health insurance summit - proceedings

7/29/2019 Health Insurance Summit - proceedings

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HealthInsuranceSummit2008

HealthInsuranceInc.:TheRoadAhead

9December2008

Mumbai


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Theprivatesectorhasplayedadominantroleinfinancingthehealthcare

expenditureinIndia,withhouseholds(Outofpocketexpenditure)accountingfora

disproportionate76percentfundingofthetotalhealthcareexpenditure1.The

scenarioisnotexpectedtochangesignificantlybyFY2015iftheGovernment

fundingofhealthcareexpenditureandthehealthinsurancecontributionto

healthcarefundingcontinuestogrowatthehistoricalgrowthrates.IfIndiawants

toachieveamoredesirableproportionofoutofpocketexpenditure,asinChina

(60percent),itrequiresincreasedparticipationfrompublic,privateora

combinationofthesesectors,withprivatehealthinsuranceplayingasignificantrole.

Theprivatehealthinsuranceindustryhasbeengrowingataremarkablegrowth

rateof37percentsinceFY2002andcurrentlystandsatINR5,125crores2.Going

forward,theindustryisexpectedtogrowataCAGRof25to30percentuntilFY

20153.However,thereareseveralimpedimentstothisgrowthsuchaslevelof

awarenessacrossdiversecustomersegments,standardizationofhealthcare

treatmentsandproceduresandproductinnovation.Itiswidelyfeltthatweareat

thethresholdofanunprecedentedgrowthforthenext5to7yearsinthe

industry.However,ifwewishtomakethisfaceliftintheindustry,itisimperative

forallthestakeholderstocometogethertodriveafewkeyinitiativesthatcould

helpformthebuildingblocksandtaketheindustryinthedesireddirection.This

reportsummarizesafewkeyinitiativessuchasincreasingcustomerawareness,

standardizationandaccreditationofhealthcareproviders,buildinga

comprehensiveandsustainabledatarepository,productandchannelinnovation

andusageoftechnologythatarelikelytobecriticalforthegrowthoftheindustry.

KPMGisprivilegedtocollaboratewithCIIasKnowledgePartnerfortheCII-KPMG

HealthInsuranceSummit2008onthethemeHealthInsuranceInc.:TheRoad

Ahead.

Foreword

1 WHO National Health Accounts

2 IRDA

3 Industry Discussions, KPMG Analysis

Pradip KanakiaHeadofMarkets

KPMGinIndia

A VaidheeshChairmanCIIWRHealthcare

SubCommitteeand

ChairmanCIIHealth

InsuranceSummit2008&ManagingDirector

Johnson&JohnsonMedical


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Economicgrowthisanimportantindicatorofanationseconomicdevelopment.

Growthinturn,amongotherthings,dependsonthehealthofitspeople,for

whichnationsneedtospendsubstantialamountsonhealthcare.Totalhealthcare

expenditureinIndiahashoveredaround5percentofGDP,withpublicfunding

contributinglessthan1percentofGDP.Limitedpublicfundingonhealthcarein

Indiahasnecessitatedout-of-pocketspendingtobethedominantcomponent,

funding76percentoftotalhealthcareexpenditureinFY20064.Highrelianceon

out-of-pocketspendingalonecanposeserioushealthpolicychallengesrelatedto

financialriskprotectioninfutureyears.Indianeedstofocusonthepotentialwaystopoolthisriskthroughinsuranceandreduceoutofpocketexpenditure,for

whichthereisaneedtostepuppublicandprivatesourcesofhealthcarefunding.

ThehealthinsurancesectorisoneofthemostpromisingsectorsinIndiannon-life

industrytoday.ThemarketsizecurrentlystandsataboutINR5,152croresinFY

2008,upfromINR761croresinFY2002,showingacompoundedannualgrowth

rateof37percent5.Severalfactorssuchasthechangingsocioeconomicand

demographicenvironmentofIndia,favorableregulatoryenvironmentaswellas

significantmarketingpushbyinsurancecompanieshavedriventhehighratesof

growthoftheindustry.

Goingforward,suchdriversareexpectedtopropelgrowthevenfurtherandthe

marketsizeisprojectedtobeapproximatelyINR28,000croresbyFY20156.

However,therearevariouschallengesfacedbythekeyparticipantsofthehealth

insurancevaluechain,whichcanimpacttheachievementoftheprojectedgrowth.

Foremostamongthesechallengesarelowawarenessabouthealthinsurance,

limitedproductofferingsbyinsurancecompanies,lackofstandardizationof

healthcareprovidersandthelackofdatathatcanempowerinformeddecisions.

Similartothekeyparticipantsofthehealthinsurancevaluechain,Indian

consumershavetheirownchallenges.Whilemostcustomersagreewiththe

conceptandnecessityofhealthinsurance,theyareskepticalabouttediousclaims

processingprocedures,limitedoptionsofhospitals/doctorsandlimitedproductofferingsbyinsurancecompanies.Moreimportantly,consumershavelimited

understandingofthefeaturesofhealthinsuranceproductswhichtheindustry

needstoaddressandchangetheperceptionabouthealthinsuranceinIndia.

Fromafuturepointofview,severalfactorsareexpectedtobeinstrumentalin

overcomingthechallengesexistinginhealthinsuranceindustryandmouldingthe

futureofhealthinsuranceindustryinIndia.Thesefactorscanbeclassifiedasthe

PillarsofChange-ConsumerAwareness,StandardizationandAccreditationof

healthcareproviders,HealthcareInfrastructureandDataandInformation

ExchangeandtheEnablersforGrowthProductandPricingInnovation,

Executive Summary and Acknow ledgements


5 IRDA


Neville Dumasia

Head-Governance,

RiskandComplianceServices

Ravi Trivedy

ExecutiveDirector,

BusinessAdvisory

Shashwat Sharma

Director,

BusinessAdvisory


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TechnologyandChannelInnovation.Withthesupportofthekeystakeholdersviz.

theGovernment,theRegulator,healthcareproviders,insurancecompanies,TPAs,

NGOs/SHGsandmedia,thesefactorscouldhelpcombatthechallengesand

facilitateextensivehealthinsurancecoverageinIndia.

Wewouldsincerelyliketoacknowledgeandthankthefollowingindustryleaders

forprovidingtheirvaluableviewsforthisreport(inalphabeticalorder):

Government of India

Mr.TarunBajaj,JointSecretary,GovernmentofIndia

Regulator

Dr.SomilNagpal,SpecialOfficerHealthInsurance,InsuranceRegulatory

andDevelopmentAuthority(IRDA)

Healthcare Providers/Health and Wellness centres/ Diagnostic

laboratories

Dr.DeviShetty,Chairman,NarayanHrudayalaya

Mr.NarinderKumar,GroupCFO&CompanySecretary,VLCCHealthcare

Ltd.

Dr.NarottamPuri,PresidentMedicalStrategy&Quality,FortisHealthcare

Ltd.

Mr.NimishR.Parekh,FounderandPresident,WellinformedHealthcare

Dr.SushilShah,Chairman,MetropolisHealthServices(India)Ltd.

Mr.VishalBali,ChiefExecutiveOfficer,WockhardtHospitals

Insurance Companies

Mr.C.Chandrasekharan,ChiefMarketingOfficer,ApolloDKVInsurance

CompanyLtd.

Mr.SandeepBakhshi,ManagingDirectorandCEO,ICICILombardGeneral

InsuranceCompanyLtd.

Dr.ShreerajDeshpande,Vice-PresidentHealthInsurance,BajajAllianzGeneralInsuranceCompanyLtd.

Microfinance Institutions

Mr.SatheeshArjilli,ManagerInsuranceBusiness,BASIX

Mr.VinayGolem,SeniorManager,SKSMicrofinancePrivateLtd.

Reinsurers

Mr.GirishRao,ManagingDirector,SwissReHealthcareServicesPvtLtd.

Technology Providers

Mr.SrivathsanAparajithan,Head-HealthcareBusinessSolutions,IBMIndia.


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Health Insurance: The Road Ahead 01

The Indian Health Insurance Industry 07

Voice of the Indian Consumer 13

22

Summary 32

Table of contents

Future Enablers and Action Steps

for the Health Insurance Industry


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Animportantindicatorofanationseconomicdevelopmentandnationalwell-

beingisitseconomicgrowth.Intheearlyyears,growthinlaborandcapitalwere

consideredtobethekeydeterminantsofeconomicgrowth.Empiricalevidence

suggeststhatasignificantportionofgrowthiscontributedbyhumancapital,the

elementsofwhicharethelevelofeducationandhealthofthepeople.Research

hasestablishedthata5-yeargaininlifeexpectancyisassociatedwithannual

averageratesofgrowthofrealGDPpercapitathatishigherbyaround0.5

percent.

WhatdoesthislinkagethenmeanforIndia?Atamacroeconomiclevel,

improvementsinhealtharelikelytoresultinimprovedeconomicperformance.

Indiaisnowundergoingademographictransition,withtheproportionofworking

populationexpectedtoincreaseinthenextquarterofacentury.Thisrisingyoung

population,ifhealthyandproductive,hasthepotentialofincreasingthegrowthof

realincomepercapitabyanannualaverageof0.7percenttill2025.Giventhe

implicationsthatahealthyandhence,productivepopulationhasonIndias

economicperformance,thereiscompellingneedtostepuphealthcarefunding

mechanismsinIndiaforpositivereturnsinthelongrun.

