IMPORTANCE OF HEALTH INSURANCE IN TIMES OF COVID 19

The coronavirus has been declared a pandemic by the

World Health Organisation (WHO) and it is necessary that
Indian citizens protect themselves against this virus
The outbreak was declared a Public Health Emergency of
International Concern on 30 January 2020.
Such is the gravity of the situation that its been
declared as a National Disaster .
 Healthcare expenditure pushes
nearly six crore (60 million)
Indians into poverty each year
in this backdrop the topic chosen
by the organisers has great
relevance.
• Insurance Institute of India is very happy to associate with Pillai
College of Arts ,commerce and science .
• To give a brief about Insurance Institute ,it was established in the year
1955, for the purpose of promoting Insurance Education & Training in
the country.
 The Institute conducts examinations at three levels: Licentiate,
Associateship and Fellowship besides other examinations –
Certificate in Foundations of Casualty Actuarial Science (General
Insurance) and Certificate in Insurance Salesmanship.
 Apart from professional trainings for industry we also
conduct Post Graduate Diploma in Health Insurance and
Marketing Insurance for fresh graduates and professionals
as well.
Its chartered member of the Institute of Global Insurance Education .
There are at present 91 Associated Institutes spread all
over the country. The Sri Lanka Insurance Institute,
The Sri Lanka Insurance Academy and The R.I.C.B.
Insurance Institute, Bhutan are the affiliated Institutes
outside India. 
PSU insurance companies are corporate members
You will be surprised to know that Health insurance has
seen a jump of 35-40 per cent , while life insurance
registered a 20 per cent growth during this period.
This has suddenly become the buzz word off
late after the breakout of the pandemic.
• Even those who were blasé about these covers in the
past are now looking to buy a new policy or want to
enhance the sum insured on their existing ones
Let us first understand the concept of health insurance

• Health Insurance’ relates to a type of insurance that essentially covers

your medical expenses.
• Slide 1
A health insurance policy like other policies is a
contract between an insurer and an individual / group
in which the insurer agrees to provide specified health
insurance cover at a particular “premium” subject to
terms and conditions specified in the policy.
Slide 1 =Health Eco space
• Its one of the fastest growing segment.- Slide 2 /Slide 3 /4
• You can see that ….now its at 28%
• Earlier 5 states and now 11 states have crossed the 1000 crs premium
With about 34 General insurance companies out
of which 32 are underwriting health insurance and
7 of which are stand alone health insurance
companies to cater to this growing segment.
• We have 24 Life insurance also doing health insurance business but
till date it has been mostly about benefit plans and that is about to
change soon.
Slide 2 -2018-2019 GDPI Classwise split

GI Council yearbook
Slide 3

GI Council year book

Slide 4 GDPI –Health and Accident
Why has health Insurance become important
• More out of pocket spend Slide 5/ 6
• Demography - more longevity/more
morbidity/less mortality
Changing Lifestyles
Increase in Non communicable diseases
- slide 7
.
Rising incomes –increase in middle class
The rising use of smartphones is leading to a burst
of IT-related investments around the digitization
of health insurance.
These experiments range from initiatives
to expand telehealth models, to diseases
specific microinsurance plans, to new
smartphone-based apps that engage and
monitor patient behaviors
Slide 5
Slide 6
Slide 7
The main elements of any Health Insurance contract depend on
proposal form and the policy document issued based on the
declaration given in the proposal form so please remember any false
information of misstatement will lead to claim being treated as void.
• Health Insurance products from General & Life Insurance Companies.
• Individual - senior citizens
• Group health insurance
• Family floater insurance
• Critical Illness Products
• Clan
• Wellness Products
• Personal Accident products.
• Travel (Overseas & Domestic) Insurance products.
• A Health Insurance Policy would normally cover expenses reasonably
and necessarily incurred under the following heads in respect of each
insured person subject to overall ceiling of sum insured (for all claims
during one policy period).
Room, Boarding expenses
Nursing expenses
Fees of surgeon, anesthetist,
physician, consultants, specialists
Anesthesia, blood, oxygen, operation theatre charges, surgical
appliances, medicines, drugs, diagnostic materials, X-ray,
Dialysis, chemotherapy, Radio therapy, cost of pace maker,
Artificial limbs, cost or organs and similar expenses.
Let us understand some common terms and what they mean

