DR .M.SUGANYA MD COMMUNITY MEDICINE ,ICM,MMC

1. Total health
expenditure
Public
Private
Social
security
Private
health ins.
Externally
sourced
Out-of-
pocket
Using central / state
revenues for health
Compulsory premium
contributions to
health
Channeling loans,
grants etc. to
healthcare
Payments to health
care providers for
services
Premium
contributions
towards health
support
Channeling donations
etc. to healthcare
Tax-funded
Externally
funded
The World Health Organization has defined possible
approach to financing of health expenditure

2. 19-01-2018 2
Rashitha Sithika D/o.Mohamed Abu-Bakr Sithik
residing at No.484, Telugu colony,
Thamaraipakkam Koot Road, Kanchipuram
District, Tamil Nadu. She is a 4 years old baby.
Since her birth, she had squint on Right Eye and
blurred vision on her both eyes. She checked
her eyes in a reputed hospital in Chennai. Under
chief minister health insurance scheme she was
operated in sankar eye hospital in pammal .she
regained her sight.

3. DR .M.suganya19-01-2018 3

4. Objectives:
1) Able to explain the terms used in health insurance .
2) Able to enumerate the types,advantage and disadvantage of health
insurance.
19-01-2018 4

5. Synopsis
Terms used in insurance
objectives
 History of health insurance
 Definition:
 Need of the health insurance
 Types of health insurance
 Chief Minister's Comprehensive Health Insurance Scheme
 Private health insurance
 IRDA
 How to go for insurance- basics
 SWOT analysis
 summary
19-01-2018 5

6. Terms used in insurance
 Insured.: The person or business that gets compensated if the loss occurs.
 Insurer: The company that agrees to pay the compensation
 Premium: The money that is paid by the Insured to the Insurer. the payment
required to keep your insurance policy in force
 Policy:legal document issued by insurance company that outlines the terms and
conditions of the insurance.
 Policyholder – the person who buys the insurance; also called the "insured."
 Claim –. a person's request for payment by an insurer of a loss covered by a policy
 first-party claims- claims to your own insurance company
pppppppppolicyPolicy Policy – the legal document issued by the insurance
company that outlines the terms and conditions of the insurance.
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7. TO BE CONTD
 third-party claims- claims made by one person against another
person's company Policyholder – the person who buys the
insurance; also called the "insured."
 Exclusion – specific conditions or circumstances listed in the policy
that are not covered by the policy.
Occurrence – an accident that results in bodily injury during the
period of an insurance policy.
 Peril – the cause of loss or damage.
 Risk – the chance of a loss
 Underwriting – the process of selecting risks for insurance, and
determining how much to charge to insure these risks and which
coverage to provide.
19-01-2018 7

8. TO BE CONTD
 TPA- means an organization, as defined and licensed under the
Insurance Regulatory and Development Authority regulations-2001
and is engaged for a fee or renumeration by an Public Sector
insurance company for the provision of health services.
19-01-2018 8

9. History of health insurance
 International origin:
 1883 Bismarck- sickness benefit to workers.
 1911 Lloyd George- National Health Insurance Scheme to cover
sickness expense, medical relief, drugs & compensation of wages
lost, to improve quality of life and improve industrial production.
 J.F.Kimball: prepayment system of health care.
 1958 the Canadian Hospital and Diagnoses Act provided full hospital
services almost free of charge in public wards
19-01-2018 9

10. National origin:
 1912 Insurance Act, 1912 passed, setting down rules and regulations specific
to insurance industry.
 1923: Workman’s compensation Act.
 1948: ESI Act passed.
 1952: First ESI hospital established.
 Mudaliar Committee(1959-1961) recommendations:
1. Long range health insurance policy for all.
2. Small fee for availing health services.
 1999: IRDA act passed.
 2001: Insurance amendment Act:
Emphasis onTPAs.
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11. HEALTH INSURANCE
 Definition:
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Health insurance is an insurance product which covers medical and
surgical expenses of an insured individual. It reimburses the expenses
incurred due to illness or injury or pays the care provider of the insured
individual directly.

