if the policy holder has already once made the claim for the same critical illness, a claim has been made thrice under the same plan and if an policy holder is diagnosed from a /ritical Illness within 36 days of the day policy begins and heJshe has not been insured continuously under the *asy :ealth plan.

%ROC&DUR& 1&'OR& CHOOSIN, (N %)(N :It is crucial for every human being to have a health insurance policy. There are two maAor factors that attract an individual while purchasing a plan. These are health benefits and an individual!s budget. 7ut, in order to make more informed decision, there are several factors to be considered. Dome of maAor ones are$

4remium amount$$ &ou have to decide the maximum amount, you can pay. In addition, keep an eye over deductibles, co$payments, exclusions and co$ insurance requirements. Blexibility$$ Dome insurer do not offer flexibility to the insured to select the doctor or hospital on their own. It is always better to stay away from these plans. There are companies that provides you the list of hospitals where you can avail cashless and quality care services, but in addition, also gives you a flexibility for treatment in non$network hospital. /overage limit$$ /hoose the plan that fulfills your healthcare needs and provide maximum cover. Bamily coverage$$ Though it might cost a bit more than an individual plan but has more number of associated benefits that will help you to save a lot on your medical bills. eviews and feedback$$The company!s update gives you a better picture of its financial structure and in turn, an idea to you, whether to invest or not.

1&N&'ITS O' (%O))O H&()TH INSUR(NC&:

. In$patient treatmentE This includes all hospitali;ation expenses. 4re$hospitali;ationE Through this the insured is eligible for lump sum amount equivalent to +C of admissible claim amount towards pre$hospitali;ation expenses. 4ost$hospitali;ationE Through this the Insured is eligible for lump sum amount equivalent to +C of admissible claim amount towards post$hospitali;ation expenses. 'ay$/are proceduresE This provides the insured with the cover for the medical expenses for +16 'ay$care procedures which do not require 21 hours hospitali;ation due to technological advancement. -rgan 'onorE This entitles the insured for the medical expenses incurred for an organ donor)s treatment for the harvesting of the organ donated. AyushE The Insured can avail %edical *xpenses for in$patient Ayurveda, @nani, Diddha and :omeopathy treatment up to +6C of the Dum Insured

DISCOUNTS:a. A family discount of +6C can be availed if 2 or more members of a family are covered under the same policy on Individual sum Insured basis. b. .oyalty 'iscount of 9C on the renewal premium of the Insure :ealth 4olicy can be availed at the time of renewal, as a cross selling credit to buy any other Apollo '(N product within 0=9 days from the renewal date.

T&R3S O' R&N&6():Ge offer renewal unless the Insured 4erson or any one acting on behalf of an Insured 4erson has acted in a dishonest or fraudulent manner or any misrepresentation under or in relation to this policy or the 4olicy poses a moral ha;ard. S 3a-i$u$ ("e C %aximum cover ceasing age in this policy would be 59 years. S Cu$ulative 1onus C ?o cumulative bonus is offered under this policy. S 6aitin" %eriod - The Gaiting 4eriods mentioned in the policy wording will get reduced by + year on every continuous renewal of your Insure :ealth policy. S Rene4al %re$iu$from I 'A. enewal premium are subAect to change with prior approval

S Su$ Insured &n ance$ent C Dum Insured can be enhanced only at the time of renewal subAect to no claim have been lodgedJ paid under the policy. If the Insured increases the Dum Insured, no 4re 4olicy /heck$up will be required but the case will be subAect to medical underwriting. In case of increase in the Dum Insured waiting period will apply afresh in relation to the amount by which the Dum Insured has been enhanced. :owever the quantum of increase shall be at the discretion of the company.

3ISSION:

/onstantly introduce innovative :ealth Insurance and Gellness solutions that meet customer needs 7uild an organi;ation on the principles of transparency, trust and integrity /reate opportunity for our employees to learn and grow in an enAoyable work culture /onstantly deliver on our commitments to all the stakeholders

/ISION:To be the trusted leader in health insurance by providing innovative solutions to the citi;ens of India

C)(I3S %ROC&DUR&:All these products are well thought, planned and designed to provide coverage to people at various stage of their life. Apollo %unich :ealth Insurance /ompany issues a :ealth /ard to all its policy holders. This health card can be displayed at the time of treatment in network hospitals, which takes an individual away from the claim procedure. 7ut, if heJshe undergoes treatment in non$network hospitals, then the claim procedure comes into scenario. The claim can be raised against the amount paid for the medical expenses. If an individual wishes to claim reimbursement using a plan purchased, heJshe can follow the steps mentioned belowE$

/ontact the T4A or Apollo %unich :ealth Insurance /ompany "the toll free number would be mentioned on the back of the health card issued with the policy#. Dpeak to the representative about the about the incident, you met or about the treatment, you undergone. Tell him about every small detail related to the emergency "ambulance transportation, hospital name, expected duration of recovery, etc.#. :eJshe will assist in raising the claim or shall provide you the related information. An insured will need to submit several documents so that heJshe can claim the reimbursement. These include the claim form "downloaded form the /ompany!s website#, discharge summary, original bills, a photocopy of the Apollo %unich :ealth /ard and other documents, depending upon the

requirements of the plan, opted for. Apollo %unich!s online assistance or telephonic assistance would be able to direct himJher through all the forms and !proof of claim! that heJshe might require so that the claim is passed quickly and smoothly. -nce the duly filled form is submitted along with asked documents at the Third$4arty$Administrator "T4A#, Apollo %unich will settle the claim in specified number of working days, as per the /ompany!s terms and conditions.

