HEALTH INSURANCE.

HEALTH INSURANCE.

Everybody wants to lead a healthy life. However with the changing lifestyle health problems have become very common. So one needs to protect oneself from any such risk that may arise in life. Moreover with the improvement in healthcare and the rising inflation the cost of health care has also increased. So having a health insurance policy has become essential.The termHealth Insuranceis used to describe a form of insurance that pays for medical expenses. It is used more broadly to include insurance that covers disability or long-term nursing or custodial care needs. In simple words, if you are covered under Health Insurance, you pay some amount of premium every year to an insurance company and if you have an accident or if you have to undergo an operation or a surgery, the insurance company will pay for the medical expenses.It takes just one visit to a hospital to make us realize how vulnerable we are.It is a tough ordeal if you are diagnosed with an illness and need to be hospitalized, no matter if you are rich or poor, male or female, young or old. The list of lifestyle diseases like heart problems, diabetes, stroke, renal failure, some cancers just seems to get longer and more common these days. Thankfully there are more specialty hospitals and specialist doctors but all that comes at a cost. The super rich can afford such costs, but what about an average middle class person? For an illness that requires hospitalization / surgery, costs can easily run into 5 figures. A Health Insurance Policy can cover such expenses to a large extent.

1.1 MEANING.

Health insurance is a system for the financing of medical expenses by means of contributions or taxes paid into a common fund to pay for all or part of health services specified in an insurance policy or law. The key elements common to most health insurance plans are advance payment of premiums or taxes, pooling of funds, and eligibility for benefits on the basis of contributions or employment.Health insurance insures you and your family against sudden medical expenses. A Medical emergency can arise due to sudden illness or injury with medical expenses rising, a health insurance policy would help you sail through a bad patch. Your medical expenses will be taken care of by the insurance company provided you pay your premium regularly. The reduction or elimination of the uncertain risk of loss for the individual or household by combining a larger number of similarly exposed individuals or households who are included in a common fund that makes good the loss caused to any one member. Insurance reduces a persons uncertainly concerning the timing and amount of possible future expenses that may be incurred. It relies on the fact what is unpredictable for an individual is highly predictable for a large number of Individuals.Health insurance is obtainable to both individual and groups (e.g. by a firm to cover its employees). In each case the covered groups or individuals pay premiums or taxes to protect themselves from high or unexpected healthcare expenses. However premium for individual policy is costlier than that of the group policy. An individual is the owner of his personal policy. Whereas in group plans the sponsor is the owner of the policy and the registered members are enclosed by the policy. You can take benefit of group health insurance to overcome the shortage of your individual insurance. People with no policy or are uninsurable due to one or the other reason can take good advantage of the group plans and be covered.By estimating the overall risk of healthcare expenses a routine finance structure such as a monthly premium or annual tax can be developed, ensuring that money is available to pay for the healthcare benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business or not-for-profit entity. The person or the insured should pay a regular fee called a premium to the insurance company. In return the insurance company will pay all or some medical expenses wanted when the insured becomes injured, ill, or otherwise hospitalized.New India Assurance Company Limited, stressing on the social security aspect of health insurance, in their written note, stated; Basically the philosophy behind the concept of Health Insurance is to provide protection against uncertainty of illness /accident by spreading the risk based on the principle that what is highly unpredictable for an individual is predictable for a group of individuals. Thus, insurance is a system by which Healthcare expenditure of few unfortunate individuals, who suffer from illness/injury, is shared by many fortunate ones who are insured and exposed to the same risk but remain healthy. The case for health insurance rests on three grounds: a) Illness can not be predicted; b) Financial burden of hospitalization is high and cannot be planned; c) The proportion of people requiring hospitalization due to illness or injury in any large population is small thus enabling risk pooling. Pooling of risks, resources, and benefits is the hall mark of any insurance system.

DEFINITIONWorld health organization defines health as complete physical, mental and social well being and not merely the absence of disease and injury. As per WHO, a countrys Health Systems comprise of all the organizations, institutions and resources that are devoted to produce health actions.

According to ILO, The reduction or elimination of the uncertain risk of loss for the individual or household by combining a larger number of similarly exposed individuals or households who are included in a common fund that makes good the loss caused to any one member.

1.2 EVOLUTION OF HEALTH INSURANCE

The concept of health insurance was proposed in 1964 by Hugh the Elder chamberlen form the Peter Chamberlen family. In the late 19th century, early health insurance was actually disability insurance, in the sense that it covered only the cost of emergency care for injuries that could led to a disability. This payment model continued until the start of the 20th century in some jurisdictions (like California), where all laws regulating health insurance actually referred to disability insurance. Patients were expected to pay all other healthcare costs out of their own packets, under what is known as the fee for-service business model. During the middle to late 20th century, traditional disability insurance evolved into modern health insurance. Over the last 50 years, India has achieved a lot in terms of health insurance. Before independence, the health structure was in dismal condition i.e. high morbidity and high mortality and prevalence of infectious diseases. Since independence, emphasis has been put on primary health care and we made considerable progress in improving the health status of the country. But still, India is way behind many fast developing countries such as China, Vietnam and Sri Lanka in health indicators. Health insurance, which remains highly underdeveloped and less significant segment of the product portfolios, is now emerging as a tool to manage financial needs of people to seek health services. Healthcare in India is in a state of enormous transition: increased income and health consciousness among the majority of the classes, price liberalization, reduction in bureaucracy, and the introduction of private healthcare financing drive the change. The new economic policy and liberalization process followed by Government of India since 1991 paved the way for privatization of insurance sector in the country. The Insurance Regulatory and Development Authority (IRDA) bill, passed in Indian parliament, is the important beginning of changes having significant implications for the health sector. Health Insurance is more complex than other segments of insurance business because of serious conflicts arising out of adverse selection, moral hazard, unavailability of data and information gap problems. Proper understanding of Indian Health situation and application of principles of insurance, keeping in view the social realities and national objectives, are important.In India, Health Insurance is not of recent origin. Concern for loss resulting from accident and illness can be traced to ancient civilizations. In fact, one of the earliest forms of health insurance may have been based on the ancient custom of paying the doctor while in good health and discontinuing payment during periods of illness. This custom existed in South East Asian countries including India. The development of health insurance in existing form in India is based on pattern followed in Europe and America.Health Insurance or medical insurance schemes had developed in India due to industrial relations problems between the employer and the employees. The Corporate Houses used to offer core and non-core benefits to the employees. The insurance policies were granted to large Corporate Houses purely on an accommodation basis. The cover usually offered to the employees was in the nature of hospitalization and domiciliary treatment for dental and non-surgical eye treatment. The benefits used to be for very small amount. There was no scheme for individuals and families. In 1981, the Apex Body of Public Sector Insurance Companies i.e. GIC designed a limited cover for individuals and families for covering their hospitalization needs. This was replaced by a mediclaim policy in the year 1986 under a market agreement to provide insurance benefits to individuals and groups under a group mediclaim policy. The scheme so introduced was modified in 1991 and 1996 in the light of experience and suggestions received from the insuring public and medical fraternity. The benefit provided under the policy was on reimbursement basis on occurrence of a major calamity in the form of accident/sickness to an insured person. The first Mediclaim Insurance Scheme was introduced by GIC in 1986 for people not covered under the above scheme. Prior to 1986, cover against sickness and diseases were provided by extension of Personal Accident Policy.

