health insurance 11 bbi
TRANSCRIPT
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CHAPTER NO.1
INTRODUCTION TO INSURANCE
1.1INTRODUCTION OF INSURANCE
Insurance is a mechanism that helps to reduce the effects of adverse
situations in the economical way. It promises to pay to the owner or
beneficiary of the asset, a certain sum if the loss occurs.
The business of insurance is related to the protection of the economic
values of assets. The asset would have been created through the efforts of
the owner. The asset is valuable to the owner, because he expects to get
some benefits from it because it meets some of his needs. This benefit
may be an income or in some other form.
In the case of a factory or a cow, the product generated by it is sold and
income is generated. In the case of a motor car, it provides comfort and
convenience in transportation, there is no direct income. Both are assets
and provide benefits.
Every asset is expected to last for a certain period of time during which it
will provide the benefits, after that, the benefit may not be available.
There is a life-time for a machine in a factory or a cow or a motor car.
None of them will last forever. The owner is aware of this and he can so
manage his affairs that by the end of that period or life-time, a substitute
is made available.
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Thus, he makes sure that the benefit is not lost. However, the asset may
get lost earlier. An accident or some other unfortunate event may destroyit or make it incapable of giving the benefits. An epidemic may kill the
cow suddenly. In that case, the owner and those enjoying the benefits
there from would be deprived of the benefits. The planned substitute
would not have been ready. There is an adverse or unpleasant situation.
Here, insurance helps to reduce the effects of such adverse situations.
1.2 PURPOSE & NEED OF INSURANCE
The risk only means that there is a possibility of loss or damage. The
damage may or may not happen. Insurance is done against the possibility
that the damage may happen. There has to be an uncertainty about the
risk. The earthquake may occur, but the building may not have been
affected at all. The word 'possibility' implies uncertainty. Insurance is
relevant only if there are uncertainties.
In case of a human being, death is certain, but it's time is uncertain. The
person is insured, because of the uncertainty about the time of his death.
In the case of a person who is ill the time of death is not uncertain, though
not exactly known. It would be 'soon'. He can't be insured.
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1.3 HOW INSURANCE WORKS
The mechanism of insurance is very simple. People who are exposed to
the same risks come together and agree that, if any one of them suffers a
loss, the others will share the loss and make good to the person who lost.
The manner in which the loss is to be shared can be determined
beforehand. It can be equal among all. It can also be proportional to the
risk that each person is exposed
Insurance is a form of risk management primarily used to hedge
against the risk of a contingent, uncertain loss. Insurance is defined as the
equitable transfer of the risk of a loss, from one entity to another, in
exchange for payment. An insurer is a company selling the insurance; the
insured, or policyholder, is the person or entity buying the insurance
policy. The amount to be charged for a certain amount of insurance
coverage is called the premium. Risk management, the practice of
appraising and controlling risk, has evolved as a discrete field of study
and practice.
The transaction involves the insured assuming a guaranteed and
known relatively small loss in the form of payment to the insurer in
exchange for the insurer's promise to compensate (indemnify) the insured
in the case of a financial (personal) loss. The insured receives a contract,
called the insurance policy, which details the conditions and
circumstances under which the insured will be financially compensated.
Insurance involves pooling funds from many insured entities (known as
exposures) to pay for the losses that some may incur. The insured entities
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are therefore protected from risk for a fee, with the fee being dependent
upon the frequency and severity of the event occurring. In order to beinsurable, the risk insured against must meet certain characteristics in
order to be an insurable risk. Insurance is a commercial enterprise and a
major part of the financial services industry, but individual entities can
also self-insure through saving money for possible future losses.
Risks which can be insured by private companies typically share
seven common characteristics:
1. Large number of similar exposure units: Since insurance operates
through pooling resources, the majority of insurance policies are provided
for individual members of large classes, allowing insurers to benefit from
the law of large numbers in which predicted losses are similar to the
actual losses. Exceptions include Lloyd's of London, which is famous for
insuring the life or health of actors, sports figures and other famous
individuals. However, all exposures will have particular differences,
which may lead to different premium rates.
2. Definite loss: The loss takes place at a known time, in a known place,
and from a known cause. The classic example is death of an insured
person on a life insurance policy. Fire, automobile accidents, and worker
injuries may all easily meet this criterion. Other types of losses may only
be definite in theory. Occupational disease, for instance, may involve
prolonged exposure to injurious conditions where no specific time, place
or cause is identifiable. Ideally, the time, place and cause of a loss should
be clear enough that a reasonable person, with sufficient information,
could objectively verify all three elements.
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3. Accidental loss: The event that constitutes the trigger of a claim
should be fortuitous, or at least outside the control of the beneficiary ofthe insurance. The loss should be pure, in the sense that it results from an
event for which there is only the opportunity for cost. Events that contain
speculative elements, such as ordinary business risks or even purchasing
a lottery ticket, are generally not considered insurable.
4. Large loss: The size of the loss must be meaningful from the
perspective of the insured. Insurance premiums need to cover both the
expected cost of losses, plus the cost of issuing and administering the
policy, adjusting losses, and supplying the capital needed to reasonably
assure that the insurer will be able to pay claims. For small losses these
latter costs may be several times the size of the expected cost of losses.