12.  System of assurance to make contingencies of health care expenses
 To provide protection against financial loss by un foreseen sickness
 To meet cost of good medical care
 Relieves anxiety and tension
19-01-2018 12

13. NEED OF THE HEALTH INSURANCE
 Lack of financial capability amongst the poor
 Increasing cost of medical care
 Health insurance protect from unexpected high cost.
 Make quality treatment affordable.
 Cashless benefits.
 Tax benefit.
19-01-2018 13

14. Types of health insurance
Health insurance
social Community based private
Governm
ent
initiated
Normally
managed by
community
/groups
Risk rated
and offered
by
commercial
organization

15. Social health insurance
 Two mandatory and contributory health insurance schemes
ESIS CGHS
RSBY

16. EMPLOYEE STATE INSURANCE ACT 1948
 Is an important measure of social security and health insurance in
India.
 It provides certain cash and medical benefits to industrial employees
in case of sickness ,maternity and employment injury.
 It was amended in 1975,1984,1989 and 2010
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17. Coverage of factories
 All factories using power & otherthan seasonal factories employing
10/more persons
 Also small factories employing 10 or more persons ,whether power is
used or not
 Shops
 Hotels and restaurants
 Cinemas and theatres
 Road motor transports etablishments
 News paper establishments
 The scheme has been extended to private medical and educational
institutions employing 20 or more persons in some states
 Excludes mines, railways and defence establishments
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18.  Coverage of employees:
 an ‘employee’ means any person employed for wages in or in
connection with the work of a factory or establishment to which this
act applies
 - employees with the monthly wage ceiling of Rs.15000
 To encourage employers :to engage persons with disabilities for
monthly wage ceiling of Rs.25000 are covered under this act , Govt.
of India fully bears the employers’ contribution for the first 3 years.
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19. ADMINISTRATION -Esi corporation
 Meets twice a year
 Chairman –union minister of labour
 Vice chairman-secretary to minister of labour
 5 reps from central government
 1 rep from each state government
 1 rep from all union territories
 5 reps from each employers and employees
 2 reps from medical profession
 3 members from parliament
 MAKES POLICIES
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20.  STANDING COMMITTEE:Acts as executive body for executing
policies and day to day administration
 Meets 4 times a year
 Headed by director general of corporation
 assisted by insurance commissioner, medical commissioner, financial
commissioner and actuary
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21.  Finance: ESI Fund
* State Government share 1/8th of expenditure on medical treatment
& attendance
* 7/8th of the expenditure borne by ESIC
-Employers: 4.75% of the total wage bill
-Employees: 1.75% of the wages
 Employees with a daily average wage upto Rs. 150 are exempted
from payment of contribution. Employers will however contribute
their share
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22. Benefits:
Section 46 of the Act envisages following 7 social security benefits
 Medical Benefit
 Sickness Benefit
 Maternity Benefit
 Disablement Benefit
 Dependant Benefit
 Funeral Expenses
 Rehabilitation
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23. MEDICAL BENEFITS
 Medical care for self and families are admissible from day-one of
entering into insurable employment.
 Whereas, the primary, out patient, inpatient and specialist services
are provided through a network of Panel Clinics, ESI Dispensaries and
Hospitals.
 Super Speciality services are provided through a large number of
empanelled medical institutions on referral basis.
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24. SYSTEM AND LEVEL OF MEDICAL CARE SERVICE
 Provision of medical care is based upon the requirement of the
region.
The various systems prevalent are:-
 Allopathy
 Ayush which include Ayurveda, Sidha, Unani, Homeopathy and Yoga
ESI Scheme provides all three different levels of care i.e. Primary care,
Secondary care and Tertiary care (Super Speciality care).
 Primary care is provided through dispensaries & panel clinics.
 Secondary care is provided through diagnostic centres and hospitals.
 Tertiary care is provided by entering into tie up arrangement with
specialized private and government diagnostic facilities and hospitals
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25.  ESI scheme is provided full medical care to its beneficiaries which
include preventive, promotive, curative and rehabilitative services.
PROVISION OF MEDICAL CARE
Medical care services to beneficiaries are provided by two ways:-
 Direct Provision through ESI schemes own network of dispensaries,
diagnostic centres and hospitals.
by service dispensaries ,part time dispensaries and mobile
dispensaries
 Indirect Provision through tie-up with private clinics (panel system),
diagnostic centres and hospitals
SCALE OF MEDICAL BENEFIT
Full Medical care is provided as per the need of the patient irrespective
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26. SICKNESS BENEFIT