1.3 TOP HEALTH INSURANCE COMPANIES IN INDIA.

STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED.Star Health and Allied health Insurance Company Limited (Star Health) is a joint venture between Oman healthInsurance Company, ETA Ascon Group and a number of insurance veterans in the country. It is also the first dedicated health insurance company in India. Known for its innovation, Star has some very unique products like Diabetes Safe which is for diabetic patients and Star Net plus which is designed for HIV+ patients.Popular Products: Star Family Health Optima, Senior Citizen Red Carpet MAX BUPA HEALTH INSURANCE.Max Bupa Health Insurance is a joint venture between Max India Limited and Bupa Group, one of the international healthcare providers. Formed in 2010, Max Bupa has brought changes in the health insurance market in India with innovative and customer friendly products. Popular products:Heart Beat Gold, Silver and Platinum.

APOLLO MUNICH.Apollo Munich Health Insurance Co. Ltd. is the new name for Apollo DKV Insurance Co. Ltd. which is a partnership between The Apollo Hospitals Group, and Germany based Munich Res newest business segment, Munich Health. They also bring a change in terms of customer friendly features like lifetime renewal and portability benefits for existing policies which means you can buy Apollos policy and get the continuation benefits of your existing policy. Apollo Munich also covers maternity after a waiting period.Popular Products: Easy Health Gold, Standard, Exclusive and Premium. RELIANCE HEALTH INSURANCE.Reliance health insurance is one of the private general insurance companies in India. They also have a few good health insurance products, in their Health wise policy range; critical illnesses are covered as a part of the policy. There is also a choice of reducing waiting period for pre-existing illnesses to 2 years from the industry standard of 4 years. It covers those between the ages of 5-75.Popular Policy: Health wise Family Floater ICICI LOMBARD.ICICI Lombard GIC Ltd. is the largest private sector general insurance company in India. It has some good health insurance plans - like Health Advantage which covers not only hospitalization expenses but also outpatient expenses like dental, upto a limit. Maternity cover is also available under this product. The company has also added Health insurance Guide, an interactive tool to help the customer select a plan to suit his requirements.Popular Product:Health Advantage.

BAJAJ ALLIANZ GENERAL INSURANCE.Bajaj Allianz General Insurance Company Limited is a joint venture between Bajaj Finserv Limited and Allianz SE. Health insurance policies offered by them include Health Guard (Mediclaim), Silver health (Senior Citizen) and Star package (Family Floater), there are also other plans like Hospital Cash which gives an amount on every day of hospitalization and Critical Illness which gives a lump sum in the event that the insured contracts one of the critical illnesses listed like cancer during the policy period. Bajaj was the first company to come up with a captive TPA with ensuing efficiencies.Popular Product: Health Guard.

HEALTH INSURANCE FROM PUBLIC SECTOR GENERAL INSURANCE COMPANIES ORIENTAL INSURANCEOriental insurance offers a number of health insurance products including Individual mediclaim, Universal health insurance scheme and family floaters to the customers.Their Happy Family floater is a popular product because it doesnt require medical check-up till the age of 60 (it is mandatory for everyone over the age of 45 to take a health check-up in other policies).Popular policy: Happy Family Floater UNITED INDIA INSURANCE.Another of the public sector units, United India health Insurance Company Limited also offers a wide range of health insurance products like Family Medicare- Gold, Platinum, Senior Citizen, Top-up and Super Top-up.Popular Policy:Family Medicare.

NEW INDIA ASSURANCEIt is one of the first Indian owned companies when it was formed in 1919. It offers different health insurance products like Mediclaim policy, senior citizen policy andUniversal health insurance policy.Popular Products:Mediclaim policy NATIONAL INSURANCENationals Varishta Mediclaim is a popular product, it covers everyone from the age from 6-80 with special features for senior citizens.Popular product: Varishta Mediclaim.

1.4 NEED OF HEALTH INSURANCE.'Look to your health; and if you have it, praise God, and value it next to a good conscience; for health is the second blessing that we mortals are capable of; a blessing that money cannot buy.'- IZAAK WALTON

Health insurance has become a necessity today because it plays a major role in health care. This is because one never knows when illnesses may strike. And in such cases hospitalization and medication expenses can be unaffordable. Health insurance can prove to be a source of support by taking care of the financial burden of your family may have to go through. Advancement in science and technology has brought about a revolutionary change in mans life. It has reduced mortality rates and increased his life span but at the same time has given rise to a number of other ills. Increasing pollution levels especially in metros, stress and strain at workplace, cut throat competition taking its toll are some of the harsh realities. Health treatment nowadays is very costly. More than the disease it is the cost of treatment that takes its toll. To get rid of health worries health / medical insurance is the answer. But over 70 per cent of these spends are out of pocket which leads to lot of hardships. According to a survey by NSSO (National Sample Survey Organization), 40 per cent of the people hospitalized have either had to borrow money or sell assets to cover their medical expenses. It is especially worse when the patient needs specialized care. Expenses are exorbitant and the situation leaves you mentally devastated also burning a deep hole in your pocket. The family balance is affected, all those comforts of life have to be given up and your family has to make up with bare minimum necessities only. A significant proportion of population may have had to forego treatment all together. Hence it is imperative that the health insurance coverage is increased. Increasing incidence of lifestyle diseases such as obesity, diabetes mellitus, hyperlipidemia, hypertension and cardiovascular diseases to name a few, and rising medical costs, further emphasize the need for health insurance. Health insurance policy not only covers expenses incurred during hospitalization but also during the pre as well as post hospitalization stages like money spent for conducting medical tests and buying medicines. The cover will be to the extent of the sum insured.Health insurance takes care of you in such circumstances. It will help you tackle such situations with ease by providing you with timely and adequate medical care. The financial burden of footing huge medical bills is taken care of by health insurance. Besides if the accident causes life long disability to the patient, the earning member of the family, the insurance company will come to the rescue

Top Reasons why Getting a Health Insurance is ImportantTime is very important to us in every possible way. It is the only thing we have; it determines the value of everything. Anything can happen to anybody at any given time. Since there are no surety as to when and where something might happen, there is one thing that you can do to make sure that even at bad times, ensure that you are not left helpless at the time of taking care of your and your familys treatment. Here comes the role of the insurance. Health Insurance is there to take care of the needs of Hospitalization Here is the 10 benefits of getting a health insurance, determining its importance:1. Preferred provider networkHospitalization does necessarily means some tie up of the hospitals with the insurance companies. An agreement is reached by the insurance companies with the hospitals that they will undertake a particular treatment at an agreed price. An open heart surgery or orthopedic surgery to take care of fractures can be undertaken at a pre- determined rate. What it does is lots of paper work is reduced, and the insured has lesser tension. Hence Health insurance gives the requisite freedom from unnecessary worries.

2. Insurance agents do the leg workInsurance companies appoint agents to do their work of selling health insurance covers. Their job does not end here. They also need to provide after sales service. The services of the agents do come handy in times of need. They are required to guide their clients through difficult period. They take care of admission of the patients to a suitable service provider, get the cashless facility approved and at times they go beyond their limits to help them. They are at times known to give mental support to the near and dear ones of the patient.

