The document discusses health insurance in India, including various state-run health insurance programs. It provides definitions of key insurance terms and explains concepts like risk pooling, cross-subsidization, and moral hazard. It then describes several major public health insurance schemes in India, including the Employment State Insurance Scheme (ESIS), Rashtriya Swasthiya Bima Yojana (RSBY), and various state-level programs. It notes that while health insurance coverage has expanded, it still only reaches about one-fourth of the Indian population.

1. Dr.Praseeda.BK

2.  Definition
 Terms
 Risks
 Health Insurance in India
 State Health Insurance
 Micro insurance
 Current trends in India

3. Insurance is a form of risk
management, where risk is transferred
from one entity to another, in
exchange of premium

4.  The revenue is generated either by individuals
paying a premium or by employers
contributing towards their employees or even
the government paying on behalf of the poor.
 This revenue (called premium) is pooled into
an autonomous fund that is used specifically
to finance health care.

5.  Otto von Bismarck(1883–84) in Germany initiated
Compulsory accident and sickness insurance
 Adopted by Great Britain, France, Chile, the Soviet
Union, and other nations after World War I.
 Act of 1946, In Britain the National Health Insurance
which went into effect in 1948, provided the most
comprehensive compulsory medical care plan.

6.  Policy – The legal document issued by the
insurance company that outlines the terms and
conditions of the insurance.
 Policyholder – The person who buys the
insurance; also called the "insured."
 Premium – The payment required to keep your
insurance policy in force

7.  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
third-party claims- claims made by one person
against another person's company
 Exclusion – Specific conditions or circumstances
listed in the policy that are not covered by the policy.

8.  Occurrence – An accident/illness 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.

9.  Premium is an amount paid periodically to the
insurer by the insured for covering his risk.
 The premium is a function of a number of
variables like age, type of employment,
medical conditions, etc

10.  Risk pooling
 Cross subsidy

11.  Risk pooling" refers to the spreading
of financial risks evenly among a large
number of contributors to the
program.
 For risk pooling to be effective, the
risk should be unforeseen and
infrequent (uncertain)

12.  The practice of charging higher prices from
one group of consumers to subsidize lower
prices for another group

13.  Adverse selection
 Cream skimming
 Moral Hazard

14.  Due to poor planning by the insurance company
 When more ill patients enrolled than healthy
subjects.
 Insurance companies do not have all of the facts
about the individual.
 Outflow exceeds inflow.
 Programme unviable.

15.  Opposite of adverse selection
 When high risk individuals are rejected.
 Low risk individuals are chosen
 Choosing less ill patients increase profit for
companies
 Less useful for demand side

16. From the part of subject(demand side)
 Indulges in risky behaviour
 Patient tends to demand more
care/treatment/investigations
From the part of the health provider(supply
side)
Intervene unnecessary
Charge huge bill

17.  Health insurance as a tool to finance health
care has very recently gained popularity In
India
 Cover approximately one-fourth of India’s
population

18.  Employment State Insurance Scheme (ESIS)
 Rashtiya Swasthiya Bima Yojana (RSBY)
 Central Government Health Scheme (CGHS)
 Aam Aadmi Bima Yojana (AABY)
 Janashree Bima Yojana (JBY)
 Universal Health Insurance Scheme (UHIS)

19.  Established by ESI act 1948
 Covers employers who earn below Rs. 15,000
per month
[increased to 21,000 recently (1/1/17)]

20.  Act is applicable to non-seasonal factories employing
10 or more persons.
The Scheme has been extended to shops, hotels,
restaurants, cinemas including preview theatres, road-
motor transport undertakings and newspaper
establishments employing 10* or more persons.
And Private Medical and Educational institutions
employing 10* or more persons in certain States/UTs.

21.  Covered employees contribute 1.75% of the
wages
 Employers contribute 4.75% of the wages
 State Gov contribute1/8 th ,cental Gov 7/8 th
share of the cost of Medical Benefit.
 If the employee is drawing upto Rs.100/- as
daily average wage, he is exempt from the
payment of his share of contribution

22.  Medical benefit
 Sickness benefit
 Maternity benefit
 Disablement benefit
 Dependants benefit
 Funeral expenses
 Rehabilitation allowance

23.  To start with for a period of 3 months or till the
spell of treatment lasts whichever is later &
thereafter based on payment of contribution
 Rate - Full medical care. Facilities including
hospitalisation for insured person and family.
 Medical care is also provided to retired and
permanently disabled insured persons and their
spouses on payment of a token annual premium
of Rs.120/- .