There is hardly any point in paying such costs unless the protection
offered has real value to a buyer.
5.Affordable premium: If the likelihood of an insured event is so high,
or the cost of the event so large, that the resulting premium is large
relative to the amount of protection offered, it is not likely that the
insurance will be purchased, even if on offer. Further, as the accounting
profession formally recognizes in financial accounting standards, the
premium cannot be so large that there is not a reasonable chance of a
significant loss to the insurer. If there is no such chance of loss, the
transaction may have the form of insurance, but not the substance. (See
the US Financial Accounting Standards Board standard number 113)
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6. Calculable loss: There are two elements that must be at least
estimable, if not formally calculable: the probability of loss, and theattendant cost. Probability of loss is generally an empirical exercise,
while cost has more to do with the ability of a reasonable person in
possession of a copy of the insurance policy and a proof of loss
associated with a claim presented under that policy to make a reasonably
definite and objective evaluation of the amount of the loss recoverable as
a result of the claim.
7. Limited risk of catastrophically large losses: Insurable losses are
ideally independent and non-catastrophic, meaning that the losses do not
happen all at once and individual losses are not severe enough to
bankrupt the insurer; insurers may prefer to limit their exposure to a loss
from a single event to some small portion of their capital base. Capital
constrains insurers' ability to sell earthquake insurance as well as windinsurance in hurricane zones. In the US, flood risk is insured by the
federal government. In commercial fire insurance it is possible to find
single properties whose total exposed value is well in excess of any
individual insurer's capital constraint. Such properties are generally
shared among several insurers, or are insured by a single insurer who
syndicates the risk into the reinsurance market.
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CHAPTER NO.2
INTRODUCTION TO HEALTH INSURANCE
2.1 DEFINITION
Insurance against loss by illness or bodily injury. Health insurance
provides coverage for medicine, visits to the doctor or emergency room,
hospital stays and other medical expenses. Policies differ in what they
cover, the size of the deductible and/or co-payment, limits of coverage
and the options for treatment available to the policyholder. Health
insurance can be directly purchased by an individual, or it may be
provided through an employer. Medicare and Medicaid are programs
which provide health insurance to elderly, disabled, or un-insured
individuals. There are a number of companies which provide private
health insurance, including Blue Cross, United Healthcare, or Aetna.
Introduction
Health insurance is insurance against the risk of incurring medical
expenses among individuals. By estimating the overall risk of health care
expenses among a targeted group, an insurer can develop a routine
finance structure, such as a monthly premium or payroll tax, to ensure
that money is available to pay for the health care benefits specified in the
insurance agreement. The benefit is administered by a central
organization such as a government agency, private business, or not-for-
profit entity.
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2.2 HEALTH INSURANCE POLICY IS:
1) A contract between an insurance provider (e.g. an insurance company
or a government) and an individual or his sponsor (e.g. an employer or a
community organization). 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. 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) Insurance coverage is provided by an employer-sponsored self-funded
ERISA plan. The company generally advertises that they have one of the
big insurance companies. However, in an ERISA case, that insurance
company "doesn't engage in the act of insurance", they just administer it.
Therefore ERISA plans are not subject to state laws. ERISA plans are
governed by federal law under the jurisdiction of the US Department of
Labor (USDOL). The specific benefits or coverage details are found in
the Summary Plan Description (SPD). An appeal must go through the
insurance company, then to the Employer's Plan Fiduciary. If still
required, the Fiduciarys decision can be brought to the USDOL to
review for ERISA compliance, and then file a lawsuit in federal court.
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2.3 IMPORTANCE OF HEALTH INSURANCE
Important Pointers in Health Insurance
We must read the policy exclusions & the limitations in various covers
properly before buying a Health Insurance plan because we should know
what all covers our policy include & exclude.
weshould note the number of network hospitals covered in the Insurers
list of network hospitals as this will help to get cashless & hassle-free
claim.
We must read the names of critical diseases being covered before
buying a Critical-Care plan.
We must know that the medical expenses incurred within the first 30
days of buying the health insurance plan are not covered unless the injury
has occurred out of an accident.
We must disclose all the Pre-Existing diseases to the insurer before
buying the health plan as the insurer doesnt cover them, now a days
General Insurers have started covering these diseases normally after 3-4
years varying from company to company.
An English proverb says that Health is Wealth. It is not a
meaningless saying as it defines a very important fact of life. Health is the
most precious wealth that God has given you. It is a own property and we
are the sole owner of it. Therefore, it is our responsibility to look after it
properly. However, it is also true that the life is full of uncertainties and
we never know what will happen in the next few hours. Therefore, it is
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also our duty to make certain arrangement so that we can take care of our
self as well as our family even if some misfortune falls upon us.
Here comes the importance of health insurance program. This
health insurance program, as the name itself tells, is entirely meant for the
proper care of our body and health. It is a permanent arrangement that we
can avail at a time when we need to undergo some serious health
disorder. These health disorders are very expensive by nature and we may
need the help from some sources to meet the expenses of this treatment.
