102 Page

EXCELSSIOR EDUCATION SOCIETY’S
K.C. COLLEGE OF ENGINEERING AND

MANAGEMENT STUDIES AND RESEARCH
(Affiliated to the University of Mumbai)
Kopri, Thane ( E ) – 400 063
Summer Internship Project Report (20 Font Size = FS)

Titled
“Project Title” (20 FS)
In the partial fulfillment of the Degree of
MMS
By (14 FS)
Mr./Ms. Surname FirstName Middlename (16 FS)
[Class, Division & Roll No:](16 FS)
Semester III & Specialization :(18 FS)
Batch: 2019-21
Under the Guidance of (14 FS)

Company Guide
Mr./Ms. (16 FS)
(Designation, Organization) (14 FS)
Faculty Guide
Prof. _____________ (16 FS)
(Project Guide) (14 FS)
2023-24 (16 FS)
EXCELSSIOR EDUCATION SOCIETY’S
K.C. COLLEGE OF ENGINEERING AND
MANAGEMENT STUDIES AND RESEARCH
(Affiliated to the University of Mumbai)
Kopri, Thane ( E ) – 400 063
CERTIFICATE
This is to certify that Mr. /Ms. _________________________________ a student of
Class: ________ Semester: __________ bearing Roll No. _______ has successfully
completed the project titled,
“________________________________________________________________”,
in the partial fulfillment of the Degree of MMS.
Place:
Date:
Name of the Project Guide:
Signature of the Project Guide:
Institutes Seal:
STUDENT DECLARATION
I hereby declare that the project titled “__________________________________”

is my own work conducted under the supervision of Prof.
_____________________________.
I further declare that no part in this project work has been plagiarized without proper
citations and has not formed the basis for the award of any degree, diploma,
associateship, fellowship previously.
Name of Student:
Signature of the Student:

KHALLIOTE COLLEGE BERHAMPUR
ACKNOWLEDGEMENT
I cherish the distinct privilege of my honorable guide DR.

Y.D.NAYAK, for his patience and invaluable advice in guiding
me at every state in bringing about this report.
I would like to thanks to all those persons who helped
significantly for completion of my project. I am very much glide
on my college and company who give me the opportunity and
permission for this summer training project. My heartily thanks
are also due to those persons who have taken keen interest and
for their blessings to make it a success.
I place in record my profound respect, sincere and out heartily
gratitude to all the eminent staff members for their suggestions
to pursue this project.
(RITESH KUMAR BISHOYI)
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CHAPTER TITLE PAGE NO.
1 INTRODUCTION 6-21
2 CONCEPTUAL 22-32
FRAMEWORK
3 METHODOLOGY 33-38
4 OVERVIEW OF 39-59
CURRENT
INSURANCE
SCHEMES IN INDIA
5 CONCLUSION AND 60-65

IMPORTANT NOTES
CONTENTS
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CHAPTER-1
(INTRODUCTION)
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INTRODUCTION
Health insurance is an insurance that covers the whole or a part of the risk of a
person incurring medical expenses, spreading the risk over numerous persons. By
estimating the overall risk of health care and health system expenses over the risk
pool, an insurer can develop a routine finance structure, such as a monthly
premium or payroll tax, to provide the money to pay for the health care benefits
specified in the insurance agreement.[1] The benefit is administered by a central
organization such as a government agency, private business, or not-for-
profit entity.
According to the Health Insurance Association of America, health insurance is

defined as "coverage that provides for the payments of benefits as a result of
sickness or injury. It includes insurance for losses from accident, medical expense,
disability, or accidental death and dismemberment" .
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Background
A health insurance policy is:
1. A contract between an insurance provider (e.g. an insurance company or a

government) and an individual or his/her sponsor (e.g. an employer or a
community organization). The contract can be renewable (e.g. annually,
monthly) or lifelong in the case of private insurance, or be mandatory for all
citizens in the case of national plans. The type and amount of health care
costs that will be covered by the health insurance provider are specified in
writing, in a member contract or "Evidence of Coverage" booklet for private
insurance, or in a national health policy for public insurance.
2. (US specific) In the U.S., there are two types of health insurance - tax payer-
funded and private-funded.[3] An example of a private-funded insurance plan
is an employer-sponsored self-funded ERISA plan. The company generally
advertises that they have one of the big insurance companies. However, in
an ERISA case, that insurance company "doesn't engage in the act of
insurance", they just administer it. Therefore, ERISA plans are not subject
to state laws. ERISA plans are governed by federal law under the
jurisdiction of the US Department of Labor (USDOL). The specific benefits
or coverage details are found in the Summary Plan Description (SPD). An
appeal must go through the insurance company, then to the Employer's Plan
Fiduciary. If still required, the Fiduciary's decision can be brought to the
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USDOL to review for ERISA compliance, and then file a lawsuit in federal
court.
The individual insured person's obligations may take several forms:
 Premium: The amount the policy-holder or their sponsor (e.g. an employer)

pays to the health plan to purchase health coverage. (US specific) According to
the healthcare law, a premium is calculated using 5 specific factors regarding
the insured person. These factors are age, location, tobacco use, individual vs.
family enrollment, and which plan category the insured chooses. [4] Under the
Affordable Care Act, the government pays a tax credit to cover part of the
premium for persons who purchase private insurance through the Insurance
Marketplace.
 Deductible: The amount that the insured must pay out-of-pocket before the
health insurer pays its share. For example, policy-holders might have to pay a
$500 deductible per year, before any of their health care is covered by the
health insurer. It may take several doctor's visits or prescription refills before
the insured person reaches the deductible and the insurance company starts to
pay for care. Furthermore, most policies do not apply co-pays for doctor's visits
or prescriptions against your deductible.
 Co-payment: The amount that the insured person must pay out of pocket
before the health insurer pays for a particular visit or service. For example, an
insured person might pay a $45 co-payment for a doctor's visit, or to obtain a
prescription. A co-payment must be paid each time a particular service is
obtained.
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 Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a

co-payment), the co-insurance is a percentage of the total cost that insured
person may also pay. For example, the member might have to pay 20% of the
cost of a surgery over and above a co-payment, while the insurance company
pays the other 80%. If there is an upper limit on coinsurance, the policy-holder
could end up owing very little, or a great deal, depending on the actual costs of
the services they obtain.
 Exclusions: Not all services are covered. Billed items like use-and-throw,
taxes, etc. are excluded from admissible claim. The insured are generally
expected to pay the full cost of non-covered services out of their own pockets.
 Coverage limits: Some health insurance policies only pay for health care up
to a certain dollar amount. The insured person may be expected to pay any
charges in excess of the health plan's maximum payment for a specific service.
In addition, some insurance company schemes have annual or lifetime coverage
maxima. In these cases, the health plan will stop payment when they reach the
benefit maximum, and the policy-holder must pay all remaining costs.
 Out-of-pocket maximum: Similar to coverage limits, except that in this case,

the insured person's payment obligation ends when they reach the out-of-pocket
maximum, and health insurance pays all further covered costs. Out-of-pocket
maximum can be limited to a specific benefit category (such as prescription
drugs) or can apply to all coverage provided during a specific benefit year.
 Capitation: An amount paid by an insurer to a health care provider, for

which the provider agrees to treat all members of the insurer.
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 In-Network Provider: (U.S. term) A health care provider on a list of

providers preselected by the insurer. The insurer will offer discounted
coinsurance or co-payments, or additional benefits, to a plan member to see an
in-network provider. Generally, providers in network are providers who have a
contract with the insurer to accept rates further discounted from the "usual and
customary" charges the insurer pays to out-of-network providers.
 Out-of-Network Provider: A health care provider that that has not contracted
with the plan. If using an out-of-network provider, the patient may have to pay
full cost of the benefits and services received from that provider. Even for
emergency services, out-of-network providers may bill patients for some
additional costs associated.
 Prior Authorization: A certification or authorization that an insurer provides

prior to medical service occurring. Obtaining an authorization means that the
insurer is obligated to pay for the service, assuming it matches what was
authorized. Many smaller, routine services do not require authorization.
 Formulary: the list of drugs that an insurance plan agrees to cover.
 Explanation of Benefits: A document that may be sent by an insurer to a

patient explaining what was covered for a medical service, and how payment
amount and patient responsibility amount were determined.[6] In the case of
emergency room billing, patients are notified within 30 days post service.
Patients are rarely notified of the cost of emergency room services in-person
due to patient conditions and other logistics until receipt of this letter.
Prescription drug plans are a form of insurance offered through some health
insurance plans. In the U.S., the patient usually pays a copayment and the
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prescription drug insurance part or all of the balance for drugs covered in
the formulary of the plan. Such plans are routinely part of national health insurance
programs. For example, in the province of Quebec, Canada, prescription drug
insurance is universally required as part of the public health insurance plan, but
may be purchased and administered either through private or group plans, or
through the public plan.
Some, if not most, health care providers in the United States will agree to bill the
insurance company if patients are willing to sign an agreement that they will be
responsible for the amount that the insurance company doesn't pay. The insurance
company pays out of network providers according to "reasonable and customary"
charges, which may be less than the provider's usual fee. The provider may also
have a separate contract with the insurer to accept what amounts to a discounted
rate or capitation to the provider's standard charges. It generally costs the patient
less to use an in-network provider.
Comparison
See also: Health system
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Health Expenditure per capita (in PPP-adjusted US$) among several OECD
member nations. Data source: OECD's iLibrary
The Commonwealth Fund, in its annual survey, "Mirror, Mirror on the Wall",
compares the performance of the health care systems in Australia, New Zealand,
the United Kingdom, Germany, Canada and the U.S. Its 2007 study found that,
although the U.S. system is the most expensive, it consistently under-performs
compared to the other countries. One difference between the U.S. and the other
countries in the study is that the U.S. is the only country without universal health
insurance coverage.
Life Expectancy of the total population at birth from 2000 until 2011 among
several OECD member nations. Data source: OECD's iLibrary
The Commonwealth Fund completed its thirteenth annual health policy survey in
2010. A study of the survey "found significant differences in access, cost burdens,
and problems with health insurance that are associated with insurance design". Of
the countries surveyed, the results indicated that people in the United States had
more out-of-pocket expenses, more disputes with insurance companies than other
countries, and more insurance payments denied; paperwork was also higher
although Germany had similarly high levels of paperwork.
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Australia
Main article: Health care in Australia
The Australian public health system is called Medicare, which provides free
universal access to hospital treatment and subsidised out-of-hospital medical
treatment. It is funded by a 2% tax levy on all taxpayers, an extra 1% levy on high
income earners, as well as general revenue.
The private health system is funded by a number of private health insurance

organizations. The largest of these is Medibank Private Limited, which was, until
2014, a government-owned entity, when it was privatized and listed on
the Australian Stock Exchange.
Australian health funds can be either 'for profit'

including Bupa and nib; 'mutual' including Australian Unity; or 'non-
profit' including GMHBA, HCF and the HBF Health Insurance. Some, such as
Police Health, have membership restricted to particular groups, but the majority
have open membership. Membership to most health funds is now also available
through comparison websites like moneytime, Compare the Market, iSelect Ltd.,
Choosi, ComparingExpert and YouCompare. These comparison sites operate on a
commission-basis by agreement with their participating health funds. The Private
Health Insurance Ombudsman also operates a free website which allows
consumers to search for and compare private health insurers' products, which
includes information on price and level of cover.
Most aspects of private health insurance in Australia are regulated by the Private
Health Insurance Act 2007. Complaints and reporting of the private health industry
is carried out by an independent government agency, the Private Health Insurance
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Ombudsman. The ombudsman publishes an annual report that outlines the number
and nature of complaints per health fund compared to their market share
The private health system in Australia operates on a "community rating" basis,

whereby premiums do not vary solely because of a person's previous medical
history, current state of health, or (generally speaking) their age (but see Lifetime
Health Cover below). Balancing this are waiting periods, in particular for pre-
existing conditions (usually referred to within the industry as PEA, which stands
for "pre-existing ailment"). Funds are entitled to impose a waiting period of up to
12 months on benefits for any medical condition the signs and symptoms of which
existed during the six months ending on the day the person first took out insurance.
They are also entitled to impose a 12-month waiting period for benefits for
treatment relating to an obstetric condition, and a 2-month waiting period for all
other benefits when a person first takes out private insurance. Funds have the
discretion to reduce or remove such waiting periods in individual cases. They are
also free not to impose them to begin with, but this would place such a fund at risk
of "adverse selection", attracting a disproportionate number of members from other
funds, or from the pool of intending members who might otherwise have joined
other funds. It would also attract people with existing medical conditions, who
might not otherwise have taken out insurance at all because of the denial of
benefits for 12 months due to the PEA Rule. The benefits paid out for these
conditions would create pressure on premiums for all the fund's members, causing
some to drop their membership, which would lead to further rises in premiums, and
a vicious cycle of higher premiums-leaving members would ensue.
The Australian government has introduced a number of incentives to encourage

adults to take out private hospital insurance. These include:
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 Lifetime Health Cover: If a person has not taken out private hospital cover
by 1 July after their 31st birthday, then when (and if) they do so after this time,
their premiums must include a loading of 2% per annum for each year they
were without hospital cover. Thus, a person taking out private cover for the first
time at age 40 will pay a 20 percent loading. The loading is removed after 10
years of continuous hospital cover. The loading applies only to premiums for
hospital cover, not to ancillary (extras) cover.
 Medicare Levy Surcharge: People whose taxable income is greater than a
specified amount (in the 2011/12 financial year $80,000 for singles and
$168,000 for couples) and who do not have an adequate level of private
hospital cover must pay a 1% surcharge on top of the standard 1.5% Medicare
Levy. The rationale is that if the people in this income group are forced to pay
more money one way or another, most would choose to purchase hospital
insurance with it, with the possibility of a benefit in the event that they need
private hospital treatment – rather than pay it in the form of extra tax as well as
having to meet their own private hospital costs.
o The Australian government announced in May 2008 that it proposes

to increase the thresholds, to $100,000 for singles and $150,000 for
families. These changes require legislative approval. A bill to change the
law has been introduced but was not passed by the Senate. [17] An amended
version was passed on 16 October 2008. There have been criticisms that the
changes will cause many people to drop their private health insurance,
causing a further burden on the public hospital system, and a rise in
premiums for those who stay with the private system. Other commentators
believe the effect will be minimal.
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 Private Health Insurance Rebate: The government subsidises the

premiums for all private health insurance cover, including hospital and
ancillary (extras), by 10%, 20% or 30%, depending on age. The Rudd
Government announced in May 2009 that as of July 2010, the Rebate would
become means-tested, and offered on a sliding scale. While this move (which
would have required legislation) was defeated in the Senate at the time, in early
2011 the Gillard Government announced plans to reintroduce the legislation
after the Opposition loses the balance of power in the Senate.
The ALP and Greens have long been against the rebate, referring to it as
"middle-class welfare".
Canada
Main article: Health care in Canada
As per the Constitution of Canada, health care is mainly a provincial government

responsibility in Canada (the main exceptions being federal government
responsibility for services provided to aboriginal peoples covered by treaties,
the Royal Canadian Mounted Police, the armed forces, and Members of
Parliament). Consequently, each province administers its own health insurance
program. The federal government influences health insurance by virtue of its fiscal
powers – it transfers cash and tax points to the provinces to help cover the costs of
the universal health insurance programs. Under the Canada Health Act, the federal
government mandates and enforces the requirement that all people have free access
to what are termed "medically necessary services," defined primarily as care
delivered by physicians or in hospitals, and the nursing component of long-term
residential care. If provinces allow doctors or institutions to charge patients for
medically necessary services, the federal government reduces its payments to the
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provinces by the amount of the prohibited charges. Collectively, the public

provincial health insurance systems in Canada are frequently referred to
as Medicare. This public insurance is tax-funded out of general government
revenues, although British Columbia and Ontario levy a mandatory premium with
flat rates for individuals and families to generate additional revenues - in essence, a
surtax. Private health insurance is allowed, but in six provincial governments only
for services that the public health plans do not cover (for example, semi-private or
private rooms in hospitals and prescription drug plans). Four provinces allow
insurance for services also mandated by the Canada Health Act, but in practice
there is no market for it. All Canadians are free to use private insurance for elective
medical services such as laser vision correction surgery, cosmetic surgery, and
other non-basic medical procedures. Some 65% of Canadians have some form of
supplementary private health insurance; many of them receive it through their
employers. Private-sector services not paid for by the government account for
nearly 30 percent of total health care spending.
In 2005, the Supreme Court of Canada ruled, in Chaoulli v. Quebec, that the
province's prohibition on private insurance for health care already insured by the
provincial plan violated the Quebec Charter of Rights and Freedoms, and in
particular the sections dealing with the right to life and security, if there were
unacceptably long wait times for treatment, as was alleged in this case. The ruling
has not changed the overall pattern of health insurance across Canada, but has
spurred on attempts to tackle the core issues of supply and demand and the impact
of wait times.
China
Main articles: Healthcare reform in the People's Republic of
China and Pharmaceutical industry in the People's Republic of China
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France
Main article: Health care in France
The national system of health insurance was instituted in 1945, just after the end of
the Second World War. It was a compromise
between Gaullist and Communist representatives in the French parliament. The
Conservative Gaullists were opposed to a state-run healthcare system, while the
Communists were supportive of a complete nationalisation of health care along a
British Beveridge model.
The resulting programme is profession-based: all people working are required to