• All the features that you get under your chosen health insurance
plan will be applicable to COVID-19 treatment.
• 24 hours hospitalization
• Sub limits
Pre existing disease-cataract/hernia/knee
/ Pre hospitalization expenses// Post
hospitalization expenses
Co pay/ Deductible / Network hospitals TPA
/Restoration of SI/Free Look period /
Migration Multiple policies
Cashless / Reimbursement
•Proportionate deduction: if the rent of the room taken by the insured exceeds the
rent covered in the policy, then the hospital bill is not reimbursed fully. The insurer
subjects the bill to 'proportionate deduction'.
•The proposed changes will benefit those policyholders who have sub-limits in their
health insurance policies. Majority of health insurance policies have sub-limits
associated medical expenses will be clearly defined if the deduction is to be
proposed but will not include :
•which include the cost of medicines,
•cost of implants and medical devices, and
•cost of diagnostics
•are not allowed to be part of the proportionate deduction;
•proportionate deduction would be applied only in case of a hospital that follows
differential billing practice based on the room category occupied by a patient.
Items not to excluded

• According to IRDAI, these conditions can no

longer be excluded from health insurance
policies: genetic disorders, mental health
procedures, artificial life maintenance, internal
congenital diseases, age-related muscular
degeneration, and mental illnesses.
insurers may offer cover either as
part of a basic cover or as an add-on,
optional or otherwise under a health
insurance policy
consumables, non-medical items including toiletries,
cosmetics, convenience items, apart from certain
elements of room charges, administrative charges, cost
of external durable devices
• Does a regular health Insurance policy cover CORONA
• Yes it does
• Let us take an example of a product
1) Arogya Sanjeevani policy – standard cover as per GOI directives –
cover for 1- 5 lakhs
2) Same cover as in hospital indemnity policy
3) Capping on room rent-maximum 5000/day and ICU charges upto Rs
10,000 /day
4) No deductibles are allowed
5) Cumulative bonus 5% of SI maximum 50%- Will reduce at same rate
as accrued
• Can be offered as family floater / Indemnity basis – no add ons/
Can pay in instalment/ age cover is from 18 to 65
• Life long renewability/ Fixed co pay across all ages
• Cataract sub limit/ PED - 24 months waiting period
• Has a free look period
• Single premium across India
Government Interventions
• IRDA has notified all insurers to cover Covid-19
for existing policies, aimed at easing matters for
customers. Subject to 30 days waiting period
( fresh policies only ) and exclusions - COVID will
be covered,
Government guidelines requiring
companies to provide medical insurance
to all workers while restarting operations
as they are coming out of lockdown.
IRDAI permitted companies offering health
insurance to allow customers to pay their
premiums in instalments. “The premium amount
will remain the same irrespective of the mode of
payment
IRDAI- Give pre authorization
within two hours (the same limit
applies at the time of discharge).
• Decision within two hours from the time of
receipt of final bill and last necessary
requirement from the hospital either to the
insurer or to the Third Party Administrator (TPA),
whichever is earlier.

•
IRDAI has also asked insurers to
simplify procedures, which means they
should not ask for too many documents
or conduct time-taking checks.
Most health policies offer a grace period of 30 days for
payment of renewal premium. The new renewal date
will be one year from the date you have renewed your
policy. For instance, if your policy renewal date was
April 15, 2020, and you renew your policy during the
grace period i.e. on May 15, 2020, then the new policy
renewal date will be May 15, 2021.