%RODUCTS:Apollo %unich 4lans are designed by a team of experts after extensive market survey. The customer)s needs are kept as the focus point while creating each plan in the platter. The products offered by Apollo %unich areE

*asy :ealth 4lanE The *asy :ealth 4lan from Apollo %unich has been tailor$ made to suit a customer)s needs while availing good quality medical treatment. The plan also incorporates many preventive tips which enable a customer to find the right life$style and diet according to hisJ her daily needs and place of dwelling. *asy Travel 4lanE The *asy Travel 4lan is designed to take on all unexpected events while a person is traveling away from his hometown or place of residence. It takes into consideration all the requirements of the insured while heJshe is traveling. 4ersonal Accident 4lanE This plan has been created to fulfill all the necessities of a person after an accident. The plan incorporates transportation and travel allowances of a family while heJshe travels. The plan is made to ease the mental trauma a person faces in such situations. %aximaE India!s first 0=6 degree plan that incorporates both inpatient and outpatient care. It provides health check$ups for the insured. Anyone under the age of =9 can opt for this plan "life$long renewal is an option created specifically to keep you covered and safe through$out your life#. Insure :ealthE Apollo %unich!s easy$to$buy health insurance policy that has been designed to bring health care within the reach of one and all. A simple form needs to be filled to buy this policy. %edical tests are not required for this policy, subAect to the company rule and regulations.

3&DIC)(I3 INSUR(NC&:Apollo %unich, a tie$up between the Apollo :ospitals 8roup and %unich :ealth, is a pure health insurance company in India. Apollo %unich has brought numerous health insurance plans, travel plans and accidental plans, looking into the significance of medical treatment in case of exigency. These plans make the treatment affordable.

S&R/IC&S:Apollo %unich offers a client an array of preventive services to take the fear out of faces, the Aargon out of words, the bitter out of medicines and the trouble out of treatment. The below stated services are offered to clients to evaluate their health and get medical advice from our doctors.

:ealthline <ust call at our toll$free number and tell your customer I' in order to reach our experts and avail their help or advice in several aspects, such as, primary consultation, individual referral, nutrition, diet, and health information. These services are available on :ealth line for free to our clients. They may be advised to augment their cover in the well being areas including wellness solutions and personali;ed services. /ashless hospitali;ation Apollo %unich offers you the facility of cashless hospitali;ation in more than 1666 hospitals in India. These hospitals are listed on the site and in the guidebook, which is received by every client along with the policy papers. &ou can get the treatment, up to the sum insured, for free in these hospitals. It can be either a planned or an emergency hospitali;ation. All the information regarding approval process is stated in the given guidebook. *ven if an individual undergo treatment, for the diseases covered, in non$network hospitals, heJshe can claim the reimbursement of the medical expenses incurred :ealth isk Assessment An insured is provided an access to online :ealth isk Assessment tool , which assists them to profile their health status. @sing this tool, they can get the personali;ed recommendation services on their lifestyle, diet and nutrition regimen from the team of physicians.

<. 'ORTIS H&()TH INSUR(NC&

INTRODUCTION:Bortis :ealth Insurance /ompany only offers health insurance. They do not try to provide other products, which they say lets them offer more focused and attentive service. :igh quality coverage and superior service being the ultimate goal. Bortis :ealth Insurance /ompany offers plans for individuals, families and small groups. The needs of the customer are always at the forefront, so there are many options in coverage that allow customers to choose a policy that works well for them. Gith Bortis :ealth Insurance /ompany there is a combination of good service and great choice. Ghen you are shopping for health insurance both of these things are important this is why Bortis wants to make sure that you consider them when comparing insurance providers.Gith so many providers around the country, you may wonder how to determine if Bortis :ealth Insurance /ompany is the best choice for you. This article will give you information on the health insurance offerings that Bortis /ompany offers, and will give some suggestions for making this important decision. emember, no one health insurance company is the bottom line best in the business; the true question is if Bortis is the best one for you.

(R&(S O' H&()TH INSUR(NC&:If you are looking to place your insurance needs in a new company, Bortis :ealth may be right for you. Gith roots going back to +,32, Bortis :ealth is the company whom over one million people look to for insurance. Dome of the areas of Bortis health insurance includeE

Individual :ealth Insurance Bamily :ealth Insurance Dhort Term :ealth Insurance Dmall 7usiness :ealth Insurance

Dtudent :ealth Insurance 'ental Insurance

?ot only has Bortis :ealth been providing customers with insurance for over +66 years, but the company is very involved in the community, giving grants and donations to educational and non$profit organi;ations. Nolunteering and mentoring is a priority with Bortis :ealth, so when you get insurance through Bortis :ealth, you can know that you are giving back to the community as well.

1&N&'ITS:Gith the plans offered from Bortis :ealth Insurance /ompany you will get a range of benefits. /an they meet your needs and price rangeH :ere are some of the benefits that may make a difference in your life. No Referrals:- &ou will never need a referral under any Bortis plan. eferrals are not

required for any service covered under the plan. This is a great freedom since so many insurance companies make referrals a mandatory part of their plans. It also saves you an added co$pay and the time involved in visiting your primary provider. &ou will never need a referral under any Bortis plan. eferrals are not required for

any service covered under the plan. This is a great freedom since so many insurance companies make referrals a mandatory part of their plans. It also saves you an added co$pay and the time involved in visiting your primary provider. 6orld 6ide. The Bortis plans also provide world wide coverage. This is a great peace of mind if you travel often, especially to different countries. &ou are always assured that your medical coverage is handled when you have a Bortis plan. 1 Year ,uarantee. The first year)s rate of a Bortis plan is always guaranteed. &ou will not have to worry about skyrocketing costs once you sign on because you will have the rate you were given for at least the whole first year of coverage. %rovider C oice. &ou also get a choice of doctors and hospitals under every Bortis plan. &ou will be able to choose the doctor you want to handle your care instead of have dictated to you who you can and can not see. There are many factors you are going to consider when you are shopping around for a health insurance provider. The benefits explained here are some of the top things that

people are looking for in an insurance provider. Bortis claims that they work hard to stay on top by making sure all your needs are handled, even before you are a customer.

