UNIVERSITY OF MUMBAI

PROJECT REPORT ON

A PRODUCT LIFECYCLE OF PARLE

SUBMITTED BY

ANSARI IMRAN AFZAL

ROLL NO. 03

BACHELOR OF MANAGEMENT STUDIES (BMS)

SEMESTER VI

ACADEMIC YEAR 2021 -22

PROJECT GUIDE

PROF. SWATI SAIGAL

VIDYA VIKAS COLLEGE OF ARTS ,SCIENCE, COMMERCE, B.M.M

& B.M.S
CHINCHOLI BUNDER ROAD, MALAD WEST
MUMBAI- 400064
 CERTIFICATE

I, PROF. SWATI SAIGAL hereby certify that ANSARI IMRAN AFZAL of

Third Year Bachelor of Management Studies TYBMS Sem VI Vidya Vikas
College Of Arts, Science, Commerce, B.m.m, B.m.s, has successfully
completed project on A STUDY OF PRODUCT LIFECYCLE OF PARLE
G in Semester VI of the academic year 2021-22.

Principal  Coordinator Project

Mr. Santosh Yadav Mr. Bhavesh Kapuria PROF. Mrs. Swati
Saigal

Internal Examiner External Examiner

Date: 28th March, 2022

 DECLARATION
I, ANSARI IMRAN AFZAL student of Third Year Bachelor of
Management Studies TYBMS Sem VI, Vidya Vikas College Of Arts, Science,
Commerce, B.m.m, B.m.s, hereby declare that I have completed the project on
A STUDY OF PRODUCT LIFECYCLE OF PARLE G in the academic
year 2021-22.

The information submitted is true and original to the best of my knowledge.

Wherever reference has been made to previous works of others, it has been
clearly indicated as such and included in the bibliography.

I, here by further declare that all information of this documents has been
obtained and presented in accordance with academic rules and ethical
conduct.

Name and signature of the learner

ANSARI IMRAN AFZAL

Certified by

Name and signature of the Guiding Teacher

 ACKNOWLEDGEMENT

To list who all have helped me is difficult because they are so numerous
and the depth is so enormous.

I would like to acknowledge the following as being idealistic channels and

fresh dimensions in the completion of this project.

I take this opportunity to thank the University of Mumbai for giving me

chance to do this project.

I would like to thank my Principal, MR. Santosh Yadav for providing the
necessary facilities required for completion of this project.

I take this opportunity to thank our Coordinator, Mr. Bhavesh kapuria

for his moral support and guidance.

I would also like to express my sincere gratitude towards my project guide

PROF. SWATI SAIGAL whose guidance and care made the project
successful.

I would like to thank my College Library, for having provided various

reference books and magazines related to my project.

Lastly, I would like to thank each and every person who directly or
indirectly helped me in the completion of the project especially my
Parents and Peers who supported me throughout my project.
 INDEX

1. INTRODUCTION OF PARLE

2. HISTORY OF PARLE

3. RESEARCH METHODOLOGY

4. STRATEGIES AND STP OF PARLE

5. THE MARKETING STRENGTH OF PARLE

6. PORTER'S FIVE FORCE MODEL

7. COMPETITOR OF PARLE

8. DATA ANALYSIS

9. CONSUMER BUYING BEHAVIOUR

10. CASE STUDY

11. RECOMMENDATIONS

12. CONCLUSION

13. BIBLIOGRAPHY

14. ANNEXURE
1. INTRODUCTION OF PARLE
 I. Objectives of the study

1. To study the concept and structure of health insurance in India.

2. To describe the sector wise distribution of health insurance in India.

3. To identify the key areas for improvising this sector.

Health insurance in India

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

The healthcare industry provides a variety of services to support the healthcare needs of a
community or individuals. The healthcare industry classifies the different products it offers
by sector. Hospitals and healthcare systems are continually changing their service offerings
and responding to various internal and external forces including reimbursement issues,
advances in technology, and shifts in the populations they serve. A universally agreed-upon
classification of sectors does not exist, so a non-exhaustive but the inclusive and simplified
classification of broad sectors will be used in this exploration.

The key sectors of the healthcare industry can be broadly classified into the
following four sub-segments:

1. Health care services and facilities

2. Medical devices, equipment, and hospital supplies manufacturers
3. Medical insurance, medical services, and managed care
4. Pharmaceuticals & Related Segments

Healthcare Segment 1: Health care services and facilities:

Health care services and facilities subsector is comprised of many subsectors.

The broad classification includes:

 (A) Hospitals:

Hospitals provide medical, diagnostic, and treatment services to inpatients and some

outpatient services. This category includes General medical and surgical hospitals,
psychiatric and substance abuse hospitals, Specialty hospitals (not including psychiatric and
substance abuse facilities), Family Planning & Abortion Clinics, Hospices & Palliative Care
Centers, Emergency & Other Outpatient Care Centers, Sleep Disorder Clinics, Dental
Laboratories, and Blood & Organ Banks.

Given below are different types of hospital:

 General Medical And Surgical Hospitals

 Psychiatric and substance abuse hospitals
 Speciality Hospital (not including psychiatric and substance abuse facilities)
 Family Planning & Abortion Clinics
 Hospices & Palliative Care Centers
 Emergency & Other Outpatient Care Centers
 Sleep Disorder Clinics
 Dental Laboratories
 Blood & Organ Banks
 Teaching or University Hospital

(B) Nursing and residential care facilities:

They provide residential care combined with either nursing, supervisory, or other types of
care as needed. This category includes Home health care services, Nursing Care Facilities,
 Urgent Care Centers, Mental health and residential developmental handicap facilities, In-
Home Senior Care, Community care facilities for the elderly, and other residential care
facilities.

Given below are different nursing and residential care facilities:

 Home health care services

 Nursing Care Facilities
 Urgent Care Centers 
 Mental health and residential developmental handicap facilities
 In-Home Senior Care
 Community care facilities for the elderly
 Other residential care facilities

(C) Ambulatory health care services:

Players provide direct and indirect health care services to ambulatory patients. This category
includes Outpatient care centers, medical and diagnostic laboratories, Ambulance Services,
and other ambulatory health care services.

Given below are different ambulatory health care services:

 Outpatient care centers

 Medical and diagnostic laboratories
 Ambulance Services
 Other ambulatory health care services
 (D) Medical Practitioners & Healthcare Professionals:

This category includes Medical Practitioners, Chiropractors, Homeopaths, Psychologists,

Social Workers & Marriage Counselors, Dermatologists, Nutritionists & Dietitians,
Optometrists, Physical Therapists, and other alternative Healthcare Providers.

Given below are different types of Medical Practitioners and healthcare professionals:

 Medical Practitioners
 Chiropractors
 Homeopaths
 Psychologists, Social Workers & Marriage Counselors
 Dermatologists
 Nutritionists & Dietitians
 Optometrists
 Physical Therapists
 Alternative Healthcare Providers

Healthcare Segment 2: Medical devices, equipment, and hospital supplies

manufacturers:

These are medical companies at the forefront of the latest medical technology offering their
products across the whole spectrum of medical equipment, hospital supplies, products, and
services, including specialist applications. This sector further consists of many players
including In-vitro diagnostic substances, Electro-medical and electrotherapeutic apparatuses ,
Irradiation apparatuses, Surgical Instrument & Medical Instrument Manufacturing, Surgical
appliances and supplies, Dental equipment and supplies, Ophthalmic goods, Vital Signs
Monitor Manufacturing, Mammography Machine Manufacturing, TENS Machine
Manufacturing, Nebulizer Manufacturing, Hot & Cold Topical Therapy Manufacturing,
Optical Coherence Tomography Machine Manufacturing, Medical Laser Machine
Manufacturing, Medical Device Manufacturing, Medical Instrument & Supply
 Manufacturing, Robotic Surgery Equipment Manufacturing, Endoscope Manufacturing,
Venous Access Device Manufacturing, Wound Care Product Manufacturing, Toxicology
Laboratories, Glucose Meter Manufacturing, Instrument Sterilization Product Manufacturing,
Intravenous (IV) Solution Manufacturing, Ultrasonic Cleaning Equipment Manufacturing,
Hospital Bed Manufacturing and Hospital Furniture Manufacturing etc.

Given below are different Medical devices, equipment, and hospital supplies manufacturers:

 In-vitro diagnostic substances

 Electro-medical and electrotherapeutic apparatuses
 Irradiation apparatuses
 Surgical Instrument & Medical Instrument Manufacturing
 Surgical appliances and supplies
 Dental equipment and supplies
 Ophthalmic goods
 Vital Signs Monitor Manufacturing
 Mammography Machine Manufacturing
 TENS Machine Manufacturing
 Nebulizer Manufacturing
 Hot & Cold Topical Therapy Manufacturing
 Optical Coherence Tomography Machine Manufacturing
 Medical Laser Machine Manufacturing
 Medical Device Manufacturing
 Medical Instrument & Supply Manufacturing
 Robotic Surgery Equipment Manufacturing
 Endoscope Manufacturing
 Venous Access Device Manufacturing
 Wound Care Product Manufacturing
 Toxicology Laboratories
 Glucose Meter Manufacturing
 Instrument Sterilization Product Manufacturing
 Intravenous (IV) Solution Manufacturing
 Ultrasonic Cleaning Equipment Manufacturing
 Hospital Bed Manufacturing
 Hospital Furniture Manufacturing

Healthcare Segment 3: Medical insurance, medical services, and managed

care:

This segment deals with the players that provide medical insurance or different types of
services to either patients or other medical sector players. The term managed care or managed
health care is used to describe a variety of techniques intended to reduce the cost of providing
health benefits and improve the quality of care for organizations that use those techniques or
provide them as services to other organizations. This sector further consists of many players
including Health maintenance organizations (HMOs), Preferred provider organizations,
exclusive provider organizations, Medicare, Medicaid, Healthcare Consultants, Medical
Patient Financing, Healthcare Staff Recruitment Agencies, Health & Medical Insurance,
Surgical Apparel Manufacturing, Medical Supplies Wholesaling, Medical Waste Disposal
Services, Dental Insurance, Medical Couriers, Medical Device Cleaning & Recycling,
Medical Claims Processing Services, Pharmacy Benefit Management, Corporate Wellness
Services, Home Medical Equipment Rentals and Medical Case Management Services, etc.

Given below are different medical insurance, medical services, and managed care providers:

 Health maintenance organizations (HMOs)

 Preferred provider organizations
 Exclusive provider organizations
 Medicare
 Medicaid
 Healthcare Consultants
 Medical Patient Financing
 Healthcare Staff Recruitment Agencies
 Health & Medical Insurance
 Surgical Apparel Manufacturing            
 Medical Supplies Wholesaling
 Medical Waste Disposal Services
 Dental Insurance
 Medical Couriers
 Medical Device Cleaning & Recycling
 Medical Claims Processing Services
 Pharmacy Benefit Management           
 Corporate Wellness Services
 Home Medical Equipment Rentals
 Medical Case Management Services

Healthcare Segment 4: Pharmaceuticals & Related Segments:

The pharmaceutical industry develops, produces, and markets drugs or pharmaceuticals

licensed for use as medications. Pharmaceuticals eliminate the need for inpatient and invasive
care services. They are subject to a variety of laws and regulations regarding the patenting,
testing, and ensuring the safety and efficacy and marketing of drugs. This sector further
consists of many players including Over-the-counter (OTC) drugs & Drug Stores,
Prescription drugs, Biopharmaceutical drugs, Generic drugs, Pharmaceuticals Packing &
Labeling Services, Dietary Fiber Supplement Manufacturing, Vitamin & Supplement
Manufacturing, Cough & Cold Medicine Manufacturing, Health Stores and Eye Glasses &
Contact Lens Stores, etc.

Given below are different types of Pharmacy and Medical Stores:

 Over-the-counter (OTC) drugs & Drug Stores

 Prescription drugs
 Biopharmaceutical drugs
 Generic drugs
 Pharmaceuticals Packing & Labeling Services
 Dietary Fiber Supplement Manufacturing
 Vitamin & Supplement Manufacturing
 Cough & Cold Medicine Manufacturing
 Health Stores
 Eye Glasses & Contact Lens Stores
Types of Medical Insurance Policies Explained

There is nothing more painful than losing your loved ones and it is worst when it happens just
because you could not afford their treatment. Dukh k Samay Mei Sirf Apne hi Kaam Ate Hai,
Right? You all have not just heard it but must have experienced it several times in life.

A Health Insurance Policy in India is the best saviour more than any other thing considering
the rise in the cost of healthcare facilities. There are different types of insurance policies
available to meet your requirements. Let us discuss different types of health insurance
available in India.

7 Types of Health Insurance Policies in India

1. Individual Health Insurance

An Individual Health Insurance is a policy which you may buy to cover you, your spouse,
children and parents. This type of insurance policy covers your medical expenses for injury &
illnesses related hospitalization, surgery costs, room rent, daycare procedures and more.

Every member covered under the Individual Health Insurance plan will have an Individual
Sum Insured. For example, if you take an Individual health policy of 3 lakhs sum insured
covering your spouse, 2 kids and yourself, then each person covered will have an individual
sum insured of Rs.3 lakhs. Though it makes the premium comparatively higher.

Individuals like you who fall in the age bracket of 18 years to 70 years can choose to buy this
plan. The best part of buying an Individual Policy is that it offers individual Sum Insured
limit for each covered member.
2. Family Floater Health Insurance

If you want an affordable health insurance policy for all the members of your family then
Family Floater Health Insurance should be your choice.

Under a Family Floater Health Insurance, single Sum Insured floats for all the members
covered under the policy. A Family Floater Health Insurance Plan is beneficial because the
premium is comparatively lower than the Individual Health Insurance policy. This policy can
cover yourself, your spouse, children and parents.

You should not consider adding members of your family who are above 60 years of age.
They are more prone to illness and hence it will impact the premium.

If you or the eldest member of your family is below 60 years of age, then you should buy a
family floater policy.

3. Group Health Insurance

A Group Health Insurance policy is designed for a group of employees working together. So
if you own a start-up or a corporate house, you should buy such plans for your employees. It
is a kind of benefit offered to the employees. As an employer, you can buy the cover to boost
the rate of employee retention.

Group Health Insurance Plan comes with a low cost premium. Some insurance companies
allow to refill the sum insured, that too, unlimited times, if it is exhausted. A Group Health
Insurance Plan covers you for hospitalization due to accident, illness, critical illness,
psychiatric illness, and maternity.
Buying a Group Health Insurance policy not only offers coverage to your employees but also
enhance the goodwill of your company. A very crucial point here is that the employees are
covered only till the time they work with your company.

4. Senior Citizens Health Insurance

The health insurance policy which is dedicatedly designed for old people above the age of 60
years is called Senior Citizen Health Insurance Plan. If your parents or grandparents are
above 60, then this cover is a good choice for you.