3. Cashless facilityBiggest constraint that affects timely treatment is the non-availability of funds. For all sorts of medical treatment cash payments need to be made immediately on treatment. However, if one does not have the fund there will be no treatment? To overcome such a situation the insurance companies have come up with a noble way of doing things. The insured will not need to shell lots of cash from his pocket to meet such situation. The insurers will, directly or indirectly, pay off the legitimate dues to the hospital authorities. Such a benefit is known as a cashless facility. Each hospital has help desk wherein the patients family members provide the necessary papers to avail of the benefit. These help desks with the consent of the concerned doctor pass on the request to the insurance company for approval.4. Avoidance of delay in medical treatmentThough medical science has developed rapidly over the years but this does not necessarily mean that they are available to common people at an economical price. In most of the cases it is very costly. Such costs, as usual, do discourage commoners to take timely action. However, when health insurance is affordable it does definitely help in taking timely actions and thus the avoidance of suffering.5. Regular check upsInsurance companies are quiet aware that if the general health condition of the population that they cater are not good then the claim amounts will be woefully big. Such situation can ruin their financial base and may make them loss making organisation. To take care of such a situation each of the insurance companies provides the benefit of a regular health check up at a regular interval, subject to a certain cap. Health check up at a regular interval helps in reducing the incidence of ill health. Thus such incentive encourages the insured and his family members to have a healthy life.6. Peace of mindNow- a-days men are subjected to lots of tension. The fear of something wrong happening to him and to his near and dear ones, subjects him to even more pressure. One of the biggest worry is the health problem. Low premium for Health insurance provides some relief to the otherwise tensed life of individuals.Insured, which has taken cover, knows that he is insured against the treatment of illness. Though insurance cover may at times not cover the whole amount of the bill but it does certainly covers a major part of the cost and therefore the burden is not so unbearable. This assurance gives the insured the peace of mind that the insured so deserves.

7. Health care for the employeesIndustries, the world over, employ a huge number of employees. Who are these people? They are the people who are exposed to many sorts of adverse situations as far as health is concerned. Some may fall ill while working for an industry. Labour laws ensure that the employees are provided with proper treatment. Accidents may happen and is it right that employers should leave their employees to take care of their illnesses? No, it is not right. Laws have been promulgated likeWorkmensCompensation, etc. Health insurance is a social security measure. Most of the employers do take cover for the family members of their workmen, to keep them motivated.8. Access to health care at an affordable rateHealth is of primary concern to all concerned. It is the duty of all to ensure that Health care is made accessible to near and dear ones.To make this possible general insurance companies have come out with variations of health insurance. The premiums are reasonably priced so that common people can afford it.The concept of health insurance is nothing but one of sharing. Premiums are calculated based on the probability of a certain situation arising in a population and the likely payout needed by the insurance companies.

To be able to estimate the reliability of a report, the methods which it is based upon have to be considered. Hence, this chapter,methodology, will give the reader aninsight into my research process, selection and data collection.

2.1 OBJECTIVE OF THE STUDY.

The main objective of research is to identify the awareness consumption patterns of the people. About what they think about Health Insurance and are they aware or not about its benefits. The objective of present study can be accomplished by conducting a systematic research.The following are the objectives of the study: To understand the position of health insurance in India. To understand the different schemes of health insurance by different companies. To find out the future of Insurance sector in India. To study the need of health insurance. To check the awareness among people regarding health Insurance. To study about benefits provided by various insurance plan. To find out conclusion and give Suggestions.

2.2 SCOPE OF STUDY.

Is mostly to identify weather the customers are aware of insurance or not and how much they are willing to pay for theirfamilies. and what are the different perceptions having towardsinsurance policies.

SIGNIFICANCE OF THE STUDY.This dissertation presents review of health insurance situation in India - the opportunities it provides, the challenges it faces and the concerns it raises. A discussion of the health insurance for senior citizens and for low income people is also done.The paper covers following areas: Health insurance scenario in India Health insurance for the low income people. Types of Health Insurance schemes in India. Major companies providing Health insurance. Need of Health Insurance. Role of Regulators in Health Insurance. Health Insurance products available in India.

2.3 DATA COLLECTION.

Market research requires two kinds of data that is primary data and secondary data.

Primary Sources:Primary data is collected using a well structured questionnaire, surveys etc. Survey is carried out in 2 steps1) Firstvisit2) Appointment or personal interview

SECONDARY SOURCES:Secondary Data is data collected by someone other than the user.Common sources of secondary data includes organizational records and qualitative methodologies or qualitative research.The data for study has been collected through various sources: Books Newspapers Internet sources

2.4 LIMITATION OF THE STUDY. Due to time constraint, a detailed study could not be done. The projection is purely based on verbal meetings and may be influenced by unprecedented factors. The analysis and conclusion made by me as per my limited understanding and there may be something variation in the actual situation.

3.1HEALTH INSURANCE IN INDIA: CURRENT SCENARIO.

Health care has always been a problem area for India, a nation with a large population and larger percentage of this population living in urban slums and in rural area, below the poverty line. The government and people have started exploring various health financing options to manage problem arising out of increasing cost of care and changing epidemiological pattern of diseases. The control of government expenditure to manage fiscal deficits in early 1990s has let to severe resource constraints in the health sector. Under this situation, one of the ways for the government to reduce under funding and augment the resources in the health sector was to encourage the development of health insurance. In the light of escalating health care costs, coupled with demand for health care services, lack of easy access of people from low income group to quality health care, health insurance is emerging as an alternative mechanism for financing health care. Indian health financing scene raises number of challenges, which are: Increase in health care costs High financial burden on poor eroding their incomes Need for long term and nursing care for senior citizens because of increasing nuclear family system. Increasing burden of new diseases and health risks Due to under funding of government health care, preventive and primary care and public health functions have been neglected

In the above scenario, exploring health financing options became critical. Naturally, health insurance has emerged as one of the financing options to overcome some of the problems of our system. In simple terms, health insurance can be defined as a contract where an individual or group purchases in advance health coverage by paying a fee called premium. Health insurance refers to a wide variety of policies. These range from policies that cover the cost of doctors and hospitals to those that meet a specific need, such as paying for long term care. Even disability insurance, which replaces lost income if you cannot work because of illness or accident, is considered health insurance, even though it is not specifically for medical expenses. Health insurance is very well established in many countries, but Health Insurance in India still remains an untapped market.In a country where less than 15 per cent of population has some form of health insurance coverage, the potential for the health insurance segment remains high. It seems that there is an urgent need to ramp up the health insurance coverage in the country as out-of-pocket payments are still among the highest in the world. Reasoning out the low health insurance coverage in India, Antony Jacob, CEO, Apollo Munich Health Insurance, said, Only about 12-13 per cent of population has some form of health insurance coverage, including those who are covered through some form of government schemes. People are yet to accept health insurance as a financial tool for medical emergencies. They usually procrastinate when it comes to buying health insurance unless they are faced by a challenging situation. Although the Indian health insurance market still lags behind other countries in terms of penetration yet the health insurance segment is rising. It continues to be one of the most rapidly growing sectors in the Indian insurance industry with gross written premiums for health insurance increased by 16 per cent from Rs 13,212 crore in 2011-12 to Rs 15,341 crore in 2012-13. The health insurance premium has registered a compounded annual growth rate (CAGR) of 32 per cent for the past eight financial years. Health insurance segment still remains an unexplored territory in India. Jacob at Apollo Munich Health Insurance asserted, Health insurance has become one of the most prominent segments in the insurance space today and is expected to grow significantly in the next few years. As spending on healthcare in India is expected to double in a couple of years, we believe that health insurance will eventually become the biggest contributor in the non-life segment. Furthermore, in the present scenario, the health insurance industry is dominated by four public sector entities (National, New India, Oriental, and United India) that together have 60 per cent market share. The rest of the share is with 17 private sector players, of which four are standalone health insurance players (Star Health, Apollo Munich, Max Bupa, and Religare Health). ICICI Lombard continued to be the largest private sector non-life insurance company, with market share of 9.74 per cent.