%lan O#tions 'ro$ 'ortis Healt Insurance Co$#an!

Bortis :ealth Insurance /ompany is not shy abut offering choices in different plans. They also strive to offer more than choice with their variety of plan options. Dome of the plan choices from Bortis includeE
Dpecial

plans M long term, short term, self employed, student, international plans plans

?etwork

Traditional :ealth

Davings Accounts ":DA#

The special plans listed above are why many people are drawn to this company. Gith comprehensive coverage options, Bortis :ealth Insurance /ompany provides variety and choice which allows them to serve a large range of customers. It is also quite easy to get information on what Bortis plans offer because of their friendly and informative customer service and well maintained website, which are also tools you will be able to use as a customer of the company. Bortis 7enefits Insurance /ompany against competing firms in the %edical Dervice, Accident and :ealth Insurance 4lans industry worldwide. The results are two speciali;ed reportsE "+# global financial benchmarks using common$si;e statement ratios "vertical analysis#, and ; "2# labor productivity and utili;ation measures collected across borders. Binancial 8ap Analysis :ow does Bortis 7enefits Insurance /ompany)s balance sheet structure differ from global benchmarksH 'oes Bortis 7enefits Insurance /ompany hold more cash and short$term assets, or does it concentrate its assets in physical plant and equipmentH 'oes it have a higher percent of payables compared to the benchmarksH 'oes it hold a higher concentration of long$term debtH 'oes Bortis 7enefits Insurance /ompany have a relatively higher cost of goods sold, operating costs, income taxes, or profit

margins compared to global benchmarksH Intended for consultants and other strategic planners, this study goes beyond traditional gap analyses by considering firms competing in the same economic sector based on a sample drawn from numerous countries and gives do;ens of statistical benchmarks, and some 06 graphs summari;ing a statistical gap analysis. .abor 8ap Analysis Are workers at Bortis 7enefits Insurance /ompany productiveH There is no absolute answer to this economic question. The second forward$looking study considers how labor deployment and productivity indicators for Bortis 7enefits Insurance /ompany differ from the global benchmarks. It looks at the amount of labor required to operate Bortis 7enefits Insurance /ompany and the resulting return on human investment. Ghat is the ratio of short$term and long$term assets to employeeH Ghat are comparative capital$labor ratiosH Ghat are the average sales and net profits per employee in Bortis 7enefits Insurance /ompany compared to benchmarks from the same economic sector. Dualit! 'ocus and (ccreditations Bortis :ealthcare has been at the forefront of providing quality healthcare services and has raised the bar of quality standards in the country. The hospitals employ renowned medical talent at par with the best in the world. Dome of these doctors are American 7oard /ertified. 'ue to its excellent quality care and safety for patients, Bortis :ospital %ohali has received the highly respected </I accreditation "<oint /ommission International#. </I is the largest accreditor of healthcare organi;ations in the @nited Dtates. In addition to this, four Bortis hospitals have received ?A7: accreditation, the highest national recognition for quality patient care and safety. These include hospitals in ?oida, <aipur, %ohali and *scorts :eart Institute in ?ew 'elhi. 7lood 7anks at Bortis :ospital ?oida and *scorts :eart Institute and Bortis Blt. .t. aAan 'hall :ospital, Nasant (unA have also been awarded ?A7: accreditation by Ruality /ouncil of India. 4atient /entricity, excellence in medical delivery, empathy, care and compassion are the guiding principles at Bortis. This is reflected in every aspect of the company beginning from architecture, processes, larger than average bed$to$floor space ratio, nurse to patient ratio, front office staff to name a few. Bor its patient centric design, Bortis :ospital, %ohali, has been awarded the American Institute of Architecture Award, for the best hospital design. Standardi0ed O#eratin" S!ste$ eali;ing the need to standardi;e non$clinical processes which impact patient experience directly during their stay at any of the group)s hospital, Bortis introduced standardi;ed operating system called B-D "Bortis -perating Dystem#. It is imperative that patients experience similar service levels irrespective of the hospital they visit within the group. B-D was conceived and implemented with an obAective to increase efficiency in non clinical processes and thereby increasing patient satisfaction in various departments like -4's, 4:/s, -Ts, *mergency, adiology etc. The core team on the proAect focuses on achieving performance difference with an aim toE

S Improve efficiency by making changes on processes and benchmark them to best in the industry S /reate manuals for each process so that they are repeatable, reliable and replicable S /reate next generation leaders for the organi;ation The company)s :ID ":ospital Information Dystem# incorporates an *lectronic 4atient ecord "*4 # or 4icture Archiving I /ommunication Dystem facilitating quick access to patient information and consequently speedier diagnosis. The seamless :ID allows patient consults at any facility with access to patients reports online.