 Sickness Benefit is payable to an insured person in cash, in
the event of sickness resulting in absence from work and duly
certified by an authorized medical officer/practitioner.
 The benefit becomes admissible to insured persons in respect of
whom contribution is paid or payable for at least 78 days in
corresponding contribution period of six months and have completed
9 months in insurable employment.
 Sickness Benefit is payable for a maximum of 91 days in two
consecutive benefit periods of sickness benefit at 70% of average
daily wages
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27. EXTENDED SICKNESS BENEFIT (CASH)
 Extended Sickness Benefit becomes payable to insured
persons for the period of certified sickness in case of specified 34
long term diseases and in case of rare diseases that need prolonged
treatment and absence from work on medical advice.
 For entitlement to this benefit an insured person should have been in
insurable employment for at least two years.
 He/she should also have paid contribution for a minimum of 156 days
in the preceding four contribution periods or say two years.
 Extended sickness benefit at 80% of average daily wages
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28. EXTENDED SICKNESS BENEFIT
 ESB is payable for a maximum period of two years (including 91 days
as SB) on the basis of proper medical certification and authentication
by the designated authority.
 The benefit is payable within 7 days following the submission of
complete claim papers at the Branch Office concerned
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29. ENHANCED SICKNESS BENEFIT (CASH)
 This cash benefit is payable to insured persons in the productive age
group for undergoing sterilization operation, -vasectomy/tubectomy.
 The contributory conditions are same as for the normal Sickness
Benefit.
 Enhanced Sickness Benefit is payable to an Insured Women for 14
days for tubectomy and for 7 days in case of vasectomy in respect of
male IPs.
 The amount payable is 100% of the average daily wages.
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30. MATERNITY BENEFIT (CASH)
 Maternity Benefit is payable to Insured Women in case of
confinement or miscarriage or sickness related thereto in a
benefit period.
 The benefit is normally payable for 12 weeks for normal delivery and
6 weeks for miscarriage, extendable by 4 weeks for sickness arising
out of confinement.
 The rate of payment of the benefit is 100% of the average daily
wages.
 The benefit is payable within 14 days of submission of records
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31. DISABLEMENT BENEFIT (CASH)
 Disablement Benefit is payable to insured employees, being in
insurable employment, suffering from physical disablement due to
employment injury or occupational diseases.
 An insured person should be an employee on the date of the accident.
 Temporary disablement benefit at 90% of the average daily wages is payable
till temporary disablement lasts.
 In case of permanent disablement, the cash benefit is payable for whole life.
 Amount payable is worked out on the basis of loss of earning capacity
determined by a Medical Board.
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32. DEPENDANTS’ BENEFIT (CASH)
 Dependants’ Benefit (Family Pension) becomes payable to
dependants of a deceased insured person where death occurs due to
employment injury or due to occupational disease. Minimum amount-Rs
1200/family
 A widow can receive this benefit on a monthly basis for life or till her re-
marriage.
 Son upto age of 25 years and unmarried daughter can receive benefit.
 Other dependants like parents including a widowed mother etc. can also
receive this benefit under certain conditions.
 The rate of payment is 90% of the average daily wages distributed among the
dependants in a fixed prescribed/ ratio/ proportion.
 The first payment is payable within a period of three months following the
death of an insured person and thereafter periodically on regular monthly
basis.
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33. OTHER BENEFITS OFFERED BY THE SCHEME
 Funeral expenses on death of an I.P. subject to a maximum of
a Rs10,000/- payable at the Branch Office. The claim of such
payment should be made within three month of the death of IP.
 Vocational Rehabilitation in case of physical disablement due
to employment injury under 45 years of age with 40 percent or
more disablement. Payable as long as vocational training lasts -
actual fee charged or Rs.123/- a day whichever is higher
 Rehabilitation: The rate of contribution for superannuated/disabled IP
is Rs.120/- per annum payable in lump sum at the Branch Office for
availing reasonable medical care for self and spouse.
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34. OTHER BENEFITS OFFERED
 Free supply of physical aids and appliances such as crutches,
wheelchairs, dentures, spectacles and other such physical aids.
 Preventive health care services such as immunization, family welfare
service, HIV/AIDS detection, treatment etc.
 Confinement Allowance @ Rs.2500/- is paid to an insured woman
or insured person in respect of his wife in case confinement occurs at
a place where necessary medical facilities under ESI Scheme are not
available. This is paid for two confinements only
19-01-2018 34