pay a portion of their income to a not-for-profit health insurance fund, which
mutualises the risk of illness, and which reimburses medical expenses at varying
rates. Children and spouses of insured people are eligible for benefits, as well.
Each fund is free to manage its own budget, and used to reimburse medical
expenses at the rate it saw fit, however following a number of reforms in recent
years, the majority of funds provide the same level of reimbursement and benefits.
The government has two responsibilities in this system.
 The first government responsibility is the fixing of the rate at which medical
expenses should be negotiated, and it does so in two ways: The Ministry of
Health directly negotiates prices of medicine with the manufacturers, based on
the average price of sale observed in neighboring countries. A board of doctors
and experts decides if the medicine provides a valuable enough medical benefit
to be reimbursed (note that most medicine is reimbursed, including
homeopathy). In parallel, the government fixes the reimbursement rate for
medical services: this means that a doctor is free to charge the fee that he
wishes for a consultation or an examination, but the social security system will
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only reimburse it at a pre-set rate. These tariffs are set annually through
negotiation with doctors' representative organisations.
 The second government responsibility is oversight of the health-insurance
funds, to ensure that they are correctly managing the sums they receive, and to
ensure oversight of the public hospital network.
Today, this system is more or less intact. All citizens and legal foreign residents of
France are covered by one of these mandatory programs, which continue to be
funded by worker participation. However, since 1945, a number of major changes
have been introduced. Firstly, the different health care funds (there are five:
General, Independent, Agricultural, Student, Public Servants) now all reimburse at
the same rate. Secondly, since 2000, the government now provides health care to
those who are not covered by a mandatory regime (those who have never worked
and who are not students, meaning the very rich or the very poor). This regime,
unlike the worker-financed ones, is financed via general taxation and reimburses at
a higher rate than the profession-based system for those who cannot afford to make
up the difference. Finally, to counter the rise in health care costs, the government
has installed two plans, (in 2004 and 2006), which require insured people to
declare a referring doctor in order to be fully reimbursed for specialist visits, and
which installed a mandatory co-pay of €1 for a doctor visit, €0.50 for each box of
medicine prescribed, and a fee of €16–18 per day for hospital stays and for
expensive procedures.
An important element of the French insurance system is solidarity: the more ill a
person becomes, the less the person pays. This means that for people with serious
or chronic illnesses, the insurance system reimburses them 100% of expenses, and
waives their co-pay charges.
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Finally, for fees that the mandatory system does not cover, there is a large range of
private complementary insurance plans available. The market for these programs is
very competitive, and often subsidised by the employer, which means that
premiums are usually modest. 85% of French people benefit from complementary
private health insurance.
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CHAPTER – 2
(CONCEPTUAL
FRAMEWORK)
Health insurance in India is a growing segment of India's economy. The Indian

health system is one of the largest in the world, with the number of people it
concerns: nearly 1.3 billion potential beneficiaries. The health industry in India has
rapidly become one of the most important sectors in the country in terms of income
and job creation. In 2018, one hundred million Indian households (500 million
people) do not benefit from health coverage. In 2011, 3.9%of India's gross
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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.
For the financial year 2014-15, Health Insurance premium was ₹20,440
The health situation and the provision of services vary considerably from one State
to another. Although public health services in principle provide free basic health
care to all, the care provided by most state health systems suffers from inadequate
resources and poor management. As a result, the majority of the population turns to
private health services that offer more expensive care and of very unequal quality.
In India, the health system mixes public and private providers. Public health
facilities - local clinics providing basic care, regional hospitals, national hospitals -
are funded by the federal states and the federal state and managed by the state
authorities.
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Public health services differ greatly from one federated state to another. In some
states such as Tamil Nadu or Kerala, public health facilities play their role as the
first stage of the care journey, but, outside of these few states, the public sector
does not reach the goal to provide the basic health needs of the population.
India's public health expenditures are lower than those of other middle-income
countries. In 2012, they accounted for 4% of GDP, which is half as much as in
China with 5.1%. In terms of public health spending per capita, India ranks 184th
out of 191 countries in 2012. Patients' remaining costs represent about 58% of the
total. The remaining costs borne by the patient represent an increasing share of the
household budget, from 5% of this budget in 2000 to over 11% in 2004-2005. On
average, the remaining costs of poor households as a result of hospitalization
accounted for 140% of their annual income in rural areas and 90% in urban areas.
This financial burden has been one of the main reasons for the introduction of
health insurance covering the hospital costs of the poorest.
Objectives and expectations :

A national health insurance system will be judged with regard to the achievements
of promised improvements, and success as well as sustainability will depend on the
support of the society as a whole. Achieving objectives and realising broad societal
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support requires on the one hand professionalism in technical design, e.g.

regarding economic and administrative feasibility. On the other hand, it is crucial
to match new institutions with values and historical processes that have led to
current characteristics of politics, labour movements, communal patterns,
distribution of wealth and poverty, religion, and culture. The impact of the existing
socio-political environment and related constraints in achieving overall objectives
is often underestimated when developing new health protection schemes. However,
international experience with implementing nationwide health insurance schemes
shows that a lack of support of key stakeholders and even failure might be a
consequence of mismatching a new system with existing structures and
behavioural patterns in a society. Therefore, it is necessary to develop policy
features addressing challenges beyond technical feasibility, and thereby ensure that
overall objectives are likely to be achieved. 5.1 Objectives and guiding principles
aiming at establishing a fair and sustainable national health insurance scheme The
existing overall legal and policy framework in Yemen emphasises improving
living conditions, socio-economic environment and health of the population. These
overall objectives are reflected in the past health sector reforms, the final draft of
the social health insurance law and major programmes and activities carried out by
the Government of Yemen and other institutions in cooperation with international
and bilateral organizations such as WHO, ILO and GTZ. International activities
included technical cooperation projects supported by the International Labour
Organization (ILO) such as a comparative analysis of national legislation and
practice in the light of ILO Core Conventions, implementing components related to
labour market information systems and human resources development. In addition,
workers’ and employers’ organizations in Yemen benefited from technical and
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financial contributions of ILO. This led to the ratification of many ILO

Conventions including all eight Core Conventions namely,
• Convention No 29: Forced Labour, 1930
• Convention No 87: Freedom of Association and Protection the Right to Organise,

1948
• Convention No 98: Right to Organise and Collective Bargaining, 1949j
• Convention No 100: Equal Remuneration Convention, 1951
• Convention No 105: Abolition of Forced Labour, 1957
• Convention No 111: Discrimination (Employment and Occupation), 1958
• Convention No 138: Minimum Age Convention, 1973
• Convention No 182: Worst Forms of Child Labour, 1999
• Convention No 144: Tripartite Consultation (International Labour Standards),

1976 Currently, the Consortium of GTZ, WHO and ILO on Social Health
Insurance is supporting the Government’s efforts to introduce the national health
insurance system in Yemen. The overall political framework of the national health
insurance in Yemen aims at contributing to better health particularly for the poor
through improving financing mechanisms. Thus the national health insurance
system should strive for an inclusive access to health services and link with the
programmes and activities related to the achievement of the Millennium
Development Goals (MDG) and poverty reduction strategies (PRSP). Particularly
relevant in this context are efforts to eradicate extreme poverty, promote gender
equality, particularly remove barriers to women’s access to health 76 Towards a
national health insurance system in Yemen – Part 1: Background and assessments
care, reduce child mortality, improve maternal health, and combat HIV/AIDS,
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tuberculosis, malaria and other diseases. Consequently, the design of the national
health insurance needs to emphasise on the following core objectives:
• Achieving universal access through introducing national health insurance

coverage and protecting from health-related poverty. This includes ensuring that
coverage reaches out to the poor, women, migrants, elderly, pensioners and other
vulnerable groups. In addition, the inclusion of the excluded should focus on
responding to needs, improving accessibility and utilisation of health services
while taking into account the households’ capacity to pay.
• Striving for sustainability and solidarity in financing based on good governance

and efficient use of resources. This should lead to a significant lowering or
removal of user fees for vulnerable groups, such as the poor, women and children,
particularly for primary care. Further features to be taken into account include
effective control and auditing of funds, monitoring of implementation of the law
and regulations.
• Supporting an active role of the state in facilitation, promotion and extension of

national health insurance. This includes supporting the development of innovative
mechanisms such as community-based micro-insurance schemes, in particular in
areas with low administrative and financial capacities, where coverage cannot be
immediately provided through statutory schemes. Linkages between the national
health insurance and the innovative schemes should be built in order to sustain
small-scale schemes and support the provision of comprehensive benefit packages.
There are various options to detail these core objectives according to financial
means, economic and socio-economic context and there is considerable flexibility
as to how to achieve them. Strategic goals include maximization of membership,
income and benefits e.g. through improving efficiency of management,
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decentralization, and need-oriented decision-making on benefit packages. Some

generally agreed guiding principles help to identify appropriate ways to meet the
objectives mentioned:
• Equality of treatment and equal access to health services
• Solidarity in financing through risk pooling
• Inclusiveness in framing rights
• Overall responsibility of the State
• Transparent and democratic management including a participatory approach of

management and governance based on social dialogue with workers, employers
and other stakeholders. When implementing the national health insurance system it
should be taken into account that the political process of collective decision-
making and active involvement of all stakeholders in national health insurance will
take time and resources. Key stakeholders in the national health insurance system
include besides representatives of members, potential members such as the
excluded, workers’ and employers’ organisations, Government, community-based
schemes and other innovative schemes providing health services, the poor, women,
medical professions, providers and donors. Further, obtaining agreement from
various external parties such as the Women National Committee for increased
cooperation will be key issues.
Meeting overall objectives through addressing socio-political challenges -Meeting

overall objectives through addressing socio-political challenges in design and
implementation of national health insurance In order to meet these objectives,
Yemen’s health system, its institutions and the behaviour of individuals, families
and the population as a whole need to comply with and adjust to change. An
Towards a national health insurance system in Yemen – Part 1: Background and
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assessments 77 enabling policy framework for a fair and sustainable national

health insurance scheme in Yemen requires particularly removing barriers and
developing country specific solutions. This holds especially true for health-related
aspects of poverty and empowerment of the poor, gender inequality and impact on
access to health services, and accountability and corruption related to health
services. The most recent UNDP report stated that Yemen is “infested with
corruption” throughout all sectors including those agencies who are in charge of
accountability and preventing corruption. The lack of political accountability is
closely related to the missing separation of powers and the concentration of
forces.36 Thus, mutual control of the State’s pillars is limited, and Yemen’s
participation in the “War on Terror” is certainly the only reason why United States
refrains from commenting the lack of transparency and political accountability.
Journalists who bring irregular incidents to the public and write about possible
fraud where representatives of the Government might be involved, are running the
risk of becoming victims of kidnapping and physical violations. Politicians of
opposition parties go to the public for criticizing the practise of personal
enrichment, arbitrariness and immunity of powerful and privileged groups. With
regard to the health system in Yemen, the MoPH&P faces strong accusations of
being a stronghold of misuse and mislead of resources. Due to the blacklisting, the
Minister had to proceed to shut down 107 health institutions in the country after
public health violations (Yemen Times, 12th Sept. 2005). These factors have
profound effects on future beneficiaries’ access to health services and thus on
equity and equality. They will directly impact on the scheme’s effectiveness.
Accordingly, design and implementation of national health insurance need to deal
with relevant evidence of the country’s socio-political environment. And it has to
take measures in order to prevent as far as possible corruptive behaviour of health
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insurance personnel, to minimise fraud and to tackle with deficiencies with regard
to social trust and reliability.
 Health-related aspects of poverty and empowerment- of the poor Large parts

of the population in Yemen are living in extreme poverty. Limited access to
health services impacts on ill health, income security and poverty; on the
other hand, health system development can contribute significantly to
poverty alleviation and is an integral part of sustainable development. In
developing countries, every year 178 million people are exposed to
catastrophic health expenditure, and more than 100 million are forced into
poverty by health care cost (WHO 2005c). Given the high share of out-of-
pocket payments on health expenditure in Yemen it can be assumed that
health care costs play an important role in impoverishment and deepened
poverty of the population. The poor often bear the financial burden of ill
health and the related loss of income and savings. In many cases, ill health
leads to a medical poverty trap. In order to cope with the financial burden of
ill health households often use welfare threatening strategies for example
selling assets such as land. Even those who have some kind of health
protection might experience that the benefit packages do not protect against
catastrophic costs. That means that they are exceeding the households
capacity to pay and people have to use up their savings or even to sell assets
which are important for income generation. Consequently, negative impacts
on poverty, malnutrition, child mortality, maternal health and diseases such
as HIV/AIDS are experienced. Mostly concerned is the rural population,
women, workers in the informal economy, the self-employed, unemployed
and elderly.
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• If sick, women and their children have to get the agreement and need to be
accompanied/ guarded e.g. by their husbands, fathers, brothers or sons if they wish
to access health services. Due to time and cost impacts of out-of-pocket payments
this is often refused until severe stages of diseases. Further, transportation costs to
health services are doubled. • Female doctor’s and nurses need to cover their head
– sometimes even the whole face except their eyes, with sharsharfs even when
carrying out their profession.
• The same rule applies to female patients who are only allowed to remove the
sharsharf if treatments in the face have to be carried out. The situation is worsened
by the fact that in many cases male health is given priority in health budget
allocations in case of scarce resources. A current example can be seen in the lack
of budgets allocated to blood banks used to 45 % by women giving birth. These
patterns and poor medical infrastructure, particularly in rural areas, have far
ranging implications on women’s and children’s access to health services and their
health status. Women in poor households are most often victims of these norms.
Women’s life expectancy, child mortality, the high rate of breast and cervix cancer
reflect this lifestyle and related circumstances described. Against this background,
it is not surprising that poverty often has a female face in Yemen. Therefore, the
new national health insurance scheme needs to address women’ issues as outlined
above. The overall objective in this respect should be to improve women’s access
to health services through features such as
• Equal representation of women and men in new advisory and executing

institutions such as the stakeholders’ task force, the board of directors of the health
insurance authority and controlling institutions.
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• Equal representation of female and male advisors on the design of benefit

packages and other advisory groups
• Inclusion of families in the coverage of the national health insurance
• Extended coverage to the rural population, the poor, workers and their families
in the informal sector from the initial stages of implementation
• Specific provisions to improve women’s access to health services e.g. financial

incentives for regular check-ups of women and children.
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CHAPTER – 3
(METHODOLOGY)
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33
IMPPORTANCE OF STUDY:
The percentage of India's national budget allocated to the health sector remains one
of the lowest in the world, and healthcare expenditures are largely out-of-pocket
(OOP). Currently, efforts are being made to expand health insurance coverage as
one means of addressing health disparity and reducing catastrophic health costs. In
this review, we document reasons for rising interest in health insurance and
summarize the country's history of insurance projects to date. We note that most of
these projects focus on in-patient hospital costs, not the larger burden of out-patient
costs. We briefly highlight some of the more popular forms that government,
private, and community-based insurance schemes have taken and the results of
quantitative research conducted to assess their reach and cost-effectiveness. We
argue that ethnographic case studies could add much to existing health service and
policy research, and provide a better understanding of the life cycle and impact of
insurance programs on both insurance holders and healthcare providers. Drawing
on preliminary fieldwork in South India and recognizing the need for a broad-
based implementation science perspective (studying up, down and sideways),
we identify six key topics demanding more in-depth research, among others:
(1) public awareness and understanding of insurance;
(2) misunderstanding of insurance and how this influences health care utilization;
(3) differences in behavior patterns in cash and cashless insurance systems;
(4) impact of insurance on quality of care and doctor-patient relations;
(5) mistrust in health insurance schemes; and
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(6) health insurance coverage of chronic illnesses, rehabilitation and OOP expenses
METHOD OF STUDY
Our explorations of health insurance in India started with one of the authors, Mark
Nichter, carrying out initial ethnographic observations on the topic intermittingly
between 2001 and 2012, in the course of broad-based research on healthcare
utilization and provision on the border between Karnataka and Kerala. All three
authors followed up these observations for six months in 2014 in several districts
across Kerala, the state with the highest density of public and private medical
facilities and high rates of utilization of health services (Levesque et al. 2006).
Most of our research took place in urban and semi-urban areas, which are most
prevalent in Kerala, a densely populated state characterized by small and medium
towns (Levesque et al. 2006).
We conducted open-ended interviews with a total sample of 63 community

members hailing from a mix of social classes, nine public and 11 private
practitioners as well as three healthcare administrators and 10 representatives of
private and public insurance providers. We chose a purposeful sample of
community members who had recently been placed in economic distress due to
medical expenses related to an illness they or a family member had suffered. They
were interviewed in the privacy of their own homes. The community members we
interviewed about general impressions were long-time key informants of two
authors, Mark Nichter and Tanja Ahlin. Additionally, Mark Nichter and
Gopukrishnan Pillai, who is a medical doctor originating from Kerala, interviewed
healthcare practitioners and administrators at well-known and well-attended health
clinics. These study participants were experienced with having to navigate the
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insurance system, were known to the authors from their previous research, and
were willing to discuss the topic confidentially. We interviewed the research
participants one or more times. We informed them of the exploratory nature of this
research and that their participation was voluntary and confidential. Following this,
we obtained oral informed consent for participation from the interviewees.
According to Dao and Nichter (2015), ethnographic investigations of the ‘social

life of insurance’ are a necessary complement to the quantitative studies conducted
to date. Toward that end, fieldwork was conducted in Kerala to shed light on both
public impressions of health insurance and the manner in which these perceptions
influence the engagement of insurance, and how insurance influences healthcare
providers’ practices. As Kerala has been hailed as one of the most progressive
Indian states, with high rates of urbanization and education as well as better living
conditions and healthcare access compared with the poorer states (Levesque et al.
2006), this study is limited in terms of generalizing the findings across India. We
do not claim to offer a comprehensive study of all concerns related to health
insurance in India. Instead, we shed light on some issues that we believe can and
should also be addressed in other Indian states, as the literature review suggests
that the problems related to health insurance are similar across states with different
demographic characteristics. However, we encourage further research in the
various states to pay attention to specific local contexts. Based on short extracts
from our interviews and observations, we summarize some of our more salient
observations and highlight additional themes for further investigation. Rather than
a full ethnographic account, the material presented in the continuation should be
viewed as indicating several points of entry for more in-depth investigations by
means of ethnography, attentive to all that is less visible, ignored or uncertain
(Pigg 2013
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ADVANTAGES AND DISADVANTAGES
Advantages
Rising costs of healthcare as well as the evident need for adequate healthcare today
makes health insurance a definite must. When it comes to critical illnesses, the
strain that it can put on a family's wellbeing is undeniable, leaving people to turn to
their life savings for aid.
This however, does not ascertain a concrete solution due to inflation, meaning
savings are rarely sufficient to meet such healthcare expenses.
In a typical average Indian household, the male head of the family is usually the
only earning member with about 3-4 dependants. Often times, if the primary
breadwinner’s ability to work is compromised due to a major illness, the rest of the
family remains in dire straits. It would not be possible for them to sustain their
lifestyle, repay debts or even afford the high costs of treatment.
Health Insurance is important because
 Lifestyle related ailments are common these days