CURR&NT S&N&RIO:S /ompany)s green field multi$specialty hospital in Dhalimar 7agh is will be operational in B&+6. S Bortis International Institute of 7io$%edical Dciences "BII7%D# at 8urgaon, a seven$star multi super$ specialty flagship hospital is under construction. Bortis %ohali, is the region)s leading multi$speciality hospital, with a super$speciality in :eart. The world$class environment is nurtured by an affiliation with one of the world)s leading health delivery systems$ 4artners :ealth/are Dystem Inc. "4:D#, @DA. The affiliation facilitates B:.)s access toE clinical protocols, quality assurance, criteria for accreditation in accordance with @D hospital standards besides training material for staff and recommendations concerning critical medical equipment. Bortis %ohali)s emergence as a premier super$speciality facility in ?orth India has been underlined by the accomplishment of numerous high$end procedures such asE /ardiac e$ %odeling; 4ediatric Arterial Dwitch operation, Aortic Aneurysms; (idney Tumour removal to cite a few. Gith the addition of the *scorts :eart Institute and esearch /entre, Bortis :ealthcare .imited today runs amongst the largest /ardiac 4rogram in the world with over =666 surgeries, 9666 Angioplasties and +1666 angiographies on an annual basis. The competencies of the two systems Aointly will help in enhancing service delivery capability and set benchmarks for the way healthcare is delivered in India. Bortis :ealthcare .td. is fast establishing a maAor presence within the ?ational /apital egion of 'elhi. In a span of one year the new 096$bed Bortis :ospital in ?oida, has become India)s leading tertiary care hospital in -rthopaedics and ?euro Dciences. This is possible because of our doctors $ 'r Ashok aAgopal, one of India)s most experienced -rthopedic Durgeons who performed +666 Durgeries in the first year and 'r A. (. Dingh, 'irector$ ?euro Dciences who is credited to being amongst the first in performing many critical procedures. Bortis :ospital ?oida also provides tertiary treatment in key specialities such asE enal Dciences; 8enito$urinary diseases; gastrointestinal diseases as well as many other disciplines. In Aust about five years since the first hospital, Bortis :ospital .imited is rated amongst top two in India in terms ofE /ardiac 4rocedures, Total (nee eplacement,

Total :ip eplacement and in ?euro Dciences. 7esides cutting edge surgeries are performed in /osmetology, -phthalmology, 'ental, *?T, -ncology, %inimal Invasive Durgery, Gomen I /hild :ealth to name a few within the 8roup :ospitals.

>. CH())&N,&S '(C&D 1Y H&()TH INSUR(NC&:-ver the last few decades, the Indian population has experienced great advances in its health situation. Bor instance, life expectancy at birth increased from 96 years in +356 to an estimated =2 years in +339 and is possibly even greater now. Infant mortality rates have fallen as well, from +05 per +,666 live births in +356 to =3 per +,666 live births in +33+ "Gorld 7ank +339#. These are substantial improvements, but much remains to be done, relative to some its neighbors as well in terms of reducing differences in performance across states and socioeconomic groups. Bor instance, /hina has done much better, with its life expectancy at birth hovering around 56 years, and India)s neighbour, Dri .anka, has a life expectancy of nearly 50 years "Gorld 7ank +335#. 7oth countries have much lower infant mortality rates as well, and in the case of Dri .anka, less than one$quarter that of India. Again, (erala has infant mortality rates below those in /hina, but states such as %adhya 4radesh, -rissa and aAasthan have infant mortality rates of well over +66 per +,666 live births in rural areas "'re;e and Den +339; %ahal, Drivastava and Danan 2666#. Dimilarly, in rural India, the infant mortality rates among the top two income quintiles are nearly 01 $ 96 per cent lower than the rates reported for the bottom two quintiles. + Dubstantial differences in life expectancies at birth are present across states and socio economic groupings "'re;e and Den +339#. Another issue of concern is the growing prevalence of chronic illness in the Indian population, such as obesity, heart disease, diabetes, hypertension and the like. This has partly to do with changing dietary habits, from coarse grain to energy rich diets of meat, milk products, and sugar. Risin" %re$iu$s ising health insurance premiums are one of the toughest challenges facing the industry today. The cost of providing health benefits to employees is outpacing what employers are able to budget. The gap between the cost of health care and what companies budget for employee benefits has been increasing every year. Increasin" Dru" Costs 'rug prices continue to rise at double$digit rates. According to industry reports, drug costs increased by over +9 percent in the past year. Burther, drug costs for specialty drugs, or inAectable medications and biopharmaceuticals, increased by over 0, percent. These new and more expensive biopharmaceuticals are being introduced at record levels. In +33=, only +9 percent of all medications approved by the B'A were