As we all know, the cost of medical treatment has become very costly and
a person from the lower or middle income group cannot think about such
a costly treatment.
A health insurance program is a service of the insurance
companies that keeps your ensured against any serious illness like cancer.
If, unfortunately, happen to suffer from this serious disease ever in our
life, we would not be worried about the cost of treatment as we can get
the sum for treatment. As far as success of treatment is concerned, it is
not sure, however, our family gets a huge sum of money if we happen to
die in the process of our treatment.
The advantage of this health insurance program is very unique. we
need not spend a penny from our pocket and the whole cost of treatment
is borne by the insurance company. It is a great relief for the members of
our family as well because they need not worry about our treatment. A
health insurance program is a very useful investment because it helps us
at the time when you need the money most. If we do not have the health
insurance program for our self, then will be in deep trouble when a
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situation like occurs in front of you and leaves you in want of a huge sum
of money.
2.4 FEATURE OF HEALTH INSURANCE
1. Premium: The amount the policy-holder or his sponsor (e.g. an
employer) pays to the health plan to purchase health coverage.
2. Deductible: The amount that the insured must pay out-of-pocket
before the health insurer pays its share. For example, policy-holdersmight have to pay a $500 deductible per year, before any of their health
care is covered by the health insurer. It may take several doctor's visits or
prescription refills before the insured person reaches the deductible and
the insurance company starts to pay for care.
3. Co-payment: The amount that the insured person must pay out of
pocket before the health insurer pays for a particular visit or service. For
example, an insured person might pay a $45 co-payment for a doctor's
visit, or to obtain a prescription. A co-payment must be paid each time a
particular service is obtained.
4. 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. For example, the member might have to
pay 20% of the cost of a surgery over and above a co-payment, while the
insurance company pays the other 80%. If there is an upper limit on
coinsurance, the policy-holder could end up owing very little, or a great
deal, depending on the actual costs of the services they obtain.
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5. Exclusions: Not all services are covered. The insured are generally
expected to pay the full cost of non-covered services out of their ownpockets.
6. Coverage limits: Some health insurance policies only pay for health
care up to a certain dollar amount. The insured person may be expected to
pay any charges in excess of the health plan's maximum payment for a
specific service. In addition, some insurance company schemes have
annual or lifetime coverage maximums. In these cases, the health plan
will stop payment when they reach the benefit maximum, and the policy-
holder must pay all remaining costs.
7. Out-of-pocket maximums: Similar to coverage limits, except that in
this case, the insured person's payment obligation ends when they reach
the out-of-pocket maximum, and health insurance pays all further covered
costs. Out-of-pocket maximums can be limited to a specific benefit
category (such as prescription drugs) or can apply to all coverage
provided during a specific benefit year.
8. Capitation: An amount paid by an insurer to a health care provider, for
which the provider agrees to treat all members of the insurer.
9. In-Network Provider: (U.S. term) A health care provider on a list ofproviders preselected by the insurer. The insurer will offer discounted
coinsurance or co-payments, or additional benefits, to a plan member to
see an in-network provider. Generally, providers in network are providers
who have a contract with the insurer to accept rates further discounted
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from the "usual and customary" charges the insurer pays to out-of-
network providers.
10. Prior Authorization: A certification or authorization that an insurer
provides prior to medical service occurring. Obtaining an authorization
means that the insurer is obligated to pay for the service, assuming it
matches what was authorized. Many smaller, routine services do not
require authorization.
11. 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.
Prescription drug plans are a form of insurance offered through some
health insurance plans. In the U.S., the patient usually pays a copayment
and the prescription drug insurance part or all of the balance for drugs
covered in the formulary of the plan. Such plans are routinely part of
national health insurance programs. For example in the province of
Quebec, Canada, prescription drug insurance is universally required as
part of the public health insurance plan, but may be purchased and
administered either through private or group plans, or through the public
plan.
Some, if not most, health care providers in the United States will agree to
bill the insurance company if patients are willing to sign an agreement
that they will be responsible for the amount that the insurance company
doesn't pay. The insurance company pays out of network providers
according to "reasonable and customary" charges, which may be less than
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the provider's usual fee. The provider may also have a separate contract
with the insurer to accept what amounts to a discounted rate or capitationto the provider's standard charges. It generally costs the patient less to use
an in-network provider.
2.5 FUNCTIONS OF HEALTH INSURANCE
The primary function of health insurance is to pay those covered
expenses, as outlined in the policy, incurred as a result of an accident or
illness. It often has two elements, one being hospitalization expenses and
the other being for the medical care rendered by a physician or other
health care professional.
The vast majority of health insurance is employer-based, meaning that
people have access to it through their employment. Not all employers
offer it, and for those whose employers do not, they are free to obtain
individual/family policies on their own.
Health insurance comes in a variety of types. These include traditional
indemnity plans, which are becoming less common, and an array of
managed care plans, including Health Maintenance Organizations and
Preferred Provider Organizations. Both of the latter provide medical care
on a prepaid basis, but differ in their delivery models, including by the
degree of choice of provider that the member retains.