A Senior Citizen Policy will offer coverage for cost of medicines, hospitalization arising out
of accident or illness, pre and post hospitalization and treatment. Along with these, some
other benefits like Domiciliary Hospitalization and Psychiatric benefits are also covered.

Add-ons like “Zone Upgrade” helps to meet the city-wise price escalation for treatment.
Other than this, you can also choose to buy alternative treatment (AYUSH) cover as an
addition.

Some insurers may ask for a complete body check-up before they sell a Senior Citizen Health
Insurance Policy. The maximum entry age limit has been pushed to 70 years of age with
lifetime renewability. And, as we know, the senior citizens are more prone to illnesses, these
plans are more expensive than other health insurance policies.

5. Maternity Health Insurance

A Maternity cover can be bought as a rider along with the basic health insurance plan. All the
expenses incurred in the prenatal stage, delivery and post-natal stage are covered.
Newly married couples or families who are planning a baby in the coming years should buy
this policy. It covers for child-delivery (including medically necessary terminations),
infertility expenses and coverage for the newborn baby up to its first 90 days. The Maternity
Cover has a minimum waiting period of 2 years.

Know more about

Health Insurance with Maternity Cover

Health Insurance for COVID 19

6. Critical Illness Insurance

The occurrence of the lifestyle-related diseases are on the rise. Keeping this in mind, the
insurance companies have offered the Critical Illness Policy.

Dedicatedly designed for middle-class families, this health plan covers diseases like:

Cancer

Stroke

Kidney Failure

Paralysis

Coronary Artery Bypass Surgery

First heart attack

Pulmonary Arterial Hypertension

Multiple Sclerosis

Aorta Graft Surgery

Getting treatment for these diseases is an expensive affair. Under the Critical Illness Plan as
soon as you are diagnosed with the disease, it will pay you a predefined amount irrespective
of the actual cost of treatment incurred.

Nothing can be a smart move than buying a Critical Illness Policy as it prevents any impact
on your savings. The policy has lifetime renewability. If you take the Critical Illness Policy,
then you should survive for 30 days after diagnosis of the illness.

It will be wise to buy this policy if you have had a family history of some diseases. Other
than the lump sum amount, a Critical Illness Policy reimburses you the cost of care and
hospitalization expenses. You can also avail the benefit of the complementary health check-
ups.

But you should remember that once a claim is filed, then the Sum Insured is released in lump
sum. After the release of the Sum Insured, the policy terminates.

Digit is providing an additional 25% Sum insured for Critical illness-related Hospitalization
as an added benefit in the Health Insurance policy.

7. Top-Up Health Insurance

You can buy a top-up policy if you seek coverage for higher amounts. But such plans come
with a “Deductible Clause”. So, in case of a claim the payment will be made over and above
a defined limit mentioned in the policy.
Like if you have taken a cover for 15 lakhs and it has a deductible of Rs.3 lakhs, then you
will have to bear claim up to Rs.3 lakhs. The amount over and above this, will be paid by the
insurer.

So, if you seek a wider cover over and above your basic health insurance policy, then you can
buy this plan.

Under the Health Insurance Plans, you also get a Daily Cash Allowance offered by the
insurance company. These are daily expenses reimbursed for 30-45 days and are separate
from the hospitalization expenses.

As the demand for health insurance policies increased, so increased the number of insurance
companies and their products. The medical costs are soaring and it is wise to buy either of the
policies above

Effects of Health Insurance on Health

This chapter presents the Committee's review of studies that address the impact of health
insurance on various health-related outcomes. It examines research on the relationship
between health insurance (or lack of insurance), use of medical care and health outcomes for
specific conditions and types of services, and with overall health status and mortality. There
is a consistent, positive relationship between health insurance coverage and health-related
outcomes across a body of studies that use a variety of data sources and different analytic
approaches. The best evidence suggests that health insurance is associated with more
appropriate use of health care services and better health outcomes for adults.
The discussion of the research in this chapter is organized within sections that encompass
virtually all of the research literature on health outcomes and insurance status that the
Committee identified. The chapter sections include the following:

Primary prevention and screening services

Cancer care and outcomes

Chronic disease management, with specific discussions of diabetes, hypertension, end-stage

renal disease (ESRD), HIV disease, and mental illness

Hospital-based care (emergency services, traumatic injury, cardiovascular disease)

Overall mortality and general measures of health status

What is a Mediclaim Policy

Mediclaim policy is an insurance cover which shields you against increasing medical

costs arising out of hospitalisation. It offers financial protection in case of hospitalisation
due to illness or an accident. Similar to other forms of insurance, mediclaim policy benefits
can be exercised by paying a premium annually. This type of insurance policy comes with a
defined policy period and needs to be renewed to continue enjoying the benefits of the policy.

Mediclaim is a form of health insurance through which you can either be reimbursed for
expenses arising out of hospitalisation or you can choose the cashless process to cover your
hospitalisation expenses. Additionally, the premium that you pay is eligible for tax exemption
under Section 80D of the Income Tax Act 1961, making it a good investment.

Features and Benefits of Mediclaim Policy:

 So, how does a mediclaim policy benefit you? Let’s look at some of the features and benefits
of the policy:

 It offers the ease of cashless hospitalisation.

 You can opt for self or for the entire family.

 It shields you from the financial burden.

 Removes expenses paid from your pocket.

 Insurance companies will handle the expenses arising out of hospitalisation.

 Ease of buying through online health insurance companies.

 It offers tax exemptions.

 Avail cost-effective healthcare services

Types of Mediclaim Policies:

There are different types of mediclaim policies to cater to various needs and requirements.
Let’s look at these in detail:

Individual Mediclaim Policy: Under this type of policy, only the policyholder is covered
against major medical expenses arising out of hospitalization. Individual health policy is a
coverage that the insured person purchases on their own to maintain their health and
take care of medical care whenever required by the insured person. A medical insurance
premium is required to be paid before claiming your cover. Health insurance is an agreement
between an insurance provider and an individual wherein the former guarantees to take care
of certain medical costs of the latter based on the investment made. Some plans offer health
insurance for individuals while others offer health insurance for family and group.

The Individual Health Insurance plan covers only one individual, the policyholder, who will
gain the benefits of the health insurance for his investment
 Key Features
 This kind of health insurance for individuals offers cover only for the insured individual.
 The insurance provider covers certain medical costs of the insured based on the premium
paid.
 Hospitalization- The policy covers hospitalization charges.
 Lifetime renewal.
 Tax deductions under section 80D of the Income Tax act.
 Covers surgery costs, room rent, physician’s fee and laboratory tests.
 The insured has to pay a predetermined amount for certain health care services. This is
called co-payment.
 Pre and post hospitalization expenses are covered under this plan.
 Provides coverage for critical illness.

Advantages of Individual Health Insurance Plan

 In individual health insurance plan, the insured alone earns all the benefits under the plan.
 The individual will earn the benefit of individual sum assured rather than floating sum
assured.
 Best suited for people with higher health risks.
 Parents and immediate family members can be added to the plan.
 No restrictions on the maximum age for the members for the renewal of the policy.
 There is no need to worry about making more than one claim in an year since the plan
caters only to a single person.

Who should buy this plan

 The plan is best suited for individuals with higher health risks.
 Single individuals with family members who are already insured.
 An individual who wants to earn the benefit of the sum assured rather than floating sum
assured.
 Individuals who want to renew the policy without having to worry about any age
restrictions.
 An individual who wants higher protection than what is offered under a family floater plan.
  Cashless facility for claim settlement can be availed in this plan.

Understanding Individual Health Insurance

Who does the individual health insurance plan cover
The Individual Health Insurance plan covers only the policyholder.

What is the difference between Individual Health Insurance and Family Floater Health
Insurance.
In individual health insurance plans, each individual of a family is entitled to a health cover
of a certain sum; whereas in the family floater health insurance plan, the health cover of the
same amount is shared by all the family members included in the plan.

What does individual health insurance plan cover

The charges covered by individual health insurance are listed below.

 Medical examinations
 Hospitalization
 Emergency services
 Laboratory services
 Maternity and new born care
 Room, boarding expenses
 Physician fee

 Family Floater Policy: The policyholder and parents, spouse, and children are covered
under this plan. A family floater policy is one where several members of a single family can
be covered for a sum assured by paying a single premium in a year. In case of multiple
 illnesses in the family, the sum assured can be distributed between family members and
multiple claims entertained. It works out to be more cost-effective than taking individual
policies separately in the name of family members. Most health insurance companies in
India offer family floater policies.

Key Features
 One of the key features of a family floater health insurance is that the sum assured
can be extended to cover several members of the same family if the need arises.
Depending on the healthcare risk appetite and the location, the primary policyholder
may zero in on a higher or lower sum assured and it reflects in the premium
accordingly.
 The covered members of a family floater may go in for cashless hospitalization if they
intimate their insurer within 24 hours of their hospitalization and get admitted in a
network hospital. In some cases like emergency hospitalization or accidents or
admission in non-network hospitals, insurers may allow treatment first and
reimbursement later.
 The policy may include room rent up to a certain amount per day, for every day of
hospitalization.
 Some family floaters work on the co-pay basis, where the insurers pays a percentage
of the cost incurred and the insurer the rest. This usually has lower premium as the
insured shares part of the hospitalization costs.
 Most companies seek a medical examination if a higher sum assured is involved, any
of the covered members are in the higher age groups or have a medical history. Some
insurers also offer their policies online, where barring exceptions, a declaration of
good health by the insured does not require any medical check-ups.

Advantages of Family Floater Health Insurance Plan:

Family floater insurance offers the following benefits
 Cost-effective insurance
Family floater policies offer the benefit of a sum assured which can be shared across
members of a family and can come in handy because the chances of all members falling
sick in a calendar year are rare. If there are multiple illnesses in family, then the sum
assured can be distributed among the family members. But the premium has to be paid
once and is cheaper than availing individual policies for each of the family members.
 Tax benefits
Premiums paid for Family Floater can benefit from tax deductions under section 80D of the
Income Tax Act. Amounts up to Rs. 15,000 are allowed for deduction on health insurance
premium for self, spouse and children. This gives additional exemption of Rs. 20,000 if
senior citizens are covered. This means if someone takes family floater insurance covering
his immediate family and parents who are senior citizens, he can save up to Rs. 35,000 in
taxes.

 Sum Assured can be restored

In case you are worrying about what happens if due to a hospitalization of one family
member, the sum assured gets exhausted, some insurers offer automatic restore/top-up of
sum assured by 100%. This takes care of worries about recurring hospitalization in the
same year.

 Cashless treatment
Family floater also allows the insured to be treated cashless at any network hospital.
Policyholders need not pay expensive consultation fees, diagnosis tests, room rent and so
on. All these expenses, up to the sum assured, are automatically covered by the policy

Who Should Buy this Plan

Family floater is ideal for someone who is married and has children. This is also good for
those who wish to cover their parents who are senior citizens. Overall, this offers a good
option for insurance which is cost-effective and inclusive.

What is not covered under Family Floater Insurance

 Pre-existing diseases are not covered up to a certain exclusion period under family floater
plans
 Admission of senior citizens beyond 60 may be a problem and may increase the premium
substantially, as their risk is perceived to be higher. However senior .citizens covered prior
to attaining 60 can enjoy continued coverage when policy is regularly renewed.
 Childbirths are not usually covered. But now insurers have started offering coverage for
birth as well as cover for the new-born starting with birth.
 Most insurers don’t cover treatments arising out of attempted suicide, nuclear attacks
and so on.
 Most insurers also do not allow experimental treatment, treatment for HIV/AIDS,
congenital disease, non-medical expenses under their policies
.
 Group Mediclaim Policy: An employer purchases group health insurance policy for the
employees or members of the organization under this plan. Also known as a group health
insurance plan, a group mediclaim policy for employees by employers provides several
benefits to the policyholder. To offer this policy, some employers deduct a certain amount
from the CTC of the employees. The deducted amount is the premium cost of the employer-
provided health plan. However, some organisations offer a group policy to their employees
for free. Since the plans are purchased in bulk, they are cheaper. There are many benefits of
Group Mediclaim Insurance Policy for employees.  This policy covers the policyholder
(employee) as well as his/her family members. This extended support is pretty impressive for
the professionals.
Key Features of a Group Health Insurance Plan
Highlighted below are some of the common features of a Group Health Insurance policy:

 Certain group health insurance policies may offer coverage for boarding costs other than
anesthetist, surgeon and consultation charges. Expenses for oxygen, anaesthesia and
diagnostic materials along with dialysis expenses and X-rays are amongst other expenses
covered.
 The policyholders get a cashless hospitalisation facility, wherein the insurance company
directly settles off the medical bill with the hospital.
 Certain group health insurance plans also offer coverage for domiciliary hospitalisation.
 Group health insurance plans offer the policyholder coverage for pre-hospitalisation and post-
hospitalisation expenses for a certain period of time.
 Some of the group health insurance plans offer coverage for maternity-related expenses.
 Group health insurance plans extend coverage for specific critical illnesses above the
 hospitalisation cover.
 Offers cover for less than 24 hours of hospitalisation for specific treatment procedures like
eye surgery, chemotherapy, tonsillectomy, etc.
 Other optional benefits of group health insurance plans include waiver of waiting period,
exclusion for first year other than reimbursement for ambulance expenses etc.

Benefits of the Group Health Insurance Plan

Some of the common benefits of Group Health Insurance Plans are as follows:

 Low cost because of larger risk: When it comes to cost, the group health insurance plans are
always cheaper than individual or family floater health insurance plans. This is due to the
shared premium amount among the employees. 

 Employees feel valued: With group health insurance cover, the employees feel happy that
the organisation values them. In return, they also work hard to deliver their best and make
better for all. 

 A higher number of people increases the plan advantages: As a higher number of people
are covered under group health insurance plans, its advantages increase for the policyholders.
They get a higher value with added benefits like cover for pre-existing diseases,
hospitalisation expenses, etc.

 Family protection is included: It may depend on policy to policy, but group health

insurance plans often cover your family members too. These plans protect the dependents of
the employees by offering them financial help in the time of need. If not this, the family
members may have to purchase another family floater health insurance plan and pay the
premium out of own pocket. 

 Easy to claim: Instead of running around health insurance companies for a claim, in group

health insurance plans all you need to do is connect with your employer with relevant bills.
As a large number of employees are insured, the employer ensures that your claim request
gets approved. The employees can even enjoy the cashless treatment.