 Healthcare is becoming increasingly expensive
 It is difficult for a family to quickly arrange for huge amounts of money

required for treatment
 Most of the savings of a family are in the form of fixed assets, which cannot
be liquidated quickly
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Disadvantages
One of the main disadvantages of having health insurance is the cost. Health
insurance can be very costly even for those that have a health insurance plan
through their employers. Costs may be so high that many end up struggling to
make payments. This can be quite challenging for those who have low incomes or
are self-employed. Health care coverage for families may cause an added financial
burden.
Pre-Existing Exclusion
Another disadvantage would involve people who have a pre-existing illness. They
have to undergo a waiting period which is typically four years. Insurers typically
require you need to wait for four years for any pre-existing illness to be covered.
This becomes a major obstacle for older individuals with pre-existing medical
conditions. This is particularly so because pre-existing illnesses doesn't only
include illnesses you may have received treatment for in the recent past. It includes
illnesses for which there were signs or symptoms in the 48 months prior to the
payment of the first premium.
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CHAPTER – 4
(OVERVIEWOF
CURRENT
INSURANCE
SHEMES IN INDIA)
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Overview of current insurance schemes in India
Insurance schemes introduced by the central and state governments
In 2003, the Indian government launched Universal Health Insurance (UHI) to

protect families living below the poverty line (BPL) by partially subsidizing
insurance premiums. While the scheme has been criticized for high premiums,
slow uptake (by 2008–2009 only 3.7 million people were covered), and for
covering only hospitalization, it has provided valuable lessons for future
government-sponsored health insurance schemes (Ahuja 2004; Ahuja and De
2004; Ahuja and Narang 2005; Bhat and Saha 2004; Gupta and Trivedi 2005;
Forgia and Nagpal 2012; Rao 2004). Among the most important realizations is that
in order to be successful, UHI needs to be supplemented by interventions at
various health system levels; this, in turn, should be based on local research and
policy analysis, rather than trying to ‘copy’ or ‘import’ insurance systems from
other countries (Duran, Kutzin, and Menabde 2014).
State insurance programs, in practice based on public–private partnerships, have

also been encouraged. In Andhra Pradesh, one example of private–public
partnership, Rajive Aarogyarsi, was launched in 2007 to benefit BPL families who
possess a ration card (Yellaiah 2013). The scheme is overseen by a trust that has
selected a private insurance company through an open, competitive bidding
process and established a network of private and public hospitals to provide free
secondary and tertiary healthcare. By 2013, 87% of BPL families in the state have
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been covered, which is a notable success (Yellaiah 2013). The scheme does not
reduce OOP for outpatient visits, but it does reduce unpredictable expense related
to hospitalizations that are more likely to suddenly plunge a household into
economic crises (Wagstaff and Bergkvist 2011). Ethnographic research has
highlighted significant barriers in accessing health-care among the poor rural
population in this state, reducing the impact an insurance scheme such as
Aarogyasri could have (Narasimhan et al. 2014; Chakrabarti and Shankar 2015).
Several schemes launched by the government in recent years have fostered a rapid
expansion in insurance coverage. Between 2007 and 2010, the proportion of the
Indian population with some kind of health insurance roughly tripled to 25% or
302 million people (Burns 2014, 106). However, critics have argued that state-
sponsored schemes, as currently designed, encourage the growth of tertiary care
corporate hospitals in rural areas; they suggest that a more integrated model,
including primary care, would be more beneficial to the users and more cost-
effective for the government (Rao et al. 2011; Shukla, Shatrugna, and Srivatsan
2011; Selvaraj and Karan 2012; Sodhi and Rabbani 2014). It has recently been
proposed that despite its diversity, the private health sector could be mobilized as a
potential resource to contribute to public health goals if proper regulation and
monitoring were in place (Garg and Nagpal 2014).9
Private health insurance
In 1999, the Insurance Regulatory and Development Authority Act (IRDA)

liberalized and opened the market in India to foreign insurance companies.
Private–public collaboration in health insurance, advocates claimed, would
encourage competition between different care plans and permit patient choice of
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providers affording greater flexibility (WHO 2000). Due to the investment of a

number of foreign firms, health insurance is now the second largest business in the
non-life insurance sector (Sen, Pickett, and Burns 2014). But despite the efforts of
40 private health insurance providers operating in India in 2010, only 2% of the
population had private insurance in that year (Thomas and Vel 2011). While some
see India as a lucrative business opportunity for health insurance in the future
(Yellaiah 2013), insurance schemes so far have proved to be a risky business
venture due to a low level of insurance awareness as well as poor healthcare
infrastructure in rural areas (Vellakkal 2009a; Vellakkal and Ebrahim 2013;
Ahmed 2013; Gupta 2006; Thomas and Vel 2011).
Private health insurers recognize India as a potential market due to its increasing
purchasing power, growing demand for healthcare, an expanding competitive
private healthcare market, and rising rates of chronic disease (Burns 2014; Burns,
Srinivasan, and Vaidya 2014). Because of this profit-oriented approach, private
health insurers target mainly the middle-class population. This is also evident from
the cost of insurance policies, with annual premiums typically starting at Rs 4000
(about US$65) per member and covering only inpatient treatment for a maximum
of Rs 0.4 million (about US$6500) annually (Thomas and Vel 2011).
Besides noting the limits in terms of coverage (inpatient only) and target
population (middle-class), critics argue that the market principles guiding private
healthcare insurance lead to greater health disparity and rising health costs for the
poor, serving to undermine national health equity goals (Selvaraj and Karan 2012;
Reddy et al. 2011a).10 They call for regulation of benefit packages, restrictions on
risk-selection procedures, and greater protection of customers (Mahal 2002).
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Community-based health insurance schemes (CHI)
CHI is ‘any non-for profit insurance scheme aimed primarily at the informal sector
and formed on the basis of a collective pooling of health risks, and in which the
members participate in its management’ (Devadasan et al. 2006, 225). CHIs
generally function in association with the existing community organizations such
as trade unions and cooperative societies. Most schemes follow a ‘linked model’
whereby the NGOs act as intermediaries between the community and formal
insurance companies and managerial functions are taken by professionals instead
of volunteers. Studies of CHI introduced in some other countries in Asia and
Africa suggest that they help increase access to healthcare for low-income
populations, and reduce OOP expenditure for health (Jakab and Krishnan 2001).
Since they are based on the principle of social solidarity, CHIs also tend to be
better accepted by local populations (Ahuja and Narang 2005; Bhat and Saha 2004;
Devadasan et al. 2006).
In India, over 115 CHI schemes have been initiated by local NGOs in support of
broader development programs (Aggarwal 2010; Michielsen et al. 2011;
Devadasan et al. 2006). One of the most prominent and long-standing CHIs was
launched in India in 1992 by the Self-Employed Women's Association (SEWA;
Ranson et al. 2007). Between 2003 and 2005, the mean socioeconomic status of
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those insured by SEWA increased significantly relative to the non-insured

population in the same sub-districts (Ranson et al. 2007). However, there has been
a significant difference in enrolment among rural and urban areas (Desai 2009;
Ranson et al. 2007; Sinha et al. 2006). In the South Indian state of Karnataka, the
Yeshasvini insurance scheme, based on a partnership between public, private, and
cooperative sectors, was launched in 2010 and covers over three million people,
but has only been able to persist thanks to government support and donations from
private and public bodies (Aggarawal 2010).
Lessons learnt from Rashtriya Swasthya Bima Yojna (RSBY)
The insurance scheme that has received the most attention in India is RSBY. The
Indian government launched this ‘cashless’ scheme in 2008 to cover BPL families’
hospitalization expenses tracked through the use of a smart card against only a
small enrolment fee (Shiva Kumar et al. 2011; Rao and Choudhury 2012). RSBY
has been described as offering the most inclusive and comprehensive social health
protection in India so far (Michielsen et al. 2011). Insurance is provided to families
of up to five members, covering surgical procedures and hospital admissions for up
to Rs 30,000 (about US$500) yearly (Dasgupta et al. 2013). The central
government covers 75% of the yearly insurance premium and the rest is covered by
the state governments. The initial goal was to cover the entire country by 2012–
2013 (Reddy et al. 2011b), and currently all 29 states of India have implemented
RSBY in at least one of their districts (with great variation in the number of
covered districts among states), covering over 37 million BPL families.11
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India's previous health minister, Harsh Vardhan, cited the program as an example
to follow and extend in scope (Bagcchi 2014). A study in Udupi district of
Karnataka state has, for example, shown that the majority of RSBY subscribers
have found the scheme beneficial and were willing to renew their enrolment
(Kamath et al. 2014). Studies also show that in the large majority of the states,
monthly healthcare expenditure for inpatient treatment has either reduced or
remained constant since the introduction of the scheme (Sinha and Chatterjee
2014).
Other evaluations of RSBY, however, raise issues begging further inquiry.12 One
criticism is that the scheme focuses too exclusively on BPL populations and does
not take into account the families that are above the poverty line (APL) but may
nevertheless struggle or become impoverished due to healthcare expenses (Selvaraj
and Karan 2012). This narrow approach has been linked with the early genesis of
RSBY guided by particular developmental goals and institutions, whereby
efficiency, competition and individual choice were considered most important
(Virk and Atun 2015). As a response to such criticisms, the coverage has recently
been extended to APL families in Kerala (Sinha and Chatterjee 2014). Second,
CHI schemes such as RSBY have created an increasingly complex administrative
system, which results in higher management costs requiring increases in premiums
to stay solvent (Selvaraj and Karan 2012). Third, the claims ratio among enrolled
families, reaching only up to 15%, indicates poor utilization of the scheme benefits
(Sodhi and Rabbani 2014).
Furthermore, while there has been a slight decline in OOP expenditures, there has
been a sharp increase in hospitalization expenditure in post-insurance years
(Selvaraj and Karan 2012). As Selvaraj and Karan (2012) argue, the reason behind
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this is the narrow focus of RSBY on secondary and tertiary healthcare,

encouraging inpatient care where outpatient care could suffice. An analysis of
insurance claims in public hospitals in Chhattisgarh, for example, revealed that
common conditions, which would normally be treated in outpatient care, such as
diarrhea and respiratory infections, were often treated through expensive
hospitalizations (Dasgupta et al. 2013).
Finally, evaluations by Dasgupta and colleagues (2013) and Salvaraj and Karan
(2012) suggest that rather than strengthening public institutions, schemes such as
RSBY actually contribute to a weak public health system and an unregulated
growing private health system. Instead of protecting poor and middle-income
populations against catastrophic healthcare expenses, these insurance schemes are
pushing them further into poverty. Data on RSBY from across the country indicate
that despite their health insurance coverage, the financial burden of OOP increased
faster among the poorest 20% of the population compared with the richest 20%
(Karan, Selvaraj and Mahal 2014). Because most of the expenses are due to non-
institutional treatment, which is not covered by RSBY and other schemes, poor
families tend to avoid treatment altogether or opt for low quality treatment. While
RSBY has proved relatively successful in terms of enrolment, utilization, and
impact in some states, it has not made a significant impact on a national level
(Sinha and Chatterjee 2014).
Pertinent examples of issues with health insurance
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Public awareness and understanding of insurance
Several reviewed studies have documented that public awareness of health

insurance in India is poor (Ahmed 2013; Platteau and Ontiveros 2013; Reshmi
et al. 2007, 2012; Vellakkal and Ebrahim 2013). Due to the efforts of private
insurance agents, general public awareness of health insurance in Kerala as well as
elsewhere in India has been raising (Vellakkal 2009a). Discussions regarding the
problems of implementing new technologies, including those related to managing
money and health, in any country or community often see ‘the culture’, or lack of
necessary education, as a ‘barrier’, due to which people have difficulties learning
how to use these new technologies (cf. Pigg 2013, 129). However, our fieldwork so
far indicates that the understanding of what benefits one is entitled to, when and
where, often remains confusing not only to the poor and illiterate, but also to
middle class educated citizens. Such miscomprehension may be fostered by the
promotional language of the insurance sellers that is hard to grasp for the general
public of different educational backgrounds. For example, an employee of a
government-sponsored insurance scheme juxtaposed life and health insurance as
one likely reason for misunderstandings:
Health insurance is … far more complicated than the traditional life insurance that
the general population is more familiar with. This is a major reason for lack of
interest initially and disagreement later on.… Sometimes even those who wanted
to read the detailed terms and conditions could not do so as the policy certificate
was made available only some days after the agreement is signed. There is a
cooling off period during which time an insurance contract can be terminated
without prejudice, but very few people have availed [themselves of] this and if an
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agent tells [about it] he may lose a commission after a hard sell. Health insurance
is problematic. People buy and then do not renew.
Indeed, some of our other informants expressed a wish for more transparent
explanations of differences between life and health insurance.
Three questions emerge in relation to raising awareness about health insurance:
(1) who should raise awareness about insurance;
(2) what are the issues that need to be addressed; and
(3) how should that be approached? A college-educated informant with insurance

had this to say on the topic:
I don't think the common man knows what exactly [health insurance] is all about.
… I have an insurance coverage with a particular scheme. I don't know what the
terms are, I have not found out.… I am able to read and write [but] what about the
people who may be illiterate … how much time they will spend [on finding out the
terms and conditions]? They wouldn't know much. So the average person does not
know. I think that it's the duty of socially committed organizations to create that
awareness, not insurance agents.
According to the informants, information on health insurance should be provided

by trusted parties such as respected healthcare workers, local NGOs, and members
of the local government, called panchayat (see also Ahmed, 2013; Madhukumar,
Sudeepa and Gaikwad, 2012). Regarding the content of the explanations needed,
one of the main issues to address would be the basic principle of risk pooling. A
doctor who runs a small hospital spoke about his efforts to describe insurance in
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relation to credit and debit cards that are now becoming more common in urban
areas. He was led to do so because people, in his words, confuse insurance with
having a credit card:
Patients and their family members come into my hospital with an insurance card
and treat it like a credit card and expect all expenses will be paid, or that they can
charge everything and pay later but with no interest charge.… I have to tell them
no, the insurance card is like a debit card that can only be used for certain things.
Once you run out of your funds there is no credit. I have this posted on signs in the
accounts department and near reception so there is no misunderstanding. This
misunderstanding is common.
Figure 1. Posted in a nursing home on Kerala-Karnataka border, this sign warns

against the common misunderstanding that health insurance can be used like a
credit card.
As to how insurance could be better explained to the masses, it would make sense
to draw comparisons as well as make distinctions with familiar monetary practices.
For example, some informants suggested insurance could be explained through
local institutions like the rotating credit systems or ‘chit funds’.13
Further, here is an observation of a senior official at the government-owned Life

