HEALTH INSURANCE AND SCHEMES

1. HEALTH INSURANCE
PRAMOD KUMAR

2. HEALTH
Health is defined as "a state
of complete physical,
mental, and social well-
being and not merely the
absence of disease or
infirmity."

3. HEALTH INSURANCE
Health insurance is a
type of insurance
coverage that covers
the cost of an insured
individual's medical
and surgical
expenses.

4. NEED
HEALTH
INSURANCE
WHEN YOU
ARE IN NEED HEALTH
INSURANCE
PROTECTS
YOU FROM
HIGH,
UNEXPECTED
COSTS
MAKE
QUALITY
TREATMENT
AFFORDABLE
CASHLESS
SERVICE
TAX BENEFIT

5. Health insurance in India is very limited covering
about 13% of the total population. The existing
schemes can be categorized as:
1. Voluntary health insurance schemes or private for
profit schemes:
• In the public sector, the general insurance
corporation (GIC) and its four subsidiary
companies (National insurance, corporation, new
India assurance company, oriental insurance
company and united insurance company) and life
insurance corporation (LIC) of India provide
voluntary insurance schemes.
• Currently, a few companies such as bajaj alliance,
ICICI, Royal sundaram, and cholamandalam among
others are offering health insurance schemes.

6. 2. Employer-based schemes:
• The railway, defense and security forces,
plantation sector and mining sector medical
services and / or benefits to its own
employees.

7. 3. Insurance offered by NGOs/ community
based health insurance:
Some examples of community based health insurance
schemes are:
• self employed women’s association (SEWA)
• AMUL Dairy cooperatives in Gujrat,
• The mallur milk cooperative in Karnataka
• Action for community organization, rehabilitation
and development (ACCORD) nilgiris
• Kadamalai kalanjia vattara sangam (KKVS) Madurai
• Voluntary health agencies (VHS) Chennai
• Raigarh ambikapur health association (RAHA)
Chhatisgarh

8. 4. Mandatory health insurance schemes or
government run scheme:
• The government- run schemes includes the
central govt. health schemes (CGHS) and the
employees state insurance schemes (ESIS).

9. CENTRAL GOVERNMENT HEALTH
SCHEME (CGHS)
The Central Government Health Scheme
(CGHS) was started under the Indian
Ministry of Health and Family Welfare in
1954 with the objective of providing
comprehensive medical care facilities to
Central Government employees,
pensioners and their dependents residing
in CGHS covered cities.

10. The scheme was initially started in Delhi in 1954.
Subsequently CGHS Services were extended to
the following 17 cities: Allahabad, Ahmedabad,
Bangalore, Mumbai, Kolkata, Hyderabad, Jaipur,
Jabalpur, Lucknow, Chennai, West Bengal,
Nagpur, Patna, Pune, Kanpur,
Thiruvananthapuram and Guwahati.

11. The Central Govt. Health Scheme is applicable to the
following categories of people residing in CGHS
covered cities:
• All Central Govt. Servants paid from Civil
Estimates (other than those employed in Railway
Services and those employed under Delhi
Administration except members of Delhi Police
Force).
• Pensioners drawing pension from Civil Estimates
and their family members (Pensioner residing in
non- CGHS areas also may obtain CGHS Card from
nearest CGHS covered City)

12. The medical facilities are provided through
Wellness Centers (previously referred to as
CGHS Dispensaries) /polyclinics under
Allopathic, Ayurveda, Yoga, Unani, Siddha and
Homeopathic systems of medicines. v 254
allopathic dispensaries, 19 polyclinics.78 Ayush
dispensary/ units, 3 Yoga Centers, 65
Laboratories v 17 Dental Units.

13. THE MAIN COMPONENTS OF THE
SCHEME
• The dispensary services including domiciliary care.
M.C.H. Services.
• Specialist’s consultation facilities both at
dispensary, polyclinic and hospital v level including
X-Ray, ECG and Laboratory Examinations.
• Hospitalization.
• Organization for the purchase, storage, distribution
and supply of medicines v and other requirements.
• Health Education to beneficiaries.

14. RASHTRIYA SWASTHAYA BIMA YOJNA
(RSBY)
• Central govt. health insurance scheme for the
Below Poverty Line (BPL) families in the
unorganized sector.
• It was formally launched on October 1, 2007.
• The majority of the financing, about 75 % is
provided by govt. of India, while remainder is paid
by the state govt.(25%).
• The registration fees of Rs. 30 would be collected
from the beefier by the insurance company and
adjusted against the payment of premium to be
made to the insurance company by the state govt.

15. BENEFITS:
Hospitalization expense upto Rs. 30,000
Over 725 pre-defined surgical packages
Maternity newborn care
Day care services
Cover all pre-existing diseases
1 day pre and 5 days hospitalization expenses.
Transportation costs (Rs. 100 per visit) with
overall limit of Rs. 1000 per year.

16. EXCLUSIONS
Conditions that
do not require
hospitalization.
Congenital
external
diseases
Drug and
alcohol
induced illness
Sterilization and
fertility related
procedures.
Vaccination.
War, nuclear
invasion
Suicide

17. CHALLENGES:
• Limited Influence over healthcare delivery
mechanism
• High claim ratio – Around 140%
• Low level of consumer Awareness
• Limited product development
• Limited knowledge for staff/Agents
• Pricing demands from Insurance companies

18. • Lack of proper communication between TPAs
and Hospitals
• Delay in Settlement of Claims
• Lack of Training support from Insurers as well
as TPAs
• Preexisting diseases disputes between
consumer and TPAs
• Different Insurance Companies – different
policies, terms etc

19. RESEARCH ARTICLE:
The Effect of Health Insurance Coverage on the Use of Medical
Services Michael Anderson, Carlos Dobkin, Tal Gross NBER
Working Paper No. 15823 Issued in March 2010
Substantial uncertainty exists regarding the causal effect of
health insurance on the utilization of care. Most studies cannot
determine whether the large differences in healthcare
utilization between the insured and the uninsured are due to
insurance status or to other unobserved differences between
the two groups. In this paper, we exploit a sharp change in
insurance coverage rates that results from young adults "aging
out" of their parents' insurance plans to estimate the effect of
insurance coverage on the utilization of emergency department
(ED) and inpatient services.

20. Using the National Health Interview Survey (NHIS) and a
census of emergency department records and hospital
discharge records from seven states, we find that aging out
results in an abrupt 5 to 8 percentage point reduction in the
probability of having health insurance. We find that not having
insurance leads to a 40 percent reduction in ED visits and a 61
percent reduction in inpatient hospital admissions. The drop
in ED visits and inpatient admissions is due entirely to
reductions in the care provided by privately owned hospitals,
with particularly large reductions at for profit hospitals. The
results imply that expanding health insurance coverage would
result in a substantial increase in care provided to currently
uninsured individuals.