These plans offer coverage for pre-existing illnesses and maternity-related expenses. In some
conditions, employees can get their additional members covered under the plan with a bit
higher deduction. 
 Senior Citizen Mediclaim Policy: Under this type of plan, senior citizens are covered for
medical expenses with special provisions. Health Insurance for senior citizens is a type of
health insurance plan that covers medical expenses incurred by people for above 60 years old.
While this category enjoys a lot of benefits, they also face many uncertainties in terms of
their health and fitness. For senior citizens, the best health insurance policy is the one that
protects them against unexpected medical expenses and allows them to be financially
independent during health emergencies. HDFC ERGO offers the health insurance plans for
senior citizens that covers pre-existing diseases, hospitalization expenses, critical illness and
corona virus treatment, also, it has an extensive network hospitals of 13,000+ across India
which ensures that you have a stress-free and peaceful retirement.
 What is Covered in a Health Insurance Plan for Senior Citizens
Some of the common coverage provided under senior citizen health insurance plans are
given below:

 HospitalizationExpenses: Hospitalization expenses, including room charges, doctor fees,

nursing fees, cost of medicine and drugs, ICU charges, cost of surgical appliances, and
operation theatre charges are covered under this plan. It also covers the cost of artificial
limbs, orthopedic implants, prosthetic devices, diagnostic tests,  required during the
hospitalization of the senior citizen.
 Day Care Treatments- Specific daycare treatments that require less than 24 hours of
hospitalization,like chemotherapy, dialysis, etc. are covered under most plans.
 Pre and Post-hospitalization Expenses- Medical costs before getting hospitalized and
after getting discharged are also included under a senior citizen mediclaim policy.
 COVID-19 Cover- The policy also pays for the cost of coronavirus treatment up to the
 specified limit.
 Organ Donor Expenses- Most mediclaim policies cover the donor expenses incurred
during organ transplants. 
 Ambulance Charges- It covers ambulance charges incurred on transporting the insured to
the nearest hospital up to the specified limit.
 Pre-existing Diseases- Any pre-existing diseases of the insured senior citizen are also
covered after a fixed waiting period.
 AYUSHTreatment Cost- AYUSH treatment taken in a government-recognized hospital or
institute is also covered under some senior citizen mediclaim policies.
 Domiciliary Hospitalization Cover- If the doctor suggests home treatment for the elderly
person, then his/her insurance company will pay for domiciliary hospitalization expenses as
well.

What is Not Covered in a Health Insurance Plan for Senior Citizens

Below is a list of medical expenses that are not covered under a senior citizen health
insurance plan:

 Pre-existing diseases or injuries

 Expenses arising out of self-inflicted injuries or suicide

 Expenses arising from drug or alcohol abuse and related treatment

 Medical conditions diagnosed within 30 days of purchasing the policy (except for

accidental injuries)

 Expenses related to non-allopathic treatment

 The treatment cost of injuries caused due to an act of foreign army or a civil war.

 Cosmetic surgery

 The cost of dental treatment or lenses/spectacles unless arising from an accident.

 Treatment cost of AIDS

Please note that the list of exclusions varies from one plan to another.
Things to Consider While Buying a Mediclaim Policy for Senior
Citizen.

A senior citizen mediclaim policy offers health insurance coverage  to elderly people who
are vulnerable to serious illnesses that may require expensive treatment. You can easily
buy a health insurance plan for senior citizens online from Policybazaar.com.  Take a look
at the things that should be considered while buying a mediclaim policy for senior
citizens:

1. Day Care Treatments
With the advancement in medical technology, a lot of treatments and surgeries can be
done through day care procedures. But under a regular health insurance policy, a senior
citizen must be hospitalized for at least 24 hours to raise a claim. Therefore, it is better to
choose a senior citizen plan that covers a lot of day care procedures like dialysis,
chemotherapy, radiotherapy, etc.

2. Cashless Hospitals
Every health insurance company has a broad network of hospitals where you can avail
cashless hospitalization facilities. You must check the list of network hospitals of your
insurance company before buying a plan. This will help you to know if a good hospital in
your locality falls under the list. You can check the network hospitals list by different
insurance companies and buy the best senior citizen health insurance policy  online at
Policybazaar.com.

3. Efficacy of Health Insurance Claims

Claim settlement ratio and claim settlement time taken by the insurance company should
also be taken into consideration while buying a senior citizen health policy. If an
insurance company’s claim settlement time is less and the claim settlement ratio  is high,
it means that the chances of your claim getting settled quickly are more.

4. No Claim Bonus
Almost all insurance companies provide a no claim bonus discount if no
claims are lodged by the policyholder in the previous year. In such a case, either the
policy premium decreases or the sum insured amount increases.
5. Free Medical Health Check-up Facility
The best health insurance plans for senior citizens allow the policyholders to avail
medical check-up for free on an annual basis. This usually is offered after the completion
of certain policy years or after every two/three claim-free years.

6. Co-payment
Several senior citizen health plans come with a co-payment clause in which a part of the
claim amount has to be paid by the policyholder. Only the remaining portion of the claim
amount is paid by the insurance company. Hence, you must opt for a plan with low to
zero co-payment.

7. Policy Renewability
Always look for a best health insurance plan that offers a lifetime renewability option so
that you won’t have to buy another health plan in your old age. A policy that ceases to
renew, especially after 60 years, is not the right plan for a senior citizen.

8. Pre-existing Diseases Waiting Period

Elderly people are more likely to have pre-existing diseases whose treatment can exhaust
all your savings. Therefore, you should opt for a senior citizen health insurance plan that
comes with a minimum waiting period for pre-existing diseases.

9. Domiciliary Hospitalization
There can be situations where an elderly person’s health condition may not allow him/her
to get admitted to a hospital. In such a case, health plans with domiciliary hospitalization
cover will pay for home treatment expenses as long as it has been advised by a qualified
doctor.

Claim Settlement Process for Senior Citizen Health Insurance

Senior Citizen Health Insurance plans require policyholders to file a health insurance

claim if they get hospitalized or avail an emergency medical treatment. A claim can
be raised either to avail cashless treatment at a network hospital or get reimbursement of
expenses incurred at a non-network hospital. The process to file a reimbursement and
cashless claim are given below:
 1. Senior Citizen Health Insurance Reimbursement Claim Procedure :
The following steps are involved in lodging a reimbursement claim under a  senior citizen
health insurance plan:

 In case of hospitalization, immediately notify the insurance company

 Collect all the medical documents during hospital discharge

 Fill up and sign the claim form

 Submit the claim form to the TPA or the insurer along with all the required documents like
doctor’s prescriptions, pathological reports, chemist bills, certificate of hospital admission
and discharge,

 The claim is settled by the claims team after careful review and the claim amount is
reimbursed.

2. Senior Citizen Health Insurance Cashless Claim Process:

If you avail medical treatment at a network hospital, then you can file for a cashless claim
under a senior citizen health policy. Take a look at the steps listed below:

 Get hospitalized at a network hospital of the insurance provider

 Fill out the pre-authorization form available at the hospital and give it to the hospital
authorities

 The hospital will send the thepre-authorization request to the TPA that needs to be
approved by the insurance company or the claims team to initiate cashless hospitalization
of the insured elderly person.

 Obtain the treatment after approval and get discharged

 The insurance company will settle the claim with the hospital directly.

Benefits of Senior Citizen Mediclaim Policy

A senior citizen mediclaim policy offers a variety of benefits to elderly people.  Below
 are some of the primary benefits of buying a senior citizen mediclaim policy in India:

 Medical Coverage to Elderly People- People above the age of 60 years get health cover
under senior citizen health insurance plans as regular family health insurance plans mostly
provide coverage to people up to 65 years of age.
 Pre-medical Screening- Most healthplans do not require elderly people to undergo any
medical screening before buying the policy, unlike regular plans.
 Hospitalization Expense Cover- These plans cover senior citizens against a range of
medical expenses, including pre-hospitalization, post-hospitalization, and in-patient
hospitalization expenses.
 Cashless Treatment- Senior citizens can avail the cashless medical treatment at
networkhospitals of the insurance company, provided they get admitted for a minimum of
24 hours.
 NoClaim Bonus- It provides a No Claim Bonus to the senior citizens that allows them to
avail a discount on renewal premium for every claim-free year. It can range from 20% to
100% in some plans.
 Lifetime Renewability Act.–Most health plans for senior citizens come with a lifetime
renewability option.
 Tax-Benefits- Senior citizen health insurance policy offers tax exemption benefits every
financial year on the paid premium undersection 80D of the IT

Why Do You Need Health Insurance Plans for Senior Citizens

Senior citizens need to have health insurance coverage as they can face severe health issues
due to their increasing age.  An emergency hospitalization of your parents can be both
emotionally and financially distressing. Health insurance for parents can help you to manage
the financial implications of hospitalization. Some of the other prominent reasons why you
need to buy a senior citizen health insurance plan are given below:
 Meet the Rising Healthcare Costs- With medical treatment and hospitalization
costs getting costly due to medical inflation, buying a senior citizen health insurance policy
becomes imperative for elderly people to avail the best healthcare services.
 Critical Illness Cover- With old age,the possibility of being diagnosed with critical
illnesses like heart ailments, kidney problems, cancer, etc. becomes higher. With a senior
citizen health insurance policy, you can also get coverage for critical illnesses in your basic
 plan or as an add-on cover.
 Annual Health Check-up Facilities- Senior citizens can avail free health check-ups on a
yearly basis under most senior citizen health plans. As they need to undergo medical
screening on a regular basis, this facility can help minimize out-of-pocket
expenses. However, some plans may offer this facility after every two or three claim-free
years.
 Peace of Mind- Paying off hospital bills can be distressing for elderly people, especially
with an increase in treatment costs for both minor and major illnesses. A health insurance
policy can bring peace of mind to senior citizens in such situations.All savings are provided
by the insurer as per the IRDAI approved insurance plan. Standard T&C apply.

 Critical Illness Mediclaim Policy: Medical expenses arising out of critical illnesses are high
and the Critical Illness Mediclaim policy offers to cover illnesses such as cancer, kidney
failure, cardiovascular-related illnesses, etc. A critical illness insurance cover, often referred
in laymen language as Critical Illness Insurance, refers to the insurance benefits you receive
to deal with life-threatening critical illnesses and various lifestyle diseases. Critical health
issues like Cancer, Stroke, and Kidney failure require comprehensive treatment, which can
take a toll on your finances are often covered in the Critical illness Insurance Cover in
addition to the base plan which provides a life insurance cover. The need for having critical
illness insurance cover can be realized from the fact that these illnesses impact vital body
parts, such as the brain, lungs, and heart. Because of negligence and lack of pre-emptive
health checkups, the diseases continue and later requires comprehensive treatment. With a
critical illness insurance cover, you can easily avoid facing any financial burden while getting
the necessary treatment.
Key features of Critical Illness
Investing money in Critical Illness will always be a good financial planning call as it will
mitigate the financial risk on battling many serious diseases. This critical illness insurance
rider comes with the following features.
Comprehensive Critical Illness CoverThe critical illness coverage under this Rider spans over
64 Critical Illnesses depending on the variant you select

Flexible Payment OptionYou can get critical illness cover under this Rider by paying
premiums throughout the policy tenure (regular pay) or a specific number of years only
(limited pay)

Critical Illness Coverage for an Extended PeriodOne of the significant benefits of opting for
critical illness cover under this Rider is its extended coverage period. Get coverage for
yourself or your loved ones upto age 85 years for 2 variants.

Total and Permanent Disability CoverYou can also get insurance coverage for Total and
Permanent disability under specified variant of this critical illness insurance rider

Max Fit ProgramYou also get a Wellness benefit under this critical illness and disability
insurance rider to ensure good health and lesser renewal premiums. All you have to do is to
walk/run and you will be eligible for a discounted renewal premium based on the number of
steps monitored and number of healthy weeks accumulated on Max fit app.

How to Buy Critical Illness Cover

1.Select base the policy term and sum assured : The first step to getting critical
illness cover is to use the online life insurance calculator to calculate the premium for the
desired sum assured and tenure of one of our life insurance products.

2.Choose the Critical Illness Benefit Rider: The next step will be to choose Max
Life Critical Illness and Disability rider for critical illness cover, over and above the base
cover. The critical illness coverage under this Rider enhances your financial protection in
case of unfortunate events such as a disability or being diagnosed with a life-threatening
health condition. These optional benefits are available on payment of an additional premium.

3.Payment of Premium: After selecting the plan along with critical illness cover,
 proceed to fill personal information and pay the premium*.

4.Fill out the Proposal Form : Essentially, the proposal form for critical illness cover is
a detailed version of your application form, which focuses on the information related to your
life, such as your lifestyle habits (such as smoking and drinking) and medical history

5.Medical Tests: Based on individual life-risk, a medical test may be proposed before
offering critical illness coverage. Any such medical evaluation will be conducted after the
successful completion of the proposal form and document submission.

How to file a claim for critical illness policy

A claim for critical illness can readily be processed based on a diagnostic report. You must
contact your insurance carrier and register your claim if you wish to file a claim for your
critical illness policy.

To file a claim under a critical illness insurance plan, you will need the following documents:

 Completed claim form

 Photocopy of your identification card and NEFT details / copy of cancelled bank cheque
 All pre and post hospitalization records
 All consultation records pertaining to the current diagnosis.
 All medical tests/ diagnostic reports confirming the diagnosis
Once the information has been verified by the insurance carrier, you will receive the claim
pay-out under the critical illness policy as per policy terms and conditions

Benefits of Critical Illness Insurance Plans

Critical illness insurance plans share certain specific benefits that distinguish them from other
types of insurance. The following are some of the most prominent benefits of purchasing a
critical illness policy:
1. Financial Support in times of need
You can choose a high sum insured level with critical illness plans, ensuring that you are
properly covered in the event of a severe illness or advanced treatment. A critical illness
coverage protects you against certain illnesses as well as treatments and surgery.

If you are diagnosed with a critical disease covered by the insurance, these policies pay you
the amount insured, and the regularity of the payment depends on the predetermined terms of
the critical illness policy. The claim money from critical illness insurance plans can be used
to pay for medical bills or other financial commitments.

When a person is diagnosed with a life-threatening or complicated disease, the financial

impact can be quite massive on the individual and their family members. Rather than
focusing on recovery, such circumstances lead to financial burdens leaving the family
dependent on other resources. This can exacerbate your health problems.

However, if you are covered under a critical illness policy, you can focus completely on the
quality of treatment and rehabilitation rather than worrying about the financial aspect of the
disease.

2. Numerous Critical Illnesses Covered

A list of critical illnesses is covered by a critical illness policy. Since the critical illness list
differs per insurer and the policy, you should examine the policy to see how many and what
types of illnesses it covers.

3. Acts as Income Substitute

In case of being diagnosed with a critical illness, it is possible that your health condition
doesn’t allow you to continue working. In such a situation, the livelihood of your family
might be endangered.

However, if you have adequate coverage under a critical illness policy, you can claim the
sum insured and use it to pay for treatment and living expenses. This is especially a relief for
policy buyers who are the sole breadwinners of their family.