Insurance Corporation of India (LIC) that brings out the issue of unrealistic and
misplaced expectations of the public:
When I took charge of operations in 2010, health insurance was a relatively new
idea. We had to explain to people regularly. But now there is wider understanding
of the concept of health insurance, though not the details. People are on the whole
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unwilling to take health insurance, even though they acknowledge the risks and
raising costs of healthcare. Why? Because there have been many instances reported
of consumers feeling denied of insurance benefits they feel are due to them. As a
result of this, LIC health insurance has gone out of favor with people and business
is below expectation. A major reason for this is a mismatch between customers’
expectations and poor understanding of actual terms of the contract. This is mainly
due to the failure of LIC to adequately train and monitor insurance agents who are
intermediaries employed on commission basis to convince people to buy insurance.
The agents do not convey exceptions to insurance coverage adequately to
customers. The people on their part have not been diligent in understanding the
terms of the contract, partly due to the existing trust they had for LIC as a public
sector insurer.
Poor understanding of insurance mechanisms may continue even after people

acquire health insurance policies. This may result in the insurance beneficiaries
having unrealistic or misplaced expectations about what kind of treatment is
included in the coverage (e.g., outpatient or inpatient healthcare) and what are the
limits of insurance in terms of the amount of covered expenses.
Impact of misunderstanding on health seeking behavior and

treatment
Misunderstandings about health insurance schemes, for example thinking about

them in terms of credit cards, can lead people into far more debt than they may
have incurred if they did not have insurance. This occurs when they seek out more
expensive care than they can afford without realizing that their insurance coverage
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at a hospital is limited. A healthcare practitioner at another NGO clinic explained a

common way this happens:
If a man on the street buys into health insurance for Rs 35 and gets coverage for Rs
30,000 for a full year, what does he often do? When he has an illness, because the
money is available and because the treatment can be anywhere, he is tempted to go
to the best hospital. And there he finds out that after the first three days of
treatment, the money is over. So now he borrows money – more than once! And
even after borrowing from the relatives he finds that there is no end to it. Then he
is discharged and goes to a government hospital. Now, he is no longer able to
afford food … The limited financial input from the insurance actually encourages
[people] to seek treatment from the expensive [private] hospitals. Then they find
out that they are unable to pay the whole bill in order to complete the treatment. So
they borrow and fall in the debt trap. Very often they get halfway through the
treatment and then stop because they cannot afford to continue to pay for the rest
of the treatment out of pocket.
We found that some clinics limited the amount of insurance coverage a person
could draw upon during any one hospitalization as a matter of policy, possibly to
educate patients that coverage was not in fact free but against a balance. For
example, a policy put in place at one clinic allowed patients to pay a part of their
bill by insurance (up to a limit) and then the rest out of pocket. The following case
illustrates this ad hoc procedure:
My husband has been ill for [the] past two years, due to which he has had to be
hospitalized repeatedly. We are beneficiaries of RSBY. However, the entire money
is not allowed to be withdrawn at one go. If all of the money on the card for the
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entire family is allowed to be withdrawn at once, then it could create problems

later on. So only a maximum of Rs 5000 out of a total Rs 30,000 can be issued
during one hospitalization event. At the private medical college hospital where [my
husband] is admitted in the general ward, any expense beyond this must be borne
out of pocket. Our expenses have been far beyond that covered by RSBY… We
have for the most part been helped by friends and family over the past two years.
But we are facing financial ruin due to my husband's prolonged illness. The banks
won't lend to us anymore so we have to borrow money at usurious rates.
The decision of capping was taken by the clinic administrators in order to prevent
the money available under the RSBY insurance scheme to the beneficiaries too
quickly. Such a limitation, however, is not a part of the original RSBY scheme
employed across India, in which the critical limitation is rather that the beneficiary
card can only be used once in 24 hours so as to prevent corrupt practices (Dasgupta
et al. 2013).14
Differences in behavior patterns in cash and cashless insurance

systems
The introduction of a cashless system, such as the smart card used in RSBY, may
have an impact on patients’ perceptions that through direct payment of some kind
they are establishing a bond with practitioners. In many parts of India it has long
been customary to gift or indirectly pay government and indigenous practitioners
for ‘free’ services as an incentive to poorly paid practitioners or to forge personal
relationships (Nichter 1996). This is seen less as corruption and more as socially
acceptable relationship building, a form of interaction through which a trusting
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52
relationship between the doctor and the patient becomes established and is
therefore perceived as ethical by the parties involved.
In their book, Poor Economics, Banerjee and Duflo (2011) point out that people
often choose things that cost them more due to perceptions of quality and what the
product or service means socially and to a transaction. Will removal of direct
payment for services and subsidized costs lead to patient concern that lack of an
immediate incentive will jeopardize their ability to receive best care? Will they
continue to choose private healthcare over public precisely because it is more
expensive and perceived to be of higher value (Bhatia and Cleland 2001)? Our
preliminary research suggests that unless perceptions of quality of care and
medications at public institutions change, this is likely to occur.
Impact of insurance on quality of care
Researchers will need to investigate how cashless health insurance impacts on

quality of care and practitioner decision-making. The following observations of
one doctor about RSBY captures what several of his colleagues in the private
sector saw as a likely future:
It is not true to say that the Mediclaim model has no caps on health expenditure.
They might not reveal to patients always, but they do dictate to hospitals how
much they can spend per procedure or disease. So, in case if the money allotted
only covers four days worth of hospitalization, then patient is likely to be
discharged at end of four days even if the doctor would normally have advised a
couple days more of treatment or further investigations. Thus quality of care is
likely to deteriorate if health insurance becomes the norm.
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53
Our interviews with doctors indicated that nearly all thought diagnostic tests and
Caesarean sections would increase substantially if covered by insurance, both
because of practitioners’ wish to increase their earnings and because of higher
demand from patients (see also Ajeet and Nankishore 2013; Bogg et al. 2010). It is
not clear, however, whether the caps on expenditure for Caesarean sections would
prevent excessive diagnostics and bring down costs, or increase the amount of
serious health complications. Community members, even those with low levels of
education, suspected doctors profited from ordering tests and were aware that they
may not be needed, but viewed them as indicators of both quality of care and
doctors’ interest in them (Nichter and Van Sickle 2002). It is important to note that
perception of quality of care does not equal quality of care, and a higher number of
tests and surgeries does not automatically translate into high quality of care; it may
even have the opposite effect as unnecessary surgeries and tests may lead to
unwanted side-effects. The subjective meaning of quality of care is a worthy
research topic in its own right and directly tied to perceptions of the merits
of health insurance coverage.
(Mis)trust in health insurance schemes
Misunderstanding of insurance as well as provision of information about it from

insurance sellers, who work for commission, often leads to mistrust among the
people. For example, there seems to be little understanding of risk pooling as a
population-based principle underlying insurance. While insurance experts’
calculate risk in terms of numerical probability, lay-consumers find the logic of
insurance based on contracts and continuous payments suspicious (Golomski
2013). We found a sense of ambivalence about insurance coverage and little
concern for being overcharged. Many informants felt that it was likely they were
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54
being cheated, but that since it was not their money, they were not much
concerned. One of our informants explained:
The insurance scheme is no doubt a moneymaker for the hospitals. How are we
common folk able to know what they have put down on the file by means of
medicines and tests! Only when the money is cut from our card do we know the
billed amount. Who has the inclination to ask about such things during treatment?
People are just grateful to be receiving any support at all from government. They
are ecstatic that not only don't they pay any money to hospital, but instead even
receive a sum of Rs 100 at time of discharge for bus fare back home. So they don't
mind whatever the hospital writes on file. 'It's government money, why do we care
what they do with it?' is the common attitude. But then the amount is depleted and
not available next time it is needed.
Many of those interviewed stated they have little faith in health insurance schemes
and prefer to pay OOP for services as needed. As justification they cited stories
about negative experiences of family or friends with other types of insurance.
Another issue worth examination is the extent to which trust in government-
supported insurance schemes is related to the much larger issue of trust in the state,
and the extent to which the state is seen as fulfilling its mandate to protect its
citizens. Because of widespread suspicions of corruption in public institutions (see
also Berger 2014), officials dealing with claims might be reluctant to approve
claims, even when they are clearly legitimate. As a judge in charge of a district
consumer court explained:
The organizational set-up of insurance bureaucracy could contribute to disputes.

For example, in [the] public sector, officials in charge of granting relief have to
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55
reckon with [the] possibility of enquiry from anti-corruption police. They might
feel compelled to offer only the minimum amount or contest claims … even if they
know they are legitimate. [They] prefer that the matter be settled in court so as not
to be accused of taking a bribe in future. Similarly, private companies have
engaged parallel investigation mechanisms to verify claims, and these reports
invariably tend to be conservative.
In the long run, this adds up to the perception that insurance companies are ‘cheats’
that do not want to pay and have to be forced to pay even for legitimate cases.
Needless to say, this undermines trust. Further ethnographic research is also
needed on insurance perception spillover from one type of insurance to the next as
well as how trust has been established in successful health insurance schemes, but
lost in others.
Different sectors of the population may view insurance in different ways, leading
them to be more or less inclined to participate in schemes or pay premiums
(Reshmi et al. 2012). While some segments of the population may have little trust
in insurance as a resource, other segments may see insurance as an entitlement and
associate the right to insurance with citizenship. The issues of trust seem to play a
pivotal role in insurance enrolment, expectations, and use, and this begs further
ethnographic exploration. The study of trust could be started by first examining
other kinds of insurance (e.g. life or property insurance), and especially those
contexts in which particular insurance schemes have been more successful than
others. Anthropologists could also look at various other local practices around
India that are based on trust to see what are the specific mechanisms that foster or
endanger trust.
Page
56
Health insurance coverage: chronic illnesses, rehabilitation and

OOP expenses
Insurance coverage in India, as noted in the introduction of this paper, primarily

addresses the catastrophic costs of hospitalization, while the major OOP spending
is for outpatient care and medicines. Families often slip into debt regardless of
insurance coverage for medical procedures as a result of the costs of essential
follow up care. This is an issue Selvaraj and Karan (2012, 67) have highlighted in
their critique of the narrow focus of ‘compartmentalized care’ to the neglect of
continuity of care. Lack of support enabling treatment adherence and continuity of
care can in turn lead to a much higher probability of future hospitalizations.
Consider the case of the following child being cared for by his grandmother:
My grandson was born with both knees twisted inwards. I secured an insurance
card and took him to a private medical college hospital as advised by a neighbor.
There, they surgically extended his knees. The bill for this procedure was paid
from the insurance card. However, all future expenses for care had to be met out of
pocket. We have been advised physiotherapy for at least 3 months. [The] daily fee
is Rs 150 plus travel fare. This is not paid for by the card. We depend on
remittances from his mother for sustenance. How can I meet this expense?
Most public insurance schemes also do not cover the costs of medicine and
outpatient treatment for those with chronic illnesses, even though studies suggest
that many people would prefer to acquire health insurance packages covering both
inpatient and outpatient treatment (Dror et al. 2014). The following case of an
elderly man illustrates the dilemma which many families with chronically ill
members face: they have to choose between medicine and basic necessities such as
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57
food. The case also speaks to how doctors try to work the system for the benefit of
their patients:
I have had diabetes and hypertension for the last 10 years. My doctor is good. But I
cannot purchase medicines he prescribes routinely or [visit] the clinic as directed
because the expense is too great for my wife and I to bear. We live on very limited
means and buying medicine means less money for food. The first two years I tried
to do the needful and purchase the medicines, but I fell into debt. So now I
purchase the medicine and visit the clinic when symptoms are more. If I develop
wounds on my legs or feet that look serious, the doctor sometimes admits me to the
hospital for a few days. My card will not pay for medicines, but it will pay for my
stay in the hospital. The doctor gives me samples of medicines to take home.
In this example, the doctor admitted the patient in order to treat and stabilize his
condition. The doctor was aware of the patient's dire economic situation and
inability to purchase necessary medicines. This case of a doctor working the
system on the patient's behalf provides a good counterbalance to the many cases
reported of clinics gaming the system by ordering unnecessary diagnostic tests and
operations such as Caesarean sections as a means of earning profit (Desai 2009;
Ajeet and Nandkishore 2013).
Chronic disease and mental illness are expected to increase substantially in India in
the next decade (Chatterjee 2012; Patel et al. 2011; Reddy et al. 2005; Vellakkal
2009a, 2009b). A key issue to be addressed by insurance providers is the extent to
which routine monitoring of chronic illness proves to be a cost effective means of
reducing expensive downstream costs of acute disease episodes. A community-
based study of chronic illness in Kerala suggests that a major cause of non-
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58
adherence for both diabetes and hypertension is the financial burden of follow-up
care and lack of insurance coverage (Devi and Nichter 1998; Devi 2008). Working
along with colleagues in the health service research field, anthropologists might
investigate patterns of (non)use of clinic services if and when they are made
available to those with chronic diseases.
Other areas recommended for further research
There are a number of other aspects of health insurance that call for further
investigation by anthropologists who could contribute to a more in-depth
understanding of the life cycle and impact of the existing schemes. Important
questions to look into are who buys insurance, for whom, and why. Some research
has indicated that nuclear families and families with fewer members are more
likely to buy insurance policies (Madhukumar, Sudeepa, and Gaikwad 2012) and
socio-economic factors including literacy, religion, occupation, and gender are
important (Reshmi et al. 2007, 2012; Rai and Ravi 2011; Chakrabarti and Shankar
2015). Research is needed on both motivations for and ambivalence about health
insurance experienced in different types of households. Insurance schemes often
target families, yet little is known about who encourages enrolment in insurance
schemes and for what reasons.
Further, what is the impact of health insurance on self-care and the household
production of health (Gilson et al. 2011; Olson 1994; Schumann and Mosley
1994)? Will insurance coverage influence self-care practices, such as purchasing
medicines over the counter, and reduce delay in seeking healthcare, and if so, for
what type of complaints? Also, will impoverished women feel more empowered to
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59
seek healthcare for themselves if they do not feel they are a drain on a household's
limited resources?
Other promising lines of research include the ways in which health insurance
programs impact patient referral patterns and introduce audit systems that change
the way healthcare is managed. Finally, future research will need to examine
insurance coverage for Indian indigenous medical systems such as Ayurveda,
Yoga, Unani, and Siddha (AYUSH), and when these systems of medicine are
turned to for disease management as well as promotive health and care for the
elderly.
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60
CHAPTER-5
(CONCLUSION AND
IMPORTANT
NOTES)
CONLUSION
Page
61
Assessment of the real world impact of health insurance requires a holistic, multi-
disciplinary analysis that captures its complexity and is sensitive to the larger
social, political, and economic context in which policy is created and introduced. A
health policy and systems research approach promotes such ‘systems thinking’ and
explores why and how certain programs work for some, but not for others (Gilson
et al. 2011; Mishra 2013). Such research must be people-centered and attentive to
human agency, social relations, cultural values, and trust (Sheikh, Ranson, and
Gilson 2014). At the same time, it should also be policy-minded and attentive to
processes, structures, and power relations that constitute the field in which a policy
is both constructed and negotiated.
In the case of health insurance, research needs to take stock of those factors that
lead citizens to enroll in and drop out of insurance programs as well as to use
insurance in particular ways. It should also investigate the impact of insurance on
the way healthcare is administered at multiple levels. Medical anthropology could
play a vital role in this research agenda, as is evident from a few of the many lines
of potential research proposed in this paper. Among other issues, we highlighted
the following six key areas for in-depth research:
(1) public awareness and understanding of insurance;
(2) impact of misunderstanding on health seeking behavior and treatment;
(3) differences in behavior patterns in cash and cashless insurance systems;
(4) impact of insurance on quality of care;
(5) (mis)trust in health insurance schemes; and
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62
(6) health insurance coverage, especially in relation to chronic illnesses,

rehabilitation and OOP expenses.
These topics emerged from our interviews time and again, and, combined with the
literature review, they indicate where most misunderstandings and tensions occur.
A better grasp of the enumerated areas could potentially lead to improvements in
providing, explaining and implementing health coverage, especially for those with
limited resources. We conclude with a call for organizational ethnographies of
insurance that include what Laura Nader (2008) has referred to as ‘up, down, and
sideways’ perspectives. This refers to the study of those in power (policy makers
and influential stakeholders), those subjected to the directives of those in power
(parties charged with implementing programs downstream as well as program
recipients), and those who are motivated to frame, fund, and publicize research on
insurance for a myriad of purposes.
Notes
1. On the positive side, India has also achieved success in certain healthcare areas;
for example, substantial improvements have been made in antenatal and infant care
(Balarajan, Selvaraj, and Subramanian 2011).
2. The estimated government public health expenditure was stagnant at around 1%

of GDP between 1990 and 2006, increasing only to 1.2% of GDP in 2009 (Tandon
and Cashin 2010; Rao and Choudhury 2012; Gupta 2006). In December 2014, the
government announced a cut of nearly 20% in its healthcare budget for 2015/16. It
is as yet unclear how this will affect the planned launching of a universal
healthcare program, providing all citizens with free drugs and diagnostic
treatments as well as insurance benefits (Kalra 2014).
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63
3. In Kerala, the amount of public financing of healthcare is three times higher than
in Bihar (Shiva Kumar et al. 2011), yet OOP expenditure reaches almost 7% of
total household expenditure, which is one of the highest levels in the country (Garg
and Karan 2009).
4. In 1999–2000, OOP payments constituted 4.8% of total household consumption

expenditures on a national level, with significant differences between states (from
2% in Assam to as much as 7% in Kerala), and between rural and urban areas
(Garg and Karan 2009).
5. Studies in other countries indicate the benefits of health insurance indeed

include reduced financial burdens, improved access to care and better health
outcomes (Kenney et al. 2014).
6. To add a historical perspective, see Börner (2011) for an analysis of the

implementation of national health insurance policies and the tensions this raised
with the local communities in charge of social benefits in Germany and the United
Kingdom.
7. We thank one of the anonymous reviewers for bringing our attention to this
point.
8. As Stacy L. Pigg (2013, 132) notes, there have been decades of discussion
regarding the accountability and purpose of anthropology, which were made
explicit through the dichotomy of applied and theoretical work. Here, we employ
and encourage ‘engaged anthropology’ (Nichter 2006) as a possible way to
overcome this dilemma.
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64
9. Others have argued that over-reliance on the private sector, as promoted by the
latest NHP, would encourage hospital care before integrated care, which would
combine primary, secondary and tertiary facilities for the optimum patient
wellbeing (Sharma 2015).
10. A similar argument, namely that health insurance is only one, and perhaps not
even the most important, aspect of addressing the problem of national health
disparities, has been made in the context of the Affordable Care Act in the USA
(Stewart, Hardcastle and Zelinsky 2014).
11. The data are from the official website of the RSBY scheme; see
http://www.rsby.gov.in/Overview.aspx.
12. Impact assessment of health insurance schemes has been shown to be sensitive
to methodology and the data used for the analysis; this has been pointed out as a
reason for contrasting evaluations of RSBY (Vellakkal and Ebrahim 2013).
13. Chit funds are a mix of auctioning and credit with varying interest rates
depending on auction each month.
14. A study on benefit-package design of community-based health microinsurance

showed that people preferred caps, especially if they would apply to households
rather than their individual members (Dror et al. 2014). According to Dror and
colleagues (2014), this so-called ‘family floater’ would mean that within a cap per
family and per event, one household member could claim more than one event per
year. This practice would encourage circulation of funds within households; it
would also add to the welfare of the most vulnerable family members as well as to
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65
the non-claiming ones as they would be released from the obligation to provide
financially for treatments of their close relatives.
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66
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/369874175
Managing health insurance using blockchain technology
Chapter · December 2022