3.2 TYPES OF HEALTH INSURANCEHealth Insurance TypesHealth insurance can be broken down into two broad categories:Traditional and Managed care. Within those categories, there are four basic types of plans: Traditional indemnity plans, which are now often called fee-for-service plans; Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) Point-Of-Service plans (POS);No one type of health care plan is better than the other. It really depends on your needs and preferences. Some people enjoy the autonomy offered by fee-for-service plans, while others prefer the low costs associated with closed-panel HMOsTraditional Health InsuranceUp until about 30 years ago, most people had traditional indemnity coverage. These days, it's often known as "fee-for-service." Indemnity plans are a bit like auto insurance: you pay a certain amount of your medical expenses up front in the form of a deductible and afterward the insurance company pays the majority of the bill.Advances in modern medicine increased the cost of providing health care and made it possible for people to live longer. Those advances caused many insurance companies to look for ways to reduce their costs of doing business, giving managed care the boost it enjoys today.Fee-for-serviceIndemnity plans or fee-for-service allow you to direct your own health care and visit almost any doctor or hospital you like. The insurance company then pays a set portion of your total charges. Indemnity plans are also referred to as "fee-for-service" plans.How does an fee-for-service plan work?Under a fee-for-service plan, you may see whatever doctors or specialists you like, with no referrals required. Though you may choose to get the majority of your basic care from a single doctor, your insurance company will not require you to choose a primary care physician. It may also require that you pay up front for services and then submit a claim to the insurance company for reimbursement.You'll likely be required to pay an annual deductible before the insurance company begins to pay on your claims. Once your deductible has been met, the insurance company will typically pay your claims at a set percentage of the "usual, customary and reasonable (UCR) rate" for the service. The UCR rate is the amount that healthcare providers in your area typically charge for any given service.In a nutshell, fee-for-service coverage offers flexibility in exchange for higher out-of-pocket expenses, more paperwork and higher premiums.A fee-for-service plan may be right for you if: You're looking for the greatest level of freedom possible in choosing which doctors or hospitals to visit. You don't want to designate primary care physicians or get referrals to get specialists. You want to freely visit any physician you chooseManaged care.Managed care has been around in one form or another since the 1930s, but it really took off in the last 10 years. As it grew, it evolved, leaving us with three basic types of managed care plans. Today, the majority of people with private health insurance have some type of managed care.Although there are important differences among the different types of managed care plans, there are some similarities. All managed care plans involve an arrangement between the insurer and a selected network of health care providers, and they offer policyholders significant financial incentives to use the providers in that network. There are usually explicit standards for selecting providers and a formal procedure to assure quality care.Health Maintenance Organizations (HMOs)HMO means "Health Maintenance Organization." HMO plans offer a wide range of healthcare services through a network of providers who agree to supply services to members. With an HMO you'll likely have coverage for a broader range of preventive healthcare services than you would through another type of plan.How does an HMO plan work?As a member of an HMO, you'll be required to choose a primary care physician (PCP). Your PCP will take care of most of your healthcare needs. Before you can see a specialist, you'll need to obtain a referral from your PCP. Though there are many variations, HMO plans typically enable members to have lower out-of-pocket healthcare expenses. You may not be required to pay a deductible before coverage starts and your co-payments will likely be minimal. You also typically won't have to submit any of your own claims to the insurance company. However, keep in mind that you'll likely have no coverage for services rendered by out-of-network providers or for services rendered without a proper referral from your PCP. An HMO plan may be right for you if: You're shopping for a plan with lower premiums You want a plan without a deductible and don't mind having an out-of-pocket limit You need preventive care services such as coverage for checkups and immunizations

Preferred Provider Organizations (PPOs)PPO plans, or "Preferred Provider Organization" plans, are one of the most popular types of plans in the Individual and Family market. PPO plans allow you to visit whatever in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician.How does a PPO plan work?As a member of a PPO plan, you'll be encouraged to use the insurance company's network of preferred doctors and you usually won't need to choose a primary care physician. No matter which healthcare provider you choose, in-network healthcare services will be covered at a higher benefit level than out-of-network services. It's important to check if you provider accepts your health plan so you receive the highest level of benefit coverage. You will probably have an annual deductible to pay before the insurance company starts covering your medical bills. You may also have a co-payment of about $10 - $30 for certain services or be required to cover a certain percentage of the total charges for your medical bills.A PPO plan may be right for you if: You want the freedom to choose almost any medical facility or provider for your healthcare needs You want a portion of out-of-network claims to be covered by your insurance company You don't want to get referrals before visiting a specialist.

Point-of-Service (POS)A Point of Service (POS) plan has some of the qualities of HMO and PPO plans with benefit levels varying depending on whether you receive your care in or out of the health insurance company's network of providers.How does a POS plan work?POS plans combine elements of both HMO and PPO plans. Like an HMO plan, you may be required to designate a primary care physician who will then make referrals to network specialists when needed. Depending upon the plan, services rendered by your PCP are typically not subject to a deductible and preventive care benefits are usually included. Like a PPO plan, you may receive care from non-network providers but with greater out-of-pocket costs. You may also be responsible for co-payments, coinsurance and an annual deductible.A POS plan may be right for you if: You're willing to play by the rules and possibly coordinate your care through a primary care physician Your favorite doctor already participates in the network.

3.3 VARIOUS HEALTH INSURANCE PRODUCTS AVAILABLE IN INDIA .

The existing health insurance schemes available in India can be broadly categorized as: 1. Voluntary health insurance schemes or private-for-profit schemes 2. Mandatory health insurance schemes or government run schemes (namely ESIS, CGHS) 3. Insurance offered by NGOs/Community based health insurance 4. Employer based schemes

1. Voluntary health insurance schemes or private-for-profit schemes: In private insurance, buyers are willing to pay premium to an insurance company that pools similar risks and insures them for health related expenses. The main distinction is that the premiums are set at a level, which are based on assessment of risk status of the consumer (or of the group of employees) and the level of benefits provided, rather than as a proportion of consumers income. The most popular health insurance cover offered by GIC is Mediclaim policy

Mediclaim policy: - It was introduced in 1986. It reimburses the hospitalization expenses owing to illness or injury suffered by the insured, whether the hospitalization is domiciliary or otherwise. It does not cover outpatient treatments. Government has exempted the premium paid by individuals from their taxable income. Because of high premiums it has remained limited to middle class, urban tax payer segment of population. Some of the various other voluntary health insurance schemes available in the market are :- Asha deep plan II , Jeevan Asha plan II, Jan Arogya policy, Raja Rajeswari policy, Overseas Mediclaim policy, Cancer Insurance policy, Bhavishya Arogya policy, Dreaded disease policy, Health Guard, Critical illness policy, Group Health insurance policy, Shakti Shield etc. At present Health insurance is provided mainly in the form of riders. There are very few pure health insurance policies under voluntary health insurance schemes.

2. Mandatory health insurance schemes or government run schemes (namely ESIS, CGHS) Employer State Insurance Scheme (ESIS):- Enacted in 1948, the employers state insurance (ESI) Act was the first major legislation on social security in India. The scheme applies to power using factories employing 10 persons or more and non-power & other specified establishments employing 20 persons or more. It covers employees and the dependents against loss of wages due to sickness, maternity, disability and death due to employment injury. It also covers funeral expenses and rehabilitation allowance. Medical care comprises outpatient care, hospitalization, medicines and specialist care. These services are provided through network of ESIS facilities, public care centers, non-governmental organizations (NGOs) and empanelled private practitioners. The ESIS is financed by three way contributions from employers, employees and the state government.

Even though the scheme is formulated well there are problem areas in managing this scheme. Some of the problems are :-

Remuneration compared to corporate hospitals. Rising costs and technological advancement in super specialty treatment. Management information is not satisfactory. The patients are not satisfied with the services they get Low utilization of the hospitals In rural areas, the access to services is also a problem.All these problems indicate an urgent need for reforms in the ESIS Scheme.