Globally,healthcareexpenditureisfundedbypublicandprivatesources.

Public Sources: Publicsourcesincludeexpendituresincurredonhealthbycentral

governmentdepartments,statedepartments,publicenterprises,includingbanks

andexternalfundingforhealth.Thesourceofpublicfinancingisthegeneraltax

andnon-taxrevenues,includinggrantsandloansreceivedfrombothinternaland

externalagencies,andsocialsecurityschemesthatarefundedbymeansofa

compulsorycontributiontowardshealth.

Private sources: Privatesourcesoffundingcompriseoutofpocketexpenditure

whichincludespaymentsmadebyindividualsandhouseholdsandothersources

offundingsuchasprivatehealthinsuranceandfundingbynon-profitinstitutions

suchasNGOsandSelfhelpGroups(SHGs).

Starkdifferencesexistbetweenthecompositionofhealthcarefundinginvarious

countries,drivenbythedifferencesinincomelevels,epidemiologicalfactorssuch

ashealthandnutrition,causesofmortalityfrominfectiousdiseasesorchronic

conditionsandeffectivenessofhealthinputs.

Heath Insurance: The Road Ahead

7

7 Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family

Welfare, Government of India, 2005

Figure1:Importanceofbetterhealth

Figure2:CompositionofWorldHealth

Expenditure,2005

Source:WHONationalHealthAccounts

Page1


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Forexample,inadevelopedeconomysuchasJapanortheUK,government

spendingonhealthformsamajority(over80percent)ofthehealthcarefunding8.

WhilehealthinsuranceintheUKisadministeredthroughthepubliclyfunded

NationalHealthService(NHS),Japanhastwomodelsofhealthinsurance:social

insurancesystemforcorporateemployeesandnationalhealthinsurancesystem

forpeoplewhoarenotcoveredbysocialinsurancesystem9.However,incaseof

emergingeconomiessuchasChinaandIndia,out-of-pocketspendingisthe

dominantcomponentofhealthcarefunding,accountingfornearly54percentand

76percentoftotalhealthcarespendingrespectively(FY2006).

HealthcareexpenditureinIndiainFY2006wasapproximately5percentofGDP

comparedtoJapan(7.9percentofGDP),UK(8.4percentofGDP)andBrazil(7.5

percentofGDP).Publicsectorexpenditureonhealthcarehasprogressively

decreasedovertheyearsfromabout26percentin1995tounder20percentof

thetotalhealthcarespendinginFY2006.Consequently,theprivatesectorhas

playedadominantroleinfinancingofhealthcareexpenditure,withhouseholds

accountingforadisproportionate76percentofthetotalhealthcareexpenditure,

increasingfrom67percentin199510.

Householdsspendnearly5to6percentoftheirtotalexpenditureand11percentoftheirnon-foodconsumptionexpenditureonhealth,asperconsumer

expendituredataofthevariousroundsoftheNationalSampleSurvey

Organization.Dataalsoshowanincreasinggrowthrateof14percentperannum

inhouseholdhealthspendingsinceFY1995-9611.

Intermsofhealthinsurancecoverage,statisticsinIndiahavenotbeenvery

encouraging.Severaldifferenttypesofinsurancecoverareavailable

GovernmentschemessuchastheEmployeesStateInsuranceSchemeand

CentralGovernmentHealthScheme,employercoverinPSUsandtheIndian

Railways,andfinallyprivateinsuranceschemes.Ithasbeenestimatedthataround

15percentofthepopulationwascoveredundersomepre-paidschemeinIndiain2007,withlessthan2percentshareofprivatehealthinsurance12.

Whataretheimplicationsoflimitedpublicspendingonhealthcareandlow

coverageinIndia?IncountrieslikeIndiaandanumberofotherdeveloping

countries,whichstillrelymostlyonout-of-pocketpayments,universalaccessto

healthcareiselusive.Asignificantproportionofthepopulation,whosuffersa

8 WHO National Health Accounts9 Healthcare in Japan, National Coalition on Healthcare; National Health Services, United Kingdom


11 Financing and Delivery of Health Care Services in India - Background Papers of the National

Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of

India, 2005

12 KPMG Analysis

Figure3:Comparisonoffundingofhealthcare

expenditure

Source:WHONationalHealthAccounts,KPMG

Analysis

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hand-to-mouthexistence,isforcedtomakedirectpayments,oftenwithaheavy

burdenofdebt,toaccesshealthcarefromthemarketbecausethepublic

provisionisgrosslyinadequateornon-existent.

Highrelianceonout-of-pocketspendingislikelytoposehealthpolicychallenges

relatedtofinancialriskprotectioninfutureyears.Riskpoolinginsurespeople

againstsuchrisksbytransferringthecostsofcoveringthesicktoalargenumber

ofhealthypeoplewhoneedtopayonlyasmallpremium.Indianeedstofocuson

thepotentialwaystopoolriskandreduceoutofpocketexpenditure,forwhich

othersourcesofhealthcarefundingneedtobesteppedup.

Thekeyquestionthatarisesis,byhowmuch,andwhofundsthisgap?By

developingvariousscenarios13ofthehealthcarefundingcompositioninIndia,we

canacquireaclearperspectiveonthequantumofinvestmentsneeded,andthe

impliedgrowthratethatisrequiredtobeachievedbyvarioussegmentsofthe

economythatprovidethehealthcarefunding.

AssumingthattheIndianeconomywillwitnessarealgrowthrateof

approximately7percentuntilFY2015,theprojectedGDPislikelytobeINR98lac

croresinFY2015.Theotherimportantassumptionwouldbethatthetotal

healthcareexpenditurewillremainwithinarangeof5percentto6percentof

GDP.

Assumingthattheclaimpaymentsconstitutethehealthcarefunding,the

contributionofpublicandprivatehealthinsurancecompaniestohealthcare

fundingwouldbeapproximatelyINR16,800croresforFY201514,iftheindustry

premiumsgrowata(CAGR)of25percentto30percentbetweenFY2008andFY

2015.

GiventhatpublicexpenditurehashistoricallygrownataCAGRof10.6percent

betweenFY1995toFY200615 ,itisassumedthatthegovernmentexpenditure

shallcontinuetogrowatapproximatelythesamerateuntilFY2015.Inthiscase,

governmentexpenditurewouldamounttoapproximatelyINR98,000crores.

Thus,inthisbaselinehealthcarefundingscenarioinFY2015,Out-of-Pocket

Expediture(OPE)wouldconstitue77percentor80percent(asdepictedinTable

No.1)ofthehealthcarefunding,dependingonwhethertotalhealthcarefundingis

5percentor6percentofGDPrespectively.IfIndiawantstoachieveamore

desirableproportionofOPE,asinChina(60percent),itislikelytoentailincreased

participationfrompublic,privateoracombinationofthesesectors,implying

significantlyhighergrowthinhealthfunding.

13 Estimates based on NSS 1998; Report No. 441, 52nd Round, NSSO ; Finance and revenue accounts,

New Delhi: Ministry of Finance, Govt. of India; 2004; Finances of state governments, Mumbai:

Reserve Bank of India, Govt. of India 2005 Labor year book; Health information India, New Delhi:

Ministry of Health and Family Welfare, Govt. of India; 2002.

CSO 2004, New Delhi: National Accounts Statistics, CSO, Govt. of India; 2004.

14 Assuming a claims ratio of 60 percent

15 WHO National Health Accounts, KPMG Analysis

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AnalyzingthescenarioI,wheretherequiredincreaseinfundingtobringdownthe

OPEcomponentisborneonlybytheGovernment,itwouldhavetomobilize

nearlyINR81,220crorestoINR120,420croresofadditionalfundsinFY2015.

WhiletheGovernmenthasinitiatedschemessuchastheRashtriyaSwasthya

BimaYojana(RSBY)toreducethisfundinggap,thereisclealyaneedformanysuchinitiatives.Further,thereexistsaviableopportunityforprivatesectortoshift

asizeablepopulacefromadirectout-of-pocketexpensemodeltoaprepaid,risk-

poolingmodelasillustratedinscenario2.

Thus, in order to reduce the proportion of OPE in the overall healthcare

funding there needs to be focused efforts from the public as well as the

private sector along with the possible public private partnership (PPP).

ExamplesofPPPcouldincludeapartner-agentmodelbasedcommunityinsurance

schemesinvolvingcooperativesocieties,governmentinitiativeslikeRSBYscheme

involvingcontributionbyinsurancecompaniesaswell.

Table1:Healthcarefundingscenario

Mr. Tarun Bajaj,

Joint Secretary,

Government of India

M r. Girish Rao,Managing Director,Swiss Re India

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Health Insurance in China

The Challenge

Bytheearly1980s,thecollapseofcommunityfinancinginstitutionsinrural

areasledtonearly90croreChinesepeasantsbeinguninsured.Inthecities,

residentswerecoveredbyacity-basedsocialhealthinsuranceschemewhich

coveredonlyworkersintheformalsector,leavingtheothersuninsured.In

2003,itwasfoundthatonly55.9percentofurbanand21.4percentofrural

residentswerecovered.