35. UNEMPLOYMENT ALLOWANCE
 Unemployment Allowance named as Rajiv Gandhi Shramik Kalyan
Yojana, is payable to workers facing involuntary unemployment due to
closure of factory/establishment or retrenchment or permanent invalidity.
 The daily rate of Unemployment Allowance is 50% of the average daily
wages.
 This allowance is payable for a maximum period of 12 months during entire
life either in one spell or in different spells of not less than one month’s
duration.
19-01-2018 35

36. Super Speciality Treatment (SST)
 The insured persons and their family members are entitled to Super
Speciality medical care and /or reimbursement along with the cost of
supply of medicines if the I.P completes three months service and
contribution for 39 days w.r.t self and six month service and 78 days
contribution in case of family members.
19-01-2018 36

37. INCENTIVES TO EMPLOYERS IN THE PVT. SECTOR PROVIDING
EMPLOYMENT TO
THE PERSONS WITH DISABLITIES
 Persons with disabilities employed on or after 01.04.2008 and drawing
monthly wages upto Rs.25000/- are covered under the Scheme and
Employers’ share of contribution is paid by Government for three years.
THE NATIONAL TRAINING ACADEMY is the nodal agency to handle all matters
relating to training of officers and staff of ESIC and officer and staff
working under ESIS in State Government.
NTA is presently functioning under the charge of Commissioner who is
assisted by officers of other categories and medical officers
19-01-2018 37

38. 201O AMMENDMENT SALIENT POINTS IN ESI
ACT
Enhancing age limit of children for
eligibility to dependants benefit
 Sec.2(6A)(i) & (ii): Age limit of dependant legitimate or adopted son
for eligibility to dependants benefit enhanced from 18 years to 25
years
Inclusion of minor brother/sister
the definition of family
 Sec.2(11)(vi): It is proposed that in case of unmarried IPs whose
parents are also not alive, dependant minor brother or sister be
made eligible for medical care.
19-01-2018 38

39. Change in definition of ‘factory’
 Sec.2(12): “factory” now comprises of any premises where 10 or
more persons are employed irrespective of whether power is used in
the manufacturing process or not
Replacing the words ‘insured person’ with ‘employee’
 Sec.51-A to 51-D: The words ‘insured person’ in Sec.51-A to 51-D
have been substituted with the words ‘employee’ to prevent
misuse/mis-interpretation by persons who remain IPs after going out
of employment and suffer injury.
Continuance of medical care to IPs
retiring under VRS/pre-mature retirement
 Sec.56(3) & 95(ehh): Continuing medical care to IPs retiring under
VRS schemes or taking premature retirement and their spouse.
19-01-2018 39

40. Setting up of State level autonomous
Corporations
 Sec. 58(5) (6), Sec.96: New provision empowering State Govts. to set up
state level autonomous organizations for administering medical care in the
states.
Provision for setting up of medical
colleges :
 New Sec.59-B : Provision made for establishment of medical colleges,
nursing colleges and training institutions for para-medical staff.
19-01-2018 40

41. Rajiv Gandhi Shramik Kalyan Yojana-
(Unemployment Allowance Scheme)
 Scheme introduced w.e.f. 1-4-05.
 Insured person who becomes unemployed after being insured for 5 or more
years, due to closure of factory/ establishment, retrenchment or permanent
invalidity are entitled to:-
 Unemployment Allowance equal to 50% of wage for a maximum period of
upto one year,
 Medical care for self and family from ESI Hospitals/dispensaries during the
period IP receives unemployment allowance
 Vocational Training provided for upgrading skills – Expenditure on fee/
traveling allowance borne by ESIC.
19-01-2018 41

42.  Reimbursement of Funeral expenses enhanced from Rs.5,000 to Rs.10,000/-
 Rate of Confinement Expenses payable to insured women for confinement
outside ESI Hospitals raised from Rs.1000 to Rs.2500 .
 Differently-abled workers drawing wages upto Rs.25000 covered under the
scheme and employers contribution borne by Central Government for initial
three years to encourage employers to give employment to such workers.
 ISO Certification for all ESI institutions
 Grading of ESI Hospitals through professional Agencies.
 Client satisfaction survey being conducted in-house as well as through
professional agencies.
 Utilization of underutilised capacity in ESI Hospitals to provide medical
services to BPL workers under Rashtriya Swasthya Beema Yojna.
19-01-2018 42