IRDAI has offered an additional grace period of 30 days, so that customers who use
offline payment modes like cheques are able to pay once the lockdown ends. This is
for Life health insurance policy holders.
IRDAI had also said earlier that COVID-19 cases should be
treated on a priority basis and before any claim for this
ailment is rejected, it should be reviewed by the claims
review committee (a high-level committee) of the insurer.
If a policyholder is not renewed even in the grace period, then the
policy lapses. No Claim Bonus and other benefits would not be included
if the policyholder wishes to renew/buy the policy again after the grace
period.“
can ask the policyholder to undergo the medical test if not renewed on
due date.
Simplify the procedures:
The regulator has also asked insurers to simplify the claims process for
COVID-19 deaths eg “If the claim form states that a death took place
due to COVID-19, no need to ask for additional documents. Claim can
be processed based on just a death certificate or a hospital document,”
Normally, insurers ask for treatment records, and sometimes they
investigate cases
• IRDAI has also asked all general and health
insurers to issue appropriate guidelines to their
respective TPA-n specifies norms on settlement/
rejection of claim by insurers
What are Insurers doing ?
• Our chat bot Cia is helping customers to renew policies, generate
claim status, send policy packs.Also engaging with the customers to
answer basic queries around covid-19 coverage.
Offering ( Go Active)
telemedicine and psychological
counselling
Telemedical check-ups for policy buyers
-would involve vetting of customer
applications and subsequent consultations
by doctors over the telephone.
Health care workers

• New India Assurance offers Rs 50 lakh

insurance coverage for health care providers
• In case of accidental death or death due to
complications arising from accidentally
contracting Covid-19,
tailor made comprehensive personal accident
cover, which includes accidental loss of life
on account of contracting Covid-19, will be
valid for 90 days from March 30.
the coverage will cover 22.12 lakh public healthcare
providers, community healthcare workers and
private healthcare staff who may have to be in direct
contact and care of Covid-19 patients.
COVID -19 Insurance Plans
Non-life insurer Reliance General Insurance COVID-19
protection insurance scheme,
100 percent of the sum-insured in lump sum on positive
diagnosis of coronavirus. the plan offers 50 percent of the
sum-insured during that period quarantined,
policy period of one year
• waiting period is for 15 days before one can
claim.
• For ages 3 months and 60 years, for a sum-
insured option from Rs 25,000 to Rs 2 lakh.
•
Cover for any loss of pay or job
under separate add-ons in
addition to the base policy.
• The plan has an add-on option, ‘Travel
Exclusion Removal’, which offers waiver to
the 45-day travel exclusion policy and
enables the insured to claim 100 percent of
the sum-insured if they test positive
Star Health Insurance Plan
ICICI LOMBARD COVID POLICY
• The company said that amid the contagious pandemic, this policy on
diagnosis of COVID-19 (+ve) will pay 100% of the sum insured
irrespective of hospitalization expenses. The launched insurance
policy is in group insurance mode.
In a lump sum in the event of a first
diagnosis of COVID-19 during the
policy period, subject to an initial
waiting period of 14 days.
The scope of cover shall be within the
geographical boundaries of India and
restricted to Indian nationals only.
priced at a premium of Rs 149 and provides a
sum insured of Rs 25,000 including value
added benefits.
The insurance policy will cover all
individuals across the age group of 18-
75 years.
• The cover also excludes people with travel history to any location
overseas post December 31, 2019 and
if the insured has been quarantined for
suspected COVID-19 or diagnosed with
COVID-19 prior to the risk inception date
or within the initial 14-Day waiting period
Edelweiss General Insurance

its COVID-19 policy cover will be extended to those who are

put in quarantine in specified government facilities up to 100
per cent of the claim
allowing waiver of the initial waiting period of 30 days post
policy inception, for the first time, for COVID-19 virus
coverage."
The coverage amount is up to the
sum insured under the policy.
If, patient is in a remote location and is
unable to reach the hospital during the
quarantine period, it will support
domiciliary hospitalisation for the patient.
The insurer said patients can visit any
nearby hospital for immediate treatment
and expenses will be reimbursed.
CLAIMS

•Till date Rs 15.75 cr approx. COVID -19

health insurance claims haven reported
Many plans do not cover infectious
diseases for the initial 30 days from the
inception of the policy
There are a few health insurance plans
that do not cover against
pandemic/epidemic, so it is better to
check
Positive test report from a Govt
hospital lab or authorized by govt
is required
Contact the TPA for pre auth or
contact details mentioned in
policy
For making the claim process smooth
and hassle-free amid lockdown, most
insurers have ramped up their digital
services-SMS, emails
Insurance companies have established
'Crisis Management Committee' that
ensures all necessary measures are in
place to avoid any impact due to the
present situation on servicing of our
customers
For reimbursement claims :
TPA is to be intimated
Claim documents to be submitted
to TPA or upload scanned
documents on portal or sms
Diagnostic expenses for COVID
–if part of inpatient
hospitalization and following a
line of treatment.
If COVID 19 contracted overseas
– the travel policy will cover
Domiciliary hospitalization if
there in policy is covered as per
sub limit
You have to follow the defined protocol
for testing and will be reimbursed if
followed by hospitalization
Medical expenses for isolation in a
facility/hospital after testing positive is
covered.
Quarantine is covered if associated with treatment
in a registered medical facility as per the terms
and conditions of the Health Insurance Product.
Quarantine just for isolation without any treatment
is not covered
Claim procedure
CLAIM PROCEDURE IN RESPECT OF A COVID

