Technicalities of Health Insurance

ABOUT THE BOOK

(Technicalities of Health Insurance: Underwriting, Actuarial, Reinsurance, TPA and Claims) Author: Dr Harish Sihare and Dr S.D Gupta Format: Paperback Publisher: GLOBAL VISION PUBLISHING HOUSE ISBN: 9789381695166 Edition: 2012 Price INR: 200.00 Health insurance is one of the fastest growing sectors in the Indian insurance industry. A sincere attempt has been made in this book keeping the learners in mind to provide a detailed overview of Indian as well as developed countries health insurance industry. Emphasis has been given on making elaborated explanations to the important topics and several charts, graphs and tables are provided for the better understanding of the subject. This book has been divided into eleven chapters and covers- Introduction to health insurance; health insurance in India; international perspective of health insurance; legal aspects of health insurance; underwriting and actuarial science in health insurance; reinsurance; claims management; third party administrator and the opportunities and challenges in health insurance system of India.

ABOUT AUTHORS
Dr.Harish Sihare Ph.D. in Management, MBA from JIM Lucknow and Post graduate Diploma in insurance and risk management, is presently working as faculty in Institute of Health Management and Research, Jaipur. Prof Sihare possesses a world view of

Underwriting, Actuarial, Reinsurance, TPA and Claims

Technicalities of Health Insurance

interdisciplinary education. His vision of intellectual life is universalistic and integrated, and that is reflected in his prolific writings and numerous speeches and interventions in academic meets. Prof Sihare, has total 10 years of experience with Indias leading Corporate Houses such as HDFC, Bajaj, and ICICI in addition to teaching, training and consultancy in the realm of management with specific focus on healthcare financing, financial management, life and general insurance, micro health insurance and managed care. He has several international publications to his credit in the area of financial management, micro health insurance and managed care and Health Care Financing.

Dr. S.D Gupta, is working as Director, Institute of Health Management and Research, Jaipur. He is a public health professional with a distinguished academic and research career. He obtained his M.D. (Preventive & Social Medicine) from India, and Ph.D. (Epidemiology) from Johns Hopkins University, Baltimore, USA. He was conferred Fellowship of Academy of Medical Science, India (FAMS) on him for his outstanding contribution in the field of public health. He has done pioneering work of creating and establishing new discipline of health management, and promoting research in health policy, health systems and programme management. He is Director of the WHO Collaborating Centre for District Health Systems at IIHMR facilitating management research and interventions in the health systems in order to improve efficiency and effectiveness of health care. Dr. Gupta has served as Temporary Advisor to SEARO WHO on several consultation processes. He is also the Secretary General of WHOs South East Asia Public Health Education Network (SEAPHEIN). His areas of research is public health and epidemiology, population, reproductive health and nutrition, health systems and management in the health sector. Dr. Gupta is the recipient of QIMPRO Gold Standard Award 2009 for Healthcare.

Contents
Preface (v) 1. Introduction to Health Insurance 1 Historical Perspective 1 Going Date-wise 3 Insurance and its Types 5 Health Insurance 6 History of Health Insurance 7 Common Terminologies 10 Review Questions 14

Underwriting, Actuarial, Reinsurance, TPA and Claims

Technicalities of Health Insurance

2. Health Insurance in India 15 Introduction 15 Insurance Markets 15 Insurance Scenario 17 An Overview of Indian Insurance Market 24 International Comparison of Insurance Penetration 32 Health Insurance Distribution Channels 33 Review Questions 35 3. International Perspective of Health Insurance 36 Introduction 36 France 37 The United Kingdom 44 Australia 51 Developing Nations 64 Canada 64 Brazil 71 Key Learnings for India 76 Review Questions 76 4. Legal Aspects of Health Insurance 77 Insurance Contract 77 Insurance Regulatory and Development Authority (IRDA), 1999 82 Consumer Protection Act, 1986 84 Right to Information Act, 2005 85 Insurance Ombudsman 87 Medico Legal Cases 90 Review Questions 94 5. A Historical Perspective of Underwriting and Actuary 95 Historical Perspective 95 Review Questions 98 6. Underwriting in Health Insurance 99 Introduction 99 Types of Underwriting 103 Types of Underwriting Clauses 110 Process of Underwriting 110 Methods of Risk Classification 113 Sources of Information Concerning Health Insurance 114 Issues in Underwriting 116 Review Questions 117 7. Actuarial Science in Health Insurance 118 Introduction 118 Principles Underlying Actuarial Science 120 Actuarys Work 130 IRDA Mandated Roles for the Appointed Actuary 132 A Report on Market Research to Study Untapped Opportunities for Actuaries in Health Care 134 Challenges of an Actuary and Possible Solutions to them 136 Challenges of Underwriting and Actuaries 143 Review Questions 147

Underwriting, Actuarial, Reinsurance, TPA and Claims

Technicalities of Health Insurance

8. Reinsurance 148 Introduction 148 Types 152 Other Types 154 Review Questions 156 9. Claims Management 157 Introduction 157 Claims Management Department 158 Procedure for Filing Health Insurance Claims 159 Procedure for Handling of Claims by the Insurance Company 163 Good Practices in Claims Management 166 10. Third Party Administrator 172 Introduction 172 Current Scenario of TPA in India 175 Experience of TPAs in India 178 Functioning of TPA 180 Process of Empanelment of Hospitals by TPA 181 Regulations and Conditions by IRDA 183 Medical Tourism Benefits for Insurer and TPAs 186 11. Opportunities and Challenges 191 Opportunities in Health Insurance 192 Challenges in Health Insurance 195 Key Challenges in India 200 Conclusion 202 Review Questions 202 Bibliography 203 Index 207

Underwriting, Actuarial, Reinsurance, TPA and Claims