Most health insurance plans have deductibles and co-payments, although
different terminology may be used. A deductible is an amount that the
insured/member must pay before the insurer's liability for payment is
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triggered. A co-payment is a form of cost-sharing such that the insurer
pays a percentage of a covered expense, and the insured pays theremainder. The size of the deductible and co-payment has an impact on
premium.
2.6THE ADVANTAGES OF HEALTH INSURANCE INCLUDE;
CUSTOMIZED HEALTH CARE: Her we have direct control overour policy and its benefits, unlike in group coverage. we can
negotiate to have certain provisions included or excluded in our
policy, and we can choose our deductible amount and co-payments.
CHOOSING OUR DOCTOR: Selecting a health care providerincluding doctors is another advantage of an individual health care
policy.
THE DISADVANTAGE OF HEALTH INSURANCE INCLUDE
The biggest disadvantage is the price. Individual policies can be very
expensive, especially if you have high risk potential or pre-existing health
problems. Before issuing an health insurance policy, the insurance
company usually runs a background check on your personal health
history. It is unwise to try to hide any pre-existing conditions from your
insurer. Another disadvantage is that all requirements of the insurance
company must be fully complied with before you can get health care
insurance.
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2.7 CRITERIA FOR CHOOSING A POLICY:-
Every word of policy terms and conditions is to be read and understood
before going for a particular policy. Here are few important points that
you can look for while choosing a particular policy.
1. Policy coverage: This term refers to medical conditions under which a
policy insures a person. This means a policy may not include every
medical condition of a person like most of the policies in India do not
include medical expenses from HIV, misuse of drugs and also injuries in
riots.
2. Mode of bill payment and claim: This plays a major role during
critical situations since certain policies may include conditions wherein
the person has to bear part or complete bill expense in the first place and
later on can claimed from insurer. This may also depend on the network
of hospitals that come under the insurance provider.
3. Network of hospitals: This can be one of the major criteria since the
network of hospitals an insurance company covers will give us more
options and will make us feel secure during critical situations. This is
because cashless claims can be made in these hospitals; the company will
have authorized to treat the person while the company takes care ofexpenses.
4. Premium and other benefits covered: This makes the choice to be
economical with added benefits in the basket. For ex: A condition of one
of the policies offered by Apollo Munich states includes certain bonuses
offered on every claim-free year.
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2.8 ELIGIBILITY CRITERIA FOR HEALTH INSURANCE:-
The person who purchases a policy must be minimum 18 years old.
The person who is insured for the policy can be maximum 60-65 years.
People who are more than 65 years old can be insured under policies for
senior citizens.
Certain policies also have a minimum limit for age of the person insured.
A policy may cover insurance to people above 3-5 years of age.
Providers of Health Insurance Policy:
The following are the popular health insurance policy providers in India
HDFC
ICICI
Apollo Munich
Maxbupa
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CHAPTER NO. 3
TYPES OF HEALTH INSURANCE
1.TRADITIONAL HEALTH INSURANCE OR FEE-FOR-
SERVICE
Up until about 30 years ago, most people had traditional indemnity
coverage. These days, it's often known as "fee-for-service." Indemnity
plans are a bit like auto insurance: you pay a certain amount of your
medical expenses up front in the form of a deductible and afterward the
insurance company pays the majority of the bill. Advances in modern
medicine increased the cost of providing health care and made it possible
for people to live longer. Those advances caused many insurance
companies to look for ways to reduce their costs of doing business, giving
managed care the boost it enjoys today.
For years, indemnity or fee-for-service coverage was the norm.
Under this type of health coverage, we have complete autonomy when it
comes to choosing doctors, hospitals and other health care providers. we
can refer yourself to any specialist without getting permission, and the
insurance company doesn't get to decide whether the visit was necessary.
we don't, however, have complete autonomy. Most fee-for-service
medicine is managed to a certain extent. For instance, if were not already
incapacitated, you may need to get clearance for a visit to the emergency
room.
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On the down side, fee-for-service plans usually involve more out-
of-pocket expenses. Often there is a deductible, usually of about $200-$2,500 before the insurance company starts paying. Once you've paid the
deductible, the insurer will kick in about 80 percent of any doctor bills.
You may have to pay up front and then submit the bill for reimbursement,
or your provider may bill your insurer directly.
Under fee-for-service plans, insurers will usually only pay for
reasonable and customary" medical expenses, taking into account what
other practitioners in the area charge for similar services. If your doctor
happens to charge more than what the insurance company considers
"reasonable and customary," you'll probably have to make up the
difference yourself. Traditionally, preventive care services like annual
check-ups and pelvic exams haven't been covered under fee-for-service
plans. But as the evidence mounts that preventive care can prevent morecostly illnesses down the road, some insurers are including them.
Fee-for-service plans often include a ceiling for out-of-pocket
expenses, after which the insurance company will pay 100 percent of any
costs. Needless to say, the ceiling is usually pretty high. In a nutshell, fee-
for-service coverage offers flexibility in exchange for higher out-of-
pocket expenses, more paperwork and higher premiums.
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THE ADVANTAGE FFS OR TRADITIONAL INDEMNITY
This plan is rarely provided anymore due to its high cost. The advantage
of this health care plan is that it allows you to choose any health care
provider you want. People who want the freedom to select their own
doctor, and who are willing to pay more for insurance chose this plan.