• An Insurer shall settle the claim within 30 days

from the date of receipt of last necessary
document
In the case of delay in the payment of a claim, the
insurer shall be liable to pay interest from the date
of receipt of last necessary document to the date
of payment of claim at a rate 2% above the bank
rate.
complete such investigation at the
earliest, in any case not later than 30 days
from the date of receipt of last necessary
document. In such cases, Insurer shall
settle the claim within 45 days from the
date of receipt of last necessary document
If you Purchase a new health Policy
• If you are going for a planned treatment
• Over the past four weeks, if you have been suffering from any
respiratory-related disease, then your claims under a regular
indemnity type health insurance policy or a specific coronavirus
insurance policy might not get settled.
• If you contract the disease within the policy waiting period
• The insured will not get claim filed for treatment of a disease within
the policy waiting period of a health insurance policy if the disease
treatment is excluded within the waiting period
 If you get infected
• After Irdai’s circular, insurers are mandated to cover hospitalization as
well as quarantine expenses if you test positive. “Insurance
companies will pay admissible medical expenses even during
quarantine. This does not require a separate out-patient (OPD) cover
• "However, if you already have coronavirus
disease/infection and you are thinking of buying
a health insurance policy and want to get the
claims settled then probably your claims will not
get paid under the newly bought regular health
insurance or coronavirus insurance policy,"
If you have a Standard Health Cover

• the insurer will cover for a patient’s

hospitalization expenses including surgical
procedures, room rent and ambulance costs –
however a minimum of 24 hours of
hospitalization is required and it is subject to
terms and conditions of policy.
Admissibility criteria will be defined by
medical management protocols for
treatment, evaluation and quarantine
suggested by Government along with the
terms and conditions of the Health
Insurance Product
Quarantine is covered if you are being treated in a
registered medical facility as per the terms and
conditions of the Health Insurance Product. Quarantine
just for isolation without any treatment is not covered
Everything from pre-hospitalization
expenses to post-hospitalization
expenses incurred for diagnostic and
consultation etc gets covered.
COVID 19 product
• Only Corona related
• Lumpsum Benefit
• No medical screening
• All family members are covered but SI and
premium is per member
• 15 days waiting period or less-diagnosed with
the coronavirus disease/infection within this
waiting period, your policy will not cover
• May cover loss of pay as add on- be a good
supplement to your existing health plan
• Can get benefit on being tested positive-
upfront payment
• May have exclusion of travel
history/contact/flu
• Can go to nearby hospitals in emergency
Regular health plan
• Wide range of diseases
• Indemnity based
• Medical screening beyond a certain age
• Family cover is for overall SI and Premium is
discounted
• 30 day waiting period –so if already suffering
from respiratory issues…then no claim
• No such cover for loss of Income
• Pre and post hospitalization expenses are
covered.
• Need to be hospitalised for at least 24 hours
if suffering from corona.
• No exclusion for travel history
• Preferable in Network hospital
• Will the expenses towards COVID-19 vaccination be covered in case
such vaccine is manufactured?
• The expenses towards vaccination will be covered in case the policy
has Outpatient Treatment Cover.
Are the expenses on medicines and diagnostic
tests incurred during medically advised home
isolation due to COVID-19 covered?
In case your policy has an Outpatient Treatment
Cover, then these expenses will be covered in
accordance with the policy terms and conditions.
Will the policy cover expenses due to quarantine?
In case the quarantine is in a hospital on the advice of a
Medical Practitioner, then the medical expenses incurred
will be covered in accordance with the policy terms and
conditions. However, expenses incurred on account of self-
quarantine or quarantine at home will not be covered.