biopharmaceuticals. Today, these drugs represent about half of all new drugs approved. Another contributing factor to the increase in drug costs is promotional spending, most notably direct$to$consumer marketing efforts by the pharmaceutical companies. )ess 3e$ber Cost S arin" there is a widening gap between what health plan members actually pay for health services and the actual costs of those services. Increases in total health care costs have outpaced the increase in employee out$of$pocket costs over the past several years. (n ("in" 6or+force The workforce is getting older. 7y 266,, it is estimated that the number of people over the age of 96 will grow to 11 million $ over a 96C increase since 2666. As the baby boomer generation gets older, utili;ation of health care services will continue to rise. (dvances in 3edical Tec nolo"! Advancements in medical technology can help us lead longer and more productive lives. 7ut, these advances also lead to higher medical costs. According to the B'A, the number of approved medical devices has risen +0 percent a year since +333. These new devices create new demand $ for example, drug$eluting stents to treat heart disease are expected to triple in use by 266,. 5ee#in" %ace 6it t e Consu$er 7ecause of the internet, consumers are taking a more active role in many of the purchases they make, including health care. According to a 4ew Internet and American .ife 4roAect 2660 report, nearly 30 million Americans $ roughly half of all adults and ,6 percent of adult internet users $ have searched the internet for health$ related information. -f those seeking health information on$line, three$quarters report that the internet has improved the quality of their health information, making them smarter consumers when seeking medical treatment. Dualit! of $edical in#uts in India These problems with quality have to do with a lack of well$defined laws, and where such laws exist, their poor enforcement, whether on account of Audicial delays or because of low levels of self$regulation by the medical community. It presents legislation related to the maintenance of quality standards in medical inputs such as drugs, medical personnel, and medical infrastructure. Typically, the legislation with respect to medical personnel involves the setting up of bodies "or councils# that oversee the maintenance of quality in new entrants to the profession, maintenance of membership records of the profession and, through codes of conduct and sanctions, maintenance of standards among existing members. Although quite widespread and covering all the Indian states, the record of these councils in ensuring continued good behaviour is quite poor "<esani, Dinghi and 4rakash +335#. %oreover, there is other evidence of problems in that many practitioners of traditional systems practice modern "allopathic medicine# without any sanctions. There is no premium on continuing education or examination on those who already possess a medical degree. The problem with quality control legislation is somewhat more acute in the case of health infrastructure. @ntil recently, the only relevant legislation was the ?ursing :ome egistration Act in a small group of states such as 'elhi, %aharashtra and

7engal The focus of these laws is primarily on registration of facilities, although the 'elhi legislation specifies quality standards for these facilities "?abhi 4ublications 2666, p. +2#. In any event, the enforcement of even these laws has been poor; records of private facilities are generally incomplete and the few existing studies typically find substandard facilities, understaffing and low quality of care provision. There was no law with respect to diagnostic centers until recently "in fact, the 'elhi Dhops and *stablishments Act specifically excludes medical facilities "?abhi 4ublications 2666##. ?ow, however, at least in a proposed 'elhi 4rivate %edical *stablishments TActU "Aggarwal and /haudhri +33,# would also seek to impose quality standards on diagnostic centres limited, of course, to the state of 'elhi.

%olic! C allen"es /learly maAor concerns exist in all three areas of health policy that have been highlighted earlier M in the overall costs of care, financial equity and the quality of care. A sustained improvement in these areas would play a significant role in advancing the primary goal of health policy M health, itself. The government could essentially adopt one of two methods to address these issues. The first option is to do not#ing at all beyond what it has already done. This, unfortunately, does not imply an unchanged situation. Birst, the Indian health sector would have to contend with the emergence of the private health insurance sector, given the passage of the Insurance egulatory and 'evelopment Authority "I 'A# 7ill. Decond, over the longer run, it would have to contend with an aging population and the increasing burden of expensive chronic illnesses, such as cancer, diabetes and heart disease, with substantial implications for the health budgets of the poor and of the government. we assess the potential impact of the entry of private health insurance on theobAectives of cost$containment, financial equity, and quality. The existing regulatory regime relating to private health insurance in India is also evaluated, and suggestions made for appropriate changes in it to ensure that private health insurance works to promote the various "intermediate# goals of health policy. Ge do not focus on the problem of the increasing prevalence of chronic illness, mainly because that calls for a whole new study, but note that it will serve only to highlight even further the importance of cost$ containment, equity and health insurance. If, as one suspects, the spread of the private health insurance sector, even a well$regulated one, is unable to address all of these policy challenges effectively, then other options will need to be considered. In its search for alternatives, India, in fact, is in the fortunate situation of being able to learn from a number of health system experiments that havetaken place in differentcountries around the world Dection 0 of this report, we examine and evaluate these country experiences with process of reforms and outline their main lessons for Indian policymakers.

E. 'UTUR& O' H&()TH INSUR(NC& IN INDI(

This 4/ wants to inform tomorrow)s health systems. %any countries in Asia and Africa are experiencing rapid changes that affect health$related needs. Issues such as ageing, urbanisation are putting new pressures on health systems and :IN is leading to a new pattern of need and use of health services. There is a growing dissatisfaction with the health services established in the post$ colonial or post$revolutionary period and :ealth is rapidly rising up the list of national priorities for governments in a number of countries. This has created a unique window of opportunity for health system change. The response will influence health systems for many years. The aim of the B:D 4/ is to support efforts to make the best use of this opportunity. -ur research is based on the following premises which will affect future health systemsE

@nregulated markets will not provide appropriate, cost$effective health services but the relative roles of markets, civil society organisations and the state in new kinds of health partnerships will vary between contexts. The increased availability of medical knowledge, trained and untrained health services providers and drugs has created new opportunities and challenges for individuals, communities and governments. Docial changes associated with marketisation and globalisation are leading to new patterns of poverty and vulnerability which require new approaches to social protection and health finance. ?ew technologies provide new opportunities for health system development with different impacts of different social groups. ?ew ideas and innovations will increasingly emerge in societies that are experiencing rapid economic and social change and research has an important role to play in identifying and assessing the impact of these innovations. *ffective policy adaptation to rapid change is neither Ttop$downU nor Tbottom$ upU but combines local innovations and macro$policies in a continuing process of institution building.