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Chapter 4
Managing Health Insurance using Blockchain
Technology
Tajkia Nuri Ananna1 Munshi Saifuzzaman 2
iD iD
Mohammad Jabed Morshed Chowdhury3 and Md Sadek iD
Ferdous4 iD
Abstract
Health insurance plays a significant role in ensuring quality healthcare. In response

to the escalating costs of the medical industry, the demand for health insurance is
soaring. Additionally, those with health insurance are more likely to receive pre-
ventative care than those without health insurance. However, from granting health
insurance to delivering services to insured individuals, the health insurance industry
faces numerous obstacles. Fraudulent actions, false claims, a lack of transparency
and data privacy, reliance on human effort and dishonesty from consumers, health-
care professionals, or even the insurer party itself, are the most common and im-
portant hurdles towards success. Given these constraints, this chapter briefly covers
the most immediate concerns in the health insurance industry and provides insight
into how blockchain technology integration can contribute to resolving these issues.
This chapter finishes by highlighting existing limitations as well as potential future
directions.
Keywords
Blockchain, Health insurance management, Customer service management, Fraud
detection and risk prevention, Claim and billing management, Data record and shar-
ing management
1 MetropolitanUniversity, Sylhet, Bangladesh, Email: tajkianuri@gmail.com

2 Dynamic Solution innovators, Dhaka 1206, Bangladesh, Email: munshisaifuzzaman@gmail.com
3 (Corresponding Author) La Trobe University, Bundoora, VIC, 3086, Australia, Email:
M.Chowdhury@latrobe.edu.au
4 BRAC University, Dhaka, 1206, Bangladesh, Email: sadek.ferdous@bracu.ac.bd
2
4.1 Introduction
Health insurance is a means of providing financial support for a person’s healthcare
expenses [1]. In exchange for a premium, the insured must pay all medical, surgical,
and even dental treatment charges incurred by the insurer. Many organizations pro-
vide health insurance benefits to their employees, which encourages them to perform
well [2]. Accidents and illnesses are unpredictable in life because they can happen
to anyone at any time. The unexpected cost of treatment can put a huge strain on
a person’s finances. Healthcare costs are increasing rapidly as medical technology
advances [3, 4]. Because medical costs are going up and people want better care,
more people are getting health insurance [5]. According to the study by Mendoza-
Tello et al. [5], health insurance acts as a shield of safety in three ways. To begin
with, it ensures preventative access to medicine and healthcare. When compared to
uninsured individuals, those with health insurance have a better chance of access-
ing early detection tests for any illness. In the United States of America, lack of
health insurance causes poor cancer outcomes. Uninsured individuals do not receive
preventative care, which results in delayed cancer detection and a lower chance of
survival [6, 7, 8, 9]. Uninsured people are also more likely to be diagnosed at a later
stage of the disease [10, 11] and have a lower chance of surviving [8, 11]. Second, it
enables access to disease treatment that is personalized to the insured’s preferences
by the insurer. Insured individuals are more likely to obtain evidence-based care than
uninsured individuals [9, 12]. Thirdly, it gives economic protection, discounts, and
compensation for health care expenses. Insurance companies negotiate discounts
with healthcare providers and thus pay a major portion of the insured’s medical ex-
penses [13]. That is how an insured person has access to reimbursement and financial
stability compared to an uninsured person. An uninsured person may be forced to
pay a large sum of money, resulting in a significant financial loss and health deteri-
oration [5, 14]. The health insurance issuance process starts when the customer fills
out the application form in order to purchase a plan [15, 5]. The insurance company
that provides insurance service is addressed as the insurer. A person who purchases
insurance is called an insured party. Depending on the insured’s selected plan, med-
ical background, age and insurance sum, the insurer offers the premium amount,
which is paid by the insured party to the insurer [15, 5]. In some situations, the in-
sured party is required to undergo a medical examination before the insurer decides
how much money to give the insured party [15]. Finally, the insurer is provided a
customized policy and receives health coverage based on a mutual contract between
the insurer and healthcare provider [15, 5].
The health insurance industry’s processes are riddled with inefficiencies, such
as claim falsification, duplicate claims, fraud activities, irregular billing, security
and privacy difficulties in data sharing and so on. There are numerous areas that
require development in terms of efficiency, accuracy, and management. Fraud in
health insurance is one of the major concerns among the issues. On September 30,
2020, healthcare insurance fraud to federal healthcare programs and private insurers
have resulted in a $6 billion loss in the United States. A total of 345 individuals have
charged for their roles in this fraud, with 100 of them being doctors, nurses, and
3
medical professionals [16]. According to a survey by the National Health Care Anti-
Fraud Association (NHCAA),one healthcare costs the United States more than $2.27
trillion each year, with tens of billions of dollars lost due to healthcare insurance
fraud [17]. Security and privacy issues have been a major concern when it comes to
health data sharing as people are extremely sensitive about their medical data, which
makes customers hesitant to disclose their health data. Many people believe that the
healthcare industry is not well prepared to deal with the growing number of cyber
threats [18].
Various fields, such as machine learning, blockchain, and others, have had an
effect on health insurance management. Machine learning is one of the most impor-
tant and rapidly developing fields in the world today. Although machine learning
has not been utilized extensively in the management of health insurance, there have
been a few noteworthy achievements in this area. The authors of [19] have proposed
an approach based on machine learning to combat health insurance fraud. Similarly,
machine learning implementations have been observed in [20] and [21]. In [22] au-
thors have leveraged data mining technologies to address fraud and claim manage-
ment problems in health insurance management whereas authors of [23] have made
notable contributions to the resolution of claim processing in health management.
However, the most significant issue with all of these works is that privacy and secu-
rity have not been adequately addressed. In addition, no mechanism for the secure
exchange of data has been presented. This is a vulnerable case because privacy is the
top priority for the vast majority of people today. Blockchain, on the other hand, is
one of the most secure emerging technologies, and it possesses a number of charac-
teristics that allow it to solve these significant issues. Blockchain is a distributed, de-
centralized, and immutable ledger technology that facilitates the transaction record-
ing process and assists in the tracking of both tangible (cash, land) and intangible as-
sets (intellectual property, patents, copyrights) [24, 25]. It acts as a database, storing
information electronically in a digital format [26]. Each transaction in a blockchain
is recorded as blocks that are linked together using cryptography [27, 28, 28, 29].
The connection between blocks provides the blockchain’s immutability or resistance
to manipulation by assuring that no blocks can be altered [24]. It provides immedi-
ate, shared, and completely transparent information that is stored on an immutable
ledger that is accessible only to permissioned network members [24]. Blockchain
technology has the characteristics of decentralization, tamper-resistance and trace-
ability [30]. It is capable of constructing a secure and private network as well as has
the potential to resolve a wide range of health insurance issues such as interoper-
ability, fraud activities, billing, service management and so on. Additionally, smart
contracts on the blockchain can make the entire insurance process and documen-
tation transparent. Blockchain holds all parties, including healthcare professionals,
pharmaceutical companies, and insurance companies, accountable for their activi-
ties. This contributes to the development of trust among insurers and policyholders,
healthcare professionals and patients as well as the overall healthcare industry [31].
As a result, it can be stated that blockchain has the capability of resolving the ma-
jority of the concerns inherent in the current health insurance system and creating a
secure environment to facilitate the entire health insurance system.
4
This chapter reviews the most promising research work on the management of
health insurance using blockchain technology. To the best of knowledge, there is
not a single review paper, survey study, or even book chapter that can assist future
scholars in this topic, which motivates this work. In order to classify existing works,
this chapter divides health insurance management into a number of key research
areas. Consequently, this would assist future researchers get a broad understanding
of the field and figure out where blockchain and the existing literature fall short.
Authors’ Contributions: The authors contributions in this chapter are as fol-
lows:
1. A survey on managing health insurance using blockchain technology has been
conducted. This chapter assesses the techniques, their use cases, experiment
scenarios, and their limitations by looking at the most relevant and recent re-
search studies.
2. Five different aspects are then analyzed by presenting foundational demonstra-
tions and major key concepts from existing works, and a summary was drawn.
3. This chapter concludes with a comprehensive discussion of the limitations and
future directions of the reviewed papers.
The following is how this chapter is organized: It begins with Section 4.2, which
discusses several key aspects and challenges of the health insurance industry. The
causal effects of health insurance then are discussed in Section 4.3. Section 4.4 dis-
cusses blockchain’s revolutionary impact on the health insurance industry. There is
a detailed discussion of a few of the most important core factors that affect health
insurance management from Section 4.5 to Section 4.9. The chapter concludes with
a discussion of limitations and potential future scopes focused on the reviewed liter-
ature as well as blockchain technology in Section 4.10.
4.2 The Insurance Industry: Its Aspects and Challenges

Insurance, in its simplest form, protects any individual, organization, or other entity
(entity in short) against financial loss. The purpose of insurance is to safeguard any
entity’s financial well-being in the event of an unforeseen misfortune for instance,
structural damage, loss of well-being, and so forth [32].
The insurance industry is vast, having numerous components intertwined with
it. It is one of the areas where customer service management plays an important
role in the overall process. If the consumer is dissatisfied with the service, the entire
system suffers substantial losses. The insurance company should be able to handle
the insured parties’ complaints and grievances, as they play a significant role in the
survival of any insurance company. Given all of these considerations, insurance
should be an honest field with the goal of selflessly assisting people. But, in reality,
the situation is considerably different from what was anticipated. The conviction
about insurance is that if a person receives insurance and pays the monthly premium,
he or she will not have to worry about paying in the event of an unexpected accident
or distress. That is the insurance system’s expected behavior. However, despite all
of its benefits, the insurance industry has so many dark and sophisticated sides that
5
it is difficult to comprehend. There are so many areas where the insurance sector
gets compromised by being falsely used by fraud activities. The actors behind these
activities can be the customer, the healthcare provider or even the insurer themselves.
There are many ways the insurance sector can be compromised by an insured person
or healthcare provider, which are as follows:
1. The insured party falsely claiming for additional financial assistance from the
insurance agency.
2. Insured individual claiming money from the insurer for services that were never
provided.
3. Falsifying facts while issuing insurance cards.
4. Healthcare providers may charge for irrelevant or unprovided services.
5. Extra money can be claimed by drugstores and healthcare providers for medicine
and other items.
Insurance agencies can do many things to avoid responsibility and overcharge the
customer with higher rates to tactfully gain more cash. The most common medical
coverage scams that can deceive customers are listed below [33]:
1. Insurance companies may purposefully deny claims in order to create a scenario

in which they are the victim and the healthcare professionals are the scammers.
2. The insurance company can change the coverage without notice in order to fur-
ther their selfish desires.
3. They may charge the insured for out-of-network costs that the insured is un-
aware of, or they may add hidden costs to the insurance premium.
Along with these, there is widespread concern among consumers regarding the secu-
rity and privacy of health data shared with insurance companies, as people are more
concerned about their privacy. The method of exchanging information is inefficient
and does not adequately protect individuals’ privacy. Additionally, the current insur-
ance system is so reliant on manual work that it exposes the entire system to damage.
As a result, all critical aspects of health insurance require immediate attention. The
core aspects of the health insurance industry are illustrated in Figure 4.1.
4.3 Causality in Health Insurance

In general, ”casualty” refers to the link between the cause and the impact of a specific
event or occurrence. Consequently, it is extremely significant in terms of health
insurance. The effect of the presence or absence of health insurance on healthcare
utilization and health outcomes is referred to as a casualty in health insurance. The
most important elements influencing healthcare advancement are optimized access
to healthcare and increased quality of care delivered [34, 35, 36, 37]. One of the most
concerning topics in the United States has been the lack of health insurance and its
potential impact on healthcare utilization and health outcomes [38]. The New York
Times reported a list of nearly 47 million uninsured people in the United States in
2006 [39]. In addition, the Institute of Medicine [40] and the National Coalition on
6
Fraud
Insurance
activities
claims
Customer Insurance
Service Billing
Data
Sharing Complaint &
Grievances
Figure 4.1: Health insurance aspects
Table 4.1 Research findings on the effects of health insurance
Reference Summary*
American College of Physicians: Insured are more likely to have proper access to healthcare and preventative services, they are
No health insurance? It’s enough less likely to receive delayed treatment, report mismanagement or missing services, receive better
to make you sick [42] hospital-based care, and have a lower mortality rate.
Brown et al. [43] Insured have better access to healthcare and lower mortality rate
Insured receive better preventative service and access to medical care, more likely to be diagnosed
Hadley [44]
at an early stage of any disease and have lower mortality rates
Insured have greater access to care, less likely to encounter any unmet treatment or delayed
Hoffman & Paradise [45]
treatment, access better hospitalized care and lower mortality rate
Howell [46] Increased health coverage for pregnant women before, during and after birth.
Institute of Medicine: Care Insurance provides regular healthcare facilities, an increase in preventative treatments, and proper treatment
without coverage [47] for chronic illnesses, as well as improved health outcomes.
Office of Technology Assessment:
Does health insurance make a Insured people are more likely to receive proper care and have fewer negative health outcomes.
difference? [48]
Insured people are more likely to have a regular doctor and to obtain preventive care. They have shorter
Weissman & Epstein [49]
treatment wait times, are less likely to receive delayed care, and obtain better emergency care.
*Conclusions are presented in comparison to the uninsured, with the exception of Howell (2001) and Levy and Meltzer (2001).
Health Care [41] have recommended universal health coverage to prevent a potential
health disaster.
Though most people, including citizens and politicians, believe that universal
health insurance coverage is extremely important, relatively few actions have been
taken to bring about this basic and significant change in practice. Few studies have
addressed the relation between health insurance and healthcare access, utilization
and health outcome [38].
The American college of Physicians —American society of internal medicine
[42] presents the significant data it has collected in ”No health insurance? It’s enough
to make you sick”. According to the findings, insured people have more access to
healthcare, receive better hospital-based care, have a lower likelihood of having de-
7
layed treatment, and have a lower overall death rate. Brown et al. [43] have also
summarized their work in the same way, demonstrating that insured people have bet-
ter access to healthcare, resulting in a reduced mortality rate. Hadley et al. [44]
likewise have emphasized that insured people have better access to healthcare, pre-
ventative and diagnostic services, and have lower mortality rates. Another key aspect
has been discovered: insured people are more likely to be diagnosed with any illness
at an early stage. Hoffman & Paradise [45] have highlighted the relationship between
health insurance and health outcomes. It has been observed that insured people re-
ceive better care for chronic diseases and are less likely to encounter the obstacles
of delayed treatment or missing out on necessary treatment. Howell et al. [46] have
demonstrated the benefits of health insurance coverage for pregnant women in terms
of better health outcomes before, during, and after the baby is born. Insured people
also have the chance of getting regular checkups from a doctor and have a lower
waiting time [49]. Table 4.1 illustrates some of the studies that have focused on an-
alyzing the relationship between health insurance, healthcare utilization, and health
outcomes.
Furthermore, it is obvious from the preceding discussion that there is a link
between health insurance and healthcare utilization and/or health outcomes. When
compared to uninsured people, insured people receive better treatment and facilities,
as well as more preventative care. All of these amenities contribute to lower mortality
rates since insured people receive preventative treatment, have better facilities, and
can be detected at an earlier stage of any disease. As a result, health insurance
improves health outcomes and healthcare utilization.
4.4 Blockchain Technology: A Revolution in the Health