The Approach

Thegovernmenthasbeendirectingnewinvestmentwithaviewtowardspro-

vidinguniversalbasichealthcare.

Rural: In2003,thegovernmentestablishedtheNewCooperativeMedical

Scheme(NCMS)agovernmentrun,voluntaryinsuranceprogramthataimed

toinsureruralresidentsagainstcatastrophichealthexpenses.Underthis

scheme,thecentralandthelocalgovernmentswouldeachsubsidize40Yuan

perfarmer,withthefarmerpaying10Yuanasanannualpremiumforenrol-

ment.

Urban: UndertheUrbanEmployeeBasicMedicalInsurance(BMI)introduced

in1998,employercoveragewasfinancedthroughemployerfundedcollective

funds(6percentofwages)andabeneficiaryfundedpersonalaccount(2per-

centofwages);thecentralandlocalgovernmentssubsidizenon-workerscov-

erage.

Results

Bytheendof2007,NCMScovered86percentoftheruralpopulation,andis

targetedtoreach100percentbytheendof2008.BMIontheotherhandcov-

ered160millionworkersandretireesin2006,andisexpectedextendcover-

agetoallurbanresidentsbytheendof2010.

Lessons for India

IndiahasrecentlylaunchedtheRashtriyaSwasthyaBimaYojana,similartotheChineseNCMS,tocover30crorepeoplebelowpovertylinein5years

However,itmaybenotedthatwhilepublicinsurancehas playedanimpor-

tantroleinChina,Indiadoesnothaveobligatorypublicinsuranceandis

bettingontheemergenceofprivatemicro-insurancepolicies

Besides,thedifferentformsofgovernmentinthetwocountriescould

resultindifferentoutcomesforsimilarschemes

Source:Yip,W.,Mahal,A.TheHealthCareSystemsofChinaandIndia:Performanceand

FutureChallenges,HealthAffairs,Volume27,Number4

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The Rashtriya Swasthya Bima Yojana (RSBY)TheRSBYisaCentralGovernmentSchemelaunchedinOctober2007to

providehealthinsurancetothebelowpovertylinefamiliesintheunorganized

sector.

Benefits

TheSchemeenvisagestoprovidesmartcardbasedcashlessinsurance

coveruptoINR30,000onafamilyfloaterbasis

Pre-existingdiseasesarecovered

Hospitalizationandservicesofsurgicalnatureandpre-andpost-hospital-

izationexpensesarecovered.

Funding

TheCentralgovernmentbears75percentoftheestimatedannual

premiumofINR750andthecostofthesmartcard

StateGovernmentsbear25percentofthepremiumandadministrative

andothercostsofadministeringthescheme

ThebeneficiarypaysINR30perannumas registration/renewalfee.

Coverage

Anestimated6croreBelowPovertyLine(BPL)workersinall600districts

inthecountryattherateof1lakhworkersperdistrictareexpectedtobe

coveredat120districtsperyearstartingfromFY2008.

Role of State Governments

Stategovernmentsengageinacompetitivebiddingprocessandselecta

publicorprivateinsurancecompanylicensedtoprovidehealthinsurance

byIRDA.

Role of Insurer:

Theinsurercoversthebenefitpackageasacashlessfacilitythatinturn

requirestheuseofsmartcardsissuedtoallmembers

TheinsurerengagesintermediarieswithlocalpresencesuchasNGOs,MFIs,etc.inordertoprovidegrassrootsoutreachandassistmembersin

utilizingtheservicesafterenrolment

Theinsureralsoprovidesalistofempanelledpublicandprivatehospitals

meetingcertainbasicminimumrequirements(e.g.,sizeandregistration)

thataretoparticipateinthecashlessarrangement.Thesehospitalsmust

setupaspecialRSBYdeskwithsmartcardreaderandtrainedstaff

Theinsurertracksclaims,transfersfundstothehospitalsandinvestigates

inthecaseofsuspiciousclaimpatternsthroughon-siteaudits.

WhileRSBYhassetaggressivegoalsforitself,thesuccessofthescheme

needstobeseeninIndia.Butiftheschemeisabletoachieveitsambitioustarget,itcantoplayadominantroleinincreasinghealthinsurancecoveragein

India.

Source:www.rsby.in

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The Indian Health Insurance Industry

TheIndianhealthinsuranceindustrystandsatINR5,125croreswithonlyasmall

sectionofthetotalpopulation(around2percent)beingcoveredsofar.Witha

compoundedannualgrowthrateofaround37percent(FY2002-08),health

insuranceindustryinIndiaisoneofthefastestgrowingsegmentsamongother

non-lifeinsurancesegments.

Highgrowthratesofhealthinsuranceindustryhavebeendrivenbyseveralfactors

suchaschanginghealthcarescenario,socio-economictrendsandregulatory

changesintheindustryinIndiaasdiscussedbelow.

Goingforward,thesegrowthdriversareexpectedtocontinuetodrivethegrowth

ofthehealthinsuranceindustryinIndia.

Figure4:IndiaHealthInsurancemarketsize

andgrowthrate

Source:IRDA

Key Growth Drivers Description Impact on Health Insurance Industry

Changing Healthcare sce-

nario in India

Privatehealthcareisbecomingpredominantwithpro-

liferationofprivatehospitalsinurbanareasthus

increasinghealthcarecosts

Increaseinpopularityofhealthinsurancein

urbanareas

Healthcarecostsaremounting,thusmaking

treatmentforcommonpeopleincreasingly

unaffordable

Changing demographic

environment

Increasingprevalenceoflifestylediseasesinthe

country

AgeingPopulation

Largerafflictedpatientpopulationrequiring

treatmentandmedicalprocedures

Increased awareness and

affordability

Empiricalevidenceindicatesthatthereisapositive

correlationbetweenhealthcarespendingpercapita

andproportionofpopulationcoveredbyhealthinsur-

ance.

Indiahasseenariseinincomelevelsandliteracylev-

els.

Moreinformedandawareconsumer,

demandingbetterfacilities

Greaterabilityandwillingnesstopayfor

medicaltreatmentandhealthinsurancepre-

mium

Percapitaspendonhealthcareisontherise.

Thishascreatedademandforhealthinsur-

anceproducts

Push factor by insurance

companies

Increasedfocusonhealthinsurancewiththeemer-

genceofstandalonehealthinsurancecompanies

StrongerpushfromInsurancecompaniesalongwith

increasingdistributionreach

Increasedfocusanddistributionpushlead-

ingtoincreasedpenetrationofhealthinsur-

ance

Favourable Regulatoryenvironment

Pricedetarifficationinnon-lifeinsuranceindustryin

Indiaresultingintheremovalofcross-subsidizationof

healthinsurancepoliciesinIndia

Increaseinthehealthinsurancepremium

Government focus onhealth insurance

GovernmentinitiativeslikeRSBYscheme,Janashree

BimaYojana,NationalRuralHealthMissionetctopro-

videextensivehealthinsuranceaccess

Increasedhealthinsuranceawarenessand

coverage

15 IRDA Journals

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Thefutureoutlookofthehealthinsuranceindustryremainspositive.Theindustry

witnessedagrowthrateof52percent17 inthefirstquarterofFY2009compared

toFY2008.

Whiletheindustryiswitnessingsomedecreaseinthegrouphealthinsurance

businessduetothecurrentfinancialcrisis,theretailmarketisexpectedtogrow

inthenearfuture.Overall,thehealthinsuranceindustryinIndiaisexpectedto

growataCAGRof25to30percenttillFY2015toreachthemarketsizeof

approximatelyINR28,000croresbyFY201518.

TobeabletoincreasethemarketsizebyaroundINR22,900croresormorein

sevenyearstime,theindustryparticipantswouldrequiretomakeconcerted

effortsinthisdirection.Thebuildingblockshavetobeputinplacebythekey

participantsofthehealthinsuranceindustryandtheissuesandchallengesfaced

bythemhavetobeaddressedindefiningtheseconcertedefforts,forachieving

thetargetmarketsizeandincreasedpenetrationforhealthinsuranceinIndia.

Thehealthinsuranceindustrycomprisesseveralkeyplayersacrossitsvaluechain.

Figure5:KeyparticipantsintheHealthinsurancevaluechain

17 IRDA Journals


Dr. Shreeraj Deshpande,

Vice President

Health Insurance,

Bajaj A llianz General Insuranc e

Company Ltd.

M r. Sandeep Bakhshi,Managing Director and CEO,

ICICI Lombard General Insurance

Company Ltd.