THE DISADVANTAGES OF FFS'S ARE THAT;
There are no financial incentives to reduce patient financialresponsibility, and
There is an absence of cost control which creates high premiums.
2.MANAGED CARE
Managed care has been around in one form or another since the 1930s,but it really took off in the last 10 years. As it grew, it evolved, leaving us
with three basic types of managed care plans. Today, the majority of
people with private health insurance have some type of managed care.
Although there are important differences among the different types of
managed care plans, there are some similarities. All managed care plans
involve an arrangement between the insurer and a selected network of
health care providers, and they offer policyholders significant financial
incentives to use the providers in that network. There are usually explicit
standards for selecting providers and a formal procedure to assure quality
care.
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Health care costs have seen a phenomenal rise in the recent times. This
has led the customers to insure not only themselves but their familymembers also. It will cover future medical expenses and other related
requirements if it ever arises. The need to insure has gained more
importance amongst older generation who is either retired or will retire in
the near future. Let us discuss the types of medical insurances available in
the market.
3. MEDICAL INSURANCE
This is typically a hospitalization cover and reimbursement of the medical
expenses incurred in respect of covered disease or surgery while the
insured was admitted in the hospital as a patient. Different types of
medical insurances are available in the market like individual medical
insurance, group medical insurance and overseas medical insurance.
There are health policies that reimburse you the actual hospitalization
cost for treatment of any disease and are offered by the non-life insurers
only. These policies are popularly called "Mediclaim" policies. Other
types of health insurances are provided by both the life and non-life
insurers.
4. CRITICAL ILLNESS INSURANCE
Critical Illness plan insures you against the risk of serious illnesses in
return of a premium you are required to pay. This gives you the same
security of knowing that a guaranteed cash sum will be paid if the
unexpected happens and you are diagnosed with any one of the critical
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illness. Sometimes a critical illness can change your lifestyle in addition
to help within the home or the family. In this type of health insuranceplan, the insured receives a lump sum amount within a few days of
diagnosing critical illness. Once this lump sum is paid, the plan ceases to
remain in force. Typically, a critical illness plan would provide cover for
the illnesses mentioned below.
Aorta graft surgeryCancerCoronary artery bypass surgeryFirst heart attackKidney failureMajor organ transplantMultiple sclerosisParalysisPrimary pulmonary arterial hypertension Stroke
5.PREFERRED PROVIDER ORGANIZATIONS (PPOS)
One step over the managed care border is the Preferred Provider
Organization. PPOs have made arrangements for lower fees with anetwork of health care providers. PPOs give their policyholders a
financial incentive to stay within that network.
For example, a visit to an in-network doctor might mean you'd have a
$10 co-pay. If you wanted to see an out-of-network doctor, you'd have to
pay the entire bill up front and then submit the bill to your insurance
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company for an 80 percent reimbursement. In addition, you might have to
pay a deductible if you choose to go outside the network, or pay thedifference between what the in-network and out-of-network doctors
charge.
With a PPO, you can refer yourself to a specialist without getting
approval and, as long as it's an in-network provider, enjoy the same co-
pay. Staying within the network means less money coming out of your
pocket and less paperwork. Preventive care services may not be covered
under a PPO.
Exclusive Provider Organizations are PPOs that look like HMOs. EPOs
raise the financial stakes for staying in the network. If you choose a
provider outside the network, you're responsible for the entire cost of the
visit.
THE ADVANTAGE OF PREFERRED PROVIDER
ORGANIZATION
This plan is a combination of a Traditional Indemnity plan and an HMO
plan. The advantages this plan offer is that
There are financial incentives to see doctors in the PPO networkMany services require just a co- payment for outpatient visits or
prescriptions
You can see a physician who is not part of the PPO network at areduced rate.
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THE DISADVANTAGES OF PPO'S INCLUDE;
Deductibles and coinsurance are applied for many services such ashospitalization.
Claims are submitted by the medical provider.The premiums and employee contribution are higher than an HMO
plan, but lower than a Traditional Indemnity plan.
6.POINT-OF-SERVICE (POS)
Point-of-service plans are similar to PPOs, but they introduce the
gatekeeper, or Primary Care Physician. You'll need to choose your PCP
from among the plan's network of doctors.
As with the PPO, you can choose to go out of network and still get
some kind of coverage. In order to get a referral to a specialist, though,
you usually must go through your PCP. You can still choose to refer
yourself, but it'll mean more hassles and more money coming out of your
pocket. If your PCP refers you to a doctor who is out of the network, the
plan should pick up most of the cost. But if you refer yourself out, then
you'll probably have to deal with more paperwork and a smaller
reimbursement. You may also have to pay a deductible if you go outside
the network.
POS plans may also cover more preventive care services, and may
even offer health improvement programs like workshops on nutrition and
smoking cessation, and discounts at health clubs.
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see its doctors, and that you get a referral from your primary care
physician before you see a specialist. If you can still pick up the phone,you'll probably need to get clearance before you can visit the emergency
room.