Initiating stand alone health insurance companies is a recent development in India, which is expected to boost the penetration of health insurance ":I# in the country. /urrently less than +C of the population is covered under commercial health insurance in comparison to almost =6$=9 C in developed countries. It is expected that with greater penetration of :I, the access to health care will also increase. .ack of credible data and expertise in :ealth Insurance is expected to be fulfilled by such a development. ecommendations of the sub committee at I 'A on Dtand Alone :ealth Insurance companies has also recommended lowering of capital requirements from s. +66 crores to s. 96 crores, as well as increasing Boreign 'irect Investment over the existing 2=C cap.

CURR&NT S&N&RIO:In a large diverse and complex country like ours, no single health insurance model can be successfully implemented. Ge have to also address community$ based small :%-s, but without the burdensome minimum capital requirement currently in force by the regulators. There may also be need for regulation for the self$funded health plans by maAor employers who may not find insurance as a cost effective alternative. I 'A has done well to come out with the regulations regarding T4As. The issues associated with the entry of T4As in India have been dealt with in the subsequent section of this document. :owever, apart from T4As there are other areas in managed care that needs to be regulated as followsE

Accreditation of healthcare providers. :ealth scheme and policies disclosures. Adequacy of provider network. elationships with providers. 8rievance procedure. Ruality assessment. 4rivacy of medical information. eturns and reporting.

It is not an easy task to regulate health insurance. Dome countries including the @D had to launch war$like operation to unearth large scale frauds. %alpractices in health insurance range from excessive billing to exaggerating severity of hospital patient conditions. 4aradoxically, the medical professionals are resisting standardisation in treatment coding known as I/' and cost cutting measures for making the medical treatment affordable to the ailing. They tend to forget that the future growth of healthcare in a country like India would depend upon the development of health insurance model.

The need for support from the health domain membersJplayers and the ministry of health both at the centre and the state cannot be overemphasised. :owever given the state of affairs of regulations in the healthcare sector in India, it is doubtful whether full fledged insurance companies would like to take big strides into health insurance. :ealth sector needs to be regulated and reformed to make healthcare risks manageable so that insurers may find it worthwhile to move into the sector in a big way.

F. 'INDIN,S
Dome of the leading insurance companies have come up with affordable health insurance policies. An affordable health insurance plan is designed to take complete care of the customer!s medical needs and requirements. There are certain benefits of an affordable health care insurance plan; it will secure your future. &ou will be relieved of meeting exorbitant expenses and other associated costs with an affordable health insurance policy. Ghatever your age is, you will need to insure yourselves with a health insurance policy and health care plan. Amongst the most affordable health insurance plans, like :ealth Advantage 4lus, :ealth 8uard and :ealth first deserve special mention. 7uying a health insurance plan online is the cheapest way of securing your health. &ou can purchase your policy online with the help of a quote. &our digitally signed document is available in your online account. &ou can access it whenever you want to. <ust log in to any of the popular health insurance website company, get a quote and purchase instantly. The premium is based on the amount of the coverage of the person and whether he is opting for individual or group insurance. 4ayments for the health insurance premium can be made on a quarterlyJhalf$yearlyJmonthly basis. These Affordable health plans not only reimburses your costs but also enables you to save up to s. 9633, stated under Dection ,6 ' of the Income Tax Act. Thus, buying a health insurance plan is a maAor step towards making a better futureW

2. R&CO33&DI(TION
eplace the current fee$for$service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. *stablish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. Dimplify and rationali;e federal and state laws and regulations to facilitate organi;ational innovation, support care coordination, and streamline financial and administrative functions. 'evelop a health information technology infrastructure with national standards of interoperability to promote data exchange. /reate a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de$ identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. Identify revenue sources, including a cap on the tax exclusion of employer$ based health insurance, to subsidi;e health care coverage with the goal of insuring all Americans. /reate state or regional insurance exchanges to pool risk, so that Americans without access to employer$based or other group insurance could obtain a

standard benefits package through these exchanges. *mployers should also be allowed to participate in these exchanges for their employees! coverage. /reate a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

19.CONC)USION
In conclusion, it is critical to recogni;e that in recommending any policies for financing the health system, no country starts from a blank slate. The appropriateness of particular strategies in any particular country will depend on its specific history, institutions, culture, politics and economic resources. The development of various types of mix of health care financing mechanisms could be Audged by how well they are likely to achieve the goals of equity, better health and responsiveness, and fair financing. There is a need to have a higher level of fairly distributed prepayment schemes with appropriate strategic purchasing. The existing systems of taxation, social security institutions, and the organi;ation of health care service providers and insurers have been developed out of historical processes and conditioned by experiences of nation$building, colonialism, labour movements, wars, communal and kinship patterns, and technological changes. -ut of this, citi;ens have already developed their beliefs and expectations, with regard to payment mechanism. As with all social arrangements, there are ways and means to undertake reforms, but it requires inputs from social institutions and support from all Dtakeholders. The out$of$pocket payment, which is the maAor mode of financing in most countries of the egion, tends to be quite regressive and often impedes access to health care. The challenge in revenue collection is how to expand pooling mechanisms through general tax revenue andJor social health insurance contributions. The experience on implementing nation$wide mandatory health insurance schemes in low$ and middle$income countries could be shared and appropriate adaptations could be made in accordance with the respective socioeconomic conditions of countries. The existing social health insurance schemes mainly covering the formal employed sector could be reviewed thoroughly and appropriate organi;ational and institutional reforms could be introduced in order to improve their efficiency and effectiveness. At

the same time, their coverage could also be increased. %any other forms of risk$ pooling schemes such as community$based or population$based trust funds and foundations could be introduced so that the financial and health risks of the poor are adequately protected.