43. PANCHADEEP PROJECT
IT Enablement Project under implementation which will provide [PANCHADEEP
PROJECT]:-
 PEHCHAN cards for IP and family which will enable availment of benefits
anywhere anytime.
 Insurance number & Card to remain same even if job changes.
 Online registration of factory/estt., employees
 Online submission of challan and contribution payment
 IP can access eligibility, status of claims
 Registration of patients in hospitals/dispensaries &
 Medical history of patient.
19-01-2018 43

44. 19-01-2018 44

45. RECENT INITIATIVES
 Modernisation/upgradation/expansion of all ESI Hospitals to bring them at par
with best Corporate hospitals.
 Hospital Development Committees constituted in all ESI Hospitals with
executive/financial powers and representation of stakeholders.
 Medical Colleges, Para-medical and nursing training institutions will be set up
to improve quality of medical care and to overcome shortage of medical/para-
medical personnel.
 Tie-up arrangements with 417 hospitals (govt/private ) for providing cashless
super specialty services and specialties not available in ESI Hospitals
anywhere in the country as per IPs choice
19-01-2018 45

46.  Tie- up arrangement for primary care where 5000 IPs are there and there is
no ESI dispensary within 8 Kms.
 Tie up arrangement for secondary and tertiary care where:
a] 25000 IPs but ESI Hospital is more than 25 Kms away;
b]15000 IPs but ESI hospital is 75 to 125 Kms away;
c]10000 IPs but ESI Hospital is more than 125 Kms away
19-01-2018 46

47. NETWORK OF MEDICAL FACILITIES
 1384 -Esi dispensaries
 2100 -Panel clinics
 307 -Diagnostic centres
 151 -Esi hospitals 116 hospitals directly run by STATE govt.and 35 run by
ESIC.
 Hospital annexes are-42 with 27000 beds
 Super speciality medical care given with advanced medical institution
 Cash payment –through 624 branch offices and 197 cash offices
 Head office in New Delhi .23 regional office,26 sub regional office
19-01-2018 47

48. CENTRAL GOVERNMENT HEALTH SCHEMES
 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.
 The scheme was initially started in Delhi in 1954.
 Subsequently CGHS Services were extended to the following 17
cities
Allahabad, Ahmadabad, Bangalore, Chennai ,
Guwahati,Lucknow,hyderabad Jaipur, Jabalpur, Kolkata,
Kanpur, Mumbai, nagpur, Patna, Pune ,Thiruvananthapuram
and West Bengal,
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49. The Central Govt. Health Scheme is applicable to the
following categories of people residing in CGHS
covered cities:
 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)
 Members and Ex-members of Parliament
 Judges of the Supreme Court and High Court (sitting and retired)
 Freedom Fighters
 Central Government Pensioners, Employees of Semi-Autonomous
bodies/Semi Government Organisations
 Accredited Journalists
 Ex-Governors and Ex-Vice-Presidents of India
19-01-2018 49

50. The medical facilities are provided through Wellness Centres(previously
referred to as CGHS Dispensaries) /polyclinics under Allopathic,
Ayurveda, Yoga,Unani Sidha and Homeopathic systems of medicine.
Service rendered via
 254 allopathic dispensaries
 9 polyclinics
 78 Ayush dispensary/ units
 3 Yoga Centres
 65 Laboratories
 17 Dental Units
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51.  Main components of cghs:
 The dispensary services including domiciliary care.
 F. W. & M.C.H. Services
 Specialists consultation facilities both at dispensary, polyclinic and
hospital
 including X-Ray, ECG and Laboratory Examinations
 Hospitalization
 Organization for the purchase, storage, distribution and supply of
medicines and other requirements.
 Health Education is also given to beneficiaries.
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52. 19-01-2018 52

53. UNIVERSAL HEALTH INSURANCE SCHEME
 Government of India launched the universal health insurance in 2003
 It is a standard mediclaim product with an annual cover of Rs 30,000
for a family
 It was marketed by the public sector insurance companies and was
for BPL population
 But it failed due to lack of willingness of insurers, improper
identification of beneficiaries and in adequate coverage
 It was superseded by RSBY
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54. RASHTRIYA SWASTHYA
BIMA YOJANA
 GOALS:Inability to deal with medical emergencies without facing a
financial crisis
 Heavy expenditure on medical care and hospitalization
 Recourse to adequate and competent treatment
19-01-2018 54