Page8


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A. Insurance companies:

Therobustgrowthofhealthinsurancepremiumincomeinrecentyearshas

helpedensurethathealthinsuranceisconsideredafocussegmentbymost

Insurancecompanies.Healthinsuranceiscurrentlybeingofferedbynon-life

insurancecompanies,specializedhealthinsurancecompaniesandlifeinsurance

companiesinIndia.Whilehealthinsuranceformsalowproportionofthetotal

businessforlifeinsurancecompaniesinIndia(0.2percentoftheindividualregular

premiumforFY2008),itformsasignificantproportionofthebusinessfornon-life

insurancecompanies(approx.18percentofthetotalGrossWrittenPremiumfor

FY2008).19

StarHealthandAlliedInsuranceandApolloDKVInsurancearetheonlytwo

specializedhealthinsurancecompaniesinIndiatilldate.InJuly2008,BupaGroup,

aleadinginternationalhealthandcarecompanyandMaxIndiaLtd.,formedanew

partnershiptoenterthehealthinsurancemarketinIndia20.Majorhealthinsurers

fromoverseas,suchasAetna,CIGNAaswellasothermulti-nationallifeandnon-

lifecompanies,havealsoevincedinterestinenteringtheIndianhealthinsurance

market

B. Third Party Administrators (TPAs)

TPAswereestablishedasaresultofregulationsintroducedinFY2001.Theirkey

responsibilitiesincludeprovidingadministrationsupportforinsurers,suchas

admissionandsettlementofclaims,andestablishingprovidernetworksof

hospitalsthatpolicyholderscanutilise.ManyTPAsprovideawidervarietyofvalue

addedservicessuchasambulanceservice,medicinesandsupplies,information

abouthealthfacilities,hospitals,bedavailability,andhavemovedbeyondthe

boundariesthattheywereoriginallyintendedtofulfil.

AsofMarch2008,therewere28TPAsinoperation,thoughthetopthreehave

over50percentshareofthemarket21.Interestingly,asinsurershavestarted

analyzingtheirclaimsexperience,someofthemhaverealizedthatbyusingaTPA

fortheadmissionandsettlementofclaims,theyhaveinfactoutsourcedtheir

mostimportantactivity.Asaresult,someinsurancecompanieshaveeither

establishedorareintendingtoestablishtheirownin-houseclaimsoperations.

Further,reinsurerslikeMunichReandSwissRehavetakenstakesinParamount

HealthcareandTTKHealthcarerespectively,whilstRelianceGeneralInsurance

hasacquiredamajoritystakeinMediAssist

Figure6:MarketshareofkeyplayersinHealth

insuranceindustry(FY2008)

Source:IRDA

Figure7:MarketshareofTPAs(FY2007)

Source:IRDA

19 IRDA

20 Insurance Business Review, July 2008

21 IRDA, KPMG Analysis

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C. Reinsurers

Reinsurersplayacriticalroleinthehealthinsurancevauechain.Theytakeonpart

oftheriskthatinsurersassumefromtheircustomerssothattheinsurercan

assumegreaterindividualrisks.Inthepast,mostofthetop50globalreinsurers

operatedindirectlyfromtheiroverseasofficesbysharingthereinsurancerisks

assumedbytheGeneralInsuranceCorporationofIndia.Onereasonforthiswas

thatglobalreinsurersfeltthatratesforreinsuranceproductswereinadequateand

notatallreflectiveofglobalmarketconditions22.However,withtheentryoflarge

playersintotheIndianmarket,thisseemstobechanging.

Apartfromprovidingreinsurancesupport,reinsurerscanalsosupportinsurance

companiesindefiningtheirproductandcustomersegmentsbasedontheirglobal

experience.

D. Healthcare providers

Thehealthcareindustryisestimatedtogrowatabout15percenteveryyearfor

thenextfourtofiveyears.23 Increasedfavorableregulatorydrivers,changesin

demographicsandchangesindiseaseprofilehaveledtotherapiddemandfor

qualityhealthcareprovision.

Privateplayershaveinvestedsignificantlyinthismarket,leadingto

corporatizationoremergenceofhospitalchains.However,thefocusofthese

playershasbeenlargelyurbanasthisiswheretheinfrastructureandpatientpoolisavailablefortheseplayers.ExamplesincludetheApollogroup,Manipal,Fortis,

MaxandWockhardthospitals.Infact,84percentofhospitalbedsaretoday

locatedinurbanareas,whereas75percentofthepopulationstillresidesin

villages24.Thisselectiveconcentrationofhealthcareprovidersisamajorconcern

tobeaddressed,especiallysincestudieshaveshownthatthoselivinginrural

areasspendaboutasmuchonhealthcareasthoseintowns.

CurrentlyhealthcareprovidersarenotbeingregulatedinIndiawithregardto

standardizationandaccreditationnorms.Thishasresultedineachhealthcare

providerbeingsignificantlydifferentfromtheotherintermsofthehealthcare

costs,processesandqualityamongstothers.

E. Distribution channel partners

Agentsandbrokersarethekeydistributionchannelsforsellingretailandgroup

healthinsurancerespectively.Bancassuranceisalsoevolvingasanimportant

distributionchannelforretailhealthinsurance.Theusageofdirectdistribution

channelsliketheinternet,telemarketingetcislimitedinIndiacurrently,butwill

gainimportanceastheindustrymatures.Thisformofdistributionispopularinthe

developedcountriesandiscatchingoninIndiaaswell.

22 Indian Health Insurance- A major opportunity, Watson Wyatt

23 Foreign Investments in Hospitals in India: Status and Implications, WHO India

24 The Private Health Sector in India : Nature, Trends and a Cr itique, CEHAT

M r. Girish Rao,

M D,

Sw iss Re

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F. Regulators

TheInsuranceRegulatoryandDevelopmentAuthority(IRDA)regulates,promotes,

ensuresorderlygrowthoftheinsuranceandthereinsurancebusinessinIndiaand

protectstheinterestsofthepolicyholders.Currently,healthinsuranceformsa

partofthenon-lifeinsurancebusinessandisbeinggovernedbythenon-life

insuranceregulationsinIndia.TheIRDAisconsideringannouncingseparate

guidelinesforhealthinsurancetopromotesustainablegrowthofthehealth

insuranceinIndia.TheIRDAhasalsorecommendedloweringoftheminimum

capitalrequirementforstand-alonehealthinsurancecompaniesfromINR100

crorestoINR50crores25.Thismoveisexpectedtoencouragetheentryofstand

alonehealthinsurancecompaniesinIndia,andmayalsofacilitatetheemergence

ofRegionalhealthinsurancecompaniesinIndia.

Despiteawellestablishedindustrystructureinthehealthinsuranceindustryin

India,theindustryhasnotbeenabletoachieveitstruepotential.

ThesignificanteconomicgrowthinIndiaattheturnofthemillenniumhasleftits

medicalcareandhealthinsurancesystemsstrugglingtokeepupwiththegrowing

healthcaredemandsofitspeople.Indiaischaracterizedbyagrowing(butstill

relativelysmall)middleclassandalarge(butshrinkingandmostlyrural)near-

subsistencepopulation.Giventhepopulation,geographicalsizeofthecountry,

differentlevelsofevolutionwithintheurbanandruralstrataofthesociety,itisnot

surprisingthatplayersarefacedwithvariouschallengesinincreasinghealth

insurancecoverage.

25 New Health Insurance Law on the Anvil, Business Standard, October 2008

Page11


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Thus,therearesignificantchallengesbeingfacedbytheexistingparticipantsof

thehealthinsurancevaluechainwhichhaveimpactedthegrowthofthehealth

insuranceindustryinIndia.Whilethesechallengesneedtobeaddressedto

increasethehealthinsurancecoverageinIndia,thereisalsoaneedtounderstand

thechallengesfacedbytheIndianconsumerintheexistingmarketenvironment.

IssuesandChallengesfacedbyvariousparticipantsoftheHealthInsuranceValueChain

Page12


19/43

Voice of the Indian Consumer

Theendeavorofhealthinsuranceistoprovideconsumerswiththeoptionsor

productsthatcanaddressissuesofpreventionandtreatmentofillness,leadto

wellnessandtherebyhelpthemtoleadlonger,healthierandhappierlives.Thus,

understandingthevoiceoftheIndianconsumersiscriticaltounderstandthe

healthinsuranceneedsoftheconsumers.

TounderstandthevoiceoftheIndianconsumer,KPMGcommissionedIMRB

InternationaltocarryoutaQualitativeConsumerResearchstudy.Thestudy

involved13FocusGroupDiscussions(FGDs)acrosssixcities(twocitieseachin

metro,Tier1andTier226 segments)inIndia.ThecitiesincludedMumbai,

Chennai,Ahmedabad,Lucknow,CochinandPatna.

Therewerearound6-8participantswithdiverseprofessions(salariedaswellas

selfemployed)pergroup.SeparateFGDswereconductedfortheholdersand

non-holdersofhealthinsuranceinSocio-economicclass(SEC)A/B1(Upperstrata)

andSECB2/C(Lowerstrata)27.

Itwasfoundthatwhiletheconsumersdiffersignificantlyintheirprofiles,theyare

homogenouswithrespecttotheirhealthinsuranceawarenessandneedswhich

werecapturedduringtheconsumerresearch.

Thestudyalsorevealedthatcharacteristicsofconsumerswithandwithout

insurancecoversdifferedsignificantlyasshownbelow:

Typical characteristics of a consumer with

an insurance cover

Moderatelevelofawareness,knowledgeandeducation

Professionthatiseitherhighlypayingorhasconsistent

incomestream

Taxpayingcitizen

Preferstosecurethefuture,andiscautiouswithfinan-

cialmatters

Likestoplanthingsandorganizethem

Viewsinsurancefromsecurityaswellasinvestment

standpoint

Likestostrikeabalancebetweenriskandreturns.

