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Health insurance


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Health insurance

  1. 1. Bivin Jay B Mar Baselios College of Nursing
  2. 2. Meaning of insurance • The person or business that gets compensated if the loss occurs is known as the Insured. • The company that agrees to pay the compensation is known as the Insurer. • The money that is paid by the Insured to the Insurer is called the Premium.
  3. 3. Health Insurance • System of assurance to make contingencies of health care expenses. • To provide protection against financial loss by unforseen sickness. • To meet cost of good medical care. • Relieves anxiety & tension.
  4. 4. Definition “Health insurance, like other forms of insurance, is a form of collectivism by means of which people collectively pool their risk, in this case the risk of incurring medical expenses.”
  5. 5. History of HI • 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.
  6. 6. In India • • • • • 1923: Workman’s compensation Act. 1948: ESI Act passed. 1952: First ESI hospital established. Mudaliar Committee(1959-1961) recommendations: – Long range health insurance policy for all. – Small fee for availing health services. • • 1999: IRDA act passed. 2001: Insurance amendment Act
  7. 7. Principles of Insurance • Utmost good faith – Insurer and the insured should have good faith to each other – Insurer must provide complete & accurate information – the insurance contract must be signed by both parties (i.e insurer and insured) in an absolute good faith or belief or trust.
  8. 8. Continues.. • Insurable interest – Insured must have insurable interest in the subject matter of the insurance – For example :- The owner of a taxicab has insurable interest in the taxicab because he is getting income from it. But, if he sells it, he will not have an insurable interest left in that taxicab.
  9. 9. Continues.. • Principles of indemnity – Indemnity means security, protection and compensation given against damage, loss or injury. – According to the principle of indemnity, an insurance contract is signed only for getting protection against unpredicted financial losses arising due to future uncertainties.
  10. 10. Continues.. • Principle of Subrogation – Subrogation means substituting one creditor for another. • Principle of loss minimization – It is the duty of the insured to take all possible step to minimize the loss to the insured items on the happening of the uncertain event
  11. 11. Continues.. • Principle of “Causa Proxima” – The loss of the insured property can be caused by more than one cause in succession to another – The property may be insured against some causes and tot against all causes – In such causes the proximate/nearest cause of loss to be considered
  12. 12. Forms of Health Insurance • Indemnity Insurance: where the insurer first pay to the hospital and claim is made. – E.g. Jeevan Asha II, Asha Deep II, Mediclaim. • Cashless Claim Facility: TPAs who bear the expenses on behalf of insurance company. Patients need not to pay directly as a rule – e.g. Bajaj Alliance. • CBHI (Community Based Health Insurance).
  13. 13. Characteristics of HI • It is contract between an insurance company and an individual or his sponsor (e.g. an employer). • The contract can be renewable annually or monthly. • The type and amount of health care costs that will be covered by the health insurance company are specified in advance, in the member contract or "Evidence of Coverage" booklet.
  14. 14. Terminologies related to HI • Premium: The amount the policy-holder or his sponsor (e.g. an employer) pays to the health plan each month to purchase health coverage. • Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. • Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a co-payment), the coinsurance is a percentage of the total cost that insured person may also pay. • Exclusions: The insured person is generally expected to pay the full cost of non-covered services out of their own pocket.
  15. 15. Continues.. • Coverage limits: Some health insurance policies only pay for health care up to a certain amount. • Capitation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer. • In-Network Provider: (U.S. term) A health care provider on a list of providers preselected by the insurer. • Explanation of Benefits: A document sent by an insurer to a patient explaining what was covered for a medical service, and how they arrived at the payment amount and patient responsibility amount.
  16. 16. Types of HI Accidental death and dismemberment insurance Total permanent disability insurance Vision insurance Long term care insurance Disability insurance Dental insurance
  17. 17. Health Insurance In India
  18. 18. ESI • introduced in 1948(amended in 1975, 1984 and 1989). • Benefits of ESI – Medical benefits – Sickness benefits • Extended & enhanced – Maternity benefit – Disability benefit • Permanent disability benefit – Dependants benefit – Other benefits
  19. 19. Rajiv Gandhi Shramik Kalyan Yojana • 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/travelling allowance borne by ESIC.
  20. 20. CGHS • Established in 1954 • Services – – – – – – – – – – Emergency treatment, Outdoor services, Indoor services, Domiciliary visits, Specialist’s consultation, Antenatal, natal and postnatal services Family welfare services. Supplies optical and dental aids at reasonable rates. Laboratory and x-ray investigation Paediatric services including immunization
  21. 21. Other services • Defense Medical services • Railway Medical Care • Community Health Insurance – Provider model: NGOs act both as insurer and provider of health care services. – Insurance model: NGOs is the insurer and care is purchased from a private provider. – Intermediary model: NGOs is neither the insurer nor care provider. It acts as an intermediary between the target population and the insurance provider.
  22. 22. RSBY • RSBY is supposed to become operational from 2008-2009 and all 600 districts of the country to be covered by 2012. • Objective: – To provide health security for the Below Poverty Line (BPL) workers in the unorganized sector and their families through an insurance that cover for hospital expenses. • Provider: public and private sector.
  23. 23. Advantages • Prevention: prevent diseases through early detection and doctor recommended life style changes. It keeps citizen healthier and saves money o Peace Of Mind: If a nagging problem (eg: unusual pain) persists, they can conculut doctor without expenses o Less Lost Time: Get Sick leave, visit doctor
  24. 24. Issues/limitations • Limited coverage – Only around 10% of the population is covered through health financing schemes – Geographic spread in terms of health care facilities and financing awareness is limited – Selection criteria by suppliers often restricts the poor (and more likely to be ill) from affordable pre-payment schemes • Moral hazard and Adverse selection – Claims ratios for Mediclaim and Jan Arogya policies have been in the range of 120 – 130%.
  25. 25. • System leakages – Provider malpractices leading to over-charging or preselection / selective recommendation • Lack of universal schemes – Limitations in terms of coverage of illnesses as well as treatment options – Alternative therapies often not considered / included under insurance
  26. 26. Disadvantages Cost Lack of choices Complicated rules Limited access
  27. 27. Thank Yu