55.  BENEFITS:Total sum insured of Rs 30,000 per BPL family on a family
floater basis
 Pre-existing diseases to be covered
 Coverage of health services related to hospitalization and services of
surgical nature which can be provided on a day-care basis
 Cashless coverage of all eligible health services.
 Provision of Smart Card.
 Provision of pre and post hospitalization expenses.
 Transport allowance @ Rs.100 per visit upto maximum of Rs 1000
19-01-2018 55

56. It is implemented by the
 Identification of Insurance agency
 Enrollment of Beneficiaries and Delivery of Smart Card to
commence
 Empanelment of Government and private institutions
 Payment of insurance premium to the insurance service provider.
 Delivery of health services
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57. QUALIFICATION OF INSURANCE COMPANY
 Registered with IRDA
 Should have full-fledged establishment with experience in
conceptualizing, designing and implementing large health care
schemes
 At least one year experience in catering Health Insurance of 50,000
families or more under one group insurance policy in 2005-06 or
2006-07
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58.  Both public, including ESI, and private health providers could offer
services
 The service providers should possess specified basic facilities, like:-
 At least 10 inpatient medical beds;
 Medical & Surgical facilities along with
Diagnostic facilities i.e. Pathological test,
X-Ray, ECG, etc.
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59. FUNDING
 Contribution by GOI : 75% of the estimated annual premium of Rs
750, subject to a maximum of Rs. 565 per family.
 Contribution by the State Governments: 25% of the annual
premium and any additional premium beyond Rs 750.
 Beneficiary to pay Rs. 30 per annum as Registration Fee/ Renewal
Fee
 Administrative cost to be borne by the State Government will come
from Rs 30 received from beneficiary
 Cost of Smart Card to be borne by the Central Government. An
additional amount of Rs.60 per beneficiary would be available for this
purpose.
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60. AAM ADMI BIMA YOGANA WITH RSBY
 AABY Provides for insurance of head of the family or an earning
member of the family of rural landless household between the age of
18 to 59 years against natural death as well as accidental death and
partial/permanent disability.
 AABY is now collaborating with RSBY
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61. Ex-serviceman contributory health scheme
19-01-2018 61
This scheme is meant for ex army personals
They have to contribute as per laid norms and they are entitled for
specific services in lieu of contributions.
It was launched with effect from April 1 2003
The objective was to provide medical care to its members and its
dependant
It has 227 polyclinics ,106 military and 121 non military stations
It was fully established by 31 march 2008
It covers 320lakh ex-serviceman and 10 million beneficiaries

62. COMMUNITY HEALTH INSURANCE
 Is NOT- FOR –PROFIT insurance scheme
 Aimed at the informal sector and formed on the basis of a collective
pooling of health risks, and in which the members participate in its
management
 Initiated by NGOS
 Mainly to improve access to health care
 Covers about 1000 to 100,000 people
 Covers mostly poor and near poor
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63. 3 basic models of CHI
 Provider model Insured model Linked model
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64. Example
 YESHASVINI –karnataka-june 2003
 ORGANISED BY YESHWANI TRUST
 Eligibility –cooperative farmers and their families
 Premium-Rs 120+30 per person per year
 Benefit –any surgery up to Rs 1 lakh per hospitalization and 2 lakh
per patient per year
 Providers – empanelled hospital
 Administration by TPAS
19-01-2018 64

65. KARUNA TRUST
 Initiated in September 2002 in karnataka
 Organised by karuna trust
 Eligibility –BPL families in talukas where karuna trust works
 Premium-Rs 20 per person per year
 Benefit- hospitalization expenses up to Rs 2500;loss of wages up
to Rs 1500; payment to the doctors up to Rs 1500
 Providers –only government hospitals
 Now covering 10,000 people
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66. RAJIV AAROGYA SRI HEALTH INSURANCE SCHEME
To improve access of BPL families to quality medical care for treatment
of identified diseases involving hospitalization, surgery
1. Heart
2 Cancer treatment
1. Surgery/Therapy
2. Chemo Therapy
3. Radio Therapy
4. Neurosurgery
5. Renal diseases
6. Burns
7. Poly trauma cases (not covered by the Motor Vehicles Act)
8. Cochlear Implant Surgery with Auditory-Verbal Therapy for
Children below 6 years
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67. SELF EMPLOYED WOMEN
ASSOCIATION
 SEWA is a trade union for poor, self-employed women workers in
India
 It was founded by famous gandhian and civil rights leader dr
Elabhatt in 1972
 members are women who earn a living through their own
labour or small business
 SEWA began offering health insurance, which cost their member Rs
85 annually
 Since 1992, Vimo SEWA has provided life and hospitalization
insurance for its members and their families for as little as Rs 100
per person
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68.  CONCULSION:
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Useful tool to improve access to health care and protect families
from impoverishment
But there are some preconditions-
 trustworthy organization
Good quality providers
Community with some means
Managerial skills