An HMO may have central medical offices or clinics (such as those used
by Kaiser Permanente), or it may consist of a network of individual
practices. In general, you must see HMO-approved physicians or pay the
entire cost of the visit yourself. HMOs have the best reputation for
covering preventive care services and health improvement programs
THE ADVANTAGE OF HEALTH MAINTENANCE
ORGANIZATION
These plans have become very popular as they are both comprehensive
and cheap. With an HMP plan there are no deductibles or coinsurance
expenses, only a co-payment.
Another advantage of this health care plan is that the cost of premiums
and employee contributions are low due to the presence of cost control
features. Here paperwork is minimal as there are no claims to submit.
THE DISADVANTAGES HOWEVER ARE THAT;
You can only see a doctor who belongs to the HMO networkOnly your primary care doctor can recommend a specialist
And there is a larger number of cost controls elements in the plan
such as authorizations, referrals, etc.
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8.TRAVEL HEALTH INSURANCE
HTH Worldwide is a leader in helping world travelers gain access to
quality healthcare services all around the globe. HTH combines ongoing
research, a contracted global community of physicians and hospitals,
advanced Internet applications, and wide experience in international
health insurance to ensure customers' health, safety and peace of mind.
Founded in 1997 as Highway To Health, Inc., HTH Worldwide has
grown to become a leading provider of international health insurance
programs and an innovator in online healthcare information, medical
assistance and insurance services around the globe. Presently, HTH
annually provides health insurance products or services to over 650,000
individuals who travel, study or live outside of their home country.
HTH Worldwide offers three types of travel health insurance plans.
8.1 TravelGap - Travel Medical Insurance
Offers a variety of medical limits and deductiblesFor trips up to 6 months for ages 84 and youngerCovers pre-existing conditions for medical services and medical
evacuation
Benefits include: Doctor office visits Inpatient hospital services
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Emergency services
Ambulance services prescription drugs
View Single Trip Benefits BrochureView Multi-Trip Benefits Brochure
8.2Trip Protector - Trip Protection
Coverage for trip cancellation, interruption and lost baggageUp to $1,000,000 medical and medical evacuation coverageTrip delay, flight delay, rental car damage, terrorism and moreview Benefits Brochure
8.3Global Student - For Students Studying Abroad
Global Student USA Designed for international students studying in the US $250,000 coverage per year Basic medical covered 100% up to first $5,000
US Students Abroad Designed for US study abroad students $100,000 coverage per year Basic medical covered 100% up to first $10,000
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9.SHORT TERM HEALTH INSURANCE
Short Term health insurance from Assurant Health provides you with
temporary coverage for periods of up to one year. The plans are designed
to fill gaps in your medical coverage and offer the following features.
Coverage is available for periods of 30 - 360 days.You may be covered as soon as the next day.You are covered anywhere in the US.You may choose your own doctors and hospitals.
Assurant Individual & Family health insurance plans are available in all
states EXCEPT: CT, MA, NJ, NY, & VT.
Some benefits include:
Doctor office visits
Prescription drug coverage
Hospital, lab, x-ray and ambulance
$2 million lifetime benefit
The following may benefit from Short Term health insurance:
People between jobs
People waiting for employer-sponsored benefits to begin
Temporary or seasonal employees
Early retirees
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CHAPTER NO.4
TYPES OF HEALTH INSURANCE PLAN
Health Insurance Plans are segregated into three categories, firstly the
Mediclaim Plans by Non-Life or General Insurance Companies, secondly
the Hospitalization Cash Policy by both Life & Non-Life Insurers and
thirdly the Critical Care Plans offered by both Life & Non-Life Insurers.
1.MEDICLAIM POLICY: It is basically a reimbursement plan offered
by General Insurers wherein the insured gets reimbursed of the total bill
amount of the medical expenses to the extent of an agreed sum assured. It
includes the room charges, ICU charges, surgery & doctor charges etc. It
includes a lot of exclusions which the policy holder must read before
buying the Mediclaim. The Mediclaim includes the following two
further categories:
a).Family Floater Plan: It is a very common plan these days which
covers your entire family under one premium payment giving coverage to
the family members together. This plan is being offered by almost all the
General Insurance Companies with a specific criterion of covering
individuals in the age group between 90days and 55years.
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For instance a person wants a health insurance for himself, his spouse &
their children, the Family Floater plan offers insurance coverage to theentire family under one premium payment. Lets take an example
wherein the person insures himself, his spouse & the dependent children
with the individual insurance plans with a sum assured of Rs. 1 lakh each,
he ends up paying premium ranging between Rs. 1000 - Rs. 2000 for
each family member. On the other hand if the person would have opted
for the family floater plan with the sum assured of Rs. 3 lakhs, the total
premium would surely be less than the separate premium payments in
individual health insurance plans. Moreover the separate health plan
holds the cover of only Rs. 1 lakh as against Rs. 3 lakh in case of the
Floater plan thus helping the family in case the medical treatment costs
go beyond that.
b) Group Mediclaim Insurance: It is the second variant of Mediclaim
which covers a group of individuals simultaneously. This form of
insurance includes the category of Employers Health Insurance Cover
wherein the sum assured normally varies between Rs. 15,000 and Rs.5,
00,000.