Typical characteristics of a consumer without

an insurance cover

Lowlevelofawareness,knowledgeandeducation

Earnslowlevelofincomesorhasnosuretyofregular

incomes;typicallyunemployedoremployedinlower

orderjobs

Accordslowprioritytoinsurance,primarilyduetolack

offundsandpresenceofotherinvestmentneeds

Fewdependants

Focusesonimmediatefutureneedsratherthandistant

ones

Securityaboutfuturemeanseducatingchildrenand

makingthemselfdependent.

26 Metro Cities with population more than 40 lac , Tier 1 - Cities with population between 15 lac and

40 lac , Tier 2 - Cities with population between 5 lac and 15 lac27 SEC classification is based on Chief wage earners (CWE) occupation and education level

SEC A: CWE is graduate/ post graduate and is primarily employed at executive positions or is an

industrialist/businessman

SEC B: CWE is a post graduate or below and is primarily employed at clerical/supervisory level or is a

small businessman

SEC C: CWE is educated till class XII and is primarily employed at clerical/supervisory level or is a

skilled worker/petty trader/shop owners

Page13


20/43

Perception about Health Insurance in India

Thefocusgroupdiscussionshaverevealedseveralinterestingobservations.While

asignificantportionofconsumersareawareofhealthinsuranceandits

importance,thereareseveralperceptionsbothnegativeandpositive,thathave

astronginfluenceontheirbuyingdecisions.Interestingly,consumersacrossSEC

segmentsandcitiessharemanyoftheseviews.Thisdemonstratesthat

addressingsomeofthenegativeperceptionsandcapitalizingonthepositiveones

arelikelytoplayavitalroleinincreasinghealthinsurancecoverageinIndia.We

discussthemindetailbelow.

Figure8:PerceptionsaboutHealthinsuranceinIndia

Characteristics have been classified into Core, Primary and secondary segments based on

the level of emphasis with which these characteristics were mentioned during the focus

group discussions

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Negative Perceptions: Impediments to buying Health

Insurance

Thestudyhasthrownlightonseveralpossiblereasonsthatconsumershavecited

fornotbuyinghealthinsuranceinIndia.Someofthemostpertinentonesinclude:

a. Problems with Claims processing: Problemswithclaimsprocessing,

experiencedeitherfirsthandorbypeergroups,deterconsumersacross

segmentsfrombuyinghealthinsurance.

i. Consumersbelievethatreimbursementofclaimsfrominsurance

companies,forcashpaidinhospitals,requirenumerousfollow-ups

ii. Incaseofcashlesstransactions,theperceptionisthatthereisaneedto

submitseveraldocuments

iii.Anotherpredominantperceptionisthatinsurancecompaniesrejectclaims

ondubiousgrounds,renderingtheinsurancepolicyfutile.

Suchinstancesdiscourageconsumersfrominvestinginhealthinsurance

policies.Negativeexperienceswithclaimsprocessingcouldalsoleadto

negativepublicity,makinginsurancepolicieslesspopular

b. Limited product coverage: Healthinsuranceplansdonotcoveroutpatient

careandcertainailmentssuchasdiabetes,bloodsugar,eyeanddental

surgeries.Theviewisthatthepolicycovershealthproblemsthathavealow

probabilityofoccurring,renderingthepremiumpaidfutileifhospitalizationdoesnotoccurinaparticularyear

c. Less importance given to health insurance: Formostconsumers,theneed

tosaveandinvestforahome,education,vehicle,childrensmarriageandother

lifecycleneedstotakeprecedenceovertheneedforahealthinsurancepolicy.

Amisconceptionprevalentamongmanyconsumersisthatthereturnon

investmentinhealthinsuranceislow,withlittlerewardiftheymakenoclaims.

Inaddition,severalconsumers,particularlyyoungeragegroups,tendto

believethatpeopleover45yearsofagewhoaremorepronetoailments,

needahealthinsurancepolicy.

Thereisthereforeatendencytoinvestinahealthinsurancepolicyonlywhen

extrafundsareavailable,orifconsumershavefacedhardshipsinthepast

duringamedicalemergency.Oneofthereasonsforthiscouldbethe

confusioncreatedbymultipleparticipantsaboutinsurancebeingan

investment/savingsproductorrisktransfermechanismintheconsumers

mind.

SEC B2/C,Tier 2 city,

Non -holder of health insurance

SEC B2/C,Tier 2 city,

Non-Holder of health insurance

SEC A/B1,Tier 2 city,Non-holder of health insurance

Page15


22/43

d. Limited options of doctors and hospitals: Insurancecompanieshavetheir

ownnetworkofhospitalsandseldomreimburseproceduresperformedin

hospitalsoutsideofthenetwork.

i. Intheeventthataconsumerusesanon-networkhospitalduringan

emergency,thepolicybecomesineffectual

ii. Further,Indianconsumerstendtoestablishacomfortlevelwithdoctors.

Theyarereluctanttoswitchtootherprovidersiftheirdoctorsarenotpartof

thenetwork

e. Agent and Payment Related Issues: Insuranceadvisorsdonotsuggest

suitableoptionstoconsumers,hideinformation,areunawareoftheproducts

theysellorcoercethemintobuyingpoliciesthatarenotsuitedtotheirneeds.Thishascreateddiscontentamongconsumersthatagentsdonotactintheir

interestandinsteadoftreatingadvisorsastrustedpartners,several

consumersarewaryofthem.Anothercommongrievanceofconsumersis

thattherearefewoutletstodepositpremiums.Moreover,whilecompanies

havebeenencouragingtheuseofinternettopayinsurancepremiums,

consumersinnon-metrosmakelimiteduseoftheinternet.

WhilethesereasonsfornotbuyinghealthinsurancearesimilarforSECA,BandC

Consumersegments,thereareseveralotheraspectswherethesereasonsdiffer

forSECB2/C,whicharecitedbelow:

a. Complicated policy document: Consumersfinditdifficulttounderstandthevariousjargonsandpaperworkinvolvedinthehealthinsurancepolicy

b. Limited awareness: Limitedawarenessabouthealthinsurancehasledtonon-

considerationofthisoptiontoasignificantnumberofpeople

c. Expensive: Consumersperceivethathealthinsurancepoliciesareexpensive

andaremeantfortherichandtheeducatedonly.

Ithasbeenfoundthatconsumerswithahealthinsurancecoversharesimilar

viewsasthosewithout,intermsoftheirskepticismtowardsclaimsprocessing,

limitedcoverageintermsofproducts,anddoctorsandnetworkhospitals.While

thisskepticismhasbeenbasedonexperience,manyoftheothernegative

perceptionsstemfromafundamentallackofawarenessabouthealthinsurance

itsimportance,productsavailableandtheprocesses.

SEC A/B1,Tier 2 city,

Non-holder of health insurance



SEC 2/C,

Tier 2 city,


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Positive Perceptions: Perceived benefits about Health

Insurance

Despitethenegativeperceptionsofpeopleabouthealthinsurance,thereareclear

benefitsofhealthinsuranceasperceivedbyconsumerswhoarecoveredundera

policy.

a. Cashless Hospitalization: Oneofthekeyadvantagesofhealthinsurancehas

beenfoundtobecashlesshospitalization.Thisgivestheinsuredthebenefitof

startingthetreatmentoncehispre-authorizationisapprovedbytheinsurance

company/TPA.Inaddition,thisgivesthefamilythetimeandpeaceofmindto

concentrateonthepatientandthetreatmentandrelieffromarrangingfor

funds

b. Tax benefit:Taxbenefitsoninvestmentsinhealthinsuranceforselfand

dependantsbecomesamajordriverforconsumerstoinvestinapolicy

c. Financial Independence and Security: Consumersconsiderhealthinsurance

tobeameansofensuringtheirfinancialindependenceandsecurity.Health

insurancesavesthemfromborrowingmoneyfromotherpeopleduringan

emergencyandhelpspreserveothersavingsforlateruse.

Whileconsumerswhodonotholdhealthinsurancewerefoundtobeawareof

thesebenefits,thepainpointsoverpoweredthebenefitsperceived.However,

theywerefoundtobeopentotheideaofbuyinghealthinsuranceprovidedtheinsurancecompaniesrevisetheirofferingstomatchtheirexpectationsofan

Modelhealthinsuranceofferings.

HowdifferentistheModelHealthInsuranceOfferingsthattheconsumershave

envisagedfromtheexistingproductofferings?Thefindingsrelatetotheissues

thatconsumersfaceintheexistinghealthinsurancepolicies.

Largely,newideasofconsumerswerearoundthefollowingthemes:

a. Ease of claims disbursement: Currently,consumersfindtheclaims

disbursementprocesstobevague,fraughtwithproblemsandwithnosurety

ofreimbursementofclaims.Instead,theywishtohaveahasslefreeclaims

disbursementprocess,inwhichtheinsuranceagentispresentatthehospital

totakecareoftheformalitiesduringanemergency.Useofmedicalcardsthat

arelikecreditcards,whichcanswipedathospitals,mayprovetobean

innovativeandhassle-freeprocess


Holder of health insurance

SEC A/B1,Metro,Holder of health insurance

Page17

SEC B2/C,Metro,Non-holder of health insurance


24/43

b. Increased hospital network coverage: Consumerspreferthattheirinsurance

policytocoveragreaternumberofhospitalsandcertainDoctors,particularly

FamilyDoctorsintheirnetwork

c. Product and Pricing Innovation

i. Product Innovation

i. Coverage of incidental costs and more diseases: Whilehospitalization

formsasubstantialcostinmedicalcare,pre-hospitalizationentailsvisits

tospecialists,diagnostictestsetc.,andpost-hospitalizationcarealso

entailhighcosts.Therefore,coverageoftheseexpensesisdesirable.

