Professional Documents
Culture Documents
Dr Anshuli Trivedi
I st year PG
Dept of Community Medicine.
Based on lecture by Dr Joseph Kuruvilla.
CMC Vellore. On 3/9/8.
What is Health Insurance?
“It is a contract between insurer & insured
where the latter is covered against health
costs on payment of premium as per terms
& conditions of the issues.”
It is regulated by IRDA-Insurance Regulatory
Development Authority.
Under Ministry of Finance.
Health Plans-Subscription based Medical Care.
Beneficiaries-Self Help groups, factory workers
RMP’s, students, defence personnels & other
sections of society.
C:\Documents and Settings\Administrator\My Documents\HEALTH INSURANCE.htm
Key words in Health Insurance-
Premium- The amount need to pay in policy in order
for insurer to take the risk of health care of the insured.
Contract- Documentary understanding of terms & conditions
between insurer & insured.
Sum Insured-Total amount, a policy assures as insured as a risk
coverage based on premium paid.
Third party Administrator-(TPA)-Agent who takes care of
hospital bills of insured clients as there are very few insurance
companies which deals with hospitals directly.Ex Star Health,Bajaj
Allianz.
As a
contingent
Patient claim
expenditure Insurer payment instrument,
(INR) (from premium health
pool)
Stop-loss
insurance is
level an efficient
Individual way to help
payment
individuals
prepare for
Deductible Co-insured health care
Health care
expenditur
e
(INR)
SOURCE-Russell Parera National Industry Director Financial ServicesDelhi 18 October 2004
The World Health Organization has defined
possible approach to financing of health
expenditure . . . Tax-based and
out-of-pocket
expenses are
Using central / state direct expense
Tax-funded related outlays
revenues for health
Social
Compulsory premium
Public contributions to Health
security
health insurance
Externally Channeling loans, involves a fund
funded grants etc. to pool for future
Total health
expenditure healthcare health care
Out-of- Payments to health
pocket
care providers for
External fund
Private services
Private sources rely on
health ins. Premium contributions
donations,
towards health
Externally grants
support
sourced Channeling donations
etc. to healthcare
SOURCE-Russell Parera National Industry Director Financial Services Delhi18 October 2004
Types of Health Insurance-
1)Fee for Service Health.
2) Managed Care Health Insurance.
Health Care is provided by-
1) HealthMaintenance Organization.
2) Preferred Provided Organization.
Institute - ABCDE……..
Analysis-MOU’S –Memorandum Of Understanding.
Balancing-Terms, condition, Time of settlement of Bills.
Consensus Building.
Drafting/Developing- Final agreement.
Executing.
Empanelment.
Regular Auditing of bills & validity of claims.
Timely payments of claims.
Community based health Insurance-
Ambulatory & Inpatient care.
MODELS
1) Providermodel-Usually NGO, Hospital health insurance for
community around it. Annual payment given to provide-annual
health checkup, discounted OPD & IPD facilities. Ex-Student
Health Homes in Calcutta, VHS Chennai.
2) Insurer Model-Insurer collects money from community &
purchase health service for it. Ex. Spandan in A.P.
3) Linked Model-NGO intermediately between Target population
& insurance company. Ex-SEWA Health Insurance by ICICI-
Lombard for females.
Health Insurance in India-
It is infantile stage.
Limited Coverage (10% of pop.)
Lack of uniform schemes.
Very less amount spent on health as compared to
other countries.(32 $ p.c ,5.3 % GDP.)
Insurance is not attractive due to lot of exclusions in
medical bills.
Lack of uniform CPT & DRG leading to discrepancy in
billing.
Govt. of KA,TN,M.P. are promoting micro insurance.
The proportion of insurance in health care
financing in India is extremely low . . .
Health care financing in India Public spending
in health care
2002, % is very low at
17% and the
100% National
Health Policy
has
83% from 86% from recognized
private out-of- this
sector pocket
spending expenses
More than 86% of
healthcare
financing is
through
unplanned
0% for, non-
Source of finance Means of finance contributory
Source: WHO. CII-McKinsey. 2003. spending
Universal Health Insurance Scheme-
In 2004, MOF, UHIS for BPL families, Premium of Rs200/individual,Rs-
300/5 member family,Rs-400/7 member family.