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2. HOSPITALIZATION CASH POLICY: It is a plan offered by both
Life & Non-Life Insurers wherein the Insured gets pre-determined cash
benefit on a daily basis irrespective of the hospitalization expenses being
incurred. It is not a fully comprehensive health insurance plan because it
doesnt cover the cost of medical treatment but pays lump sum amount to
the policy holder on per day basis during the treatment/hospitalization. It
acts a complimentary plan to the Mediclaim plans. TATA-AIG General
Insurance & Royal Sundaram offer Hospital cash benefit plan among
Non-Life Insurers.
3.CRITICAL-CARE PLAN: It is offered by both Life & General
Insurers covering an individual for certain specified critical illnesses like
cancer, stroke etc. This is also offered as a rider by Life Insurance
companies for quite some time now attached to their Life Insurance
Plans. You must take a cover either as a rider or as a standalone plan in
your portfolio.
4.CASHLESS HOSPITALIZATION: Cashless settlement implies that
an individual doesnt have to settle a hospital bill out of his pocket; rather
the bill gets settled directly by the insurance company. When you buy a
Health Plan you are issued a Health Card along with the policy
documents which would entitle you to get cashless claim at any of the
companys network hospitals.
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CHAPTER NO.5
TAX BENEFITS ON HEALTH INSURANCE PLAN
Health Insurance Tax Benefits
Health Insurance products are eligible for tax benefits undersection 80D of the Income Tax Act, 1961. Premium paid under
health insurance holds a tax deduction upto Rs 15,000 for you,
your spouse and dependent children.
Further more you can also claim another Rs. 15, 000 for taxdeduction for your parents, in case of senior citizens (65 years or
more) the above deductions are increased to Rs. 20,000
Health insurance has many benefits- health cover, critical illnessbenefit and additional covers. Along with this you can also avail
tax benefits under Section 80D of the Income tax Act 1961. You
can avail up to Rs 15,000 and Rs 20,000 for senior citizens.
Section 80D as per Income tax Act 1961 is as follows: Deduction in
respect of health insurance premia 80D are:
(1). In computing the total income of an assessee, being an individual or a
Hindu undivided family, there shall be deducted such sum, as specified in
sub-section (2) or sub-section (3), payment of which is made by any
mode, other than cash, in the previous year out of his income chargeable
to tax.
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(2). Where the assessee is an individual, the sum referred to in sub-
section (1) shall be the aggregate of the following, namely:
A.The whole of the amount paid to effect or to keep in force aninsurance on the health of the assessee or his family [or any
contribution made to the Central Government Health Scheme] as
does not exceed in the aggregate fifteen thousand rupees; and
B.The whole of the amount paid to effect or to keep in force aninsurance on the health of the parent or parents of the assessee as
does not exceed in the aggregate fifteen thousand rupees.
Explanation - For the purposes of clause (a), family means the spouse
and dependent children of the assessee.
(3). Where the assesses is a Hindu undivided family, the sum referred to
in sub-section (1) shall be the whole of the amount paid to effect or to
keep in force an insurance on the health of any member of that Hindu
undivided family as does not exceed in the aggregate fifteen thousand
rupees.
(4). Where the sum specified in clause (a) or clause (b) of sub-section (2)
or in sub-section (3) is paid to effect or keep in force an insurance on the
health of any person specified therein, and who is a senior citizen, the
provisions of this section shall have effect as if for the words fifteen
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thousand rupees, the words twenty thousand rupees had been
substituted.
Explanation - For the purposes of this sub-section, senior citizen means
an individual resident in India who is of the age of sixty-five years or
more at any time during the relevant previous year.
(5). The insurance referred to in this section shall be in accordance with a
scheme made in this behalf by
A .the General Insurance Corporation of India formed under section 9 of
the General Insurance Business (Nationalisation) Act, 1972 (57 of 1972)
and approved by the Central Government in this behalf; or
B .any other insurer and approved by the Insurance Regulatory and
Development Authority established under sub-section (1) of section 3 of
the Insurance Regulatory and Development Authority Act, 1999 (41 of
1999).]
The above act states that if an individual buys health insurance, then the
premium paid is deductible from his chargeable income. The premium
that is deducted cannot exceed 15,000 for individual and Rs 20,000 for
senior citizen (aged above 65).
Illustration:
a. Anil has annual salary is Rs 8 lacs 10 thousand and buys health
insurance for himself for Rs 20,000. Amount of 15,000 would be
deducted from his taxable income.
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b. Anil buys health insurance for himself and his parents who are both
senior citizens. The annual premium he pays for the same is 50,000.Amount of 35,000 can be deducted from taxable income to avail tax
benefits. If Anil is in the tax bracket of 30% already, he gets taxation
benefit of Rs 10,815.
Health Insurance Covers & Benefits
Room & Boarding expenses: There are further limits to this feature
varying from company to company.
Ambulance Charges: They are normally covered upto Rs. 1000.
ICU charges, doctor, consulting, anesthetist and surgeon fees, operation
and other diagnostic and surgical material costs are covered.
Day-Care expenses such as Chemotherapy, Dialysis & Radiotherapy
etc.