Consumersalsoexpectcoverageofdiabetes,bloodsugar,dental

ailments,surgeriessuchaseyesurgeries,rootcanaletcthatdonotrequirehospitalization,andspecializedcoverageforwomentobepartof

theirModelHealthInsuranceofferings

ii.Long term policies: Consumerswishtotakelonger-termhealth

insurancepoliciescomparedtotheexistingone-yearpolicies.Consumers

alsomentionedaneedforbundlinghealthinsurancewithlifeinsurance

iii.Simple policy documents: Smallpointerssuchasprintingpolicy

documentsinlocallanguagescanbeveryusefulinhelpingconsumers

understandtheirhealthinsurancepolicybetter.Consumersalsowantthe

policydocumenttobesimpleandeasytounderstand

ii.Pricing Innovation: Currentlyformostpolicies,thefrequencyofpayment

ofpremiumisyearly.However,severalconsumershavesuggestedan

alternativepossibilityofaone-timepremiumwithlife-longcoverage.Thisis

especiallypreferredbyself-employedpeoplewhocouldhaveaspurtin

earningsduringaparticularyear,whichcanbeinvestedinapolicyasaone-

timeinvestment.Anotheralternativeisthepaymentofaone-timelarge

premium,followedbyyearlytop-upstocoverafamilyforalongperiod

d. Regular benefits to insurance holders: Apartfromthecoveragebenefitto

theinsured,consumersalsodemandedregularbenefits.Annualhealthcheck

ups,substantialreductioninpremiumforanoclaimyearetc,weresome

exampleswhereconsumersfeltthattheycouldgainsomebenefitfromtheir

associationwiththehealthinsurancecompany.

WiththeunderstandingoftheconsumersviewsabouttheModelHealth

InsuranceOfferingsandthereasonsfornotbuyinghealthinsurance,thekey

forincreasingcoverageofhealthinsuranceinIndiaistodesignandimplement

strategiestodesignhealthinsuranceofferingsthatmeetatleastsomeofthe

consumerpreferencesandaddresssomeofthechallengesfaced.

SEC A/B1,

Metro,Holder of health insurance

SEC B2/C,

Tier 2 city,


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Withtherecentspurtingrowthofthehealthinsurancemarket,companiesare

keentotryoutdifferentplanstoensureextensivepenetrationofhealthinsurance

inIndia.ToassisttheIndiancompaniesinthisregard,weattemptedtotestthe

acceptabilityoftwosuccessfulglobalhealthinsurancemodelsamongstIndian

consumers.Theconsumerswereexposedtotwonewtypesofhealthinsurance

planstogaugetheirwillingnesstoinvestinthesetypesofplans.

Globally successful health insurance models - Managed Healthcare and HealthSavings Account

Managed Healthcare:

Internationaltrendsindicatethatinsurancecompanieshavebeenabletoinfluencehealthcareproviderstocutcostsand

improvethequalityoftheirservicesthroughtheadoptionofthemanagedhealthcaremodel.Itisthemostpopularhealth

insurancemodelintheUS.

Typical features include:

Integrationofhealthcareservicedeliveryandhealthcarefinancingfunctions

Healthcareservicedeliveryincludeseithertie-upwithexistingprovidersorbuildingonesownprovidernetworkandis

intendedtoreduceunnecessaryhealthcarecosts.Thisisdonethroughavarietyofmechanismsincludingeconomic

incentivesforphysiciansandpatientstoselectlesscostlyformsofcare,programsforreviewingthemedicalnecessityofspecificservices,increasedbeneficiarycostsharing,controlsoninpatientadmissionsandlengthsofstay,the

establishmentofcost-sharingincentivesforoutpatientsurgery,selectivecontractingwithhealthcareproviders,etc.

Consumershavetotakeservicesonlyfromthenetworkinordertohavetheirhealthcarepaidbytheplan.

Health Savings Account (HSA):

VariouscountriesliketheUS,SouthAfrica,Canada,Singapore,ChinaandHongKonghaveexperimentedwiththisconcept

andhaveachievedvaryingdegreesofsuccessinHSAsbeingacceptedasaviableandlong-termoptionforfinancing

healthcareexpenses.Forexample,inSouthAfrica,itformsaround50percentofthehealthinsurancemarket.Thereisno

uniformarchitecturethatthevariousproponentsofHSAhaveadopted.Eachcountryhasadoptedandstructureditasper

theneedsoftheirpeople.

Typical Features:

Tax-exemptsavingsaccountsimilartoanIndividualPensionAccount,butearmarkedformedicalexpenses.Depositsin

theaccountaretax-exemptfortheaccountholdersandcanbeeasilywithdrawntopayforroutinemedicalbills

HSAworksinconjunctionwithaspecialhigh-deductiblehealthinsurancepolicyresultingintheprovisionof

comprehensivehealthinsurancecoverageatthelowestpossiblenetcost

Theinsurancecompanypaysformajormedicalexpenses(coveredexpensesinexcessofthedeductibleamount)while

theHSAaccountholderpaysfortheminormedicalexpenseswithtax-exemptmoneyfromhisHSA.Unutilized

balancesintheHSAcanbeaccumulatedtowardsindividualretirementaccounts.

Page19


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Plan 1: Managed Healthcare

Asaconcept,thisplanwaslikedandappreciatedbymostconsumers.

However,peoplewerequiteapprehensiveabouttheclauseofpre-authorization

inanemergency.

Affirmative points about the plan:

a.Cashless hospitalization: Consumersappreciatedthattherewouldnotbe

anyhassleofarrangingforcashatatimewhenthefocusshouldbeon

treatment.Thiswouldalsoavoidthetediousprocessoffollowingupwith

insurancecompaniesforclaims

b.Right treatment: Doctorswillbeencouragedtousetherighttreatment

insteadofadministeringneedlessproceduresandtestsinanattempttomakesomemoremoney.Patientswillnothavetofacethetraumaof

unnecessarytreatmentsandtheywouldbeassuredthattherighttreatment

isbeinggiventothem

c. Emergency cases/pre authorized to be considered: Itwasunderstood

thataccidentcaseswilldefinitelybetakenasemergencycase,and

authorizationsinsuchcaseswouldbeabigreliefforpatients.

Apprehensions about the plan:

a.Fear of treatment compromise: Manyconsumerssharedafeelingthatin

ordertosavemoneyfortheinsurancecompanies,networkhospitalswill

tryandkeeppeopleawayfromthehospitals.Eveniftheygetadmission,

theywilltryandhastenthetimespentinthehospital,thuscompromising

onthetreatmentregimen

b.Restrictions in the choice of hospital/doctor: Consumersarecomfortable

inreceivingtreatmentfromtheirfamilydoctorordoctorstheyarefamiliar

with.Also,theremaybesmallerhospitalswhichpeoplefindeasytoaccess

owingtotheirconvenience.Thesedoctorsandhospitalsmightnotbepart

oftheinsurancecompanynetwork,andpeoplefearthattheymaybeforced

togotofarawayplacesfortreatment

c. Unclear clause of pre-authorization or authorization in an emer-

gency: Whileconsumersviewedthisasoneofthepositivepointsabout

theplan,theyalsoneedmoreclarityontheprocessofpre-authorization.

Manywereskepticalandneededtoknowhowcompanieswoulddefineanemergency.

Overall,thisplanhadhigheracceptanceamongstSECA/B1consumersandtier

2cities.

Managed Health Care Concept

Thisplancontrolsthefinancingand

deliveryofhealthservicesto

memberswhoareenrolledinthis

plan.Underthisplanthereisan

existingcontractwithhealthservice

providerslikehospitals,doctorsthus

formingaprovidernetwork.

Memberswillhavetotakeservices

fromthisnetworkonlyinorderto

havetheirhealthcarepaidbytheplan.Incaseamembertakesservice

fromabodyoutsidethisnetwork,

theplanwillnotpayfortheir

healthcareunlessitwaspre

authorizedoranemergency.

ManagedcarePlanhasbeenparticularly

popularinTier-2cities

Page20


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Plan 2: Health Savings Account

Taxsavingsemergedasthemostdominantadvantageofthisplan.Thegeneral

feelingwasthatthelock-inperiodislengthyandifreviewed,wouldmakethe

planmuchmorecustomer-friendly

Affirmative points about the plan:a. Taxsavings:Theplanwasappreciatedfortheoptionoftaxsavingandwas

wellreceivedbytaxpayersegment

b.Goodbalanceofsavingtaxandassuringsecurity:Theplanwasappreciated

forthedualbenefitofsecurityandtaxsaving.Theconceptappealedto

respondentssinceitoffersconsumerstheflexibilitytohaveacheckover

theirownmoney.

Negative points about the plan:a. Lowinterestrates:Theconcernofgettinglowerreturnswasprevalentinthe

mindsofrespondents.Theyexpecttogethigherreturnstomakeitmore

appealing

b.Limitontheinsurableageofconsumer:Respondentswereoftheopinion

thattheirinsurancecovershouldbeforlifesincethemoneywouldbe

lockedintheschemeforaverylongtime.However,theyalsofearedthat

premiumsmightbehighastheygetolder

c. Notsuitableforolderinvestors:Respondentswereoftheopinionthatto

availthetotalbenefitofsuchascheme,itisimportantthatonestarts

investingatanearlyage.Suchaschemebeyondmiddleagewouldprovide

nobenefittothem.