24.  Sickness Benefit in the form of cash
compensation at the rate of 70 % of wages is
payable to insured workers during the
periods of certified sickness for a maximum
of 91 days in a year.
 In order to qualify for sickness benefit the
insured worker is required to contribute for
78 days in a contribution period of 6 months.

25. Extended Sickness Benefit(ESB) :
 SB extendable upto two years in the case of
34 malignant and long-term diseases at an
enhanced rate of 80 per cent of wages.

26. Enhanced Sickness Benefit :
 Enhanced Sickness Benefit equal to full wage
is payable to insured persons undergoing
sterilization for 7 days/14 days for male and
female workers respectively.

27. Maternity Benefit for confinement/pregnancy is
payable for Twenty Six (26) weeks
which is extendable by further one month on
medical advice at the rate of full wage subject
to contribution for 70 days in the preceding
Two Contribution Periods.

28. 1. Temporary disablement benefit (TDB) :
From day one of entering insurable
employment & irrespective of having paid any
contribution in case of employment injury.
Temporary Disablement Benefit at the rate of
90% of wage is payable so long as disability
continues.

29. 2. Permanent disablement benefit (PDB) :
The benefit is paid at the rate of 90% of wage
in the form of monthly payment depending
upon the extent of loss of earning capacity as
certified by a Medical Board

30.  An amount of Rs.10,000/- is payable to the
dependents or to the person who performs
last rites from day one of entering insurable
employment.

31.  An Insured Women or an I.P.in respect of his
wife in case confinement occurs at a place
where necessary medical facilities under ESI
Scheme are not available.

32.  Vocational Rehabilitation :To permanently
disabled Insured Person for undergoing VR
Training at VRS.
 Physical Rehabilitation : In case of physical
disablement due to employment injury.

33.  For Insured Person retiring on attaining the
age of superannuation or under VRS/ERS and
person having to leave service due to
permanent disability insured person & spouse
on payment of Rs. 120/- per annum.

34.  This scheme of Unemployment allowance was
introduced in 01/04/05.
 An Insured Person who become unemployed after
being insured three 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
Two Years.
 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.

35.  The ESI Act covers workers in the organized
sector only (52.44% of organized sector).
 Only about 3.11% of the total work force in
the country
 A large number of otherwise eligible
employees are not covered by ESIS, (as the
scheme is only available in notified areas
characterized by higher concentration of employers
and employees. )
 Scheme still has to cover about 8 percent of
the eligible population without coverage.

36.  Launched on April 1, 2008
 Cashless health insurance cover
 Below Poverty Line (BPL) workers in India
 Unrecognised sector workers and their
family members
 In public as well as private hospitals.
 Implemented in 25 states of India

37.  In the starting RSBY is a project under the
Ministry of Labour and Employment.
 Now it is transferred to Ministry of Health
and family welfare from April 1, 2015

38.  To provide financial protection against
catastrophic health costs by reducing out
 To improve access to quality health care for
below poverty line households of pocket
expenditure for hospitalization and other
vulnerable groups in the unorganized sector

39.  The beneficiaries need to pay only Rs. 30/- as
registration fee for a year
 Hospitalization coverage up to Rs. 30,000/- per annum
 Defined diseases in the package list.
 The government has framed indicative package rates for
the hospitals for a large number of interventions.
 Pre- existing conditions are covered from day one and
there is no age limit

40.  Maximum five members of the family which
includes the head of household, spouse and
up to three dependents.
 Additionally, transport expenses of Rs.
100/- per hospitalisation will also be paid to
the beneficiary subject to a maximum of Rs.
1000/- per year per family.

41.  Sponsored by State Government
 Funding Pattern 100% State Government
 Ministry/Department - Labour and
rehabilitation department

42.  It extends to all the families other than the BPL
families (Absolute Poor) as per the Planning
Commission's guidelines who come under the
Rashtriya Swastya Bima Yojana (RSBY)

43.  The non-RSBY population will be divided
into two categories:
A - Those belonging to the BPL (Poor) list of
the State Government but not to the list as
defined by the Planning Commission
B - The APL families that belong neither to
the State government list nor to the list
prepared as per guidelines of the Planning
Commission.

