Health insurance


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Health insurance

  1. 1. WHAT IS HEALTH INSURANCE?The term health insurance is a type of insurance that covers yourmedical expenses. A contract between an insurance provider (e.g. aninsurance company or a government) and an individual or his/hersponsor (e.g. an employer or a community organization).Popularly known as Medical Insurance or Mediclaim.Some matter regarding Health Insurance The contract can be renewable (e.g. annually, monthly) or lifelong in the case of private insurance, or be mandatory for all citizens in the case of national plans. . Sometimes it is associated with covering disability and custodial needs. The type and amount of health care costs that will be covered by the health insurance provider are specified in writing, in a member contract or "Evidence of Coverage" booklet for private insurance, or in a national health policy for public insurance.
  2. 2. THE INDIVIDUAL INSURED PERSONSOBLIGATIONS MAY TAKE SEVERAL FORMS: Premium:- The amount the policy-holder or his sponsor (e.g. an employer) pays to the health plan to purchase health coverage. Deductable:- The amount that the insured must pay out-of-pocket before the health insurer pays its share Co-payment:- The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service Coinsurance:- Instead of, or in addition to, paying a fixed amount up front (a co- payment), the co-insurance is a percentage of the total cost that insured person may also pay Exclusions:- The insured are generally expected to pay the full cost of non-covered services out of their own pockets. Coverage limits:- Some health insurance policies only pay for health care up to a certain dollar 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. Prior Authorization:- A certification or authorization that an insurer provides prior to medical service occurring Explanation of benefits:- A document that may be sent by an insurer to a patient explaining what was covered for a medical service, and how payment amount and patient responsibility amount were determined.
  3. 3. BENEFIT TO INSURED Policy Feature Benefit to InsuredNo restriction on Room rent/ ICU Rent You can decide the room you/ family member would be staying in if hospitalized and not the Insurance Company No per illness limit You will not face any specific monetary limit while taking treatment for a particular illness No Loading on renewal premium You have the assurance of unchanged premium even after receiving a claimReimbursement up to 50% for cost of If your proposal is accepted , Reliance pre policy health check up General Insurance Company shares your financial burden equally where you have to undergo specific tests requested
  4. 4. THE BASIS OF PREMIUM IS DECIDED Any individual company follow certain broad guidelines and these are as follows.Personal History: It takes into consideration the individual’s health, present health status, past medical history, family history, age of the individual, personal habits (e.g. smoking, alcohol addiction etc.).Mortality Rate: These are charges incurred by an insurance company to cover the risks incase of any eventuality to an individual. The mortality expenses differ depending on the age and the ‘Sum Assured’ being availed by an individual.Administration and marketing expenses: Such expenses are incurred by the organization as part of their operational expenses. These operational expenses are recovered in the form of premium that a policyholder pays while purchasing an insurance product.Savings component: This portion of the premium is invested in various public investments approved by the Government of that country. Investments in private sectors are generally not practiced. This is based on the guidelines issued by the Regulatory Body which is approved by the government of that country.Medical Underwriting: Underwriting of various insurance products is done to create a balance between an organization and an individual. This is done with a view to analyze risks from various angles and broad-spectrum factors so as to contain fiscal bleeding and containment of losses in the insurance sector.
  5. 5. WHAT PREMIUMS COVERName of the Company Amount paid AD choices Cashless Claim Approval In 4 Hours. No Medicals up to 50 yrs.TATA AIG Med premium 4 Lakh cover for just Rs 23 a day Single premium covers a family of 3 Medical insurance Comprehensive Insurance Covering both Structure& policy Belongings for 5 yrs
  6. 6. HOW RATES ARE CALCULATED People with health problems or who engage in unhealthy activities and those in dangerous fields of work often pay significantly more for insurance than healthy individuals with safe jobs. For example, non-smokers statistically live healthier lives than smokers, and construction workers may have more serious on-the-job accidents than accountants. Therefore, a construction foreperson who smokes will typically pay much more in premiums than a non-smoking CPA. People should keep in mind that the lowest quoted price on a premium may be the better bargain, but the insurance policy may not provide much coverage.
  7. 7. WHAT CAUSES RATES TO CHANGE Insurance companies can raise premium rates for any number of reasons, but one of the most common is a high number of claims on the policy. An insurer typically bases its prices on how much it will end up paying over the life of the policy; ideally, it tries to pay out less than what the policyholder pays in. When a person regularly files claims against the insurance policy, the company has to pay out more, limiting its profit margin. As a result, it will often raise premiums to recover this cost. In this same line, an insurer may raise rates if it expects an increase in claims. For example, if an otherwise healthy individual sustains permanent injuries in a car accident, her health insurance company may increase her premiums because it expects her healthcare costs to go up. Rates may also rise generally due to a price hike in services, to pay for claims from other policy holders, or to keep up with inflation..