Insurance Industry
As discussed previously, the health insurance industry is being compelled to com-
promise its efficiency and prosperity as a result of the high number of hazardous
incidents. Blockchain technology possesses the potential to bring numerous benefits
and resolve the majority of health insurance problems and concerns. The health in-
surance industry is being disrupted by blockchain innovation and this time for good!
According to Markets & Markets [50], the global market for blockchain in insurance
is predicted to grow from USD 64.50 million in 2016 to USD 1, 393.8 million in
2025 [51].
So, on that basis, here are a few important benefits of blockchain in the health
insurance industry:
• Efficient Data Sharing: One of the most crucial components of the blockchain
is its transparency. The blockchain provides an immutable and transparent data
exchange technology that assures the integrity of the data shared through the
blocks. It aids insurance companies in ensuring the authenticity of shared data.
Blockchain is protected by cryptographic techniques such as digital signatures,
hash functions, etc., which safeguard the process of data sharing and protect the
privacy of each individual.
8
• Combating Frauds and False Claims: One of the most concerning hazards in
the health insurance industry is false claims and fraudulent activities. The health
insurance industry takes so many preventative measures in order to avoid false
claims and fraudulent activities. However, the adversaries manage to deceive
the insurance industry in some way. As a result of the Blockchain’s ability to
record time-stamped transactions with complete audit trials, counterfeiters find
it incredibly hard to commit fraud [51].
• Enhancement in Customer Experience: Customer satisfaction is a critical
component of any insurance company’s sustainability. Customers are typically
content with the provider for whom they pay lower premiums and receive en-
hanced benefits. Additionally, if an insurance agency is capable of responding
quickly to customer concerns and providing justice to any client, this contributes
significantly to strengthening consumer trust in that insurance company. How-
ever, maintaining all of these simultaneously is extremely difficult. One solution
is to leverage blockchain technology to automate processing through the use of
smart contracts. Business agreements are encoded in the blockchain, and pay-
ments are triggered and processed instantly [51].
• Improves Trust among entities: In this scenario, the blockchian smart contract
emerges as a savior by establishing trust throughout the formation of the insur-
ance contract. In every transaction, smart contracts provide immutability and
auditability. In addition, it eliminates the need for an intermediary to manage
the insurance process.
• Collect and Store Data: The insurance industry is data-driven. Using tech-
nologies such as artificial intelligence (AI) and the Internet of Things (IoT),
blockchain technology enables the collection of a wide variety of valuable data.
IoT-collected data is stored on the blockchain and then analyzed by AI. This en-
ables the company to take an informed and autonomous decision on insurance
premiums [51, 52].
• Accountability and Ownership: Accountability allows all parties involved in a
commitment to be open and honest with one another. The immutability of block
transactions and their connections enables ownership control and accountability
[53]. Using the open and decentralized nature of blockchain, customers can
see what the insurance company knows about them and how that information is
used, which means that there is more openness and honesty. [54].
According to Kuo et al. [55], the major benefit of blockchain integration for
the healthcare industry is the decentralization behavior of blockchain, which allows
relevant parties such as healthcare providers, insurance companies, and government
regulatory bodies to share data securely without relying on any central system. Im-
mutability, transparency, security, and robustness are other important factors in mak-
ing any blockchain-based system more efficient and improving data sharing. With
such exceptional benefits, it may be concluded that blockchain is the optimal way
to help the health insurance industry. In later sections, the most crucial aspects of
health insurance are investigated thoroughly, along with how blockchain can provide
a substantial path to resolving these issues.
9
4.5 Customer Service Management of Health Insurance using

Blockchain Technology
Customer service is critical in developing a positive relationship between a company
and its customers. To be specific, a company’s success is heavily reliant on customer
service and satisfaction. Customer service is the assistance provided by enterprises
before, during, and after the purchase or use of their products or services. Medical
aid supplied to patients, any type of insurance service provided by insurance firms,
or any materialistic product sold by companies are all instances of customer service.
Good customer service improves customer satisfaction and enterprise performance,
which leads to the enterprise’s ultimate success [56].
The quality of customer service is not just determined by the customer service.
It is heavily dependent on how the organization uses its current customer service sce-
nario to attract new customers and retain the loyalty of existing ones [57]. Customer
service is a kind of knowledge-based work where the main motive is to efficiently
utilize and accumulate previous knowledge to improve the customer service qual-
ity [58]. Therefore, it can be stated that an efficient customer service management
system is an essential component of every company’s success.
Health insurance provides customer service to its members who purchase health
insurance from their company. The objective of a health insurance company is to
provide financial benefits to its customers. An insured person receives health cov-
erage as a result of the insurer’s and health-care providers’ combined efforts. How-
ever, managing customers and providing adequate customer care is a difficult task.
The entire system is entirely dependent on human supervision, making it prone to
error. Other drawbacks include the insured individual fabricating information, ab-
normal billing, a lack of transparency, and, most crucially, a lack of data privacy
and security. These difficulties must be addressed in order for the health insurance
organization to be successful. Blockchain has the ability to alleviate the majority
of the problems associated with the health insurance customer administration sys-
tem. Blockchain technology can provide a secure environment in which the health
insurance management system can be easily integrated.
According to the preceding discussion, customer service management is about
providing quality service to existing customers as well as attracting new customers
with better service. Considering this information, it can be stated that there are some
factors that influence quality customer management, such as thoroughly monitoring
if current customers are receiving proper facilities; how the insurance company re-
sponds in the event of any obstacles encountered by the customer; and, most impor-
tantly, if any customer’s complaint is being resolved patiently. As a result, customer
management in health insurance falls into two broad categories: monitor and re-
sponse management and complaint and grievance Management. These two aspects
are among the core aspects of health insurance management, as demonstrated in the
following sub sections.
10
4.5.1 Monitor and Response Management

Monitor and response management in health insurance play a vital role in ensuring
quality customer service. Monitor and response management in health insurance
refers to the ability to properly manage health insurance through monitoring and
ensure better quality service by providing a proper response to customer demands
and issues.
The insurance industry’s major step in this regard is to constantly monitor all of
their customer facilities, such as whether customers are receiving all of the services
included in their insurance policy. If this factor is not ensured, achieving existing
customer satisfaction can be extremely difficult, let alone attracting new customers.
However, this aspect is more than just constantly monitoring existing client facilities;
it serves a larger purpose. With medical fields getting better and new cures and
devices being made almost every day, the cost of medical care and getting access to
it has become hard to handle. As a result, insurance companies must monitor their
policies on a regular basis and, if necessary, reform them. Otherwise, maintaining
the standard and remaining among the best companies is extremely difficult.
The main challenge in ensuring these aforementioned factors is ensuring quality
service by providing adequate privacy to customers. As monitoring and response
management are essentially about sharing information about customers, it is critical
to protect each customer’s privacy. Customers must also be assured that their pri-
vacy is not violated. Current systems, however, struggle to meet these requirements
due to inconsistencies in security policies and access control structures. Blockchain
paves the way for a revolution in this field. If the privacy and transparency proper-
ties of blockchain can be efficiently integrated into solving these issues, it could be
a massive benefit and make the monitoring and response management process run
smoothly.
4.5.2 Complaint and Grievances Management

It is crucial how a health insurer handles customer complaints and concerns. The
quality of their service is highly dependent on how they handle their customers’ con-
cerns [59]. Customer complaint resolution facilitates the resolution of unsatisfactory
situations and the tracking of complaints and grievances, paving the way for an or-
ganization to enhance its service quality [60, 61].
Any individual has the freedom to select any insurer he or she wishes, based on
the insurer’s service quality. Customers have the option of switching plans or even
insurance companies if they are displeased with the outcome of their complaints
[62]. In typical health insurance complaint and grievance management systems, the
client must physically attend in order to file a complaint or even monitor its status.
Even if the customer’s complaint is addressed, he or she might be dissatisfied with
the entire system if the settlement is too lengthy. Additionally, there is the concern
of transparency and anonymity. In today’s society, people are extremely protective
of their data, which makes them feel uncomfortable filing a complaint just because
the system lacks anonymity. There may be additional causes for ineffective com-
11
Table 4.2 Key findings in complaint and grievances management
Reference Key Finding Advantages Disadvantages

Proposed a secured and transparent BC - Applicability
Jattan et + Secure
system for complaint redressal system - Scalability
al. [64] + Transparent and immutable
using Ethereum. - Benchmarking
Presented a BC-based anonymous and
+ Secure and reliable - Simulation
transparent platform where complainants
Rahman et + Ensures anonymity of users - Privacy
can submit anonymous complaints and
al. [65] + Efficient - Efficient
communicate with authorities for resolving
+ Ensures temper resistance - Benchmarking
their complaints.
plaint and grievance management, such as a failure to enforce robust complaint and
grievance management laws and regulations or a flawed redressal system [63].
To the best of our knowledge, there is no literature that directly addresses health
insurance complaints and grievances. As a result, similar fields have been investi-
gated how research communities have addressed complaints and grievances. Health
insurance companies can utilize similar solutions to manage their clients’ complaints
and grievances, ensuring that their company’s quality continues to improve.
There is a lack of communication between the government and its citizens. In
some parts of the world, the manual process of filing a grievance can take up to a
month. Furthermore, tracking the status of a complaint is a time-consuming and tire-
some task. With these problems in hand, Jattan et al. [64] have used the ethereum
blockchain to propose a secure and transparent system for resolving complaints.
Each complaint is a smart contract processed on the ethereum Blockchain. The pro-
cess begins with a user registering a complaint. The complaint is registered and so
kept on the ethereum blockchain by including the appropriate details. To track the
status of the complaint, the user will be granted a complaint number. Officials are
able to view the complaint only if the data is stored on the blockchain and take ap-
propriate action on it. The complainant will be kept informed of all actions taken in
response to the complaint.
Quick and effective complaint resolution is a critical civic right that every citizen
expects from their government. In a typical physical complaint management system,
people must physically visit the organization to file a complaint. These complaints
are addressed in a committee-based system, which is a really long and tiresome
Table 4.3 Different utilized properties in complaint and grievances management (-

indicates that the required information is missing/not mentioned)
Implementation
Blockchain Consensus
Reference Language & Other Blockchain Platform
Type Algorithm
Platform/framework
Jattan et
Public NextJs, Web3.js - Ethereum
al. [64]
Rahman et Hyperledger aries
Public - -
al. [65] and hyperledger indy
12
process. There are various online complaint management tools accessible. Most
victims are hesitant to submit a complaint through these online platforms due to the
lack of transparency.
In [65], Rahman et al. have presented a blockchain-based platform for creat-
ing an anonymous, transparent, and decentralized environment for complaint and
grievance management. Individuals can use this method to lodge anonymous com-
plaints and communicate with the authorities responsible for resolving their prob-
lems. This platform enables officials to deal with complaints more efficiently. It
makes use of self-sovereign identity and zero-knowledge proof to ensure that users’
identities remain anonymous while lodging complaints, thereby reducing their vul-
nerability to threats. As a storage and sharing mechanism, this platform makes use
of the interplanetary file system, which, like blockchain, is resistant to tampering and
provides additional security.
Summary: To assist future researchers, the essential concepts of existing works
have been outlined in Table 4.2 and 4.3. In contrast to the work of Jattan et al. [64],
the work of Rahman et al. [65] is reliable, efficient, and ensures user anonymity.
Despite the fact that both existing works are built on public blockchain, Jattan et al.
have used ethereum, whilst Rahman et al. have used hyperledger aries and hyper-
ledger indy.
4.6 Health Insurance Claim Management using Blockchain

Technology
In the context of health insurance, a claim is any application filed for benefits from
the health insurer organization. The client must file a claim so that funds for his or
her care can be reimbursed. The health insurance provider must process the claim
request in order to manage claims. This means that the insurer must investigate the
claim request’s authenticity, rationale, and information. There are various stages
involved in the processing and management of claims. This process begins with
registering the customer, continues with policy issuance, ensures the customer’s au-
thenticity by verifying medical certificates [66], keeps customer data confidential,
detects false and anomalous claims, and reduces overall management costs [67]. If
everything is in order, the health insurance provider reimburses the client’s health
care provider.
However, the major challenges in claims management include time manage-
ment, reliance on human supervision, a lack of visibility, and security. Because
most management systems rely on human supervision, the claim management and
insurance issuance processes are prone to errors. The data collection and process-
ing procedure is entirely dependent on humans, making it prone to inaccuracy [5].
Also, a major constraint with this entire process is the lack of data visibility and
availability and security. Consequently, obtaining health insurance and managing
claims becomes a laborious and time-consuming process for both the insurer and
the insurance provider [67, 5]. Another significant issue in insurance claims is that
the insurance process is occasionally hampered by service manipulation and mis-
use by policyholders and providers seeking a higher payment for an insured incident
13
Table 4.4 Key findings in claim management

+ Eliminates the need for agents
+ Enables direct contract between
Proposed a BC-based system that stream-
Sawalka et entities - Enhancement
lines and simplifies the insurance claim
al. [31] + Secure and efficient access to - Benchmarking
process.
medical data
+ Reliable and safe
- Applicability
Developed a BC-based solution to aid
Thenmozhi + Secure and reliable - Scalability
insurance firms in establishing a tempering-
et al. [67] + Network latency - Security
free secure network.
- Benchmarking
A layer-based model is built and the three + Transaction durability
Mendoza-Tello - Feasibility
usage scenarios are presented based on the + Trust
et al. [5] - Benchmarking
characteristics provided by BC. + Reliable and safe
[5]. Because of these concerns, it has become difficult to ensure the integrity and
legitimacy of the claim request information [67, 5].
With this concern growing in health insurance claims, there is various research
work that has focused on building tempering-free claim architectures. Thenmozhi
et al. [67] have proposed their architecture based on a major objective: develop a
blockchain-based health insurance claim processing system that will assist insurance
companies in establishing a secure, tamper-resistant network. The proposed system
consists of three modules, including:
1. Registration: When a person joins the organization by paying the annual pre-
mium, the system calculates the required premium. A hospital joins every year
and its stay or drop depends upon the voting system. It can enter its offers into
the system. Patients can browse offers and choose treatments.
2. Treatment: A person chooses a hospital and an offer from the organization’s
interface (web). The hospital records the person’s treatment in the system. The
system stores the record.
3. Claim: Payment is made in the hospital following treatment. Due to the fact that
the record is still open and not closed, the organization calculates the payable
amounts. The patient can access his or her personal information, payment his-
tory, and payable balance via the user web portal.
Authors from [5] have highlighted the characteristics of blockchain technology that
are used for issuing health insurance contracts and claims, including automation,
authentication [68], transparency, immutability and decentralization. A layer model
is defined based on these characteristics to abstract the functionality of the schema
components, namely peer-to-peer mining, blockchain, smart contract and user. As a
result, the studies have noted three use cases: the issuance of an insurance contract
(policy), payment of an insurance premium, and claim management.
Transparency at all levels is absolutely critical to health insurance and more
specifically, the health sector. In [31], Sawalka et al. have proposed a blockchain-
based claim model to ensure transparency between insurance companies, obviating
the need for agents and enabling direct contact between insurance companies and
hospitals. EthInsurance, the proposed framework, enables efficient and secure access
14
Table 4.5 Different utilized properties in claim management (- indicates that the
required information is missing/not mentioned)
Implementation
Blockchain Consensus
Reference Language & Other Blockchain Platform
Type Algorithm
Platform/framework
Sawalka et
Public Ganache platform - Ethereum
al. [31]
Thenmozhi Ethereum,
- Express proof of work
et al. [67] hyperledger fabric
Mendoza-Tello
- - - -
et al. [5]
to medical data by patients, providers and other third parties while safeguarding
patient privacy.
EthInsurance consists of three modules i.e. the patient, the hospital and the
insurance company. The blockchain is intrinsically linked to the patient and it deter-
mines who is granted access. Three contracts, namely consensus, permission, and
service, are in charge of all blockchain activity. Experiment results show that EthIn-
surance is reliable and safe. Utilization of blockchain technology lowers the cost
of decentralization. It validates and authorizes data before it is transmitted over the
network, minimizing the possibility of unauthorized use of records. Furthermore,
each patient has a unique ethureum address and identifier. The authors have used
distinct contracts to convey a sense of modularity, which benefits the framework’s
data security.
Summary: An overview of the key contributions, benefits and numerous uti-
lized components of the most significant works is provided in Table 4.4 and 4.5. All
existing mechanisms are secure, reliable, and reliable. By facilitating direct con-
tracts between entities, Sawlka et al. [31] have eliminated the necessity for agents.
Mendoza-Tello et al. [5] have, on the contrary, increased transaction durability. Au-
thors from [67] have reduced network latency in order to construct a safe, tamper-free
network.
4.7 Health Insurance Bill Management using Blockchain

Technology
Billing is the procedure by which a third party, typically insurance companies, re-
imburses a patient for treatment delivered by any healthcare provider. This entire
process is referred to as the billing cycle or revenue cycle management, and it incor-
porates the management of claims, payment, and billing [69].
Claims and billing are core aspects of the health insurance system and are closely
intertwined. The whole process starts with the doctor visiting the patient and assign-
ing diagnosis and procedure codes, which are then used by the insurer in order to
define the coverage and medical necessity of the services [70]. The patient files a
claim with the insurance company, and the insurance company verifies the corre-
15
Table 4.6 Key findings in billing management

