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    Bivin Jay B Mar Baselios College of Nursing

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    SaqibKhan
    Health insurance involves three main parties: [1] The insured who pays a premium to [2] the insurer who agrees to pay compensation if a loss occurs. [3] The premium is the money paid by the insured to the insurer. Health insurance pools people's risk of incurring medical expenses so that individuals are protected from financial loss due to unforeseen sickness. It provides assurance for meeting costs of good medical care and relieves anxiety about health care expenses.

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    Bivin Jay B Mar Baselios College of Nursing

    Uploaded by

    SaqibKhan
    49 views27 pages
    Health insurance involves three main parties: [1] The insured who pays a premium to [2] the insurer who agrees to pay compensation if a loss occurs. [3] The premium is the money paid by the insured to the insurer. Health insurance pools people's risk of incurring medical expenses so that individuals are protected from financial loss due to unforeseen sickness. It provides assurance for meeting costs of good medical care and relieves anxiety about health care expenses.

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    Health insurance involves three main parties: [1] The insured who pays a premium to [2] the insurer who agrees to pay compensation if a loss occurs. [3] The premium is the money paid by the insured to the insurer. Health insurance pools people's risk of incurring medical expenses so that individuals are protected from financial loss due to unforeseen sickness. It provides assurance for meeting costs of good medical care and relieves anxiety about health care expenses.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    49 views27 pages

    Bivin Jay B Mar Baselios College of Nursing

    Uploaded by

    SaqibKhan
    Health insurance involves three main parties: [1] The insured who pays a premium to [2] the insurer who agrees to pay compensation if a loss occurs. [3] The premium is the money paid by the insured to the insurer. Health insurance pools people's risk of incurring medical expenses so that individuals are protected from financial loss due to unforeseen sickness. It provides assurance for meeting costs of good medical care and relieves anxiety about health care expenses.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 27

    Bivin Jay B

    Mar Baselios College of Nursing


    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.
    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.
    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.”
    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.
    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
    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.
    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.
    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.
    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
    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
    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).
    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.
    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 co-
    insurance 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.
    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.
    Types of HI
    Accidental death and dismemberment insurance

    Total permanent disability insurance

    Vision insurance

    Long term care insurance

    Disability insurance

    Dental insurance
    Health Insurance In India
    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
    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.
    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
    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.
    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.
    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
    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%.
    • System leakages
    – Provider malpractices leading to over-charging or pre-
    selection / 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
    Disadvantages

    Cost

    Lack of choices

    Complicated rules

    Limited access
    Thank Yu

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