  8. 8. PAYMENTS AND MISSED PREMIUMS An insurance premium is usually collected in monthly, semi- yearly, or yearly payments, depending on the type of policy. Policyholders also often have the option of combining their payments with fees for other services, or taking out several types of policies with one company to lower the overall costs. For example, buying both car and renters insurance from the same insurance company may give the buyer a discount on both. If the policyholder fails to make a scheduled payment, the company can choose to cancel the plan entirely. This is often referred to as a "lapsed policy," and the customer will typically be required to either pay the balance of the insurance premium and be reinstated or the policy will be voided. In almost all cases, a person cannot make a claim against a policy that is not current in premium payments.
  9. 9. TAX BENEFITS UNDER SECTION 80D, 80DD AND 80DDB Benefits U/S 80 D:-Available Deduction - For individuals less than 65 years of age, amount of health insurance premium paid or Rs. 15,000, whichever is lesser. For senior citizens above 65 years, amount of health insurance premium paid or Rs. 20,000, whichever is lesser. Benefits U/S 80 DD:- Available Deduction - Rs 50000, or actual expenditure incurred, whichever is lesser. For severe handicap conditions Rs. 1,00,000 is the deduction limit. Benefits U/S 80 DDB:- Available Deduction - For individual assesses less than 65 years of age, a deduction limit of Rs. 40,000 is applicable. For a senior citizen, the limit is Rs. 60,000.
  10. 10. TYPES OF HEALTH INSURANCE Family Floater Health Insurance Plans:- A single policy that secures the hospitalisation expenses of your entire family excluding dependent Parents. The floater health plan covers your entire family under one policy with one sum insured and one premium. Extended Family Floater Plan (Option to Include Dependent Parents or in-laws):- A single health insurance policy that secures the hospitalization expenses of your extended family (up to 6 dependents) including dependent Parents or you can opt for in-laws. The floater health plan covers your entire family under one policy with one sum insured and one premium. Top up Health Insurance Policy:- Policy that covers the medical expenses beyond the threshold level/deductible you have chosen. This is a good choice if you want to add additional cover up to Rs. 15 lakhs to you existing Insurance Policy with very less premium or If you are yet to opt for medical insurance, you can buy top-up policy to take medical insurance cover beyond a threshold limit that you can afford. Health Insurance Policy including OPD Expense Coverage Health Plus policy not only covers the expenses arising due to life threatening/Major Medical Illnesses and Procedures, but also for OPD (Out Patient Department) expenses like reimbursement of cost of medicines, drugs, ambulance charges and dental expenses.
  11. 11. NGO’S AND HEALTH INSURANCE SCHEMES IN INDIA So many non-profit Non-Governmental Organizations (NGOs) operate in India to provide preventive and curative health care services to the people. A small number of those NGOs also offer pre-payment health insurance schemes . Such non-profit community based insurers may offer the best hope of providing high quality, affordable and sustainable health care to the poor. This paper explores the factors associated with the long-term success of such schemes .Therefore , it is hoped, by identifying the factors, other NGOs can initiate risk sharing schemes amongst their target population. The need for involving NGOs in health insurance schemes in India arisesdue to the following four factors: Firstly, In India, private expenditure accounts for roughly two-thirds of total health care spending. Secondly, the quality of health care services available to the people in India are of poor standards. Finally, government’s combined expenditures, at the national, State and municipal levels accounted for only one-fifths of all health care spending in India.
  12. 12. EXPERIENCES IN DEVELOPING COUNTRIES NGOs were playing an important role in health care provision in countries such as Zimbabwe, Tanzania, Uganda, Nepal, Mexico, Malawi and Ghana 6. Donald S. Shepard et al7 evaluated the design, management and operational efficiency of four health insurance schemes for informal sector in both rural and urban areas of Zaire region in sub-Saharan Africa. The study findings revealed that the insurance scheme has helped the people to have access to health care services in rural and urban areas. The authors, however, did not support the rapid implementation of a nation-wide conventional health insurance system as a feasible solution but suggested decentralized , locally managed plans for success. Further, the study also suggested to initiate different types of insurance schemes for out patient and inpatient care. The schemes include health facility schemes generally initiated by hospitals, community schemes, cooperative schemes and the schemes run by the NGOs.The authors identified many problems in the existing
  13. 13. THE NEED TO SPREAD HEALTH INSURANCE AWARENESS The condition of health insurance in India is pathetic. 85% of Indian population does not use health insurance to finance their medical expenditure. These people pay for their medical expenditure from their pocket. As a result, many of these uninsured individuals either end up with poor quality healthcare or have to bear financial hardships. The financial stress that is engendered due to rising medical expenses is believed to affect the lifestyle of all family members for years. There is a need to increase the number of insured individuals in India. Working in this direction, every individual, every medical care provider and every health insurance company should play an active role. It is only then possible that people would be able to avail quality healthcare in times of medical emergency. Insurers have designed plans, but people should be encouraged to buy them so that the overall condition of medical care insurance in the country can be improved. 