44.  The beneficiary contribution will be Rs.30 per family
per annum for RSBY families
 Category A – 100 Rupees
 Category B – Entire amount of Premium

45.  INSURANCE COVERAGE - The Scheme shall provide
coverage for meeting expenses of hospitalization
and surgical procedures for beneficiary members
upto Rs.5.00 lakh per family per year subject to
limits, in any of the network hospitals.
 The benefit to the family will be on floater basis i.e.
the total reimbursement of Rs.5.00 lakh can be
availed of individually or collectively by members of
the family.

46.  Provides comprehensive health care facilities
for the Central Govt. employees and
pensioners and their dependents residing in
CGHS covered cities.

47.  The dispensary services including domiciliary care.
 F. W. & M.C.H. Services
 Specialists consultation facilities both at dispensary,
polyclinic and hospital level including X-Ray, ECG and
Laboratory Examinations.
 Hospitalization.
 Organization for the purchase, storage, distribution
and supply of medicines and other requirements.
 Health Education to beneficiaries.

48.  Aam admi bima yojana, a Social Security Scheme for
rural landless household was launched on 2nd
October, 2007.
 The head of the family or one earning member in
the family of such a household is covered under the
scheme.
 The premium of Rs.200/- per person per annum is
shared equally by the Central Government and the
State Government.
 The member to be covered should be aged between
18 and 59 years.

49. A separate fund called "Aam Admi Bima Yojana
Premium Fund" has been set up by Central Govt. to pay
the Govt. contribution.
 Fund is maintained by LIC.
 A free add-on benefit in the form of scholarship to
children is also available under the Scheme.

50.  Janashree Bima Yojana (JBY) was launched on
10th August 2000.
 The Scheme replaced Social Security Group
Insurance Scheme (SSGIS) and Rural Group
Life Insurance Scheme (RGLIS).
 45 occupational groups have been covered
under this scheme

51.  It provides life insurance protection to people
who are below poverty line or marginally
above poverty line.
 Persons between aged 18 years and 59 years
and who are the members of the identified 45
occupational groups are eligible to be
covered under the Scheme

52.  Aam Admi Bima Yojana and Janashree Bima
Yojana have been merged into one scheme.
 It is renamed as “Aam Admi Bima Yojana” ,
effective from 01.01.2013.

53.  The four public sector general insurance companies
have been implementing Universal Health Insurance
Scheme for improving the access of health care to poor
families.
 The scheme provides for reimbursement of medical
expenses upto Rs.30,000/- towards hospitalization
floated amongst the entire family,
 Death cover due to an accident @ Rs.25,000/- to the
earning head of the family and compensation due to
loss of earning of the earning member @ Rs.50/- per
day upto maximum of 15 days.

54.  The Universal Health Insurance Scheme (UHIS)
has been redesigned targeting only the BPL
families.
 The premium subsidy has been enhanced
from Rs.100 to Rs.200 for an individual,
Rs.300 for a family of five and Rs.400 for a
family of seven, without any reduction in
benefits

55.  Rajiv Aarogyasri, Andhra Pradesh
 Mukhyamantari Amrutam (MA), Gujarat
 The Chief Minister's Distress Relief Fund, Kerala
 Chief Minister's Releif Fund, Madhya Pradesh
 Rajasthan's Chief Minister's Relief fund, Rajasthan
 Chief Minister's Comprehensive Health Insurance
Scheme, Tamil Nadu

56. 
Apollo Munich Health Insurance
 Bajaj Allianz Health Insurance
 Future Generali Health Insurance
 Max Bupa Health Insurance
 Religare Health Insurance
 Royal Sundaram Health Insurance
 Star Health and Allied Insurance
 L & T Insurance

57.  The New India Assurance Co . Ltd
 United India Insurance Company
 National Insurance Co.ltd
 Oriental Insurance

58.  Pradhan Mantri Suraksha Bima Yojana
 Pradhan Mantri Jeevan Jyoti Bima Yojana
 Varishtha pension Yojna (24/1/17)

59.  Eligibility: Age between 18 years (completed) and 70
years (age nearer birthday) who give their consent to join
 Policy period: The cover shall be for one year period
starting from June 1, 2015 to May 31, 2016
 Premium: Rs. 12 per annum.
 Payment Mode: The premium will be directly auto-
debited by the bank from the subscribers account. This
is the only mode available.
 Risk Coverage: Total coverage (sum-insured) under the
scheme is Rs. 2 Lakh.