4. Additional Support On Top On Health Insurance

A critical illness policy is separate from any other health insurance coverage you may have.
Even if you already have a health plan covering your sickness, the critical illness coverage
would pay a claim if you got sick.

In the event of a critical illness, critical illness insurance can be used to enhance an existing
health insurance plan. This way, you will have ample coverage and funds to manage medical
and living expenses.

5. Funding for Expensive Treatments

Treatments for critical illnesses can be quite heavy on your pocket. Hence, there is a need for
a specific insurance plan such as critical illness insurance that pays for the expensive
treatment where standard health insurance may be insufficient.

6. Affordable Premiums
For the many benefits and the peace of mind that critical illness insurance offers, investing in
such insurance is a smart idea. Besides, you will find that critical illness insurance comes
with affordable premiums, so that you ensure protection for your health, without burning a
hole in your pocket.

7. Tax Advantages
Section 80D of the Income Tax Act of 1961 allows you to deduct the premiums you pay for
critical illness policy.

Overseas Medical Insuranc: As the name suggests, overseas mediclaim policy is a

health insurance policy which covers you against the risk of hospitalization expenses in a
foreign country. This policy covers medical expenses while the insured is outside India. It
covers medical expenses both as inpatient as well as outpatient.
 However, you get this type of coverage in the travel insurance policy as well. The
hospitalization and medical care expenses in the western countries are sky-rocketing due to
the strict Food and Drug Association guidelines in these countries. In such a scenario, if a
common man falls sick during his visit to these countries a major chunk of his savings is
wiped off. Therefore, it is common sense to safeguard your savings against such financial
tragedy by purchasing an overseas mediclaim policy. An overseas mediclaim policy not only
covers your medical expenses but also protects you against the loss of baggage, cancellation
of flights, loss of passport, and much more.
 In addition, most Insurance Companies offer specialized packages for certain places like
USA, Australia, Schengen region, Middles East and much more. So, next time you plan a
vacation take some time off to research a bit about such policies it might save you a lot of
money.

 Low-Cost Mediclaim Policy: For those looking for a lower sum insured, you can this type of
policy. Also, such policies cater to the underprivileged section of the society. Usually bought
by small and medium scale industries employers to cover their employees at low-priced
premiums.

WHAT DOES A MEDICLAIM POLICY COVER

An excellent mediclaim policy covers you against a wide range of medical expenses and it
can vary between policies. Here are some of the most common inclusions of a mediclaim
policy:

 Hospitalisation Costs: It includes all medical expenses incurred during the hospitalisation of
the policyholder or the beneficiaries of the policy. It covers expenses related to diagnostic
procedures, OT charges, medicines, blood, x-ray, oxygen, etc.
 Pre- and Post-Hospitalisation Expenses: Medical expenses arising before 30 days of
hospitalisation and up to 60 days post-discharge are covered under the mediclaim policy.
However, you need to check with the insurer if this type of hospitalisation is part of the
policy.
 Day-Care Expenses: Medical expenses arising out of advanced medical treatments which do
not require the patient to be hospitalised for more than 24 hours is covered.
 Hospital Room Expenses: Costs towards regular wards or Intensive Care Unit (ICU) are
fully reimbursed or through the cashless facility.
 Doctor’s or Medical Professionals’ Fee: Doctor’s consultation fee or medical professionals’
charges such as nurses’ fee, etc. are covered.

What is Not Covered in Mediclaim Policy

Every mediclaim policy has some exclusions and varies from one insurance company to
another. Here are some of the common exclusions in mediclaim policies:

 Pre-existing illnesses.
 Dental treatments.
 Sexually transmitted diseases.
 Birth control and hormonal treatments.
 Vaccinations.
 Plastic surgery.
 Cosmetic surgery and obesity-related treatments.
 Maternity expenses if not opted as an Add-on feature.
 Non-medical expenses such as service charges, administrative charges, toiletries, etc.
 Ailments and diseases contracted within a set period from the policy purchase date.

 How is Mediclaim Premium Calculated

Insurance companies calculate the mediclaim policy premium based on factors such as age,
geographical location, the sum insured, pre-existing medical condition (if any), the extent of
the coverage, number of members to be insured, etc. However, the final premium will be
decided by the insurer based on your unique needs and financial needs, which is as per
the IRDAI guidelines.
 Things to Remember When Buying the Best Mediclaim Insurance Plan:

If you’re planning to buy a mediclaim insurance policy, here are the factors that you need to
consider:

 Sum Insured (Coverage): While choosing the best mediclaim policy, you need to select an
adequate sum insured or the coverage amount. You might pay a higher premium for a higher
sum assured, but it’s imperative that you choose a policy based on your needs.
 Individual or Family Floater: Before you finalise your mediclaim insurance, you need to
check if this policy is for an individual or is it for your entire family. However, in a family
floater type mediclaim policy, the entire sum insured will be jointly held by the members of
your family who are beneficiaries of the policy amount.
 Co-Payment: Under this clause, you as a policyholder, are expected to pay a specific
percentage of the claims and the insurer bears the rest of the medical expenses.
 Network Hospitals: Choose an insurance provider with a wide range of network hospitals as
the cashless facility is available only with these hospitals. This will help you choose from
several options.
 Waiting Period: While registering a claim, insurance companies have a waiting
period before which you cannot claim for any medical expenses. Also, insurance companies
have a waiting period for pre-existing diseases or illnesses. Check for these exclusions to
make the best decision to buy a mediclaim policy.
 Add-ons: Usually, insurance companies do not offer Add-ons on mediclaim policy; however,
if they do, you can buy these extra features and enhance your insurance cover. Please do note
that Add-ons will increase your insurance premium

How does Health Insurance Affect Patients

Lesson 1: Coverage can be a matter of life or death

The first lesson is that health insurance coverage matters to patients’ lives. Some of the most
useful evidence in support of this observation comes from expansions in health insurance that
occurred prior to the ACA. Studying expansions of Medicaid in several states in the early
2000s by comparing them to neighboring states without expansions, we found large
reductions in the uninsured rate, improved self-reported health, and a drop in mortality of 6%
over the following five years.1 These changes were largest in lower-income areas and among
racial and ethnic minorities. We also studied Massachusetts’s 2006 health reform, the model
for the ACA, and found that the coverage expansion led to a significant reduction in mortality
for the state compared with what was happening in demographically similar counties outside
the state.2 Most of the deaths prevented were due to causes potentially more amenable to
health care, such as cancer, heart disease, and infections. Overall, we concluded that one life
was saved for every 830 adults who gained coverage. Most recently, I examined the costs of
Medicaid expansion in relation to these mortality changes, and found that the increase in
spending was a good investment compared with how much we as a society spend on other
public policies that affect survival.

Now, with Congress debating a potential repeal of the ACA, there has been renewed interest
in this work as a gauge for how many deaths might occur if the law is repealed. Policy
makers and analysts have proposed various extrapolations from these studies, including the
White House Council of Economic Advisors, which estimated that the law could be saving as
many as 24,000 lives a year.4 This is a challenging calculation to make with precision, and
no one can know the exact numbers for sure, but our research indicates that these are indeed
life and death decisions. Taking coverage from people will likely lead some to forego
medical care that could have saved their lives.

Lesson 2: The ACA has succeeded in expanding coverage and access to

care
These studies of pre-ACA expansions in coverage are illuminating, but what lessons can we
draw about the ACA’s effects in particular? Using a variety of data sources, our team and
other researchers have documented that not only has the ACA lowered the uninsured rate to
its lowest level in U.S. history but that coverage has also produced meaningful benefits for
patients. The earliest ACA studies examined the “dependent coverage” provision that allowed
young adults to remain on their parents’ plans until age 26 starting in 2010. Studies show that
this policy was more successful than even the law’s drafters had hoped, with two million to
three million more adults covered. The coverage helped young adults better afford their care,
reduced their use of nonurgent emergency department care, 5 and improved their perceived
physical and mental health.

Next came the ACA’s 2014 expansions. Medicaid expansion in the roughly 30 participating
states and new subsidized Marketplace coverage led to about 20 million more Americans
with insurance. From 2010 to 2014, as policy makers scrambled to implement the law,
researchers scrambled to figure out how to study it—and, in particular, how to study it
rigorously and quickly. Standard data sources from the federal government sometimes take a
year or more to become available. For a policy as large and consequential as the ACA, we
needed results faster. Working with colleagues at the U.S. Department of Health & Human
Services, we obtained and evaluated a new data source—the Gallup Healthways Well-Being
Index. With it, we published some of the first journal articles showing—within months of real
time—how the law was increasing coverage and also improving trends in rates of having a
primary care doctor, ease of access to prescription medications, affordability of care, and self-
reported health.

Following up on this, my colleagues at Harvard and I then conducted our own rapid-
turnaround scientific survey to evaluate the Medicaid expansion in several southern states.
This work showed that in Kentucky’s traditional Medicaid expansion and Arkansas’s private
insurance expansion, low-income adults saw major improvements in health care, compared
with those in Texas, which did not expand. Adults in the two expansion states reported more
primary care visits, better chronic disease care, more preventive care, less ER use, and again
—better self-reported health.

Given this pattern of findings, some have questioned whether policy makers and society in
general should care about changes in self-reported health. I would argue that we should for
two reasons. First, self-reported health turns out to be a strong predictor of survival; people
who say they are in poor health die younger Second, subjective well-being is a key part of
health. If you’re a doctor and you don’t care whether your patients feel better, you should
quit. We should hold our policy makers to the same standard.

Lesson 3: Challenges in coverage and access remain

The final lesson from our research is that all is not perfect. Yes, health insurance matters, and
the ACA has helped expand coverage and improve access to care. But as many as 30 million
Americans are still uninsured, and millions more find themselves switching between various
types of coverage each year. Some of this is related to the ACA, but much of it is due to the
United States’ underlying patchwork health insurance system. This switching in coverage—
sometimes called churning—has real impacts on patients. In one recent study, we found that
roughly one in four low-income adults experienced a change in coverage each year. Although
this is lower than many had predicted would occur under the ACA, these changes in coverage
were harmful—patients reported reduced continuity with providers, disruptions in medication
regimens, and negative effects on overall quality of care and health.10 In part, this research
has been useful to states and federal policy makers as they try to streamline some of the
transitions in coverage. But now, with ACA repeal on the table, our findings have another
implication. While taking coverage away from people would clearly be quite harmful, even
transient disruptions in coverage from dismantling parts of the law could also cause
significant distress.

An Uncertain Future—and the Need for Evidence-Based Policy

Despite this body of evidence, the political future of the ACA’s coverage expansion remains
uncertain. In fact, the rhetoric in the debate over the ACA raises fundamental questions about
what role research evidence plays at all. Despite hundreds of high-quality studies by
researchers across the country probing the law’s successes and shortcomings, many people
still don’t know the basic facts about the law. For instance, one recent survey by National
Public Radio found that only 49% of Americans knew that the ACA had reduced the number
of Americans without health insurance; 27% didn’t know or said it was unchanged, and a
stunning 24% thought the uninsured rate had gone up.11 Meanwhile, some physicians,
politicians, and pundits continue to argue that the ACA expanded coverage but did not
meaningfully improve access to care. But these claims are flatly contradicted by the research
evidence. That so many might still not know the basic facts about this law is, at least in part,
the fault of researchers like me in health policy and academic medicine. We certainly are not
alone in this—there are other factors too, including some media outlets’ desire for an
evenhanded cross-fire debate rather than a focus on facts, and rhetoric from some politicians
 that ranges from misleading to simply wrong.

But already there is some indication that the facts are starting to sink in and affect the policy
debate. The steady drumbeat for repeal among congressional Republicans has met the reality
of millions of Americans who have gained coverage under the ACA and are benefiting from
it. Republican governors from expansion states have stepped forward to say that a repeal and
large cuts in federal funding for Medicaid would not be good policy. 12 As of this writing, the
debate continues and is unsettled. For those of us in academic medicine who believe evidence
should guide what we do for our patients, now is the time to bring a similar mentality to the
policy discussions that will affect our patients just as surely as the next prescription we write
or the next test we order. The future of health care is too important not to have the major
policy decisions in it driven by evidence.

Advantages Of Having A Health Insurance

The increasing prevalence of lifestyle diseases such as diabetes, hypertension, stroke and
heart attack among the young as well as the elderly people in India is becoming a major cause
of concern. Having no family history of these conditions does not ensure protection from
related complications. In today's fast-paced life, you must be prepared for a medical
contingency at all times. This is where a robust health insurance policy can help. One of the
major health insurance benefits, in the face of a medical emergency, is that it allows you to
take your mind off the stress related to healthcare costs and focus on the treatment instead.

Benefits of individual health insurance

You may buy individual health policies for each family member separately depending on
their specific requirements. The major benefits of medical insurance are:
 Financial coverage
You are financially covered against treatment costs for a wide range of diseases within a
specific limit.
 Cashless claim process
If you get admitted to a network hospital, your insurer will settle the bill directly with the
hospital without you having to pay anything.
 Coverage for medical expenses

You cannot predict when a chronic medical problem may occur to you or your loved ones. If
you have a family floater or individual health policies, your insurer would take care of the
medical bills while you can concentrate on the treatment process instead. The benefits of
having health insurance are:
 Option of cashless or reimbursement expenses
With cashless treatment facilities, you do not have to pay anything from your pocket if you
opt for sufficient cover. Take the patient to any of the network hospitals with which your
insurer has a tie-up, and inform the TPA (third party administration) and the insurer at the
earliest. The insurer would settle the bill with the hospital directly. Alternately, you can get
treated at any hospital or by any healthcare provider of your choice and file for a
reimbursement claim by submitting original invoices and required documents to the insurer.
 Benefits apart from hospitalisation costs
Insurers also provide ambulance services up to a certain amount, coverage for online or e-
consultations, expenses for harvesting a major organ from a donor, lifetime renewability
options, free preventive health check-ups and more.
 Alternative treatment
Costs for alternative treatments such as AYUSH (Ayurveda, Unani, Siddha, and
Homeopathy) and Naturopathy are covered by some insurers. Other facilities include cashless
facilities for daycare treatments, treatment at home under doctor's advice, and pre and post-
hospitalisation expenses up to a certain period.
 Maternity benefits and alternative treatments
Several insurers cover maternity expenses in their health insurance policy plans. This is
particularly beneficial for young couples who are planning or expecting a child.
 

Cashless Claim Service

With cashless claim services, you can get treated at some of the best hospitals across India
without paying anything out of your pocket. You just have to get admitted at any one of the
network hospitals with which your insurer has a tie-up. Once you inform the TPA (third party
administrator) and the insurer about getting admitted, they will communicate with the
hospital staff and settle the bill directly. To get a cashless claim, your treatment cost should
be within the coverage amount.