Central Government Health Insurance Scheme (CGHS):- Established in 1954, the CGHS covers employees and retirees of the central government and certain autonomous and semi autonomous and semi-government organizations. It also covers Members of Parliament, Governors, accredited journalists and members of general public in some specified areas. Benefits under the scheme include medical care, home visits/care, free medicines and diagnostic services. These services are provided through public facilities with some specialized treatment (with reimbursement ceilings) being permissible at private facilities. Most of the expenditure is met by the central government as only 12% is the share of contribution.

Universal Health Insurance Scheme (UHIS):- For providing financial risk protection to the poor, the government announced UHIS in 2003. Under this scheme, for a premium of Rs. 165 per year per person, Rs.248 for a family of five and Rs.330 for a family of seven , health care for sum assured of Rs. 30000/- was provided. This scheme has been made eligible for below poverty line families only. To make the scheme more saleable, the insurance companies provided for a floater clause that made any member of family eligible as against mediclaim policy which is for an individual member. In spite of all these, the scheme was not successful.

The reasons for failing to attract rural poor are many :- The public sector companies who where required to implement this scheme find it to be potentially loss making and do not invest in propagating it. To meet the target, it is learnt that several field officers pay the premium under fictious names. Identification of eligible families is a difficult task Poor find it difficult to pay the entire premium at one time for future benefit, foregoing current consumption needs. Paper work required to settle the claims is cumbersome In 2004, the government also provided an insurance product to the Self Help Group (SHG) for a premium of Rs.120 and sum assured of Rs.10000/-. However, the intake is negligible. The reasons for poor intake are similar to those cited above.

3. Insurance offered by NGOs/Community based health insurance. Community based schemes are typically targeted at poorer population living in communities. Such schemes are generally run by charitable trusts or non-governmental organizations (NGOs). In these schemes the members prepay a set amount each year for specified services. The benefits offered are mainly in terms of preventive care, though ambulatory and inpatient care is also covered. Such schemes tend to be financed through patient collection, government grants and donations. Increasingly in India, CBHI schemes are negotiating with for profit insurers for the purchase of custom designed group insurance policies. Some of the popular Community Based Health Insurance schemes are: - Self-Employed Womens Association (SEWA), Tribuvandas Foundation (TF), The Mullur Milk Co-operative, Sewagram, Action for Community Organization, Rehabilitation and Development (ACCORD), Voluntary Health Services (VHS) etc.

4. Employer based schemes.Employers in both public and private sector offers employer based insurance schemes through their own employer. These facilities are by way of lump sum payments, reimbursement of employees health expenditure for out patient care and hospitalization, fixed medical allowance or covering them under the group health insurance schemes.

3.4 BENEFITS OF HEALTH INSURANCE.

There are quite a number of benefits of having a health insurance plan as compared to the regular insurance schemes. In fact, a health insurance will provide you with a great financial coverage. Every year, the health care cost increases and thus you ought to have health insurance or make certain that you are always in good health which might be difficult to achieve under certain living conditions.Health insurance is very important for both the individuals as well as families. This is because if reduces the financial burden that might arise in case of an unexpected medical emergency.Further down are a few benefits of health insurance. PreventionOne of the most significant advantages of having health insurance is the ability to prevent diseases through early detection and doctor recommended lifestyle changes. This prevention not only keeps citizens healthier, but it also saves money on the expense of the health care that would otherwise be required to deal with the problem when it arises.

Peace of MindHaving health insurance leads to peace of mind for those who have it. If a nagging problem (such as an unusual pain), persists in someone with health insurance they can go to the doctor without significant out-of-pocket expense and get it checked out even if it leads to diagnostic testing.

Less Lost TimePeople with health insurance who get sick can take a sick day from work, visit the doctor, get treated and possibly be back to work in a day or two if the illness is minor. It is an advantage to the employee and employer for this quick and easy access to medical attention, since it reduces their lost time on the job.

The chance of hospitalizationIf the doctors discover that you require to be hospitalized, the health insurance also covers these costs as well as the costs of treatment throughout your stay in that particular hospital.

Protect your family's financial futureHealth coverage costs money but not having it could cost a lot more. Unforeseen medical needs, combined with high health care costs, could leave you with large medical bills if you're not insured. Having health insurance coverage helps reduce the chance that you'll have to dip into savings to pay for unexpected medical costs. It's hard to know how much you'll spend on health care each year. But having a health plan gives you financial protection for sudden, expensive medical costs.

Scheduled Regular Check-UpsRegular health check-ups without health coverage will eat most of the individuals budget if it also includes any special services or hospitalization. Health coverage on the other hand makes it pretty easy with insurance company providing for all these charges rather than emptying the individuals pockets for general health issues.

Pre-hospitalization and Post-hospitalization expensesInsurance policies also cover pre-hospitalization and post-hospitalization expenses like doctor's consultation fees, expenses incurred on tests etc. However, the health insurance companies cover these expenses generally up to a certain period of time before or after hospitalization.

Tax BenefitThe premium paid towards health insurance is also eligible for tax benefit under section 80 D of the Income Tax Act. Factors affecting the premium cost- The premium paid towards the insurance policy depends on various factors like age and prior medical history. The older the individual the higher will be the premium. Moreover past claim history also affects the premium rates.

Increases Savings:If there is any chance that the employer provides health coverage it is sure that the individuals will not have to spend much of their savings further all the saved money can be used for any other emergencies. Also the coverage provided by employer will see that it will be included in entire income however if this coverage plan has been purchased individually it would lessen the taxes by increasing the savings from taxes.

3.5 THIRD PARTY ADMINISTRATORS.

The Third Party Administrators are intermediaries who connect insurance companies, policyholders and health care providers.

TPAs are intermediaries in health insurance sector. They facilitate access of the policy holders through a network of hospitals. They maintain the database of the policy holders and issue them the identity cards with unique identification number. TPAs handle all the post policy issue procedures including claim settlement.TPAs have fulltime medical practitioners under their employment who take decisions on whether a particular ailment is covered under the policy or not.TPAs are beneficial for both i.e., for the insurer and the insured. The insurer substantially reduces the administrative cost and the insured gets professional services.TPA license is granted to companies registered under companies act 1956. They have to fulfill certain conditions laid down by IRDA. Such license is usually granted for a period of 3 years. TPAs are entitled to receive commission from insurers on mutually agreeable terms. However as per the IRDA guidelines, such commission cannot exceed 15% of the premium amount.TPAs have to tie up with different hospitals who offer hospitalization services. A single TPA may tie up with multiple insurers and likewise a single insurer can empanel multiple TPAs.With the advent of TPA, the insurance companies aim at ensuring higher efficiency, standardization of charges, greater awareness and penetration of health insurance to a larger section of the people.

Services offered by the TPAThe TPA undoubtedly aims to give the health insurance industry the required boost in India. ID card: TPA provides ID cards to all their policyholders in order to validate their identity at the time of admission. 24 hours customer support services: The TPA provide assistance through their 24 hrs call center that provides information regarding policyholder's data, provider network, claim status, benefits available with existing cardholder, etc All these details are furnished on request. Cashless Hospitalization: Each policyholder is provided with a list of empanelled hospitals where in he/she can avail cashless hospitalization. Claim Management: On behalf of the insurance companies TPA administers and settles claims for hospitals and policyholders.

List of Third Party Administrators in India. Parekh Health Management Pvt. Ltd. Medi Assist India Pvt. Ltd. MD India Healthcare Services Pvt. Ltd. Paramount Health Services Pvt. Ltd. E-Meditek services Ltd Heritage Health Services Pvt. Ltd. Universal Medi-Aid Services Ltd. Focus Healthcare Pvt. Ltd. Medicare TPA Services Pvt. Ltd. Family Health Plan Ltd. Raksha TPA Pvt. Ltd. TTK Healthcare Services Private Limited Anyuta TPA in Healthcare East West Assist Pvt. Ltd.3.6 ROLE OF REGULATORS .