69.  PERFORMANCE OF CHI:
 Able to reach out to the weaker sections of society
 Provide some form of health security
 Has improved access to health care
 Has protected households, but only partially
 Has not improved quality of care for the patient
 Many of them require external subsidies
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70. Chief Minister's Comprehensive Health Insurance
Scheme
 Objectives:universal health care, providing affordable and quality
health service effective in fulfilling the public aspirations.
 State empowered committee under chairpersonship of chief secretary
of Tamilnadu and 12 members to process and finalize the tender and
to provide operational guidelines for the implementation of the
scheme.
 State empowered committee meeting held on 13-7-2011 has
suggested to name the NEW COMPREHENSIVE HEALTH INSURANCE
SCHEME as CHIEF MINISTER ‘S COMPREHENSIVE HEALTH
INSURANCE SCHEME
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71.  ELIGIBLE PERSON :The Eligibility to avail Chief Minister’s
Comprehensive Health Insurance Scheme, is as indicated for the
resident of tamilnadu by the presence of his/her name in the Family
card and whose annual income is less than Rs.72, 000/ per annum.
 , it is sufficient to produce family card and Income certificate by the
VAO/Revenue authorities along with the self declaration of the head
of the concerned family.
 “Family” includes the eligible member, and the members of his or her
Family as detailed below:
 (i) Legal spouse of the eligible person
(ii) Children of the eligible person
(iii) Dependent parents of the eligible person.
 Srilankan refugees in the camps are also eligible without any Income
limit.
 Migrants from other states can also join this CMCHIS based on the
request letter along with a list of Eligible member’s from labour
department, provided they have resided for more than six months in
the state as certified by suitable authority.
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72.  Orphans residing in any registered/unregistered organization can be
given a singlecard. This also includes the rescued girlchildren and any
other person defined as orphan by the government.
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73.  PREMIUM PAID: 699rs/per family per year for 1.34 crore families in
Tamilnadu.
 A 24 hour Call Centre has been set up at CMCHISTN Project Office
with sufficient manpower with toll free help line.
The Toll Free Number is 1800 425 3993.
 TPAs: United India Insurance( TTK health care TPA Private
limited,MD India health care TPA private limited,Medi Assist India TPA
Private Limited.
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74.  Free health camps / screening camps will be conducted by
network hospitals as per the directions given by Project Director of
Tamil Nadu Health Systems Society.
 Minimum of one camp per month per empanelled hospital will be
held in the districts in each policy year. The persons who need
treatment are identified in the Health camps.
 Hospitals to be covered under the scheme:both government and
private hospitals with the approval of empanelment and disciplinary
committee with a minimum criteria:
 a)hospital should have at least 30 inpatient beds.
 b) it should be equipped and engaged in providing medical and
surgical facilities along with diagnostic facilities i.e. pathological test,
x-ray and other investigation etc.
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75.  c)fully equipped OT
 d)qualified doctors,nurses,physically in charge round the clock.
 e)maintain necessary and complete records.
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76. Private health insurance
 A voluntary health insurance wherein people can enrol and purchase
the insurance product of their liking, paying a risk rate premium
 Both public and private insurance companies market a variety of
health insurance products
 Out of these mediclaim is the most sold product.
 Introduced in 1986
 A voluntary health insurance scheme offered by the private sector
since 1999
 Any body =3 months to 80 yrs. who can afford the risk related
premium is eligible to join the scheme
 The premium depends on the age, risk and the benefit package opted
for
 The subscribers are usually the middle and upper class, especially as
there is a tax benefit
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77. legislation
 Insurance regulation formally began in India with the passing of the
Life Insurance Companies Act of 1912 and the provident fund Act of
1912
 Insurance is a federal subject in India. There are two legislations that
govern the sector- The Insurance Act- 1938 and the IRDA Act- 1999.
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78. IRDA
 A regulatory body, controlled by the Indian govern ,governing
insurance companies across India
 The head quarters of IRDA is in Hyderabad
AIMS
 To protect the interests of the policy holders, and
 To regulate ,promote and ensure orderly growth of the insurance
industry
 Conduction of insurance business across the country in ethical
manner
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79. Composition of Authority
 As per the section 4 of IRDA Act' 1999, Insurance Regulatory and
Development Authority (IRDA, which was constituted by an act of
parliament) specify the composition of Authority
The Authority is a ten member team consisting of
(a) a Chairman;
(b) five whole-time members;
(c) four part-time members,
(all appointed by the Government of India)
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80. Claim disputes/grievances
 Ombudsman is a special court constituted under IRDA for addressing
grievances associated with insurance claims
 The claimant can approach the ombudsman for resolving claim issues
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81. Viewers at this time ……
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82. List of health insurance companies in India
 Apollo Munich Health Insurance Company limited
 Star Health and Allied insurance Co Ltd
 Future Generali India Insurance Company Ltd
 Bajaj Allianz General Insurance Co Ltd
 ICICI Lombard General Insurance Co Ltd
 National Insurance Co Ltd
 The New India Assurance Co Ltd
 Reliance General Insurance Co Ltd
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83.  United India insurance Co Ltd
It is a nationalized general insurance company having its operation in
whole country
 Royal Sundaram Alliance Insurance Co Ltd
 Religare Health Insurance Co Ltd
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84. How to go for insurance- basic knowledge
 If you are healthy- Basic Health Insurance Plan
 If at hereditary risk/poor health-Critical Illness Policy
-pays lump sum when holder is diagnosed with one of specified
critical illness.( cancer, CAD, Heart attack, major organ
transplant, paralysis, stroke)
-after lump sum is paid policy terminates
-these policies are far cheaper than basic health policies, so can’t
depend alone on these.
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85. Senior citizens specific covers
 Bajaj Allianz general insurance
 Silver Health
 National Insurance
 Varishtha Mediclaim
 New India Assurance
 Sr. Citizen Mediclaim
 Oriental Insurance
 Health of Privileged Elder
 Star Health Allied
 Sr. Citizen Red Carpet
 United India Insurance
 Sr. Citizen Mediclaim
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Bajaj Allianz general insurance Silver Health
National Insurance Varishtha Mediclaim
New India Assurance Sr. Citizen Mediclaim
Oriental Insurance Health of Privileged Elder
Star Health Allied Sr. Citizen Red Carpet