Portability Benefits

Portability of health insurance means you can change your insurance policy from one
insurance company to another, or one plan to another without losing the benefits that you
have accumulated. This is as per the new rules of the IRDAI (Insurance Regulatory and
Development Authority of India). Your new insurer should give you the credit relating to the
waiting period for pre-existing conditions that you had received from your previous insurer.
Your new insurer has to insure you at least up to the sum insured under the old policy. A
required condition is that you must port the policy only during the renewal so that the new
insurance period will be with a new insurer.
Tax Benefits

Under Section 80D of the Income Tax Act, the premium that you pay towards health
insurance coverage under 80D is exempted from your income tax liability for a particular
financial year. This exemption is available on individual plans andfamily floater plans that
cover you, your spouse, children and your parents. Claim a deduction of Rs 25,000 for self,
spouse and dependent children. File an additional deduction for insurance of dependent
parents up to Rs 25,000, if they are less than 60 years of age. If the parents are aged above 60
years, the deduction amount is Rs 50,000. You can claim a total deduction of Rs 75,000,
consisting of Rs 25,000 on the premium paid for self, spouse and dependent children and Rs
50,000 on the premium paid for parents. If both you and your parents are senior citizens, the
maximum deduction that you can claim would be Rs 1,00,000 = Rs 50,000+Rs 50,000.
Hospitalisation Daily Allowance

A daily hospital cash benefit or daily allowance provides a lump sum amount every day in
case of hospitalisation and you can use it as per your requirement or for compensating the
loss of income during the period of hospitalisation. Some expenses called inadmissible
expenses include surgical accessories, X-Ray charges, and expenses incurred by
accompanying family members may not be covered by your health plan. Daily hospital cash
benefit does not require supporting bills. A valid hospitalisation of at least 24 to 48 hours is
sufficient to avail of this benefit.

Financial Security against Rising Medical Costs

Staying healthy is extremely important but several factors such as physical inactivity,
extreme workload, unhealthy personal habits, and poor diet can have an adverse effect on the
health of most people. The outcome could be multiple health challenges and excessive cost of
medical treatment. A health insurance plan can be a solution to deal with the rising medical
costs. It provides financial security by covering the costs related to treatment, hospitalisation,
free health check-up, and pre and post hospitalisation expenses. Also, you can get tax relief
on the premium under Section 80D.

No Claim Bonus

No Claim Bonus or NCB is the reward given by your insurer for consecutive claim-free years
on your health insurance. There are two ways through which insurers provide NCB on their
health insurance policies—by offering an increase in the sum assured or by offering a
discount on the renewal premium. You can transfer the accumulated NCB on a particular
health insurance policy to a new health policy provided by a different insurer.
 

Lifetime Renewability Benefit

Earlier, many insurers did not provide insurance coverage after a particular age. However,
now, the IRDAI has made guaranteed renewability compulsory for health insurance policies
so, you can get the benefits of the policy throughout your life with a lifetime renewability
option. There would be no restriction on age. You can renew the tenure of the plans for a
lifetime without any fresh medical declaration at each renewal. You would be eligible to buy
a new health policy even at the age of 65 years.
 How Can You Get an Individual Health Insurance Cover at Less Premium

With rising prices of necessities, it would become difficult for you to spend a lot on policy
premiums. The following tips would help you stay covered at a lesser premium and reduce
your expenses on insurance:
 Purchase health insurance when young
It will be good if you purchase health insurance when you are young as your premium will be
much lower compared to what you have to pay when you are older.
 Buy a policy with low sum insured (SI)
Initially, keep your SI low and gradually increase it over the years. This way, you can have a
much more affordable policy.
 Co-pay and deductibles
Opt for co-pay and voluntary deductibles so that your premium goes down. Co-pay and
voluntary deductibles give you the option to pay for part of the expenses when you make a
claim.
 Go for different options
If you have an existing group health cover from your employer, choose the additional policies
carefully so that you do not spend a lot unnecessarily on premiums.
 Buy long-term health policies
The premium for long-term insurance policies is usually lower than the traditional plans with
one-year terms. You can buy long-term health insurance plans with 2-3 years tenure as they
would lower your premium payment by a substantial amount.
 Top-up plans
Top-up plans are good for availing of higher coverage without paying a huge amount of
premium. Top-up plans help to split your cover and raise higher claims.
 Family floaters
In some cases, you will find family floater plans to be cheaper than the total premium that
you have to pay for different individual plans. So, you can reduce your premium by
purchasing a family floater policy.
 
 Compare plans
Compare and purchase policies online to get attractive offers and discounts on your insurance
policy. This way, you can reduce the premium paid towards your health policy to some
 extent. You will also be able to maximise your benefits.
 
 Purchase policies for your parents before they turn 60 years
The premium of most health insurance policies increases as the age of the insured person
crosses 60 years. So, it would be best if you cover your parents before they become senior
citizens.
 
Things to Watch Out For
Consider the following factors while selecting the best health insurance cover for you and
your family:
 Maximum coverage
Look for a plan that provides maximum coverage, daycare and domiciliary treatments.
Certain treatments such as cataract surgery require hospitalisation for less than 24 hours.
Again, for bone fractures, treatments can be done from home instead of in a hospital.
 Eligibility
Certain policies may have attractive features related to healthcare, provide extensive coverage
and NCB but with a limit on the enrolment age. Check the eligibility criteria for various
health insurance plans and select policies with maximum renewal age and lifetime coverage.
 Waiting period
It is a minimum period between the issuance of policy and availing of the benefits. You may
find policies without a waiting period. Others have a waiting period ranging from 30 days to
one year or more. Select policies with short waiting periods.
 Exclusions
A policy, no matter how extensive, would have a limit up to which it can cover. Before
purchasing a policy, go through the exclusions carefully to avoid confusion in future. Buy
policies with the minimum number of exclusions.
 Premium
Do not go for policies based on low premiums only. Generally, low-priced policies have
limited coverage or other limitations. Choose a policy with maximum coverage at an
affordable premium.

Types of Health Insurance Add-Ons

One must have health insurance but sometimes the health insurance is a very basic plan and
there is a need to get some add-ons which can give the extra protection to the individual
which is needed. There are plenty of add-ons which the insurers offer in return you have to
pay some extra premium amount. This is also called Health Insurance riders which means the
same as having an additional health insurance plan. 

What is a Health Insurance add-on

These are the additional benefits which do come with the basic health insurance you
purchase. They can be added at an extra cost in your premium amount and will cover you
when the time comes. IRDA has however that for any kind of add on amount cannot exceed
30% of the total premium amount. For example, if you get health insurance at 4000 premium
per annum with sum insurance of 50,000 then you decide to get the add-ons then the total
price of the add-ons cannot exceed 1200 which is 30% of the 4000 annual premium amounts. 

Top 4 add-ons which you can get with your policy are

Room rent Wavier

The medical bill not only depends on the type of treatment you are getting but are also highly
influenced by the rent of the room. It can be one of the highest expenses in some cases. The
standard health insurance policy generally comes with a limit in the room rent if you read the
policy in details. This means that if under the insurance you have been allotted room rent of
5000 and you get into a costly one then the additional cost has to be covered by you. The
hospital charges the person according to the type of the room as there are many from AC
rooms to normal rooms to deluxe ones. Having room rent wavier will ensure that whole of
the room rent charge is covered by the insurer and you don't have to pay anything.
Maternity Cover
This is specially designed health cover for the child however the policy often has a waiting
period of 24-48 months thus you may have to wait for the coverage to start. But it will cover
all the expenses incurred during childbirth.

Critical Illness Rider

This is the add-on which provides full cover against any critical illness such as cancer, heart
attack, kidney failure and others. This could be under the add-on by some insurer while for
someone it could be standalone critical illness insurance policy separately. With this add-on
you become eligible to get the lump-sum cover in case you are diagnosed with any critical
illness.
Hospital Cash

This is the add-on which takes care of any kind of non-medical expenses that are incurred at
the time of hospitalisation. Also, a daily cash allowance is paid at the policyholder as per the
mentioned terms in the documents which range from Rs 500 to 5000. 

8 Features You Must Compare Before Buying A Health Insurance Plan

A health insurance plan popularly known as 'Mediclaim' has become inevitable in today's era
of sky rocketing medical expenses. And if you don't have one of your own, then you may end
up shelling out huge amount from your pocket.
Knowing the importance of health insurance for your family is just the starting point. A step
forward - and an important one - is selection of an ideal health insurance plan, when there is
 gamut of them available today. Some of them have really unique features, but there are some
common features available in all policies which you must compare before finalizing
any health insurance plan.
Let's have a look at 8 features you must compare before buying a health insurance plan:

 Sub-limits on Room Rent : Room Rent is one of the major expenses you have to bear if any
member of your family gets hospitalized; so some general insurance companies cap the
maximum amount that they will pay under their health insurance plan. Generally such limit is
to the extent of 1% of sum assured and in case of ICU (Intensive Care Unit) the maximum
limit is 2% of sum assured. But there are various general insurance companies which do not
have any maximum limit on room rent, so you should look for such health insurance plans.

 Pre-Existing Diseases : Pre-Existing Diseases are those which you are suffering from before
opting to buy a health insurance plan, and therefore insurance companies do not cover them
from day 1 of your policy. They have a waiting period ranging between 2-4 years in which
they will not be liable for any claim arising on account of your pre-existing disease.
Therefore you should look for health plans which will cover your existing disease and have
the least number of years of waiting period.

 Co-payment : Co-payment is a clause in health insurance plans that requires cost-sharing by

the policyholder. Cost sharing is the specified percentage of the admissible claim amount.
Let's take an example to understand it better. Suppose you have a health insurance plan which
has a 20% co-payment clause; so in case you are hospitalized and your claim amount is Rs 1
lakh, then you as an insured would be liable to bear Rs 20,000 (Rs 1,00,000 * 20%), while
the rest i.e. Rs 80,000 would be settled by the insurance company. Hence, ideally you should
look for health insurance plans which do not have any co-payment clause at any stage of your
life.

 Network Hospital : Network hospitals are those which have a direct tie up with your health
insurance company; so in case of a claim you can avail the cashless facility. Cashless facility
saves you from the headache of settling the bill amount with the hospital, as insurance
companies directly settles your bill on your behalf. Hence in such a case, you do not have to
file for the reimbursement of claim due to insurance company already haven settled the
claim. You should ideally look for health insurance plans which have the maximum number
 of network hospitals, and more importantly, maximum number of good network hospitals in
your city.
 Pre & Post Hospitalization Expenses : Pre-Hospitalization expenses are those expenses
which are incurred before you are hospitalized while Post-Hospitalization expenses are those
which are incurred after you are hospitalized. Pre-Hospitalization expenses are generally
covered for minimum of 30 days while Post-Hospitalization expenses are generally covered
for 60 days. But there are insurance companies which cover pre and post hospitalization
expenses for more number of days as well. So you should look out for health insurance plans
which cover you for maximum number of days of pre and post hospitalization period.

 No Claim Bonus : Health insurance claim only erupts in the year of hospitalization, in the
years where you've been in pink of your health (by God's grace), the insurance companies
also provides you with a no claim bonus. This has an effect of increasing your sum assured in
next renewal of the policy. Such bonus can range between 10-50% for a claim free year.
Hence you should look for a policy which provides you highest no claim bonus.
 Exclusions: Once you buy a health insurance plan, you might feel relaxed that you have
covered you and your family against any possible hospitalization in future. But if you don't
go through the exclusion section of your policy, then you might get surprises at the time of
claim. So before finalizing on any health insurance plan go through its exclusion and select
the one which has least number of exclusions and are clearly defined.

 Premium: Premium you would pay is a vital aspect you should consider while buying a
health insurance plan; but mind you, it shouldn't be paramount in your selection process. Just
think, you buy a health plan with a very low premium without even taking into consideration
the features of the policy. At the time of claim you learn that the insurance company is not
liable to reimburse you as the cause for which you were hospitalized was not covered under
the policy. So you should be well aware of all the feature, or else you may find yourself in a
soup with a huge hospital bill to be paid, amid times where you just recovering with your
health conditions or God forbid, yet ailing.
It is noteworthy that medical emergencies can erupt anytime. Hence, it is important to have
an adequate health insurance cover, which can help you financially manage medical
emergencies better. It is noteworthy than having an optimal insurance coverage, is integral in
the exercise of financial planning , which helps you to put your personal finance in order and
aids you achieve long-term financial goals.
Health Insurance Claim Process

A health Insurance policy equips you to get the best healthcare treatment without worrying
about the huge costs payable at the time of discharge. Therefore knowing about the claim
process is an essential piece of information that the insured individual should be aware of at
all times. The two main types of health insurance claim which an individual can choose from
when making a claim are:

 Cashless Claim Process

 Reimbursement Claim Process

When the insured individual provides their health insurance details to the respective hospital,
he/she begins to receive treatment. Upon discharge, the hospital will forward the medical
bills to the designated health insurance company. The company will then audit the expenses
and settle the outstanding payment due to the hospital. This process is hassle-free for the
insured as the payments are between the hospital and insurance company. In the
reimbursement claim process, the insured individual who has been admitted to a certain
hospital pays for the entire treatment until discharge.

Once the insurer has paid for the treatment and hospitalization costs incurred, he/she have to
make a reimbursement claim to the particular insurance company. The insured individual will
have to provide original bills of the hospital to the health insurance and claim reimbursement.
The insurance company will audit the claim and will then decide to approve or reject it. On
approval of the insurance company, the claim will be made to the policyholder. The insurance
company will notify the insured individual in case the claim has been rejected.

Healthcare Schemes by Government of India

The Indian government (center & state) have launched numerous medical insurance schemes
to improve healthcare and make it accessible for the weaker sections of society Here is a list
of health insurance schemes provided by the government:
 Rashtriya Swasthya Bima Yojana (RSBY): This scheme was launched by the
Ministry of Labour and Employment to provide health insurance coverage for families
below the poverty line. The Beneficiaries under this scheme can avail a health benefits
cover of up to Rs.30,000. A registration fee of Rs 30 is chargeable.

 Pradhan Mantri Suraksha Bima Yojana: Is an initiative by the government to bring

access to insurance especially for the economically weaker sections of society. This
scheme features affordable premiums and provides compensation to the family of the
deceased.

 Central Government Health Scheme (CGHS): This scheme was launched in 1954. It

provides comprehensive healthcare facilities to the central government employees,
pensioners and dependents of these employees.

 Aam Aadmi Bima Yojana (AABY): This is a social security scheme launched in

2017 to provide healthcare facilities for rural landless individuals. The head of the
household or earning member of a family will be covered under the scheme (AABY).
The beneficiary should be between 18 to 59 years of age. The dependent of the
beneficiary will receive Rs.30,000 upon natural death, Rs.75,000 upon accidental death
or permanent disability, and Rs.37,500 on partial disability.