The government has established Insurance Regulatory and Development Authority (IRDA) which is the statutory body for regulation of the whole insurance industry. They would be granting licenses to private companies and will regulate the insurance business. As the health insurance is in its very early phase, the role of IRDA will be very crucial. They have to ensure that the sector develops rapidly and the benefit of the insurance goes to the consumers. But it has to guard against the ill effects of private insurance. The main danger in the health insurance business we see is that the private companies will cover the risk of middle class who can afford to pay high premiums. Unregulated reimbursement of medical costs by the insurance companies will push up the prices of private care. So large section of India's population who are not insured will be at a relative disadvantage as they will, in future, have to pay much more for the private care. Thus checking increase in the costs of medical care will be very important role of the IRDA. Secondly, IRDA will need to evolve mechanisms by which it puts some kind of statue in place that private insurance companies do not skim the market by focusing on rich and upper- class clients and in the process neglect a major section of India's population. They must ensure that companies develop products for such poorer segments of the community and possibly build an element of cross-subsidy for them. Government companies can take the lead in this matter and catalyze new products for the poor and lower middle class as they have done in the past. Thirdly the regulators should also encourage NGOs, Co-operatives and other collectives to inter into the health insurance business and develop products for the poor as well as for the middle class employed in the services sector such as education, transportation, retailing etc and the self employed. This could be run as no-profit-no loss basis similar to the scheme pioneered by Indian Medical Association for its members. Special licenses will have to be given to NGO for this purpose without insisting on the minimum capital norms, which are for commercial insurance companies.As Health Insurance is in its very early phase, the role of IRDA will be very crucial. It has to ensure that this sector develops rapidly and benefit of insurance goes to the consumers. It has to guard against the ill effects of privatization. Unless privatization and development of health insurance is managed well it may have negative impact of health care, especially to a large segment of rural population in the country. If it is well managed then it can improve access to care and health status in the country rapidly. Experience from other countries suggest that the entry of private firms into the health insurance sectors, if not properly regulated , does have adverse consequences for the cost of care, equity, consumer satisfaction, fraud and ethical standards. Some of the areas of concern which the regulator has to look into are:

Many times the insurance claims are rejected due to small technical reasons. This leads to disputes. Various conditions included in the insurance policy contract is not negotiable and these are binding on consumer. There no analysis on what is fair practice and what is unfair practice.IRDA has stipulated regulations for both life and non-life insurance companies in many aspects of business but the same is lacking in respect of health insurance business. IRDA will have to evolve mechanism so that the private insurance companies do not skim the market by focusing on rich and upper class clients and in the process neglect a major section of Indias population. IRDA should ensure and encourage different organizations and private insurers to develop products for the poorer segment of the community and if possible build an element of cross subsidy for them.The IRDA will have a significant role in regulating the health insurance sector and safe guarding the interests of the policy holders by minimizing the unintended consequences.

3.7 HEALTH INSURANCE FOR SENIOR CITIZENS.According to the new guidelines by IRDA, every health insurance provider has to offer coverage to individuals upto 65 years of age.These senior citizen health insurance policies are for people aged between 65 years and 80 years. The points of senior citizen health insurance comparison can be max age at renewability, coverage of specific diseases and waiting periods.For example Varistha Medicalim policy covers Hospitalization and Domiciliary Hospitalization Expenses as well as expenses for treatment of Critical Illness, if opted for. The Critical Illnesses covered are Coronary Artery Surgery, Cancer, Renal Failure and Stroke. The senior citizen mediclaim policy can be renewed upto 90 years of age. Senior Citizen Health Insurance Plans in IndiaGeneral insurance companies offer medical insurance for senior citizens in India and have niche products to cater to this segment in our society. Some of the senior citizen health insurance plans are Silver Health from Bajaj Allianz, Varistha Mediclaim offered by National Insurance, Red Carpet Health Insurance from Star Health Insurance, Optima Restore from Apollo Munich, Complete from ICICI Lombard and Gold from Max Bupa. These senior citizen mediclaim policies ensure that you are financially protected during your golden years and are able to keep pace with sky rocketing medical costs.What does the Senior Citizen Health Insurance Plan cover? Hospitalization Cover: Expenses incurred as a patient after admission of more than 24 hrs. The expenses include room charges, doctor fees, nursing fees, cost of medicine and drugs, etc. Day care expenses which arise from use of special equipments or procedures like chemotherapy, dialysis, etc. Medical expenses prior and post of hospitalization, the number of days will vary across insurers. Ambulance charges for transporting the insured subject to maximum limit3.8 CONSUMER AND SOCIAL PERSPECTIVE ON HEALTH INSURANCE.With the liberalization of insurance and entry of private companies in this business it is very important that specific interventions are developed which focus on increasing the consumer awareness about insurance products. One of the major challenges after privatization of insurance would be how to develop such mechanisms, which help making consumers aware about the various intricacies of insurance plans. With Consumer Protection Act coming in force it has become easy for aggrieved consumers to complain and seek redressal for their problems. Consumer organizations such as CERC of Ahmedabad have been helping consumers to get due justice in disputes with the insurance companies. Most of the time the conditions and various points included in insurance policy contracts is not negotiable and these are binding on consumers. Many times insurance companies do not strictly follow the conditions in all cases and this create confusion and disputes. (Shah M 1999) The most important area of dispute and unfair treatment is the knowledge and implications of pre-exiting conditions. A number of cases of litigation are disagreement on these pre-existing conditions.This is also because some chronic conditions such as high blood pressure and diabetes can increase the risk of many other disease of organs such as heart, kidney, vascular and eyes diseases. The patients with these pre-existing conditions are denied claims for treatment of complications. This is not fair and leads to disputes. Health insurance is typically annual and has to be renewed yearly. Policy, which is not renewed in time lapses and a new policy has to be taken out. Medical conditions detected during the interim period are treated as pre-existing condition for the new policy, which is not fair. Courts, however, have ruled that even if there is delay in renewing the policies it should be considered as renewed policy. In case two doctors give different reports one favouring consumer and other insurance company, the insurance company generally follows the later opinion. There are several such consumer-related issues, which need to be addressed in health insurance. Consumer organizations have to play very active role in future development of the health insurance sector in India.3.9 IMPLICATIONS OF PRIVATIZATION ON HEALTH INSURANCE.

The privatization of insurance sector and constitution of IRDA envisage improving the performance of state insurance sector in the country by increasing benefits from competition in terms of lowered costs and increased level of consumer satisfaction.However, the implications of the entry of private insurance companies in health sector are not very clear. There are several contentious issues pertaining to development in thissector and these need critical examination. Role of private insurance varies depending on the economic, social and institutional settings in a country or a region.Critics of private insurance argue that privatization will divert scarce resources away form the pool, escalate health costs, allow cream skimming and adverse selection.According to this view, private health insurance largely neglects the social aspect of health protection. In the contrast, supporters of private health insurance claim that private insurance can bridge financing gaps by offering consumers value for money and help them avoid waiting lines, low quality care and under the table payments-problems often observed when households can use public health facilities for free or participate in mandatory social insurance schemes. Both the arguments are correct in the sense, private health insurance can be valuable tool to compliment or supplement existing health financing options only if they are carefully managed and adapted to local needs and preferences.India, with relatively developed economy and a strong middle class population, offers most promising environment for private health insurance development. Currently, private health insurance plays only a marginal role in health care systems but it is gradually gaining importance.Private health insurance is certainly not the only alternative or the ultimate solution to address alarming health care challenges in India. However, it is an option that warrants and already receives-growing consideration by policy makers in the country. Thus the question is not if this tool will be used in the future but whether it will be applied to the best of its potential to serve the needs of the countrys health care system.4.1 WAYS TO FILE HEALTH INSURANCE CLAIMS