Overall,thisplanhadhigheracceptanceamongstSECA/B1consumersand

metrocities.Theplanwasalsofoundtohavehigheracceptanceamongst

salariedconsumersasitwasviewedasataxsavingtool.

Health Savings Account

Concept

Thisplanallowsmemberstocreate

fundsorsavingsaccountswith

banks/insurancecompaniesthat

aretobeusedforhealthcare

expensesonly.Inthisplanthereare

twoparts

Healthinsuranceplan

Medicalsavingsaccount

Individualwillbecontributingtomedicalsavingsaccountsregularly

andwithdrawincaseofhealth

emergencies.Theuserisgenerally

providedwithaspecialdebitcard

whichhecanusetopayformedical

expensesfromhismedicalsavings

account.Howeverifthebalancein

theaccountrunsout,userhasto

payfromhisownpocket.

Thepremiumherewillbedivided

intotwocomponents:

Oneusedforhealthinsurance

whichwillprovide

comprehensivehospitalization,

criticalillnessandout-patient

care

Secondpartwillbefor

investmentthatcanbe

shelteredfromtaxationuntil

withdrawn

Deposittomedicalsavingsaccount

maybemadebyanypolicyholder,

byanemployeronbehalfofa

policyholderoranyotherperson.

Howeveriffundsarewithdrawnfor

areasonotherthanaqualified

medicalexpense,thewithdrawn

fundscanbeliabletoincometax

andpenalty.Onceapersonreaches

retirementageorbecomes

disabled,fundscanbewithdrawn

withoutpenalty.

TheHSAPlanhasbeenparticularlypopularintheMetros

Page21


28/43

Future enablers and action steps for thehealth insurance industry

Fromthefutureperspective,severalinitiativesareexpectedtobeinstrumentalin

overcomingthechallengesexistinginthehealthinsuranceindustryinIndiaand

mouldingthefutureoftheindustry.

KPMGbelievesthatachievingthefuturegrowthpotentialisdependentonthe

abilityofthekeystakeholdersviz.Government,Regulator,healthcareproviders,

insurancecompanies,NGOs/SHGs,TPAs,distributionchannelpartners,health

centersandthemediatostrengthentheindustryaroundthePillars of Change

and Enablers for Growth.

WhilethePillarsofChangearecriticalforbuildingarobusthealthinsurance

industry,theEnablersforGrowtharecriticalforthepropellingthegrowthofthe

industryinthefuture.

ThissectiondiscussestheexpectedPillarsofChangeandEnablersforGrowth

oftheHealthInsuranceindustryinIndiaandsomeofthepertinentactionsteps

whichneedtobeconsideredbyvariousstakeholderstoimplementthese

changes.

Pillars of Change

Pillar1:ConsumerAwareness

TheIndianhealthinsuranceindustryfacesachallengeoflowlevelsofawareness

amongconsumersoftheneedsandpotentialbenefitsofahealthinsurance

policy,andthislackofawarenesscreatesahindrancetoexpandingcoverage.

UnlesstheIndianconsumersaremadeawareofthehealthinsuranceconceptand

itsbenefits,theindustryisnotlikelytobeabletoachieveitsgrowthpotential.

Figure9:PillarsofchangeandEnablersfor

growthforhealthinsuranceindustry

Figure10:Keystakeholdersofthehealthinsuranceindustry

M r. Nimish R Parekh,Founder & Director,

Wellinformed Healthcare

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Consumerresearchhasrevealedtwoimportantaspectsrelatedtotheawareness

oftheconsumersabouthealthinsurance:

Theconsumershavelimitedawarenessaboutthehealthinsuranceproducts,

theirfunctionalitiesandtheirfeaturesandbenefits

Theconsumerswhoareawareabouthealthinsurancehaveseveralnegative

perceptionsaboutthesame,whichimpacttheirpurchasedecision.

Thus,theobjectiveofcreatingconsumerawarenessneedstobetwofold:

Increaseawarenessofthehealthinsuranceconcept,itsfunctionalities,

featuresandbenefits

DeveloppositiveperceptionabouthealthinsuranceamongsttheIndian

consumers.

Toachievetheseobjectives,someofthekeyactionstepsforthevarious

stakeholdersinclude:

Apartfromtheseactionsteps,stakeholdersshouldsupporttheGovernment,the

regulatorandtheinsurancecompaniesinincreasinghealthinsuranceawareness

inIndia.

M r. C. Chandrashekhar,Chief M arketing Officer,

Apollo DKV Insuranc e Company Ltd.

Dr. Narottam Puri,

President M edical Strategy & Quality,

Fortis Healthcare Ltd.

M r. Vishal Bali, CEO, Woc khardt Hospitals Group, India

Page23


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Pillar 2: Standardization of Healthcare costs and

Accreditation norms

Anoffshootofthelackofstandardizationofhealthcareprovidersisthediffering

qualitiesofservice,costs,procedures,treatmentsacrossdifferentproviders.This

hasresultedinlowcustomersatisfaction,unethicalpracticessuchaslong

hospitalstays,expensivetreatmentsanddrugs.Forbuildingastrongand

consistenthealthcareinfrastructure,standardizationofhealthcarecostsand

introductionofaccreditationnormsisapre-requisite.

HealthcareinIndiaistheresponsibilityofeachIndianstate.Therehavebeen

attemptsinsomestatestoinstitutionalizeuniformstandardsforhospitals.Apart

fromthissomeeffortshavebeenmadebyconsumerbodies,groupsofhealth

professionals,hospitalorganizationsandnon-governmentalorganizationstohelp

medicalbodiesadoptstandardsforaccreditation.Butwhatislacking,isa

concertedefforttomonitorthefunctioningofhospitalsinIndiaandthestringency

ofcompliancetoestablishedstandards28.

Figure11:StandardsandAccreditationsforhealthcareprovidersinIndia

Source:Accreditationofhospitals:AnOverview:Dr.GarimaChandra,ExpressHealthcareManagement

28 Accreditationofhospitals:AnOverview:Dr.GarimaChandra,ExpressHealthcareManagement

Dr. Sushil Shah,Chairman,

M etropolis Health Services India Ltd.

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31/43

Someofthekeyinitiativesandactionstepsforthevariousstakeholdersinclude:

Dr. Shreera j Deshpande,Vice President Health Insurance,

Bajaj Allianz General Insurance

Company Ltd

c

Dr. Narottam Puri, President Medical Strategy & Quality, Fortis Healthcare Ltd.

C. Chandrashekhar, Chief M arketing Officer, Apollo DKV Insuran ce Company Ltd.

Page25


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Pillar 3: Healthcare Infrastructure

ForthegrowthofhealthinsurancecoverageinIndia,thereisaneedtodevelopa

networkofhealthcareinfrastructuretodeliverqualityhealthcaretothecon-

sumers.

Someofthekeyinitiativesandactionstepsforvariousstakeholderstoimprove

healthcareinfrastructureinIndiainclude:

M r. Sandeep Bakhshi,M D & CEO,


Company Ltd.

Dr. Narottam Puri, President Medical Strategy & Quality, Fortis Healthcare Ltd.

Page26


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Pillar 4: Data and Information Exchange

Buildingacomprehensiveandsustainabledatarepositoryandinformation

exchangemechanismsiscriticalforbuildingarobusthealthinsuranceindustryin

India.Thecomprehensivedatabasecouldhelpinthedevelopmentofnewprod-

ucts,analyzingexistingandemergingtrends,promotingnewresearch,testingof

neworalternativehypothesesandmethodsofanalysis.

IRDAhasalreadyinitiatedstepsinthisdirection.TariffAdvisoryCommittee(TAC)

hasbeendesignatedbyIRDAasthedatarepositoryforthenon-lifeinsurance

industryinIndia.Presently,thetransactionleveldataonMotor,Healthandother

linesarebeingcollectedfortherepository.Thesummaryreportsforhealthinsur-ance(2003-04,2004-05and2005-06)arealsoavailableinthepublicdomainon

TAC'swebsite.

Whilethesestepsmarkthebeginningofthedataandinformationexchangesys-

teminIndia,thereisstillalongwaytogo.Variousstakeholdersinthehealth

insuranceindustryhavesignificantamountofinformationaroundconsumers,dis-

easepatternsetcwhichisnotbeingsharedamongstthem.

Someofthekeyinitiativesandactionstepsforvariousstakeholderstohelp

ensuredataandinformationexchangeinclude:

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Enablers for Growth

Enabler1:ProductandPricingInnovation

Productandpricinginnovationisexpectedtobethekeydriverforpenetrationof

HealthInsuranceinIndia.BasedontheConsumerResearchitwasevidentthat

theIndianconsumersdesirenewproductstobeintroducedintheIndianmarket.

Developmentandintroductionofnewproductsattheoptimumpricehasthe

potenialtonotonlydrivethepenetrationofhealthinsuranceinIndia,butalso

helpreducetheclaimscostbeingincurredbyexistinginsurancecompaniesin

India.