 Janashree Bima Yojana (JBY): This scheme was launched in August 2000. This
scheme targets people falling below the poverty line (BPL) in 45 occupational groups
covered under the scheme.

 Employment State Insurance Scheme (ESIS): This is a social security initiative

aimed at providing socio-economic protection to the working class and their
dependents. The scheme ensures that all member and their family will receive full
medical care from day one.

 Universal Health Insurance Scheme (UHIS): The Indian public sector insurance

companies have implemented this scheme to improve the access to healthcare for poor
underprivileged families. Beneficiaries will receive reimbursement for medical
expenses up to Rs.30,000 and accidental death cover up to Rs.25,000. The insurance
premium for this scheme is Rs.200 per person, Rs.300 for a family of five, and Rs.400
for a family of seven.
 Chapter 2

Research and methodology

Research design

A household survey was carried out by the Institute for Health and Development (ISED) in
Dakar in cooperation with the Center for Development Research in Bonn. It started with a
pre-test in March 2000 and the final survey took place in May 2000. The participation rate in
the interviews was very high, with more than 95%.

For the survey, we chose a two stage sampling procedure: First, we selected 4 villages out of
the 16 villages in which mutuals operate. In each of the selected villages Fandène, Sanghé,
Ngaye Ngaye and Mont Rolland only one mutual is in place, which has the same name as the
village itself. The following table summarizes the major differences between the analyzed
schemes:
Source: ZEF-ISED survey, 2000 In a second step, we selected randomly the households for
the interviews. In all four villages, members and non-members were interviewed. In order to
get a random sample out of the four villages, we used household lists of all inhabitants
(members and non-members) of the four villages in order to calculate the percentage
distribution between members and non-members and their respective weight in the sample.
We interviewed a total of 346 households, 70% of which are members and 30 % of which are
non-members. The data set contains information of roughly 2.900 persons, from which are 60
% members and 40 % non-members. This means that some household heads have not insured
their complete family. The data was entered immediately after completing the survey using
SPSS Windows. In addition to the household survey, we interviewed key persons (leaders of
the mutuals) in order to get complementary information about the functioning, problems and
success of the mutuals.

Methodology

The modeling of an impact of mutual health insurance schemes on health care use and
expenditure faces the important challenge of dealing with the problem of “endogenity” and
“self-selection”. This problem receives currently a lot of attention in different areas of 9
development economics: Publications focus on measuring the impact of micro-finance
institutions (e.g. COLEMAN 1999, NADA 1999), estimating the returns of education (e.g.
BEDI and GASTON 1999) as well as analyzing the impact of health insurance on various
outcomes such as health demand and financial protection (WATERS 1999, YIP and
BERMAN 2001). In each of these cases the evaluation of a policy intervention or
institutional innovation poses the problem that it is very difficult to assign individuals
randomly to non-program control groups and others to program treatment groups. From this it
results, that the identification of an adequate control group is the first and even most
important step when trying to control for self-selection. With respect to the impact of health
insurance on the health care use, WATERS 1999 names the potential endogenity of the
choice of insurance for health care use as the main problem, leading to potential selection
bias. Individuals who self-select into the insurance program have unobservable characteristics
– related to preference or health status (adverse selection) – that might make them more
likely than other to join the program and also might influence their decision to use health care
services. An observed association between health insurance affiliation and health care use
and expenditure may therefore be due not to insurance but to the underlying unobservable
characteristics. To control for this effect, in the Senegal study an omitted variable version of
the Hausman test (HAUSMAN 1978) is applied. This test is based on two steps: First, the
reduced form of the participation equation is estimated. Second, the fitted values are included
into the health care demand equation as a regressor. A significantly non zero coefficient for
the predicted value term is an indication that the suspected endogenous variable is in fact
endogenous (WATERS 1999)5 . To specifically control for selfselection into the program,
proxies for the health status and health risks have been included in all of the studies. Finally,
village or district dummies are included to control for unobservable characteristics of
communities such as social values and solidarity to see if it influences individual choice to
enroll in a community-financing scheme. To control for a sample selection bias in the
demand equation for health care the total sample is included, i.e. those sick and those not sick
as well as those being member and nonmembers. Finally, the models are checked for stability
and robustness through adding and subtracting key variables and by applying the F-test.

To estimate the determinants of participation in a mutual health organization, we follow an

approach applied by WEINBERGER (2000). In that approach participation in a local
organization is depended on the rational choice of an individual weighting costs and benefits
of membership. It is assumed that participation of a household (p) in a mutual depend on the
current income of the household (y), characteristics of the household head (H), who decides if
the household joins or not, household characteristics (Z), community characteristics (C) and
on the error term u, who is uncovariant with the other regressors. The following equation
describes our model: (1) pi = f (yi, Zi, Hi, C) In order to estimate the probability of
participation we use a binary probit model: (2) Binary probit model: pi* = ßyi + Zi + Hi +C+
ui pi = 1 if p* > 0, meaning the household i is member of the insurance scheme pi = 0
otherwise To assess the impact of mutual health organization on financial protection of
members two aspects have to be taken into account: the probability of visiting a health care
provider and the out-of-pocket expenditure borne by the individuals. The strong disadvantage
of using health care expenditure alone as a predictor of financial protection is that this would
allow to capture the lack of financial protection for those who choose not to seek health care
because they cannot afford it. The first part of the model assesses the determinants of
utilization and thereby we can analyze whether membership in a mutual reduces barriers to
assess health care services. We use a two-part model developed as part of the Rand Health
Insurance Experiment in the US (MANNING ET AL. 1987).6 - a logit model, which assesses
the probability of visiting a health care provider: Prob (visit >0) = Xß +MD + u, where X
stand as a vector for individual, household and community characteristics (including
membership) and

a log-linear model that estimates the incurred level of out-of-pocket expenditures,

conditioning on positive use of health care services: Log(out-of pocket expenditure / visit >
0) = Xy +MF + e Where X again represents a set of independent variables that are
hypothesized to affect individual pattern of utilization, M represents a dummy variable for
membership in a mutual health organizations and u and e as terms of interference. The
independent variables determining the demand for health care and expenditure in the case of
illness are – among others – age, gender, education, health status and income.

Results

Determinants of membership in a health insurance scheme

The following table gives an overview of the variables which are included in the analysis of
the determinants of participation. As outline above the decision of a household to participate
in a mutual health organization is supposed to be influenced by individual, household and
community characteristics. The variables representing individual characteristics of the
household head involves age, education and sex and membership in another organization.
With respect to age we hypothesize that younger household heads are more open for
innovations (age group 1: positive coefficient) and that with increasing age people tend to
participate less (age group 3: negative coefficient). Furthermore we expect that better
educated people and male headed households tend to join a mutual more often than people
with less education and female headed households. The following characteristics of the
household is supposed to influence membership in a mutual: income; ethnic group, religion
and the illness ratio (Figure 1).
The most important variable to be looked at in the context of our research question is income
and it’s effect on the decision to participate or not. In our study we have measured “income”
13 as calculated by expenditure of the household per year and member7 . We assume that
income has a positive influence on the decision to participate and that the poorer strata of the
population will not participate due to difficulties in paying the premium. Also, it will be of
interest to analyze whether the richer part of the population participates as this is important
for risk pooling reasons. Hence, we include into the regression analysis income terzils, i.e. we
divided our sample in three subgroups “rich”, “average” and “poor”. Added to the
quantitative measures of wealth was relative wealth. Households were asked to classify
themselves according to relative wealth within the community on a rank from one (poorer
than the average) to three (wealthier than the average). We expect the same findings in
tendency for the relative measures than for the quantitative measures. We have included a
dummy variable “Wolof” in order to measure the influence of belonging to a specific ethnic.
The Wolof are know for their openness for institutional innovations in the Senegalese context
(Diallo 2000). The variable “religion” is included in order to take into account that the
mutuals have an exclusive contract with the catholic owned hospital St. Jean de Dieu.
Moreover, the mutuals get active support by the diocese de Thiès. Hence, we expect that
Christians tend to enroll proportionally more than Muslims. We assume also a positive
relationship between membership in a mutual and membership in other organizations. People
who have already experience in participation in local organizations are most likely more
willing to join a mutual insurance than people who have no experience in participation at all.
To control for adverse selection we integrate the illness ratio of the household as a proxy for
the health status. The variable describes the number of cases of illness of household members
in relation to the overall household size. It is assumed that less healthier households tend to
join mutuals more than healthier ones, leading to adverse selection problems. Finally, we
include dummy variables capturing village characteristics: acknowledgement of solidarity in
the village (solidarity) and village factors. We assume that people acknowledging a high
value of solidarity in their village tend to participate more. With respect to the village effects,
we want to control if the type of insurance matters, i.e. hospitalization care versus primary
health care (Ngaye Ngaye) as well as for the specific local setting, i.e. the cultural
environment in the specific village and specific characteristics of the mutual, i.e. distance to
the hospital, the functioning of the mutual etc.
The results presented in table 3 show the marginal effects of the probit analysis. Three
different models were evaluated, differing in their definition of the income variable. In the
first model income is defined as a metric variable so as to analyze whether income has an
influence on membership in a mutual. In the second model income groups are established, in
order to determine effects between different income groups. In the third model income groups
were also formed, but in contrast to model 2 they were not determined based on expenditure,
but on the basis of self-assessment by the people surveyed8 . Table 3 shows that all three
methods used are highly significant. Income has the anticipated positive influence on
membership. Models 2 and 3 show furthermore that the lower income groups in the villages
are significantly less represented in the mutuals. That means that the wealthy people in the
communities are more likely to (be able to) participate in the insurance schemes. At the
household level, religion and ethnic identity play an important role in addition to income. The
clearly higher participation by Christians – the probability increases by about nearly 40 %-
age points compared to non-Christians – was to be expected because of the intensive
promotion of the mutuals by the Catholic church. While household characteristics do have an
influence on the decision as to membership, this is obviously not the case for the individual
characteristics of the head of the household, such as education, gender and age. All three
characteristics are not significant. Membership in other organizations is a positive factor
however. People who have already experienced the advantages and disadvantages of being
associated to local groups are obviously more disposed towards membership in a health
insurance scheme. The village effects that were discovered are also interesting. Different
model variations show, for example, that the inhabitants of the villages Sanghé and Mont
Rolland have a significantly lower probability of membership than people coming from the
village Ngaye Ngaye and Fandène (in Table 8 and 9 vis a vis Ngaye Ngaye). These results
indicate, that obviously the different type of health insurance provided – primary health care
in Ngaye Ngaye and in patient care in the other three mutuals - had no significant influence
on the decision to participate. Instead specific village factors, i.e. the management of the
mutual seem to play a role. The mutual of Sanghé has faced several financing and managerial
difficulties which have lead to a stop of operation for some time. As a consequence several
people left the mutual. Efforts to reestablish the mutual have been successful and today the
mutual is functioning again, however with a lower participation rate than before.
So far the results have shown that the main factors influencing the demand for health
insurance in rural Senegal are religion, income, belonging to a certain ethnic group, access to
a social network and village effects. These results are largely confirmed by looking at the
determinants of participation at the individual level. Regarding the individual level, it is
interesting to analyze which type of household members are insured. From a theoretical
perspective one would assume that those individuals are insured which are more prone to the
risk of illness. As the table 5 shows, this is largely confirmed as the probability for women
and older people is higher than for male and younger persons in the household. It is
reasonable to assume that women in the child bearing age and older people do need
hospitalization care more often than other household members. Whereas the coefficient for
both variables is significant, the marginal effect with less than 0,1 % points is rather low,
which makes it to difficult to diagnose severe adverse selection problems.
Impact of membership on access to modern health care services
In this section we test the hypothesis that members of a mutual have a better access to
modern health care facilities than non-members. As outline we measure access in two
respects: the probability of frequentation of a health care facility, i.e. in this case a hospital
and the out-ofpocket expenditure at the point of use. Our primary variable of interest is
membership in a mutual. We hypothesize that the probability of members to frequent a
hospital is higher, while at the same time they pay less for their treatment in comparison to
non-members after controlling for individual, household and community characteristics. This
would mean that membership has a positive coefficient for the demand for health care and a
negative one for the effect on expenditure. Beside membership, the other variable of key
interest is income as we want to see how much demand health care utilization and out of
pocket expenditure is due to the income level and the ability to pay. As control variables we
include age, sex, education and the frequency of illness, which capture the need for health
care and the health status of an individual. The following household characteristics are
included and aim to control for health preferences due to factors like religion and belonging
to an ethnic group. Finally, village effects are taken into account for differences in the cost of
seeking health care as well as the specific design of the mutuals. One assumption here is that
inhabitants from the village in Fandène have a better access to health care due to their
relatively close distance to the hospital as well as to the reported well functioning of the
mutual. The results of the estimates for the determinants of demand for health care services
and the costs in the case of illness are presented in table 6. Both models are highly
significant. 151 of the 2,856 people have been in hospital within the last two years9 . The
findings of the estimates for both models suggest that the members of a mutual have better
access to health care services than non-members. The probability of making use of
hospitalization increases by 2 %-age points with membership and expenditure in case of need
is reduced by about 50% compared with non-members. Regarding the individual
characteristics and besides membership, age and gender play a role. Moreover, the results
suggest that younger people make less use of the hospital than the elderly and they pay less
on average if they do get ill. Furthermore, women use the hospital more than men. Women go
to hospital especially when they have problems during pregnancy or birth.
As far as the variables at the household level are concerned, it turns out that income has an
impact on the demand for health care services and expenditure. The relatively better-off
people in a community make more use of services and spend more money in the case of
hospitalization. This is in line with findings on the demand for health care in other developing
countries (Gertler and van der Gaag 1990). With respect to village effects, it seems that
people living in Fandène have a higher effective demand for hospitalization than the people
in the other three communities10. A possible explanation is the fact that Fandène is the oldest
mutual, which is according to our interview partners well organized and well functioning. In
addition it is also the closest mutual to the hospital St. Jean de Dieu. To sum up, it can be said
that members are (can be) hospitalized more often and pay considerable less for treatment
than non-members. Other important factors are "age", "type of illness", "gender", "income",
and "village effects". The case study on the community-based health insurance schemes in
Senegal shows that the formation of a health insurance scheme for households in rural areas
is possible and can result in a better access to health care for otherwise excluded people.
Especially in places where local institutions have already developed forms of mutual help,
there seem to exist possibilities to develop them to more formalized approaches. From the
Senegalese case study it turns out that beside an existing local network, the existence of
viable health care provider is of tremendous importance. Without the financial support of the
hospital as well as the well perceived quality provided – the hospital is well know for it’s
good quality in service provision - , it is difficult to imagine that the mutals would still exists.
Hence, subsidies seem to be necessary if one wants to set up an insurance scheme for poor
people. Finally, also individual and household characteristics play a role for the viability of
rural health insurance schemes. In areas with widespread poverty and a scattered population
setting up a health insurance scheme is much more difficult than in more richer and populated
areas. As the analysis of the determinants of participation in micro-insurance schemes has
revealed against the expectations of most donors and policy makers they do not necessarily
reach all population groups in a village. In fact, for the lowest income group the premium to
insure the 10 This effect clearly pops up, when leaving the mutual Fandène outside and the
remaining mutuals get a significant negative coefficient. 22 whole family reaches nearly 8 %
of the annual income of the household11. Support for this group should therefore be secured
by the state. This could be done for example in the form of subsidized premiums.