A consumer metering and billing system + Scalable energy efficient
Ahmet et is presented that uses BC technology + Less vulnerability to cyber - Security
al. [73] and IoT devices to address scalability, attacks - Privacy
trust, and privacy concerns. + Privacy
+ Eliminates the need for agents
+ enables direct contract between
Sawalka Proposed a BC-based system that streamlines - Enhancement
entities
et al. [31] and simplifies the insurance claim process. - Benchmarking
+ Secure and efficient acess to
medical data, reliable and safe
lation between the services provided by the healthcare provider and the percentage
they must pay. Depending on the outcome, the insurance pays the amount to the
healthcare provider on the patient’s behalf [71]. The insurer must verify if there is
any relevance between the service provided by the healthcare provider, the necessity
of those medical treatments and the amount of finances demanded in the claim. The
reason behind this procedure is that there can be fraud cases which can be executed
by the healthcare provider for higher benefits or even the patient themselves. Cus-
tomers can deceive insurers by claiming for services that were never delivered, for
unneeded medications, for repeated claims, or even for fraudulent insurance cards.
Similarly, healthcare professionals may charge a fee for any service or treatment
that was not provided, or for providing medically excessive and unneeded services
[72]. As a result, billing management is a crucial part of the insurance system for the
seamless operation of the whole process. For a long time, health insurance compa-
nies managed their whole billing system using pen and paper. Currently, the majority
of companies manage claims and billing through the use of digital technologies.
To the best of our knowledge, billing management in health insurance has not
been addressed separately over the years. Instead of that, research communities
focused on this aspect during fraud and claim management activities. As a result,
additional domains have been searched in which researchers have addressed billing
management in order to reduce fraudulent activity and streamline the claim process.
Authors from [73] have proposed a blockchain-based approach that uses Inter-
net of things (IoT) devices for the metering and billing of customer for the electric
network. The proposed mechanism aims to solve both rust and privacy issues. They
Table 4.7 Different utilized properties in billing management (- indicates that the
required information is missing/not mentioned)
Implementation
Blockchain
Reference Language & Other Consensus algorithm Blockchain Platform
Type
Platform/framework
Ahmet
Private Javascript Proof of concept Hyperledger fabric
et al. [73]
Sawalka
Public Ganache platform - Ethereum
et al. [31]
16
used raspberry pi to simulate metering and hyperledger fabric, with its decentral-
ized structure, to provide transparent and safer solutions. Experimental results show
the proposed system is less vulnerable to cyber attacks as a consequence of using
blockchain. In addition, by implementing smart contracts and automating all energy
tracking procedures, the rate of wrong manual measurements will be reduced.
Sawalka et al. [31] have aimed to make the insurance process more seamless
and less time-consuming. They use insurance as a mode of payment at the hospital.
The hospital directly requests a claim from the company, and the insurance company
responds with a claim record after checking details in the patient’s records. This
system reduces the patient’s workload while also keeping the process transparent.
This paper’s details have been skipped because they have already been discussed in
Section 4.6.
Summary: Table 4.6 and 4.7 provide a summary of the findings of the reviewed
papers, which might help researchers gain a rapid understanding of what previous
researchers have accomplished. Both the mechanisms from Ahmed et al. [73] and
Sawalka et al. [31] have given secure and efficient data access, hence reducing the
exposure to cyber threats. In addition to the comparison, Ahmed et al. have em-
ployed hyperledger fabric, while Sawalka et al. have employed ethereum. As part
of the implementation, Ahmed et al. utilized javascript for their private blockchain,
whereas Sawalka et al. leveraged the ganache platform for their public blockchain.
4.8 Fraud Detection and Risk Prevention in Health Insurance

using Blockchain Technology
Fraud is the intentional deception or manipulation of information by an individual
or organization in order to obtain a financial or personal advantage [74]. Healthcare
is a prime target for adversaries to attack and profit from. Among these attacks,
healthcare insurance fraud has been a significant source of burden on the healthcare
industry in recent years. It has attracted the attention of the government and health
insurance companies due to the significant losses it causes them [75]. Faking infor-
mation, hiding third-party liability, and falsifying electronic bills are all examples of
common health insurance fraud. These types of instances can be incredibly harmful
to an authentic customer, both physically and financially [30].
The traditional health-care system is built on trust. The patient who provides
the insurance card is trusted by the health insurance provider. The service providers,
understandably, believe that the patient did not falsify the insurance card. In the
event of doubt, they have to go to the insurance company physically. Furthermore,
employees cannot be trusted because fraud can occur from within the insurance or-
ganization. As a result, the old system cannot be trusted as a system, which leads
us back to the issue of trust [75]. The issues of privacy and security are inextrica-
bly linked to this trust issue. People are always concerned about their security and
privacy before they are concerned about anything else. They will never trust any
organization if their security is not ensured. As a result, people’s trust in the health-
care system is deteriorating. Also, it is very frustrating considering the time, effort
and money wasted on the paperwork of the whole manual process [75]. Calculations
17
indicate that American insurance firms waste up to $375 billion per year as a result
of the paperwork and administrative box-ticking [76].
Another significant issue with the current health insurance sector is that the
claims are submitted manually to the insurance providers. As a result, if there are
potential fraud cases, they often go unnoticed. Furthermore, the manual process of-
ten includes private individuals whose responsibilities include detecting fraud and
abusive instances and proving them to the government or other regulatory author-
ity. If they achieve their goal, they are financially rewarded, which motivates them
to perform their duties more sincerely [77]. Still, the manual system is prone to
errors. Many fraud instances go undetected owing to a lack of appropriate proof,
resulting in massive economic loss [74]. Additionally, the current manpower and re-
sources available for healthcare insurance are insufficient to prevent these fraudulent
instances [30]. Furthermore, policyholders and medical service providers sometimes
take advantage of a customer’s health insurance benefits through falsification and ser-
vice abuse to obtain additional funds [19]. In Fig. 4.2, different aspects of fraudulent
incidents in healthcare insurance have been illustrated.
Pinging System
Provider refers patient for
unnecessary laboratory
tests, medications and
pharmacy.
Commission-based
Waiving Copayments 1. Provider refers a patient.
2. Pharmacist provides
Routinely waiving patients specific brand of medicine.
copayments1 and 01 3. Company provides
overbilling the healthcare incentives to doctors to
insurance provider. promote unapproved or
02
off-label drugs.
07
Managed Care Healthcare Self-referral

Frauds
03
Doctor refers patients to

06
Managed care
clinic, hospitals with which
organizations2 creates
the referring doctor has a
Denial of service,
financial relationship.
substandard care and
creation of administrative 05
obstacles for patients. 04
Billing Manipulation
1. Doctor Manipulates diagnosis Doctor Shopping
in the claims without patients
knowledge. An Addictive patient is visiting
2. Providers provides unwanted multiple healthcare providers
care to increase bills. to buy unprescribed medical
3. Unlicensed care providers drugs.
provide billing to patients.
Figure 4.2: Different aspects of health insurance fraud (inspired by [74])

1 Patients
pay fixed amount to providers as defined by healthcare insurance policy.
2 An entity that connects the healthcare insurance providers and the insurers
(patients)
Taking various forms of healthcare insurance fraud in mind, Liu et al. [30] have
proposed a blockchain-based anti-fraud system for healthcare insurance that consists
of a cloud platform, a network layer, a core layer, an interface layer, and an appli-
cation layer. The main objective of this system is to verify the patient’s medical
reimbursement request and ensure it complies with the policy’s provisions. The pro-
posed architecture includes three blockchain services to address three types of fraud,
namely medical process information inspection, third-party responsibility inspec-
18
Table 4.8 Key findings in fraud detection and risk prevention

+ Secured
Proposed a healthcare insurance anti-fraud
+ Protects privacy of three-chain
Liu et system based on BC and cloud computing - Enhancement
data
al. [30] that reduces the need of resources and man- - Benchmarking
+ Supports better system
power and provides various medical services.
performance
Proposed and implemented a novel framework + Usability and efficiency - Applicability
Alhasan
and consensus algorithm to eliminate fraud in + Effective in terms of security - Scalability
et al. [75]
the health insurance industry. + Privacy and speed - Benchmarking
Presented a taxonomy of healthcare insurance
+ Performance enhancement
Ismail et claim frauds and proposed and evaluated a - Simulation
in terms of execution time and
al. [74] BC-based healthcare insurance claims fraud - Feasibility
the amount of data transferred
detection framework.
tion, healthcare insurance bill inspection. From the experiment results, the authors
have shown that the proposed system is tailored to business needs and is based on
resolving current real-world problems. It does not require any modifications to the
existing information system. Additionally, the architecture is used to call services
between systems, decouple systems, and internal modules are also a loosely coupled
architecture of building blocks that can adapt to changing business requirements.
The capability of solving anti-fraud issues, such as fraudulent data, concealing third-
party liability accident fraud, false electronic bill reimbursement and other issues has
made the architecture suitable for the current trend of medical information.
In [75], Alhasan et al. have highlighted the trust between patients and service
providers, which leads to counterfeit (fraud) in the health insurance industry. Gov-
ernments are spending countless amounts of money and time to stop this dilemma.
To prevent this, authors have discussed recent articles that looked into various health
insurance systems based on blockchain technology and hence proposed a new frame-
work and consensus algorithm to ensure the security and decentralization of a dis-
tributed ledger. The proposed BC-based framework is composed of five major com-
ponents: the insurance company, the patient, treatment providers (hospitals, medical
centers, and pharmacies), the ministry of health (MOH), and the blockchain network.
The proposed system is evaluated in terms of validation time, upload time, time
required to append blocks to the chain, data integrity verification, and data privacy.
Table 4.9 Different utilized properties in fraud detection and risk prevention (-
Implementation
Blockchain
Reference Language & Other Consensus Algorithm Blockchain Platform
Type
Platform/framework
Liu et
Private - - Hyperledger fabric
al. [30]
Alhasan
Consortium C# Self proposed -
et al. [75]
Ismail
Private - PBFT -
et al. [74]
19
Experiment results demonstrate the system’s robustness and effectiveness in terms

of performance, security, and privacy. The advantages are highlighted below.
• The use of blockchain in storing health information can be effectively secured
by having data over multiple machines which are supervised and authorized by
a distributed community in preference to a centralized approach.
• This method provides a way for everyone in the party to view and verify the
data that is added and modified.
• Moreover, there is a record of each transaction and modification made within
the network.
• The performance of middleware to parse and transform medical health data is
fast and there is not much observable delay to loading that processed data into
blockchain.
Additionally, the proposed consensus algorithm reinforces the distributed concept by
selecting randomly based on two rules: FIFO and length results, implying that the
system is completely distributed.
Each year, the healthcare industry in the United States loses tens of billions of
dollars to fraud. Certain types of fraud put the patient’s health at risk. This drives
Ismail et al. [74] to develop a system capable of detecting and preventing fraud
based on twelve different fraud scenarios. Because of the peer-to-peer distributed
nature of blockchain, they have proposed Block-Hi, a blockchain-based health insur-
ance fraud-detection system. Furthermore, they have created a taxonomy of health
insurance fraud based on various fraud scenarios as well as relationships between
insurance claim contents, associated fraud categories, and corresponding validators.
The authors have investigated the performance of their system in terms of ex-
ecution time and data transfer amount when the number of claims and the number
of healthcare insurance company branches increased. When the number of health
insurance branches increases, the performance of Block-HI in terms of execution
time and data transferred degrades by only 0.69% on average. While the number of
claims have increased, performance declined by 33.51%. This is due to the consen-
sus protocol’s execution.
Summary: To conclude this section, Table 4.8 and 4.9 highlight the findings on
fraud management using blockchain technology. In addition to providing a blockchain-
based solution, Ismail et al. [74] have presented a potential taxonomy of fraud at-
tacks in the healthcare insurance industry. The authors have included PBFT into their
private blockchain. On the other hand, Liu et al. [30] facilitate enhanced system per-
formance. The architecture of Alhasan et al. [75] has improved transaction speed
and usability. They have introduced a new consensus method for their consortium
blockchain.
4.9 Health Insurance Data Record and Sharing Management

using Blockchain Technology
Patient health data is one of the most powerful weapons in the health insurance sec-
tor. As a result of technology breakthroughs such as the invention of the IoT and
20
Table 4.10 Key findings in data record and sharing management (- indicates that
the required information is not found)

Proposed a system which is capable of excha-
Lokhande + Highly ascendable
nging health data by using permissioned bloc- - Benchmarking
et al. [79] + Trusted and liable
kchain to ensure security and concealment.
Presented a novel framework that uses a smart + Protect data from potential
contract to implement an access control threats
Iman et
system for sharing the financial premiums of + Authorized access within less -
al. [80]
insureds with stakeholder as non-participants/ time
authorized parties. + Off-chain db
Proposed a sharing framework which deals with
+ Interoperability
Lee et reliability and interoperability issues by utiliz- - Emphasize on
+ Identity
al. [82] ing the data integrity and consortium BC key factors
+ On/Off-chain
network.
wearable devices, healthcare data is exploding [78]. This data can provide useful
insights to the health insurance company, which can subsequently use it for a variety
of purposes, including policy customization and claim management [79, 80]. Health
insurance companies can use IoT devices to collect data in real-time and build pre-
cise and customized policies based on individual lifestyles [81, 80]. As a result, it
might be said that a secure data sharing infrastructure is required for sharing health
data with a healthcare insurance provider in order for the consumer to obtain the full
benefits of health insurance.
However, there are several obstacles, such as data privacy, security, and inter-
operability, that can have a significant impact on the entire data sharing architecture
[81, 82]. To begin with, there is concern about client data privacy and security,
as health data is extremely sensitive by nature and contains personally identifiable
information [83]. If this data is compromised, serious financial and physical conse-
quences may occur. As a result, the current data sharing architectures pose a reliabil-
ity concern [82, 81]. Second, effective data integration and interoperability amongst
healthcare systems remain a major challenge [82, 81]. Another challenge is that cus-
tomers have little control over their private health data [84]. All of these obstacles
necessitate the development of a secure and private infrastructure for data sharing so
that data can be shared with proper access control and privacy.
To address the inefficiency and time-consuming nature of the current system,
Lokhande et al. [79] have devised a new method of sharing health data that makes
use of permissioned blockchain technology to safeguard the data and conceal it from
those who do not wish to see it. Additionally, authors have utilized the participation
service, which is provided by blockchain to assist with distinctiveness management.
Their designed mobile healthcare system can collect, distribute and collaborate on
individual health data between entities and insurance companies.
The authors of [80] have proposed a method for sharing personal data while
maintaining privacy and security through the use of blockchain technology. The pro-
posed novel framework integrates health insurers, IoT-based networks, and blockchain
technology to implement an access control protocol based on a smart contract for
sharing insureds’ financial premiums with stakeholders acting as non-participants or
21
Table 4.11 Different utilized properties in data record and sharing management (-
Implementation
Blockchain
Reference Language & Other Consensus Algorithm Blockchain Platform
Type
Platform/framework
Top score, Proof of
Lokhande
Private - veracity and authen- hyperledger fabric
et al. [79]
tication
Iman HTML, CSS, JS,
Private PBFT -
et al. [80] ASP.net, C#
Lee
Consortium XDS, FHIR - -
et al. [82]
authorized parties. In comparison to traditional data-sharing systems, the proposal

evaluation results in authorized access in less time. The proposed method, according
to the security analysis, ensures transaction integrity via SHA-256, user authenticity
via asymmetric encryption, non-repudiation, avoids single point failure, and privacy.
As the volume of healthcare data increases, issues with unstandardized data for-
mats and provenance become more vulnerable. Lee et al. [82] have proposed a
standards-based sharing framework, SHAREChain, which incorporates two features
to deal with reliability and interoperability issues. These are:
1. It enhances reliability by leveraging the data integrity of a blockchain registry
and establishing a consortium blockchain network to exchange data between
authenticated institutions.
2. The second feature enhances interoperability with standards relating to health-
care data sharing. To ensure data interoperability, the authors have used FHIR
as well as XDSs actor and transaction concepts in the system architecture.
Summary: Table 4.10 and 4.11 provide a comprehensive summary of the over-
all elaboration of this aspect. Compared to prior publications, [79, 80] authors have
provided trustworthy and reliable techniques. The mechanism from Iman et al. [80]
only supports off-chain databases, but the mechanism from Lee et al. [82] supports
both on-chain and off-chain databases. Iman et al.’s technique requires less time due
to their usage of PBFT as their private blockchain’s consensus algorithm. Lokhande
et al. have worked with private blockchains as well, but their consensus techniques
are top score, proof of veracity, and authentication. SHAREChain, the consortium
blockchain technology proposed by Lee et al., is implemented using XDS and FHIR.
4.10 Limitations and Future Directions
Blockchain technology has the potential to revolutionize the health insurance sector
by resolving complex issues such as claim management, fraud detection etc. Re-
searchers are recognizing the benefits of integrating blockchain in resolving these
challenges of the health insurance sector. Numerous notable research projects have
already been suggested and have been demonstrated to be successful in fixing the
22
challenges for which they were established. However, many systems have one or
more drawbacks that must be addressed, and additional research must be conducted
to solve these limitations.
4.10.1 Limitations
In this subsection, an attempt has been made to highlight the key drawbacks of the
reviewed literature in this area. A demonstration of the limitations of the existing
literature is given in Table 4.12.
• Lack of literature: Blockchain technology is still in its nascent stage. The