11. (NN&GUR&S

C(S& STUDI&S:1A %eter and 8ane:

4eter was =2 years old and looking forward to retiring and being able to play more golf and travel with his wife. %ost of his working life was with the banking industry and his family had gained independence and left home. In April 2661. 4eter went to his 84 as he was having difficulty passing urine. 7lood tests were taken and he was found to have a 4DA level of =.0. 4eter was referred to a @rologist, had prostate biopsies and recommended brachytherapy as treatment. Thankfully 4eter and <ane had health insurance as they were advised the cost of this treatment would be O22,666. 4eter was able to have the treatment, and because he got prior approval the providers were paid directly and he was able to contentrate on a speedy recovery and a return to the golf course.

.A David:-

'avid aged 19, divorced with two school aged children, went to his 84 for a routine medical for his truck drivers licence and was found to have high blood pressure by his 84 I sent to a cardiologist for investigations. *ight months later 'avid started experiencing Angina. An engiogram, angioplasty and eventually bypass surgery was required over a period of +, months. Total claim cost to date has been O=6,666. 'avid has a health insurance policy with a nil excess and he was able to have all his treatment and surgery performend in a private hospital and have Fpeace of mindF knowing all costs would be covered and he could concentrate on getting better.

:A 3ulti#le ealt conditions* carrier denial of covera"e

-ur female client had multiple non$severe health conditions, and was looking for health insurance. Initially she conducted her own research, and applied to carriers directly. *ach application involved a long, drawn$out process requiring her to assemble comprehensive medical history records, and compile and submit extensive paperwork. 7ecause of her various conditions, she was denied by all carriers. After = months without success, she approached <ohn B. Dipp I Associates on the advice of a friend of a friend. The first meeting lasted a couple of hours, during which we gathered all the background of her medical history and her attempts at getting coverage. Ge then researched her options, and presented them to her in a second meeting. Ge chose one, and made an application to an individual carrier. :owever, the application process started delving into her medical history in some detail, and put our client on an emotional roller coaster. 7ecause of her discomfort, we told her that if it was something she didn)t want to go through, we could stop the process and explore other options. After much further discussion and exploration of a wide range of creative solutions, we reali;ed that she owned an ../. This gave us the option of writing a one$person guaranteed issued group policy. 7y writing her a policy this way, we were able to answer medical questions without the invasive emotional medical interview, so she did not have to relive uncomfortable medical memories. There were no telephone interviews, no requirements for extensive medical history, and while it was time$ consuming, it was not nearly as time$consuming as writing an individual policy. The premium on the individual policy we were applying for was in the region of O+,,96 a month. The one$person group policy was around O966. Do our client saved over 56C by taking this approach. In addition, the plan benefits were richer than the individual policy in the long run.Ge maintained her on this policy for several years, before moving her on to a %edicare supplemental policy.

;A %re-e-istin" condition re=uirin" sur"er!* carrier refusal to #a! clai$s

<ohn B Dipp I Associates have always been accessible and able to answer our questions in a timely manner. They always take my calls and always have the answers I need. They have played a large role in my search for lower insurance rates and are always eager to find the best options for us.%andy Dummerson, 7usiness %anager .erner <ewish /ommunity 'ay Dchool, location, 'urham and /hapel :ill ?/ A 01$year$old female, after working for the state and being on their insurance plan for 9$5 years, decided to make a career change. Dince /-7 A was too expensive for her, she came to us and we wrote her a short$term policy, which covers catastrophic and maAor medical costs, and, at the time, covered pre$existing conditions. Dhe then had to undergo an unexpected surgical procedure, and she approached us to help file her claims. Ge submitted the claims, but the insurance carrier denied them all. The bills amounted to around O+2,666, a sum that our client simply did not have.Do we took up the case directly with the carrier, trying to understand why they were denying the claims. :owever, after many phone calls, many hours, and long explanations from the carrier, they still wouldn)t budge and agree to pay the claims. Do we wrote letters to the carrier, and filed a grievance with the ?orth /arolina 'epartment of Insurance. Ge followed up, to make sure our case was getting attention. And with patience and persistence, we managed to get the claims paid. Ge advocate on their behalf of our clients when the situation requires it. In this case, we were able to relieve our client of a significant financial worry by being persistent and going through the right channels to get it resolved. -ur client was so concerned about it that when we told her that the claim would be paid, she broke down with relief.The client has since moved on to a permanent Aob with a group policy, but she still corresponds with us. A final noteE Dince this case took place, legislation has been passed that removes pre$ existing conditions from the coverage provided under short$term policies.

<A CO1R( e-#irin"* $aBor sur"er! re=uired* inabilit! to afford i" #re$iu$
A self$employed man with a hardwood refinishing company was insured under his wife)s group policy with her employer. :owever, she lost her Aob, so they took out /-7 A to continue their coverage. The husband developed a severe infection in his leg, and the doctors told him that the leg would need to be amputated. :owever, their coverage under /-7 A was about to expire, and the premium for the one carrier they applied to was more than they could afford. Do they approached <ohn B. Dipp I Associates to investigate options for them.Ge knew that, with /-7 A about to expire, we had to find coverage within the =0$day grace period, after which his pre$existing condition would not be covered. Ge also knew that an individual policy that would cover his condition and the upcoming surgery would be prohibitively expensive.