Chapter3
Review of Literature
K Swathi and R Anuradha (2017), Health insurance in India- An overview. The paper
highlights the concept and benefits of health insurance besides presenting an overview of
health insurance sector in India. A brief of number of persons covered under various schemes
such as government sponsored, group insurance, family insurance, individual policies is
portrayed. Sector wise health insurance policies along with number of persons covered by
public, private and specialized insurers are depicted. Suggestions of the study are for
government to introduce new health insurance schemes for welfare of the common people.
The Insurance Regularity and Development Authority (IRDA) is suggested to take initiatives
to promote competition in health insurers as available in telecom service providers.
Government is also advised to conduct awareness campaigns to inform people about benefits
of taking health insurance policies

Binny, Dr. Meenu Gupta (2017), Health insurance in India- Opportunities and challenges.
The paper is about present trends of health insurance sector in India. Growth opportunities
and challenges in the sector are identified. The study is of the opinion that health insurance is
a growing sector in India. Companies are required to enhance their business by introduction
of new business models with innovative products. Need of a universal health insurance
program is recognized to cover families below poverty line. Medical tourism is also a
growing business in India and health insurance companies can take advantage of this sector to
enhance business. The sector is also advised to have a common information bank for
information sharing which may help customers in assessment of prices, quality and services
provided by health insurance companies. BC Lakshmanna, P Jayarami Reddy, P Sravan
Kumar (2019), Operational efficiency of selected general insurance companies in India. The
study is conducted on selected general insurance companies regarding pattern of insurance
premium, claim settlement procedure and evaluate performance of companies. In percentage
analysis of the insurance premium collected by both public and private sector insurance
companies showed a significant growth from 13.55% to 24.29% during the years 2011 to
2013 which later decreased to 13.42% in the year 2018. Average growth rate during the years
2010 to 2018 was 13.85%. After the

study was conducted it was observed that public sector general insurance providers required
new and innovative products in order to compete with their private counterparts. IRDA, being
a regulatory authority of the sector was suggested to formulate standard policies and
benchmarks to be followed by both public and private sector players. Suman Devi and Dr.
Vazir Singh Nehra (2015), The problems with health insurance sector in India. The study
narrates some of the new inventions in the health insurance sector such as health insurance
portability, RashtriyaSwasthyaBimaYojna (RSBY), hybrid products and critical illness cover.
Problems associated with the health insurance are highlighted and probable solutions are
given. Examples of Bajaj Allianz, Cholamandalam MS and Star Health are given that have
eliminated Third Party Administrators (TPAs) and have opted for direct settlement of claims.
As per study, insurers now have started visiting hospitals to meet patients for claims in the
category of group insurance. If any fault is found then policy renewal is stopped. There are
also pre-agreed rates for surgeries and treatments which prevents differential charging of
tariffs. Other problems like high claim pay-out ratio in public sector insurers,
unprofessionalism of TPAs, lack of development of health insurance in rural areas, wrong
selection of health insurance policies, and lack of awareness about health insurance policies
are highlighted. SatakshiChatterjee, Dr. ArunangshuGiri, Dr. S.N. Bandyopadhyay (2018),
Health insurance sector in India: A study. The study is descriptive and describes various
health insurance products offered in India. It attempts to analyze the insurance models of
healthcare of selected other countries as well. Non amalgamation between public and private
companies is identified as a major hindrance in development of the health insurance sector in
the country. Health insurance is regarded as an unsaturated market in India and the middle
income group i.e. the targeted population of this industry will definitely create a boom in
health insurance in years to come. It is estimated that overall insurance sector will value
around USD 280 billion by the end of 2020. The health insurance sector is required to be
made universal irrespective of the income level and background of individual and a family.

Shejwalker (1989)1 in his article “Training in Life Insurance Marketing” discussed the
importance of trained agents' force to develop the life insurance business. He stressed that
present selection pattern of the agent should be changed. He expressed his opinion that
private or independent institute should be invited to impart training to the agents.
Shesha Ayyer.V. (1999)2 in his article entitled, New Insurance products in the next century”,
forecasted the importance of insurance cover at old age. He forecasted that because of the
advancement of medical facilities and the possibility of aged living, pension scheme would
become popular though at a slow pace.
Vijayavani.J., (1999)3 in her prize winning technical l paper entitled “ Cost effective
1
Shejwalker.P.C , “Training in Life Insurance Marketing”, Yogashema, August (1989 )p.27
2
Shesha Ayyer.V., “ New insurance products in the next century” , The Journal of Insurance Institute of India,
Jan -June (1999)p.47
3
Vijayavani.J.,”Cost effective Distribution channels of life insurance products”, The Journal of Insurance
Institute of India, July-December,1999,p.57
distribution channels of life insurance products” suggested that to tap policy holders,
insurance tie -ups with banks, mutual funds and benefit consultants and brokerage and
benefit consultants, company and fund managers can be introduced.
Holsboer Jan H (1999)4 investigated the link between insurance sector development and
economic growth in context with the recent changes in the external environment for
insurance companies in Europe. He developed a model based on the interest rate(r), growth of
the working population (n), the economic growth rate (g). The benefits of the pay pension
system of the funded pension system were analysed in this model.
Prof. Mike Adams (1999)5 and others examined the dynamic historical relation between
banking, insurance and economic growth in Sweden using time-series data from 1830 to
1998.They examined long-run historical trends in the data using econometric tests for co
integration. The results arrived indicate that the development of domestic banking, but not
insurance, preceded economic growth in Sweden during the nineteenth century. They also
found that the development of bank lending in the nineteenth century increased the demand
for insurance as well as promoting economic growth. In contrast, the insurance market
appears to be driven more by the pace of growth in the economy rather than leading
economic development.

Literature Review on the Effects of Health Insurance

When a person experiences a bad shock to health, their medical expenses typically rise and
their contribution to household income and home production (e.g. cooking or childcare)
declines (e.g. Wagstaff and Doorslaer, 2003; Gertler, Levine & Moretti, 2003; Gertler and
Gruber, 2002). According to the WHO, “Each year, approximately 150 million people
experience financial catastrophe, meaning they are obliged to spend on health care more than

40% of the income available to them after meeting their basic needs.” (WHO Factsheet
N°320, 2007)

4
Holsboer Jan H ‘Repositioning of the Insurance industry in the financial sector and its economic role”, The
Geneva papers on Risk and Insurance, Vol.24,No.3, pp.243

5
Prof. Mike Adams, Prof.Jonas Andersson, Prof. Lars-Fredrik Andersson and Prof. Magnus Lind mark,“The
Historical Relation between Banking, Insurance and Economic Growth in Sweden: 1830 to 1998” by University
of Wales, & Norwegian School of Economics, 1999.
 Low income and high medical expenses can also lead to debt, sale of assets, and removal
of children from school, especially in poor nations. A short-term health shock can thus
contribute to long-term poverty (e.g. Van Damme et al, 2004; Annear et al, 2006). At the
same time, because households often cannot borrow easily, they may instead forego high-
value care. When they do access care it will often be of low quality (Das, Hammer and
Leonard, 2008), which can lead to poor health outcomes.

Theory suggests that health insurance can address some of these problems. By covering
the cost of care after a health shock, insurance can help to smooth consumption, reduce asset
sales and new debt, increase the quantity and quality of care sought, and can improve health
outcomes.

Unfortunately, rigorous evidence on the impact of insurance is scarce, and there are even
fewer studies on the effects of insurance in developing countries. One reason for the lack of
evidence is that it is difficult to find a valid control group for the insured. We cannot simply
compare the outcomes of insured and uninsured households, since health insurance status is
typically strongly correlated with to them after meeting their basic needs.” (WHO Factsheet
N°320, 2007)

Low income and high medical expenses can also lead to debt, sale of assets, and removal
of children from school, especially in poor nations. A short-term health shock can thus
contribute to long-term poverty (e.g. Van Damme et al, 2004; Annear et al, 2006). At the
same time, because households often cannot borrow easily, they may instead forego high-
value care. When they do access care it will often be of low quality (Das, Hammer and
Leonard, 2008), which can lead to poor health outcomes.

Theory suggests that health insurance can address some of these problems. By covering
the cost of care after a health shock, insurance can help to smooth consumption, reduce asset
sales and new debt, increase the quantity and quality of care sought, and can improve health
outcomes.

Unfortunately, rigorous evidence on the impact of insurance is scarce, and there are even
fewer studies on the effects of insurance in developing countries. One reason for the lack of
evidence is that it is difficult to find a valid control group for the insured. We cannot simply
compare the outcomes of insured and uninsured households, since health insurance status is
typically strongly correlated with other household characteristics. For example, rich and well
educated households typically have both better health (Asfaw, 2003) and better health
insurance coverage (Jütting, 2004; Cameron and Trivedi, 1991), but the positive correlation
between health and insurance status tells us nothing about the impact of insurance. On the
other hand, those in poor health may be more likely to pay for health insurance (Cutler and
Reber, 1998; Ellis, 1989), but finding that the insured tend to be sicker would not imply that
insurance causes illness.

Below we review past evidence on the impacts of health insurance, focusing on studies
where health insurance status is plausibly exogenous, or where studies have attempted to
eliminate bias due to self-selection. A majority of the rigorous studies are based on United
States data. We follow Levy and Meltzer (2004, 2008) in both our choice of U.S. studies and
in our main conclusions.

Studies in Developed Countries

The literature describing causal effects of health insurance on health comes almost
entirely from the United States. We first review studies that use policy changes (including
one in Canada) as an exogenous source of change in health insurance status, and then
describe the single randomized trial to date: the RAND Health Insurance Experiment.

“Quasi-Random Experiments” Based on Government Policy

Several studies use changes in health insurance policy to measure the impact of health
insurance on outcomes. A change in insurance status due to a policy shift can be considered
exogenous to an individual, since the individual’s actions do not affect policy. Other studies
take advantage of well-defined eligibility rules and compare outcomes for individuals who
are just eligible to those who are just ineligible, since whether an individual falls just above
or just below an eligibility cutoff is somewhat arbitrary. By examining outcomes for people
whose insurance status is a result of policy changes or eligibility cutoffs, these studies
produce credible impact estimates.

Fihn and Wicher (1988) and Lurie et al. (1984, 1986) study insurance impact using
the cancellation of some insurance benefits for former U.S. veterans in Seattle and some poor
households in Los Angeles. In both cases, health status of the insured was not strongly
correlated with the choice by the Seattle VA Medical Center and the state of California,
respectively, to withdraw insurance coverage. The authors found that the cancellation of
insurance for both groups of people was associated with reduced use of medical care and
increases in blood pressure.

Several studies have examined the effects of the very large Medicare (for those over
65) and Medicaid (for the poor and near-poor) insurance programs in the United States.
Currie and Gruber (1996a, 1996b & 1997) study how the variable timing of the expansion of
Medicaid across states affected children and pregnant women. Both groups increased doctor
and hospital usage in states where Medicaid was first to expand, as compared to states where
the program was enacted later. The authors estimate that increased utilization of care led to a
decline of 1.3 deaths per 10,000 children, relative to a baseline mortality rate of 3.1
deaths/10,000 children. They also found an 8.5% decline in the infant mortality rate. In
contrast, in a smaller study, Haas (1993a and b) studied the expansion of the Healthy Start
program covering low-income pregnant women in Massachusetts and found that increasing
the program eligibility cut-off from 100% to 185% of the poverty line had no effect on birth
outcomes.

Lichtenberg (2002) and Card, Dobkin and Maestas (2007) study the effect of Medicare by
comparing health and health care outcomes of people just below 65 (many of whom lack
health
insurance) to outcomes of those just over 65 (all of whom are covered by Medicare).
Both papers found that the group with more insurance received more care and had better
health outcomes (although the reductions in mortality were often not statistically significant
in the Card, et al. study). Finkelstein (2005) finds that health care utilization increased fastest
in areas where Medicare caused the largest increase in health insurance coverage; Finkelstein
and McKnight (2005) do not find such areas experienced a faster decline in mortality.

Hanratty (2005) compares health outcomes across Canadian provinces that were early
adopters of universal health insurance (1962) to outcomes in provinces that were later
adopters (up to 1972). Her results suggest that there was a significant reduction of 4% in the
infant mortality rate as a result of this government health insurance program and a smaller
reduction in low birth weight of about 1.3%.

The RAND Health Insurance Experiment

The RAND Health Insurance Experiment (from 1974 to 1982) in the United States is
the only randomized experiment examining the effects of health insurance on health to date.
This experiment studied almost 4000 people in 2000 families. Some families were randomly
assigned to a free care plan while others were assigned one of several plans that required
varying co-payments.

The study found that those assigned to a cost-sharing plan sought less treatment than
those with full coverage. (e.g., Lohr et al., 1986; Manning et al., 1987) Forgone treatment for
those with cost-sharing was primarily for preventive visits to doctors and “elective” care such
as mental health treatment as opposed to emergency care. (e.g., Keeler, 1992)

For most health outcomes there were no general health benefits from having more
complete insurance (i.e. full coverage) (e.g., Brook et al. 1983). Health benefits were found,
however, for individuals with poor vision and for persons with elevated blood pressure.
Importantly, the improvement in high blood pressure led to a statistically significant 10%
reduction in mortality risk, apparently due to increased detection and treatment of high blood
pressure among low-income households with free care. (e.g., Keeler, 1992)

Evidence from poor nations

To our knowledge, no study of insurance in developing countries presents a rigorous

causal relationship between household insurance status and health spending, health utilization
or health outcomes.