adoption of this technology is low in comparison to the number of problems it
can solve. Despite the fact that the health insurance industry has integrated
blockchain in numerous areas, there are still significant areas for which no
blockchain-specific solutions exist. Health insurance billing management and
complaint and grievance management are two sectors where high-quality blockchain-
based solutions are needed. While billing is slightly related to the concept of
claiming, it has a significant impact on its own. Although several writers have
highlighted the billing process in connection with the claim management pro-
cess, relatively little study has been conducted on the blockchain-based health
insurance billing system. In addition, there is no research on the subject of
monitoring and response management, which is highly alarming and should be
addressed immediately.
• Lack of applicability and scalability: As previously noted, researchers can
employ blockchain-based solutions that have already been implemented in other
industries to address health insurance challenges. Nonetheless, this poses two
crucial questions:
– Are these approaches sufficient for addressing health insurance concerns?
– Are these methods capable of handling health data, which contains sensitive
and personally identifying information?
For instance, the authors of [64] have developed a method to control complaints
and grievances between the government and the people. They have incorpo-
rated blockchain, and the use of blockchain has increased the complaint man-
agement system’s security, transparency, and immutability. However, they have
not provided evidence of the scalability or adaptability of their system, making it
extremely difficult to implement the recommended strategy in the health insur-
ance industry or any other sector. In addition, the authors from [67] have failed
to clarify the adaptability and performance comparison of their systems, which
are critical needs for any insurance firm seeking to use their proposed architec-
ture in a real-world scenario. Alhasan et al. [75] have proposed an excellent
method for resolving health insurance fraud events, but they have not described
the scalability of their method.
Before even considering integrating an existing solution from another indus-
try into the health insurance system, the above two concerns must be answered.
Consequently, there is insufficient study to fully comprehend the applicability
and scalability of existing solutions in the health insurance industry.
23
• Lack of Simulation and benchmarking: Simulation and benchmarking play

a crucial part in the success of any scientific study. Most research papers that
use blockchain technology to solve problems with health insurance do not have
quality benchmarking.
The authors of [65] offer a significant method for managing complaints and
grievances using blockchain technology. However, the authors have not pro-
vided a simulation of their proposed system, which is necessary if this strategy
is to be successfully integrated into the health insurance system. Similarly, Al-
hasan et al. [75] have offered a practical and effective strategy for addressing
the fraudulent concerns that occur in the health insurance market, but they have
not presented any benchmarks to evaluate their work. The same restrictions ap-
ply to Ismail et al. [74], who have not compared the energy consumption and
performance of different consensus procedures in Block-HI.
• Lack of feasibility: Researchers have presented a variety of potential solutions
for health insurance-related problems. However, several of them are missing
the feasibility study component. The purpose of a feasibility study is to deter-
mine whether the proposed solution to a problem is sufficient. For instance,
the approach presented in [5] can be quite effective in the processing of health
insurance claims. Though the benefits of incorporating blockchain into claim
management are evident, rules cannot be established for every component of
any system, especially for the extremely uncertain fraudulent scenarios in claim
administration. In some instances, a sophisticated medical treatment must be
rigorously validated, which demands a significant deal of experience and ex-
pertise. Similarly, Ismail et al. [74] have presented a solution to the problem
of health insurance fraud. To achieve this, they have divided fraudulent actions
into twelve distinct groups. However, manually identifying activities is quite
difficult due to the possibility of unanticipated challenges.
• Security : System security is a significant consideration while attempting to
resolve health insurance problems. A secure environment is one of the grounds
for implementing blockchain in health insurance. However, while many of the
ideas presented by researchers have the ability to tackle the problems, they also
pose significant security risks. The solution given by [67] for the claim man-
agement aspect creates serious security problems. The problem with this study
is that the database used in the suggested architecture has not been encrypted.
The most promising billing management study discovered is a blockchain-based
billing system [73]m whose concept can be applied into the health insurance
billing situation. However, in order to achieve the best results, it is necessary to
address the proposed solution’s limits first. The authors of this study have de-
ployed rest servers and demonstrated that these can actually accelerate software
development; nevertheless, they have not considered server security in order to
incorporate higher security for identity management.
In addition to security, user privacy is a particularly delicate issue in any
framework that must be addressed prior to using this system for health insur-
ance, as users are highly worried about their health information. The healthcare
and health insurance sectors heavily rely on data. However, the nature of health
24
data is so sensitive since it contains personally identifiable information that ev-

ery individual is exceedingly protective of his or her data. If the system for
data sharing is insufficiently secure, privacy breaches can occur, causing seri-
ous harm to any individual. Therefore, data privacy and system security are key
considerations when offering a solution to health insurance problems.
The authors [65] have presented a way for addressing complaints and con-
cerns in the health insurance business. However, they have neglected to account
for user privacy, a crucial component of any complaint and grievance manage-
ment system. On any online forum for complaint and grievance management, if
the user’s identity is not anonymous, the majority of users do not feel comfort-
able sharing their issues. Similarly, although the authors of[73] have offered a
solid strategy that emphasizes the billing notion of health insurance, they have
not disclosed how they protect their customers’ privacy.
• Lack of accuracy and paperwork: The success rate of a mechanism is pro-
portional to its accuracy. Therefore, any proposed method must strive for the
best level of accuracy possible. Based on their findings, the anti-fraud method
for healthcare insurance presented in [30] is quite reliable. However, the ac-
curacy falls short of expectations. Similarly, EhtInsurance [31] is a potential
method for the handling of health insurance claims that has been shown to be
reliable and secure. However, it lacks sufficient documentation.
• Lack of emphasis on key factors: Prior to implementing a solution, the first
step in attempting to handle a problem in the real world is to identify the major
components that must be addressed. Without it, obtaining maximum achieve-
ment is somewhat unpredictable and difficult. Consequently, the first stage in
fixing a problem is to identify the crucial parts that must be addressed prior to
implementing the solution. However, several of the research have not adhered to
this fundamental guideline, which is a major flaw of their system. ShareChain
[82] presents a data sharing structure that is mainly absent of this characteristic.
Numerous studies have emphasized the need of secure and effective data shar-
ing in the health insurance industry. ShareChain [82] is one of them, and it has
introduced an efficient data-sharing solution to address interoperability and re-
liability issues. Existing works have been compared to the proposed framework
to evaluate their success and limits. The primary issue with this strategy is that
it lacks a patient-centered approach. Due to the fact that the customer or patient
is at the heart of the healthcare or health insurance industry and is the ultimate
owner of their data, the framework should concentrate largely on them. If data
collection fails, it is useless to adopt any data-sharing system, and the insurance
industry suffers huge losses.
4.10.2 Future Directions

In the previous sub section, the limitations of existing blockchain-based health in-
surance management systems have been highlighted. Based on these limitations,
potential future directions have been provided in this subsection.
25
Table 4.12 Limitations founded in reviewed literature ( means limitation exists

and means it does not)
Benchmarking
Emphasize on
Enhancement
Applicability
key factors
Simulation
Scalability
Feasibility
Security
Privacy
Limitations
in
Reference
Sawalka et al. [31]
Thenmozhi et al. [67]
Mendoza-Tello [5]
Mangaonkar [85]
Goyal et al. [86]
Jattan et al. [64]
Rahman et al. [65]
Ahmet et al. [73]
Liu et al. [30]
Alhasan et al. [75]
Ismail et al. [74]
Lokhande et al. [79]
Iman et al. [80]
Lee et al. [82]
• Need for effective solutions: There is a large gap in the use of blockchain
technology to address several areas of health insurance. As indicated in the
preceding section, monitoring and response management are lacking in the lit-
erature and are not being investigated by researchers. The authors of [87] have
provided a monitoring framework that future researchers might use to generate
ideas for health insurance monitoring and response management. Perhaps this
remains an open question that future scholars should explore. However, there
has been a few research on blockchain-based complaint and grievance manage-
ment systems and blockchain-based billing management systems in numerous
areas [88, 89]. Using this work, researchers can attempt to integrate these con-
cepts into the health insurance system by resolving the underlying dependencies.
Compared to the preceding aspect, numerous contributions have been made
to claim management and fraud detection in health insurance. Mentioned are
several potential approaches that could be utilized in the context of health insur-
ance claim management and the detection of fraudulent activity. The authors of
[67] have suggested a blockchain-based strategy for developing a tamper-proof
claims processing system for health insurance claims administration. Detecting
fraud and preventing risks in health insurance is another area where blockchain
has been utilized in multiple research. This chapter looks at the most promising
26
studies from the authors’ point of view to give readers a full understanding of
how fraud happens and how to stop it.
• Solutions’ applicability and scalability: A common behavior among health
insurance researchers is a lack of awareness or motivation to verify the appli-
cability and scalability of their suggested solutions.There are a few excellent
solutions for various aspects of health insurance, such as a complaint redressal
system from [64], an anti-fraud system from company [75], and a claim man-
agement system from company [67], but none of the architectures have under-
went applicability and scalability testing. Future research should be conducted
to demonstrate the efficacy and scalability of their proposed method so that it
can be applied to the detection of fraud in health insurance and other aspects.
Regarding the possibility of incorporating an existing solution from another
sector into the health insurance system, two considerations are outlined in Sec-
tion 1. Therefore, substantial research is necessary to comprehend the applica-
bility and scalability of existing health insurance systems.
• Increasing trend in simulation and becnhmarking: As described in the pre-
ceding section, simulation and benchmarking play a crucial role in assessing
any architecture. If it is unknown whether a newly offered solution will out-
perform current alternatives, then there is no reason to choose the new one over
the old one. This is where simulation and benchmarking come into play, some-
thing the majority of studies have lacked. Consequently, future researchers must
incorporate simulation and benchmarking prior to deeming their solution ben-
eficial. Additionally, case studies should be presented in exceptional circum-
stances, such as a consumer emergency complaint registry.
• Increase feasibility: For the successful integration of a certain solution, it is
essential to ensure that it is feasible. Several of the works that we analyzed
lacked this quality. For instance, Ismail et al. have developed a very success-
ful method for claim management in health insurance, however it fails to meet
some practical situations. As stated previously, authors set up rules for their
component, which is not feasible at all. Setting up rules for every component,
especially in fraudulent activities, is an unstable state. Critical scenarios such
as medical treatment requiring rigorous validation need a lot of expertise and
knowledge. Therefore, additional study must be conducted on the integration
of machine learning algorithms and blockchain smart contracts. This will aid
in the discovery of fraudulent instances and the overall success of the claims
management process.
Likewise, Ismail et al. [74] have manually categorized fraudulent acts into
twelve distinct groups. However, the amount of possible fraudulent actions
remains uncertain. In this regard, substantial research is required so that the
behavior of various fraudulent operations can be incorporated into future frame-
works. Future additions to this proposed system could include an interoperabil-
ity framework for data claims.
• Security: Numerous studies have the potentiality to overcome health insur-
ance management. But their mechanisms raise security concerns which need
utmost consideration. For instance, mechanisms from Thenmozhi et al. [67]
27
have not made use of encrypted databases. By utilizing fine-grained access con-
trol, this concern can be easily accomplished. Ahmet et al. [73] have utilized
restful servers, which have introduced the topic of finding better servers. This
topic needs exhaustive research in order to integrate greater security for identity
management. Additionally, post-quantum cryptography can be investigated and
included into the process as quantum computers become more widespread as
well as a symmetric encryption should be investigated as an alternative.
• Privacy: User privacy is a vital aspect in any complaint and grievance man-
agement system. In their complaint and grievance management system, Rahman
et al. [65] have not considered the user’s privacy. Therefore, the communica-
tion must be made anonymous by utilizing the blockchain’s anonymity feature,
as this makes the communication more trustworthy, faster, and safe. Besides,
Ahmet et al. [73] have made no mention of how their proposed billing sys-
tem would protect their customers’ privacy. Thus, planning to integrate a new
privacy mechanism is a matter of urgency in these cases because health data
is continuous in nature. Privacy techniques such as differential privacy is an
excellent strategy for ensuring users’ data privacy [83].
• Increase accuracy and paperwork: For any proposed method to be effective,
a minimum level of precision and essential documentation are required. An
anti-fraud system proposed by [30] is a very promising solution to the problem
of fraud in the health insurance system, but it lacks a crucial element: accu-
racy. Subsequently, if additional work is done to improve the system’s accuracy,
this proposed model could be nearly unbeatable. In addition, written documen-
tation permits us to monitor the development of any project and reveals how
to enhance the system. Similarly, EhrInsurance [31] is a promising approach
to claim management; however, a major element it lacks is proper amount of
paperwork.
• Emphasize on key factors: The first and most important stage in proposing
a novel solution is to identify the key aspects that must be considered. If this
is not ensured, there is a significant chance that the proposed method will be-
come a useless solution. ShareChain [82] is a really promising piece of work
that focuses on data sharing in the context of health insurance. However, the
most critical issue with this solution is that they have not considered making it
patient-centered, which is the most important requirement from a health insur-
ance standpoint. Therefore, it must be taken into account for the system to be
functional. The authors have also mentioned that they want to put their system in
the real world, which is the ultimate objective of any proposal for a data-sharing
platform.
4.11 Conclusions
The benefits of blockchain technology in the health insurance industry are evident.
With its core qualities of decentralization, persistence, anonymity, and verifiability,
blockchain technology has the potential to influence the existing health insurance
sector. This chapter discusses numerous aspects of health insurance and how they
28
might interact using blockchain technology. This emerging technology has the abil-
ity to minimize the costs associated with a decentralized environment if employed
effectively. Numerous studies have examined insurance claims, fraud detection, and
data sharing among insurance participants while preserving their privacy and secu-
rity. Whereas there is a shortage of literature regarding the proper handling of medi-
cal bills for insurance claims and the management of complaints within the insurance
cycle. Overall, there are very few studies that have explored the various aspects and
challenges of health insurance. In addition, future research ought to concentrate on
implementing the blockchain-based service in a real world environment in order to
assess the practicality and scalability of such a system. Finally, blockchain technol-
ogy has the ability to alleviate health insurance concerns through decentralization
and the elimination of third parties, thereby accelerating the process. Regarding
blockchain, health insurers must be fearless. To utilize the unique characteristics of
blockchain technology, insurer have to have the courage to develop a new security
policy, strengthen the entire process, and contribute to the company’s success.
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EXCELSSIOR EDUCATION SOCIETY’S

K.C. COLLEGE OF ENGINEERING AND

Summer Internship Project Report (20 Font Size = FS)

Under the Guidance of (14 FS)

Name of the Project Guide:

Signature of the Project Guide:

I hereby declare that the project titled “__________________________________”

Signature of the Student:

I cherish the distinct privilege of my honorable guide DR.

(RITESH KUMAR BISHOYI)

CHAPTER TITLE PAGE NO.

5 CONCLUSION AND 60-65

According to the Health Insurance Association of America, health insurance is

A health insurance policy is:

1. A contract between an insurance provider (e.g. an insurance company or a

The individual insured person's obligations may take several forms:

 Premium: The amount the policy-holder or their sponsor (e.g. an employer)

 Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a

 Out-of-pocket maximum: Similar to coverage limits, except that in this case,

 Capitation: An amount paid by an insurer to a health care provider, for

 In-Network Provider: (U.S. term) A health care provider on a list of

 Prior Authorization: A certification or authorization that an insurer provides

 Formulary: the list of drugs that an insurance plan agrees to cover.

 Explanation of Benefits: A document that may be sent by an insurer to a

The private health system is funded by a number of private health insurance

Australian health funds can be either 'for profit'

The private health system in Australia operates on a "community rating" basis,

The Australian government has introduced a number of incentives to encourage

o The Australian government announced in May 2008 that it proposes

 Private Health Insurance Rebate: The government subsidises the

As per the Constitution of Canada, health care is mainly a provincial government

provinces by the amount of the prohibited charges. Collectively, the public

The resulting programme is profession-based: all people working are required to

The government has two responsibilities in this system.

Health insurance in India is a growing segment of India's economy. The Indian

Objectives and expectations :

support requires on the one hand professionalism in technical design, e.g.

financial contributions of ILO. This led to the ratification of many ILO

• Convention No 29: Forced Labour, 1930

• Convention No 87: Freedom of Association and Protection the Right to Organise,

• Convention No 98: Right to Organise and Collective Bargaining, 1949j

• Convention No 100: Equal Remuneration Convention, 1951

• Convention No 105: Abolition of Forced Labour, 1957

• Convention No 111: Discrimination (Employment and Occupation), 1958

• Convention No 138: Minimum Age Convention, 1973

• Convention No 182: Worst Forms of Child Labour, 1999

• Convention No 144: Tripartite Consultation (International Labour Standards),

• Achieving universal access through introducing national health insurance

• Striving for sustainability and solidarity in financing based on good governance

• Supporting an active role of the state in facilitation, promotion and extension of

decentralization, and need-oriented decision-making on benefit packages. Some

• Equality of treatment and equal access to health services

• Solidarity in financing through risk pooling

• Inclusiveness in framing rights

• Overall responsibility of the State

• Transparent and democratic management including a participatory approach of

Meeting overall objectives through addressing socio-political challenges -Meeting

assessments 77 enabling policy framework for a fair and sustainable national

 Health-related aspects of poverty and empowerment- of the poor Large parts

• Equal representation of women and men in new advisory and executing

• Equal representation of female and male advisors on the design of benefit

• Inclusion of families in the coverage of the national health insurance

• Specific provisions to improve women’s access to health services e.g. financial