The following documents are needed in order to register the claims for a health insurance policy: Properly filled and signed claim form Reports and receipts of diagnostic tests accompanied by doctor's notes Discharge certificate of the hospital Receipts and bills from consultants, anesthetists, or specialists with diagnosis certificate Illness related documents right from the day it was detected - this includes consultations with the physician and the insured's medical history and reports Surgeon or doctor's certificate that states the complete recovery of the insured Bills, cash memos, and receipts from the healthcare facility - this needs to be backed up with proper prescriptions Providing previous policies' details to the third party administrator - accidents are regarded as exceptionsIf the hospitalization is planned the following procedures need to be followed:

Getting in touch with the 3rd party administrator for the particular policy and providing them the information about hospitalization Making sure that the healthcare facility is in the network - even if the hospital or nursing home is not in the network the money will be provided Verification of coverage terms Contacting the TPA (third party administrator) regarding the availability of cash less facility. If the hospitalization is not planned the processes mentioned below have to be adhered to:

The TPA has to be informed as early as possible and the claim form has to be collected and filled up properly The claim form along with necessary documents has to be submitted within 7 days of the insured's recovery Procure all the treatment related documents from the hospital once treatment is completed Bills have to be paid by the insured initially - the insurance company will only reimburse them The policy document has to be read properly to understand which expenses are included

There is a possibility that the claimant may be rejected if the disease is not covered by the plan. In such circumstances the claimant needs to send a letter to the organization within 15 days to file a complaint. If the payment is incomplete the claimant needs to contact the TPA and find out the reasons for the same. In majority of such cases it has been seen that if additional papers are provided the remainder of the claim is settled.

4.2 CLAIM SETTLEMENT PROCESS IN HEALTH INSURANCE.

Health insurance product is meant to insure and pay for unplanned and expensive medicalexpenses. Taking health insurance is first step in insuring against medical expenses. Thesettlement of medical expensesagainst the health insurance product is the later onprocess of paying for the medical expenses. So after taking health insurance product it is advisable to be aware of the medical expenses settlement process. Settlement process can be cashless or reimbursementA bit on how health insurance claims processing works. In most cases, the Insurance companies appoint a third part administrator (TPA) for claims processing. That means once the health insurance policy is sold, the insurer passes on the baton to the TPA. In case of a claim, the insured has to get in touch with the TPA for all verification and formalities.

There are 2 ways by which health insurance claims are settled: Cashless: For availing cashless treatment (only at authorized network hospitals), the TPA has to be notified in advance (for planned hospitalization) or within the stipulated time limits (for emergencies). The insurance desk at hospitals usually helps with all paper work. The claim amount need to be approved by the TPA, and the hospital settles the amount with the TPA/ Insurer. Typically there will be exclusions and such amount will have to be settled directly at the hospital.

Reimbursement: Reimbursement facility can be availed at both the network and non-network hospitals. Here the insured avails the treatment and settles the hospital bills directly at the hospital. The insured can claim reimbursement for hospitalization by submitting relevant bills/ documents for the claimed amount to the TPA.

In a reimbursement plan, the patient can be admitted in any hospital, which may or may not be in the network hospitals list, wherein the money spent on the treatment is compensated by the insurance company at a later stage. To make a reimbursement claim, documents related to the treatment like bills, original test reports, etc. have to be produced while filing a claim. The health insurance provider then starts processing the claim and determines the amount that will be reimbursed.To seek reimbursement from your health insurance provider, you have to submit the following documents: Discharge summary Hospital and pharmacy bills Doctor's prescriptions Diagnosis reports

Hence, policies with cashless hospitalization enable the policy holder to receive immediate medical attention without having to worry about payments and processing .However, the hospitals one can go to need to be within the network of the insurance company. In the case of reimbursement plans, one can go to any hospital, but at a later stage, the reimbursement needs to be filed for and claimed.While both forms of health insurance policies are common today, the cashless hospitalization facility is a more convenient way to combat medical emergencies.

4.3 HOW HEALTH INSURANCE COVERAGE WORKS.When you have insurance, you pay some costs and your insurance plan pays some others. Here are some of the ways that the payments break down: Premium: A premium is a fixed amount you pay to your insurance plan, usually every month. You pay this even if you don't use medical care that month. Deductible: If you need medical care, a deductible is the amount you pay for care before the insurance company starts to pay its share. Once you meet your deductible, your insurance company begins to cover some costs of your care. Some plans have lower deductibles, like $250. Some have higher deductibles, like $2000. Many plans providepreventive services, and sometimes other care, before you've met your deductible. Copayment: A copayment is a fixed amount you'll pay for a medical service after you've met your deductible. For example, after meeting your deductible you may pay $25 for a visit to the doctor's office that would cost $150 if you didn't have coverage. The health plan pays the rest. Coinsurance: Coinsurance is similar to copayment, except it's a percentage of costs you pay. For instance, you may pay 20% of the cost of a $100 medical bill. So you would pay $20 and the health plan would pay the rest.

4.4 HEALTH INSURANCE PREMIUM.

Following are the factors that are considered significant in determining a health insurance policy's premium: Age - the older the insured, the higher the premium Policy terms - if the term period is higher the premium will come down Earlier medical history - if the insured does not have a disease already premium will be lower Claim free years - the more claim free years a person has the lower the premium will be Work atmosphere of insured - pilots and miners need to pay more than teachers or clerks. The logic is that in occupations perceived as more hazardous there are greater chances that the insured will encounter health problemsCoinsurance: As per this arrangement, a certain percentage of insurance will be paid by the company. This has a direct effect on the premium

Copay: This benefit is provided in case of individual health insurance plans. Hereby, insurance providers share the medical expenses like fees for doctor and medicine charges.

4.5 HOW TO SELECT THE BEST HEALTH INSURANCE PLAN.

Health insurance provides financial security when you need it the most.Which health insurance plan is right for you depends on numerous factors, mainly your age, and in case you are employed, do you get insurance from your employer or you need to buy it on your own. Regardless of your situation, here are some easy-to-follow guides for what you need to consider to choose the best health insurance policy. Buy health insurance when young and healthy -Typically, people tend to consider buying a health insurance policy in the middle of their life spans when they are in their forties or fifties. By that time, health risks might have increased with growing age. Further, all health insurance policies come with a waiting period for 2-3 years for certain pre-existing diseases.

Choose an adequate sum insured -You need to ensure that your health insurance plan offers you with adequate health care coverage by giving due consideration to factors like your age, age of all your family members, increased health care costs, etc.

Individual insurance policy Vs family floater policy -You must also consider whether you want to buy individual policies for all family members or a family floater policy for all. In case of a young nuclear family, it is better to opt for a family floater policy that extents coverage to two adults and two children. Compared to individual plans, family floater plans come at a marginally incremental premium.

Understand the limits and exclusions - In order to offer effective coverage, each health insurance plan has certain broad exclusions along with waiting periods. Thus, you should refer to your policy documents to determine which health care services are covered and to what extent. Furthermore, you should make it a point to ask for sample policy wordings so as to get in depth knowledge about certain definitions, terms and conditions, exclusions and benefits being offered while comparing different insurance policies offered by other companies.

Claim limitation related to treatment -You should carefully note the treatment-respective limits in the health insurance plan you choose. Certain policies cap the amount you can claim for a particular surgery. Such limits would restrict your claim, even if there is a large sum insured under your policy.

Hospital network of the insurance company -It is important to take time in obtaining and reviewing the details of the hospital network of the insurance company. An insurer with an extensive list of hospitals in its network across cities should be a prime consideration.