For example, Wagstaff and Pradhan (2003) overcome some of the selection bias
plaguing most studies in their study of Vietnam’s health insurance (VHI) program. This
program was much more likely to cover those enrolled in high school or college or those
working for the government or state-owned employers. To reduce selection bias, the authors
“match” insured households to uninsured households with similar characteristics, and
compare outcomes of the insured to those of the uninsured with similar profiles. They also
use a double-difference estimator, comparing the change in outcomes over time between the
insured and uninsured. This technique reduces selection bias since it does not assume that
insured and uninsured households are identical on unobservable characteristics. However, as
the authors note, their study still must assume that in the absence of insurance, changes in
outcomes over the study period would have been the same for the insured and the uninsured,
an assumption which may not hold. With this possible bias in mind, the authors find positive
impacts of insurance. In the insured group, children grew more rapidly and adults had
improved BMI (body mass index) scores. The authors also find that the probability of contact
with health care providers was higher, out- of-pocket health expenditures were lower, and
non-medical household consumption was higher among the insured group.
 Though a firm causal relationship between insurance status and outcomes has yet to
be established, many studies do present interesting evidence on the correlation between
insurance status and outcomes. In all of these studies the relationship tends to vary across
income deciles.

For the most part, other non-causal studies find a positive relationship between
insurance coverage and health-care utilization (Jütting, 2004; Yip and Berman, 2001) and
quality of care (Wagstaff et al, 2007; Dong et al, 1999).

Limited understanding of health insurance leads to suboptima l decision-making,

access problems such as delaying care, having difficulty finding a provider and not having a
usual source for care, and ignorance of incentives embedded in policies (Loewenstein et al.
2013). Additionally, when individuals do not understand how to access information or
services, they are more likely to get more expensive medical care in advanced stages of poor
health (Kim, Braun, and Williams 2013)

 Since the full force of the Patient Protection and Affordable Care Act (ACA) taking effect in
January 2014, the United States has increased health insurance coverage for over 20 million
adults, with large gains seen among young adults (ages [19][20][21][22][23][24][25]. In fact,
between October 2013 and early 2016, the uninsured rate among nonelderly adults declined
43%. 1 Improving health insurance coverage has been shown to improve healthcare quality
and outcomes with increased outpatient utilization and preventive care, reduction in
emergency department use among some patient populations-including younger adults-and
improved self-reported health. ...
... 18,19 Given that the majority of this population has health insurance, it becomes necessary
to address health insurance literacy when exploring factors that influence healthcare
utilization. 20 Health insurance literacy, a facet of health literacy, is the degree that a person
has the knowledge, ability, and confidence to select and use health insurance plans. 21 Thus,
health insurance literacy can be decomposed into multiple constructs: knowledge,
selfefficacy, and actual ability to select and use healthcare coverage
However, recent research has shown disparities in health insurance literacy among the
general public. In a national survey conducted by the Kaiser Family Foundation (KFF),
younger Americans (age [18][19][20][21][22][23][24][25][26][27][28][29], people with
lower levels of education, and people who were uninsured were less familiar with basic
health insurance terms and calculations. 23 Of those ages 18-29, 43% were considered low
scorers (ie, getting 0-4 of the 10 questions correct) and had the lowest mean score of all the
age groups; these findings are further corroborated by other studies indicating low health
insurance knowledge among highly educated young adults, who had difficulty in defining
"deductible", "coinsurance", and "PPO" among other health insurance terms.
the Health Reform Monitoring Survey found that 61 % of consumers who were still
uninsured after the first open enrollment period had heard ''little'' or ''nothing'' about tax
credits or cost-sharing subsidies introduced by the ACA (Dorn 2011). In addition, success of
health care reform is attributable, at least partially, to consumers' health insurance literacy
(Paez et al. 2014 Kim et al. 2013;Loewenstein et al. 2013). Together, these findings present
an opportunity to increase awareness and understanding of the ACA and to address health
insurance literacy.
Under the ACA, uninsured consumers were expected to make an enrollment decision-one
that requires a relatively high level of prose, document, and numerical literacy. For these
reasons, health insurance literacy is essential to the well-being of American families (Kim et
al. 2013). Possessing a high level of both health and financial literacy is necessary, given the
complexity of the marketplace, the abundance of choices in coverage, and the required
understanding of individual family and health needs as well as financial considerations. ...
... Several studies suggest that consumers want to better understand health insurance
terminology, plan costs, and the details of their health insurance benefits (Consumers Union
2011;Kim et al. 2013;Sinaiko and Hirth 2011). Most American adults (75 %) were
moderately or very confident they knew how to use health insurance, yet when presented
with a cost-sharing scenario only 20 % could estimate the correct cost of a doctor's visit (Paez
et al. 2014)

Results are more mixed regarding the relationship between insurance status and health
expenditures. Most studies find a negative relationship between insurance coverage and
health expenditures (Jütting, 2004 in Senegal; Jowett, et al., 2003 in Vietnam; and Yip and
Berman, 2001, in Egypt) but some find that out-of-pocket spending is the same or even
higher for the insured when compared to the uninsured, for example, Wagstaff et al. (2007a)
and Wagstaff et al., (2007b), in their studies of China. These authors explain this surprising
finding as being a result of the institutional
 structure of health-care in China, which favors increased utilization and substitution
toward more expensive services and treatments.

Note that all of these studies rely on insurance status that is almost certainly subject to
selection bias, as selection into insurance—whether self-selection or selection based on other
factors (for example, being a public employee)—is related to many other household
characteristics and thus not exogenous. As a result, the uninsured in these studies are
typically not a plausible control group for the insured. Studies using the uninsured as a
control group can thus not produce causal impact estimates.

4 Chapter

Analysis and interpretation data

Analyzing and Interpreting Data

Introduction

Data analysis and interpretation is the process of assigning meaning to the collected
information and determining the conclusions, significance, and implications of the findings.
The steps involved in data analysis are a function of the type of information collected,
however, returning to the purpose of the assessment and the assessment questions will
provide a structure for the organization of the data and a focus for the analysis.

The analysis of NUMERICAL (QUANTITATIVE) DATA is represented in mathematical

terms. The most common statistical terms include:

 Mean – The mean score represents a numerical average for a set of responses.
 Standard deviation – The standard deviation represents the distribution of the
responses around the mean. It indicates the degree of consistency among the
responses. The standard deviation, in conjunction with the mean, provides a better
understanding of the data. For example, if the mean is 3.3 with a standard deviation
(StD) of 0.4, then two-thirds of the responses lie between 2.9 (3.3 – 0.4) and 3.7 (3.3
+ 0.4).
  Frequency distribution – Frequency distribution indicates the frequency of each
response. For example, if respondents answer a question using an agree/disagree
scale, the percentage of respondents who selected each response on the scale would be
indicated. The frequency distribution provides additional information beyond the
mean, since it allows for examining the level of consensus among the data.

Higher levels of statistical analysis (e.g., t-test, factor analysis, regression, ANOVA) can be
conducted on the data, but these are not frequently used in most program/project assessments.

The analysis of NARRATIVE (QUALITATIVE) DATA is conducted by organizing the data

into common themes or categories. It is often more difficult to interpret narrative data since it
lacks the built-in structure found in numerical data. Initially, the narrative data appears to be a
collection of random, unconnected statements. The assessment purpose and questions can
help direct the focus of the data organization. The following strategies may also be helpful
when analyzing narrative data.

Focus groups and Interviews

 Read and organize the data from each question separately. This approach permits
focusing on one question at a time (e.g., experiences with tutoring services,
characteristics of tutor, student responsibility in the tutoring process).
 Group the comments by themes, topics, or categories. This approach allows for
focusing on one area at a time (e.g., characteristics of tutor – level of preparation,
knowledge of content area, availability).

Documents

 Code content and characteristics of documents into various categories (e.g., training
manual – policies and procedures, communication, responsibilities).

Observations

 Code patterns from the focus of the observation (e.g., behavioral patterns – amount of
time engaged/not engaged in activity, type of engagement, communication,
interpersonal skills).
The analysis of the data via statistical measures and/or narrative themes should provide
answers to the assessment questions. Interpreting the analyzed data from the appropriate
perspective allows for determination of the significance and implications of the assessment.

Number of lives covered under health insurance in India FY 2016-2021

Published by Statista Research Department, Feb 17, 2022

 In the fiscal year of 2021, nearly 514 million people across India were covered under health
insurance schemes. Of these, the highest number of people were insured under government-
sponsored health insurance schemes, while individual insurance plans had the lowest number
of people. Overall, the penetration of health insurance in India stood at just around 35 percent
in financial year 2018.

Key figures of public health insurance

The gross direct premium income of the Indian health insurance industry was about 470
billion Indian rupees in financial year 2020. Public health insurance recorded the highest
premium income of over 225 billion Indian rupees that year with the highest share of
premiums written in the western state of Maharashtra.

The healthcare system

India has a decentralized approach to health care and that allows health insurance to be
optional. Technically, all citizens are eligible for free healthcare at government facilities and
individual states are responsible for organizing these services. However, the country’s health
system is severely underfunded in terms of staff as well as supply shortages. A vast number
of people seek care from private providers. Over 64 percent of the total healthcare
expenditure in the country was from out-of-pocket expenses in fiscal year 2016.

Market Overview

The global health insurance market reached a value of US$ 1,590 Billion in 2021.
Looking forward, IMARC Group expects the market to reach US$ 2426.6 Billion by
2027, exhibiting at a CAGR of 7.2% during 2022-2027. Keeping in mind the
uncertainties of COVID-19, we are continuously tracking and evaluating the direct as
well as the indirect influence of the pandemic on different end use sectors. These
insights are included in the report as a major market contributor.
Health insurance protects an insured individual against financial losses arising due to
a medical emergency. It covers medical treatment expenditures, such as ambulance
charges, doctor consultation fees, and hospitalization, medicines and daycare
procedures costs. The payout is generally either made on actual expenses incurred in
the hospital using original medical bills or diagnosis of diseases without submitting
bills. Health insurance also provides easy access to medical treatment with a cashless
facility at network hospitals of the insurer. Apart from this, health insurance also
provided tax benefits for a vast array of medical conditions. Nowadays, various  health
insurance companies are offering coverage for domiciliary treatment, wherein
medical supervision is provided at home for specific diseases.

Key Market Segmentation:

IMARC Group provides an analysis of the key trends in each sub-segment of the
global health insurance market, along with forecasts at the global, regional and
country level from 2022-2027. Our report has categorized the market based on
provider, type, plan type, demographics and provider type.

Breakup by Provider:

 Private Providers
 Public Providers
 

At present, private providers dominate the market globally, accounting for the
majority of the total market

 Life-Time Coverage
 Term Insurance
 
Among these, life-time health insurance holds the largest market share.

Breakup by Plan Type:

 Medical Insurance
 Critical Illness Insurance
 Family Floater Health Insurance
 Others
 

Medical insurance represents the leading plan type in the market.

Breakup by Demographics:

 Minor
 Adults
 Senior Citizen
 

Adults represent the leading demographics segment, account for the largest market
share.

Breakup by Provider Type:

 Preferred Provider Organizations (PPOs)

 Point of Service (POS)
 Health Maintenance Organizations (HMOs)
 Exclusive Provider Organizations (EPOs)
 

In 2021, PPOs represented the largest provider type in the market.

Competitive Landscape:

The competitive landscape of the industry has been examined in the report with the
detailed profiles of the key players. Some of these key players include Aetna Inc.
(CVS Health Corporation), AIA Group Limited, Allianz SE, Aviva Plc, Berkshire
Hathaway Inc., Cigna Corporation, International Medical Group Inc. (Sirius
International Insurance Group Ltd.), Prudential Plc, United Health Group Inc. and
Zurich Insurance Group AG.

Report Coverage:
 5.Chapter

Findings, conclusion&Suggestions

FINDINGS
 From the Table 4.1 its can understand that the growth Rate of health insurance
schemes that public health insurance company has highest growth rate in 2015-16
36.21% and lowest value for 2007-2008. The private health insurance company has
highest value of 2005-2006 in 91.84% and lowest growth rate 2012-13.
  From the Table 1.2 its can understand that the growth Rate of Premium of Health
Insurance company has highest growth rate of 2008-09 in 31.43 % and lowest value
for 2009-10 in 12.45%. The Mean value of premium is 75324.39.
 From the Table 1.3 its can understand that the growth Rate of health insurance
schemes that public health insurance company has highest growth rate in 2010-11
119.85 % and lowest value for 2013.-2014. The private health insurance company has
highest value of 2008-2009 in 112.36% and lowest growth rate 2005-06.
 From the Table 1.5 its can understand that the growth Rate of Premium of Apollo
Munich Health Insurance company has highest growth rate of 2013 in 25.30 % and
lowest value for 2015. The Mean value of 4995505.
 From the Table 1.6 its can understand that the growth Rate of Premium of Apollo
Munich Health Insurance company has highest growth rate of 2013 in 25.30 % and
lowest value for 2015. The Mean value is 4995505.
 From the Table 1.7 its can understand that the growth Rate of Premium of Apollo
Munich Health Insurance company has highest growth rate of 2015 in 22.99% and
lowest value for 2016. The Mean value is 615654.
 From the Table 1.08 its can understand that the growth Rate of Premium of Apollo
Munich Health Insurance company has highest growth rate of 2014 in 48.14 % and
lowest value for 2016. The Mean value is 5336728.

SUGGESTIONS
• Encouraged by IRDA( Insurance Regulatory Development Authority) by providing
subsidies to increase the level of premium
• Provide financial incentives of policy holders.
• Liberal financial assistance should be available to the growers in the form
premium
• loans and development loans
• Provide assistance for eliminating the risk of life towards the nominees.
 In a country like India, there is a need of universal health insurance program at low cost
to be made compulsory with an intention to insure each and every citizen of the country
especially people residing below the poverty line.  Innovation in products and services
catering to the distinguished needs of public will definitely attract those who are still in
dilemma. The health insurers are advised to adopt new business models to enhance their
 customer base, revenue and business.  Public health insurance companies are advised to
be cautious in dealing with the present and potential customers to eliminate any
possibility of churn rate or customer turnover.  Health insurance companies should
popularize health insurance portability by highlighting their specialties and advantages to
attract new customers.  IRDA should frame policies to promote competition among
health insurance sector just like competition prevalent in telecom sector of the country. 
Both the Central and State governments should include chapters on insurance in the
textbooks at appropriate levels of education besides conducting awareness programs at
micro levels to inform public about the benefits of health insurance.

CONCLUSION
Everyone should be covered by some form of health insurance. People are always
vulnerable to injury and illnesses from their everyday activities. Whether it is an
individual plan or employer- or government-sponsored coverage, having health insurance
is better than not having it at all. Millions of Americans are uninsured in part due to high
premium costs. Many are forced to pay these high health costs out of pocket, which can
create more problems medically and financially.
Indian Health insurance or medical insurance sector has been growing, since the
country's economic reforms. The reason why mediclaim insurance, has grown is that it
ensures good medical care from reliable health care institutions. With numerous companies
offering health insurance and with a variety of health insurance plans on the offer it’s hard
to decide which plan you should go for. This is the study for finding which plan fits your
needs the best. This competitive market means that you will need to compare policies to
find the best health insurance policies or the best medical insurance plans.