7ecause the husband had an ../ for his business, we were able to write a one$person guaranteed issued group policy. And because we set the policy up within the =0$day grace period after the expiration of /-7 A, there was no lapse in coverage, so the pre$existing exclusion clause did not apply. @nfortunately, the leg did have to be amputated, but the procedure was covered under the one$person group policy. The cost of an individual policy for the husband was around O+,,66 a month. The one$person group policy was O166. Do we managed to save our client over 59C and get his procedure covered. *ven though the wife has since moved on to a new Aob with group coverage, the husband has chosen to stay on the one$person group policy to ensure that he has continuous coverage

>A &$#lo!ee 4it si"nificant un#aid clai$s for cancer treat$ent

An employee of a company with a group plan written by <ohn B. Dipp I Associates had the misfortune of developing a rare type of lymph node cancer. This required extensive radiation, chemotherapy, physical therapy, and other treatments. 'uring her many traumatic hours of treatments, she was physically unable to follow her claims to make sure that everything was coded and processed appropriately by the medical facility to the insurance company. Dhe asked us for assistance in resolving over O06,666 of unpaid claims, involving well over +66 pages of claims that had been denied or only partially covered. -n examination of the policy, we discovered that she had used providers covered under the policy, and that she was liable for a maximum of O0,666 of out$of$pocket expenses. Through frequent phone calls and persistence, we badgered the insurance company until we were finally put in touch with a claims specialist. These people seldom, if ever, deal directly with the public or with brokers. Ge went through every page of every claim with the claims specialist, and discovered that many of the services had been coded incorrectly. Do we recoded the claims and resubmitted them. The claims were eventually paid as per the policy, liberating the employee from a O06,666$plus headache. The claims specialist drove all the way from /harlotte to the employee)s home in the Triangle to deliver the claim payments and apologi;e to the employee for her inconvenience.

EA 3ulti#le ealt conditions* si"nificant #rescri#tion costs* ris+ of la#sed covera"e

A novelist in her 96)s moved from the %idwest to ?/, bringing with her pages of medical conditions, including diabetes, hepatitis and obesity. 4art of her treatment regimen involved a O2,666$plus prescription drug that needed to be inAected.

It was highly unlikely that we would have been able to find a carrier to insure her under an individual policy, and even if we could, it would have been prohibitively expensive. Do we wrote her a one$person group policy. :owever, because of her expensive medications, her prescription benefit ran the risk of maxing out early in the policy period. If it lapsed, her condition would have been classified as pre$existing, and the resultant cost of coverage would have left her bankrupt. Do we rewrote the policy multiple times a year to ensure her continued coverage. Ge went the extra yard to ensure that our client received continuous coverage at the best price available to her. The agent involved even called the client from her sick bed during a troubled pregnancy to manage her situation. The client is now in assisted living, and because she can no longer afford health insurance, she is considering applying for social security disability. Ge are continuing to help her, providing guidance and advice in an endeavor that has no financial gain for <ohn B. Dipp I Associates.

DU&STION(IR&:-

(%O))O 3UNICH H&()TH INSUR(NC&:+# Ghat is aim behind opening an health in IndiaH AnsE $ To be the trusted leader in health insurance by providing innovative solutions to the citi;ens of India 2# Ghat are the futures for your development in these sectorsH AnsE$ To be trusted partner in positive health and to provide innovative health care solution to individuals. 0# Ghere are the branches of Apollo %unich situated in IndiaH AnsE $ list of branches along with addresses of Apollo %unich :ealth Insurance /ompanyE 'elhi, .ucknow, /handigarh, 8urgaon, <aipur, %ysore, 7angalore, /hennai, /ochin, Trivandrum, /oimbatore, %adurai, %umbai and Thane. 1# In India, :ow many branches do you have H AnsE$ 1 7ranches In %umbai, 06 branches All -ver India.

9# Ghat kind -f after sales services provided to your /ustomersH AnsE$ 8ood /laim Dettlement "T4A#, B:T. "Bamily :ealth 4lan .imited# And Time .imit Is 8iven *very Type -f /laim Dettlement. =# Ghat are your Dhort I .ong Term -bAectiveH AnsE$ /urrent &ear we are planning a Turnover -f 206$296 /orers I .ong Term -bAective Is 7ased -n -ur Nision. 5# Ghat are different challenges faced by you in Insurance DectorH AnsE$ .ess /hallenges Ghere Baced 7ecause -f '(N I.*. Gorlds %ost :ealth Insurance I Also 'ue To *xpertise I /onsultant. eputed

'ORTIS H&()TH INSUR(NC&:+# Ghat is aim behind opening an health in IndiaH AnsE $ I'7I and Bortis stated on 5 %arch 266= that they were Aointly seeking a third partner to pursue life insurance business in India. I'7I and Bortis have Aointly identified Bederal 7ank as their third partner. It is the intention to establish a .ife insurance company of which I'7I will initially own 1,C, Bederal 7ank 2=C and Bortis 2=C. 2# Ghat are the futures for your development in these sectorsH AnsE$ &our company grow to 1= hospitals, since the opening of our first hospital at %ohali in 266+. The company intends to be a 16Y hospital network with more than =666 beds by the year 26+2. 0# Ghere are the branches of Borties situated in IndiaH AnsE$ %ilwaukee, Gisconsin and has operations offices in %innesota, Idaho, Blorida and -hio. 1# Ghat kind of after sales services provided to your customerH

AnsE$ The Bortis plans also provide world wide coverage. This is a great peace of mind if you travel often, especially to different countries. &ou are always assured that your medical coverage is handled when you have a Bortis plan.

9# Ghat are the different challenges you faced in insurance sectorH AnsE$ Bortis ranks among the twenty largest financial institutions in *urope. -ur sound solvency position, our presence in 96 countries and our dedicated, professional workforce of 9,,666 enable us to combine global strength with local flexibility and provide our clients with optimum support

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