Fill up the proposal form yourself -The questions asked in a proposal form are comprehensive as well as personal in nature, thus one should make it a point to fill up a health insurance proposal form on their own. Furthermore, for the insurer to be able to underwrite the policy in an appropriate manner, it is required that you fill all details correctly. You should never hide any information or overwrite on the proposal form. Inadequate information or exclusion of medical conditions during the proposal time can lead to issues of delayed or non-payment of claims during times of need.

Read and understand the policy wordings -It is of utmost importance that you read the policy wordings and other documents carefully so as to reap maximum benefits from your respective health insurance policy. Every health insurer provides a policy wording document that contains details about the policy.QUESTIONS1. Are you aware of Health Insurance Schemes?OPTIONSNO. OF RESPONDENTS

Yes100

No0

INTREPRETATION: According to the survey 100 percent of the customers are aware of the health insurance schemes.

1. Do you have Health Insurance Policy?OPTIONSNO. OF RESPONDENTS

Yes42

No8

INTERPRETATION:According to the survey 42 percent of the respondents agreed to have Health insurance policy and 8 percent of the respondents do not have health insurance policy.

1. How much is the Medical cost annually?OPTIONSNO. OF RESPONDENTS

40,000-60,00018

60,000-80,00023

1,00,000 and Above9

INTERPRETATION:According to the survey 18 percent of the customers annually incurs medical cost of between 40,000-60,000, 23 percent of the customer incurs medical costs between 60,000-80,000 and 9 percent of the customer incurs medical costs between 1,00,000 and Above.

1. Your views on Health Insurance Scheme?OPTIONSNO. OF RESPONDENTS

A.Level of satisfaction of the scheme26

B.Quality service provided19

C.Agent and customer Relationship15

INTERPRETATION:According to the survey 26 percent of the customers are satisfied with the schemes, 15 percent of the customers are provided with quality service and 19 percent of the customers enjoys better agent and customer relationship.

1. Is taking insurance for health is worth?OPTIONSNO. OF RESPONDENTS

Yes38

No12

INTERPRETATION:According to the survey 38 percent of the customers believes that taking health insurance is worth and 12 percent of the customers are of the opinion that taking a health insurance policy is not worth.

1. Which insurance policy is better?OPTIONSNO. OF RESPONDENTS

A.Life13

B.Health32

C.Other5

INTERPRETATION:According to the survey 13 percent of the customers are of the opinion that life insurance policy is better, 32 percent of the customers prefer health insurance policy as better option and 5 percent of the customers are of the opinion that other insurance policy is better.

1. Do I have to get private health insurance?OPTIONSNO. OF RESPONDENTS

Yes36

No14

INTERPRETATION:According to the survey 36 percent of the customer agreed to get private health insurance and 14 percent of the customers did not agree to get private health insurance.

1. What do you feel after investing in Health Insurance plans?OPTIONSNO. OF RESPONDENTS

A.Good17

B.Averagely satisfied with the investment decision26

C.Cheated7

INTERPRETATION:According to the survey 17 percent of the customers feels good after investing in health insurance plans, 26 percent of the customers are averagely satisfied with the investment decision and 7 percent of the customer are cheated.

1. Reasons of Investing in Health Insurance Plans?OPTIONSNO. OF RESPONDENTS

A.Returns0

B.Recommended by Family and Friends21

C.Needs to save Tax2

D.Offers Multiple benefits like investment+Insurance+Taxsaving15

E.Schemes are good12

INTERPRETATION:According to the survey 0 percent of the customers invest in health insurance plans for returns, 21 percent of the customers invest as they are recommended by family and friends, 2 percent of the customers invest inorder to save tax, 15 percent of the customers invest in health insurance as they are attracted to the multiple benefits offered like investment +insurance +tax saving, 12 percent of the customers invest as they find good health insurance schemes.

1. What would you like more in Health Insurance Policies?

OPTIONSNO. OF RESPONDENTS

A.More benefits22

B.More security26

C.Others2

INTERPRETATION:According to the survey 22 percent of the customers would like to have more benefits, 26 percent of the customers are interested to have more security in the health insurance policies and 2 percent of the customers would like to have other reasons in health insurance policies.

1. Insurance Purchased directly from an insurance company (By this person or another family member)?OPTIONSNO. OF RESPONDENTS

Yes35

No15

INTERPRETATION:According to the survey 35 percent of the customers purchased directly from an insurance company, 15 percent of the customer did not purchased directly from an insurance company.

1. How are the charges of Health Insurance policies?OPTIONSNO. OF RESPONDENTS

A.High 19

B.Average27

C.Low4

INTERPRETATION:According to the survey 19 percent of the customers experiences high charges for health insurance policies, 27 percent of the customers experiences average charges for health insurance policies and 3 percent of the customer experiences low charges for health insurance policies.

5.2 QUESTIONNAIRE.

NAME: - ____________________E-Mail ID: - ___________________MOBILE NO:- _________________

TOPIC:-HEALTH INSURANCE

QUESTIONNAIRE:-1. Are you aware of Health Insurance Schemes? Yes No1. Do you have Health Insurance Policy? Yes No1. How much is the medical cost annually?1. 40,000-60,0001. 60,000-80,0001. 1,00,000 and Above

1. Your views on Health insurance scheme?1. Level of satisfaction of the scheme1. Quality service provided1. Agent and customer relationship1. Is taking insurance for Health is worth? Yes No

1. Which insurance policy is better?1. Life1. Health 1. Other

1. Do I have to get private health insurance? Yes No1. What do you feel after investing in Health insurance plans?1. Good1. Averagely satisfied with the investment decision1. Cheated

1. Reasons of investing in Health insurance plans?1. Returns1. Recommended by Family and Friends1. Needs to save tax1. Offers multiple benefits like investment+ Insurance +Tax saving1. Schemes are good

1. What would you like more in Health insurance policies?1. More benefits1. More security1. Others

1. Insurance purchased directly from an insurance company (By this person or another family member)? Yes No

1. How are the OF charges Health insurance policies?1. High1. Average1. Low

CHAPTER 6. CONCLUSION.

In India, people has limited experience of health insurance. Given that government has liberalized the insurance industry, health insurance is going to develop rapidly in future. Health insurance is insurance against the risk of incurring medical expenses. By estimating the overall risk of health care expenses, an insurer can develop a routine finance structure, such as monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement. The challenge is to see that it benefits the poor and the weak in terms of better coverage and health services at lower costs without the negative aspects of cost increase and over use of procedures and technology in provision of health care. The experience from other places suggest that if health insurance is left to the private market it will only cover those which have substantial ability to pay leaving out the poor and making them more vulnerable. Hence India should proactively make efforts to develop Social Health Insurance patterned after the German model where there is universal coverage, equal access to all and cost controlling measures such as prospective per capita payment to providers. Given that India does not have large organized sector employment the only option for such social health insurance is to develop it through co-operatives, associations and unions. The existing health insurance programmes such as ESIS and Mediclaim also need substantial reforms to make them more efficient and socially useful. Government should catalyze and guide development of such social health insurance in India. Researchers and donors should support such development.

6.1 BIBILOGRAPHY

Book refered :Insurance ProductsBy Indian Institute Of Banking And Finance.

WEBSITES:http://www.medindia.net/http://www.medimanage.com/ http://www.medindia.net/ http://business.mapsofindia.com/ https://www.healthcare.gov/ http://www.ehealthinsurance.com/http://benefitof.net/benefits-of-health-insurance/

http://www.actuariesindia.org/ An%20overview_J%20Anitha.pdfhttp://listdose.com/ http://www.policybazaar.com/http://www.cccindia.co/

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