61.  Eligibility: age between 18 years (completed) and 50
years (age nearer birthday) who have given the
consent to join
 Policy period: The cover shall be for one year period
starting from June 1, 2015 to May 31, 2016
 Premium: Rs. 330 (per annum).
 Payment Mode: The premium will be directly auto-
debited by the bank from the subscribers’ savings
bank account. This is the only mode available
currently.
 Risk Coverage: Sum Assured of Rs. 2 Lakh on death
of the Insured member for any reason is payable to
the Nominee.

62.  Senior citizen pension scheme as advocated
by GOI incorporated in LIC
Key Features
 no medical check up required
 Only need to pay a single premium

64.  Microinsurance is the protection of low-income
people (those living on between approximately $1
and $4 per day) against specific perils in exchange
for regular premium payment proportionate to the
likelihood and cost of the risks involved.

65.  Small schemes, community-based
 For poor and not-for-profit motive.
 Managed by community members, and accountable
back to members.
 ‘Facilitators’, usually NGOs, may play an important
role.
 May outsource part (or all) of risk and/or health
services provision through tie-up with hospitals,
insurers.
 Gujarat: Self Employed Women’s Association (SEWA)
 Maharashtra: Sewagram, Wardha
 Kerala: ACCORD AMS Aswini ( Deal with New India
Assurance Company)

66. Source: Data from
Annual reports,
websites and
respective Schemes

67.  Health insurance as a tool to finance health
care has very recently gained popularity in
India
 Serious effort by the Government to introduce
health insurance for the poor in last four
years
 Currently any form of insurance covered
approximately 302 million individuals or 25
percent of India’s population in 2010.

68. An autonomous body tasked with the
regulation and promotion of the
insurance and Re-insurance industries in
India.
Established by Insurance Regulatory and
Development Authority Act1999,Government
of India

69.  In the US, it's mandatory to get health
insurance (pay penality if not chosen)
 Employers in the US, as per government
guidelines, are supposed to provide health
insurance to their employees.
 In the US, health insurance cover is generally
comprehensive (OP care also)

70.  Patient Protection and Affordable Care
Act (PPACA) Obama care 2010
To reform the health insurance sector and
to provide more Americans accessible,
affordable and quality healthcare services.
 The ACA has caused a significant reduction in the
number of people without health insurance, with
estimates ranging from 20–24 million additional
people covered during 2016.

71.  The National Health Service (NHS) is the publicly
funded national healthcare system for England
 Largest and the oldest single-payer healthcare system
in the world.
 Primarily funded through the general taxation system
and overseen by the Department of Health
 System provides healthcare to every legal resident in
England, with most services free at the point of use.
 Some services, such as emergency treatment and
treatment of infectious diseases are free for everyone,
including visitors.

72.  most of the western european countries-
social health insurance
 Austria, Belgium, France, Germany,
Luxembourg, the Netherlands and
Switzerland

73.  Timely coverage for regular health check
ups.
 Ability to afford for the medical expenses.
 Prevent catastrophic health expenditure
 Get screening or preventive services.

74.  Pvt Insurance companies –now a money-
making businesses with little interest in
insurance.
 Insurance policies contain too many
exclusion clauses.
RajbirKaur,MPH,PU

76.  In 2004-05, only 1.62% of the total union
budget was spent on health.
 The share of the health sector in the total
spending of the union government has
gradually caressed to 2.4% in 2011-12.
However as a proportion of the GDP.
 The union government‟s spending on health
shows a less perceptible increase from 0.25%
in 2003-04 to 0.34% in 2011-12.

78.  APY will be focussed on all citizens in the
unorganised sector, who join the National
Pension System (NPS) administered by the
Pension Fund Regulatory and Development
Authority (PFRDA).
 Benefit - Fixed pension for the subscribers
ranging between Rs. 1000 to Rs. 5000, if he
joins and contributes between the age of 18
years and 40 years.