86. ADVANTAGES OF HEALTH INSURANCE
 Risk Cover
 Protection against rising health expenses
 Daily hospital cash allowance
 Peace of Mind
 Tax Benefits
 Coverage of expenses related to organ donors
 Convalescence Benefits
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87. DISADVANTAGE
 Restricted hospital
 Health does not cover pre-existing diseases
 Expenses of defect related aids is not covered Eg:- Contact lens, Hearing aids,
general ability & intoxicating Drugs
 Most company do not have separate health insurance cover for a child
 Older the age higher the cost of premium
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88. TAX BENEFITS
 under section 80 D for paying medical insurance premium earlier the
deduction allowed was Rs. 15000
 In march 2015 which has now been increased to Rs. 25000, which
means by additional saving of Rs. 10000, the tax saving will be Rs.
3000 who are in 30% tax bracket and Rs. 1000 for those who are in
10% tax bracket.
 above 80 years of age. For them additional allowance of Rs. 30000
for expenditure incurred for treatment on certain specified diseases
has also been allowed
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89. conclusion
 Growth potential for the insurance sector is immense.
 Consideration required to poor and unemployed.
 Private health insurance has positive role to play.
 Insurance sector needs to widen its scope from only providing
treatment facilities to promotive and preventive health care
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90. RajbirKaur,MPH,PU
References
 World Health Organization
 Park K: Preventive and Social Medicine
 Rowitz Louis: Public Health for the 21st
Century
 www.google.com
 Textbook of community medicine
suryakantha
 Global Journal of Management and
Business Studies.
 THE GAZETTE OF INDIA : EXTRAORDINARY
[PART II—SEC. 3(i)]
 www.slidesshare.com

91. 19-01-2018 91
Ignoring health insurance is ignoring health...
We must select our proper insurance plan !!!

92. ANY doubts???????
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