Productandpricinginnovationincreasetheoptionsavailabletotheconsumersin

termsofnumberofproductsavailable,diseases/illnessescovered,improvecus-tomersatisfaction,providebetteraccesstocosteffectiveandqualityhealthcare

andreducefraud.

Someofthekeyinitiativesandtheactionstepsforthevariousstakeholders

include:

M r. Nimish R Parekh,Founder & Director,

Wellinformed Healthcare

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Case study: Wellness Products offered by Insurance companies

OfferedbyInsurancecompanieslikeCIGNA,PhiladelphiaInsurance,United

HealthcareintheUSandBUPA,PrudentialintheUK

Features:

Coversbenefitsthatencouragehealthybehaviorsorlifestylechanges

intendedtoimprovehealth,qualityoflifeandresultinavoidingthecosts

associatedwithbehavior-inducedchronicillness

Offersfinancialincentivessuchaslowerpremiums,co-paymentsor

deductiblesforparticipationinawellnessprogram

Examples:Nutritioneducation,physicalactivityeducation,weightloss,stressmanagement,maternitymanagement,diabeteseducation,and

asthmaandhearthealthylifestylemodifications

Win-Win situation:

Advantageforconsumers:Products/healthplansareofferedatdiscounted

rates

Advantageforinsurancecompany:Thereductioninriskforeachindividual

Preventivemorethancurative;leadingtolowerclaimsratio

Dr. Sushil Shah,

Chairman,M etropolis Health Services India Ltd.

M r. Narinder Kumar,

Group CFO & Company Sec retar y,

VLCC Health Care Ltd.

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Enabler 2: Technology

Asatransaction-intensiveindustry,healthinsuranceisexpectedtocontinueto

benefitfromtheefficienciesthattechnologybringstotraditionallypaper-driven

processes.Buttheindustryisatacrossroads:Itnotonlymustimproveexisting

processes,itmustalsodevelopnewprocessesandcapabilitiestomeetnew

customerdemands.

Therearevarioustouch-pointswheretechnologycanhelpcreateandmonitor

processesinamuchmoreefficientmanner.Someofthekeyinitiativesandthe

actionstepsforthevariousstakeholdersinclude:

M r. Sandeep Bakhshi,M D & CEO,


Company Ltd.

M r. Srivathsan Aparajithan, Head- Healthcare B usiness Solutions, IBM India

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Enabler 3: Innovative Distribution Channels

ToincreasethepenetrationofHealthInsuranceinIndia,thereisaneedto

exploreinnovativedistributionchannels.Someofthekeyinitiativesandtheaction

stepsforthevariousstakeholdersinclude:

Mr. Vishal Bali,CEO,

Woc khardt Hospitals Group, India

M r. C. Chandrashekhar,Chief M arketing Officer,

Apollo DKV Insuranc e Company Ltd..

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Summary

TheindustryhasgrownataCAGRof37percentoverthelast6yearsandis

poisedtogrowataCAGRof25-30percenttoreachamarketsizeof

approximatelyINR28,000croresbyFY2015,whichtranslatestoanincremental

growthofaroundINR23,000croresinthenext7years.KPMGbelievesthat

achievingthisgrowthisdependentontheabilityofthekeystakeholdersviz.

Government,Regulator,healthcareproviders,insurancecompanies,NGOs/SHGs,

TPAs,distributionchannelpartners,healthcentersandthemediatostrengthen

theindustryaroundthePillarsofChangeandEnablersforGrowth.

WhilethePillarsofChangearecriticalforbuildingarobusthealthinsurance

industry,theEnablersforGrowtharecriticalforthepropellingthegrowthofthe

industryinthefuture.Inanutshell,themostcriticalparadigmsinclude:

Increasingcustomerawarenessabouthealthinsuranceanditsbenefits

Standardizationandaccreditationofallhealthcareproviderstohelpensure

qualityhealthcare

Enhancinghealthcareinfrastructureespeciallyintier2/3andruralareasinIndia

Buildingacomprehensiveandsustainablehealthinsurancedatarepositorylike

acreditinformationdatabasemanagedbyCreditInformationBureau(India)

Ltd.

Encouraginginnovationaroundproducts,channelsandusageoftechnology.

Thus,thereisaneedforconcertedeffortbyallthestakeholdersofthehealth

insuranceindustrytocollaborateandpavetheroadaheadfortheIndianhealth

insuranceindustry.

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List of Abbreviations

BPL BelowPovertyLine

CAGR CompoundedAnnualGrowthRate

CGHS CentralGovernmentHealthScheme

ESIS EmployeesStateInsuranceScheme

FGD FocusGroupDiscussion

FY FinancialYear

GDP GrossDomesticProduct

GWP GrossWrittenPremium

INR IndianRupee

IRDA InsuranceRegulatoryandDevelopmentAuthority

MFI Microfinanceinstitutions

NCMS NewCooperativeMedicalScheme

NGO Non-GovernmentOrganization

OPE Out-of-PocketExpenditure

OTC OvertheCounter

PHC PrimaryHealthCenter

PPP Public-PrivatePartnership

PSU PublicSectorUnit

RSBY RashtriyaSwasthyaBimaYojana

SEC SocioEconomicClass

SHG SelfHelpGroup

TAC TariffAdvisoryCommittee

TPA ThirdPartyAdministrators

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About KPMG in India

KPMGisaglobalnetworkofprofessionalfirmsprovidingAudit,TaxandAdvisory

services.Weoperatein145countriesandhave123,000peopleworkingin

memberfirmsaroundtheworld.TheindependentmemberfirmsoftheKPMG

networkareaffiliatedwithKPMGInternational,aSwisscooperative.EachKPMG

firmisalegallydistinctandseparateentityanddescribesitselfassuch.

TheIndianmemberfirmsaffiliatedwithKPMGInternationalwereestablishedin

September1993.Asmembersofacohesivebusinessunittheyrespondtoa

clientserviceenvironmentbyleveragingtheresourcesofaglobalnetworkoffirms,providingdetailedknowledgeoflocallaws,regulations,marketsand

competition.Weprovideservicestoover5,000internationalandnationalclients,

inIndia.KPMGhasofficesinIndiainMumbai,Delhi,Bangalore,Chennai,

Hyderabad,KolkataandPune.ThefirmsinIndiahaveaccesstomorethan3000

Indianandexpatriateprofessionals,manyofwhomareinternationallytrained.We

strivetoproviderapid,performance-based,industry-focusedandtechnology-

enabledservices,whichreflectasharedknowledgeofglobalandlocalindustries

andourexperienceoftheIndianbusinessenvironment.

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About CII

TheConfederationofIndianIndustry(CII)workstocreateandsustainan

environmentconducivetothegrowthofindustryinIndia,partneringindustryand

governmentalikethroughadvisoryandconsultativeprocesses.

CIIisanon-government,not-for-profit,industryledandindustrymanaged

organisation,playingaproactiveroleinIndia'sdevelopmentprocess.Founded

over113yearsago,itisIndia'spremierbusinessassociation,withadirect

membershipofover7500organisationsfromtheprivateaswellaspublicsectors,

includingSMEsandMNCs,andanindirectmembershipofover83,000companiesfromaround380nationalandregionalsectoralassociations.

CIIcatalyseschangebyworkingcloselywithgovernmentonpolicyissues,

enhancingefficiency,competitivenessandexpandingbusinessopportunitiesfor

industrythrougharangeofspecialisedservicesandgloballinkages.Italso

providesaplatformforsectoralconsensusbuildingandnetworking.Major

emphasisislaidonprojectingapositiveimageofbusiness,assistingindustryto

identifyandexecutecorporatecitizenshipprogrammes.Partnershipswithover

120NGOsacrossthecountrycarryforwardourinitiativesinintegratedand

inclusivedevelopment,whichincludehealth,education,livelihood,diversity

management,skilldevelopmentandwater,tonameafew.

Complementingthisvision,CII'stheme"India@75:TheEmergingAgenda",

reflectsitsaspirationalroletofacilitatetheaccelerationinIndia'stransformation

intoaneconomicallyvital,technologicallyinnovative,sociallyandethicallyvibrant

globalleaderbyyear2022.

With64officesinIndia,8overseasinAustralia,Austria,China,France,Japan,

Singapore,UK,USandinstitutionalpartnershipswith271counterpart

organisationsin100countries,CIIservesasareferencepointforIndianindustry

andtheinternationalbusinesscommunity.

Confederation of Indian Industry

105,KakadChambers,132,Dr.A.B.Road,

Worli,Mumbai-400018

Phone:022-24931790,

Fax:022-24939463,24945831

Website:www.ciionline.org

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Acknowledgement

This report was wr itten wi th valuable inputs from Shalin i Pillay, Avani Shah, Nidh i Goel, Pratixa Davawala,

Shouvik Paul, Gaurav Mahant, Swati Shankar, Naren Gorthy, Ashish Sing la, Kavya Shetty and Riddhi Kaul.


43/43

in.kpmg.com

KPMG in India

Mumbai

KPMG House, Kamala Mill s Compound

448, Senapati Bapat M arg,Lower Parel, M umbai - 400 013

Tel: +91 22 3989 6000

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Tel: +91 22 3983 5301

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Tel: +91 22 3983 6202

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Head - Conference

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