Pre & Post Hospitalization Expenses which normally are 30 days prior
and 60 days after hospitalization.
Cashless Hospitalization is offered by almost all Non-Life Insurers.
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Limited-Benefit Health Plans
Health Access is a limited-benefit health plan offered by Assurant Health.
The plans cover certain services such as doctor office visits and
prescription drugs up to a set dollar amount. They are not major medical
health insurance plans and should not be used to replace such coverage.
Some of the covered services include:
Doctor office visits
Inpatient services (Hospital)
Prescription drugs
Emergency services
Ambulance
Outpatient Lab & X-ray
Surgical services
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CHAPERT NO.6
CLAIM PROCEDURE
we should walk into a network hospital & get the treatment done &
the bills paid through the Health Card. In case of hospitalization we needto give the card number to the network hospital, we must pre-authorize
from the TPA (Intermediary between the Insurance Company & the
hospital) & will process the cashless settlement after the verification of
our policy details.we should know the formalities required for cashless
settlement as some insurance companies are required to be notified 48
hours before hospitalization.
If we dont opt for cashless settlement, we need to settle bills at the
hospital and get them reimbursed later.
CLAIM PROCEDURE
Claims are broadly of two types:
1. Cashless Claims and
2 .Reimbursement Claims
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GENERAL CLAIM PROCEDURE:
As soon as there is a need for hospitalisation, please intimate theHCMT/TPA on 24x7 Customer Helpline number as mentioned in your
Health Card/Policy Schedule.
You are required to furnish the following information while intimating a
claim:
a. Contact Numbersb. Policy Number (as on the Health Card//Policy Schedule)c. Name of Insured person who is hospitalisedd. Nature of sickness/accidente. Date & Time in case of accident, commencement date of symptom
of disease in case of sickness
f. Location of accident.
The benefit of choosing a network hospital is that we can avail of
"Cashless Facility" while we are hospitalised whereas we will have to
settle our hospital bills in the hospital which is outside our network.
we have to follow the procedures listed below to get the services in
different situations.
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1.PROCEDURES FOR "CASHLESS FACILITY"
"Cashless Facility" is the service wherein we need not pay our
hospitalisation bills to the hospital either at the time of admission or at the
time of discharge from the hospital. This facility is available only at our
Network Hospitals. To avail the "Cashless Facility" we need to fill
"Cashless request form" available in all the network hospitals. The
hospitals will co-ordinate to get the authorisation from the HCMT/TPA
for such "Cashless Facility". This authorisation along with a copy of the
card issued by us needs to be given to the Hospital at the time of
admission. we are also required to carry a Photo ID Card. Please Note:
HCMT/TPA shall authorise "Cashless Facility" at the Network Hospitals
in respect of treatments which are covered under the policy.
"Cashless Facility" may be denied by the HCMT/TPA in some of the
situations as listed below.
In case of any doubt on coverage of the present ailment/ treatment underthe policy
If the information sent by you /hospital is insufficient The ailment/condition etc. not being covered under the policy If the request for preauthorization is not sent in time
Denial of "Cashless Facility" is not denial of treatment. we may continue
with the treatment, pay for the services to the hospital, and later submit
the claim for processing and reimbursement.
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1.1 Emergency hospitalization:
Step 1. Take admission into the hospital.
Step 2. As soon as possible, Intimate the claim at the call centre, obtain
the pre-authorisation form from hospital and get the same filled in and
signed by the attending doctor.
Step 3. Fax the pre-authorisation form to the HCMT/TPA along with
necessary medical details like investigation report etc at the number
mentioned in our Health Card/Policy Schedule. The hospital will co-
ordinate for the same.
Step 4. (Option I)
A. If an authorisation for "Cashless Facility" from HCMT/TPA has been
received
i. At the time of dischargea. we will be required to pay for all such expenses that are not
payable as per the terms of the policy.
b. Verify the bills and sign on all the billsc. Leave the original discharge summary and other investigation
reports with the hospital. Retain a Xerox copy for your records
Step 4. (Option II)
B. In case "Cashless Facility" has been denied by HCMT/TPA
I. At the time of discharge settle the hospital bills in full andcollect all the original bill documents and reports
II. Lodge your claim with HCMT/TPA for processing andreimbursement
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1.2 Planned hospitalization:
Step 1. Please co-ordinate with our doctor and the hospital and send allthe details about the planned hospitalisation including the plan of
treatment, cost estimates etc. to HCMT/TPA.
This may be sent at least 2 days prior to the planned admission.
Step 2. (Option I)
A. If authorisation for "Cashless Facility" from TPA has been received
I. At the time of admission, present the authorisation letter and photoID card to the hospital
II. At the time of dischargea. Pay for those expenses that are not reimbursable under the policyb. Verify the bills and sign on all the bills.c. Leave the original discharge summary and other investigationsreports with the hospital. Retain a Xerox copy for your records
Step 2. (Option II)
B. In case "Cashless Facility" has been denied by HCMT/TPA
a. Get admitted and take treatmentb. At the time of discharge settle the hospital bills in full and collect
all the original bill documents and reports
c. Lodge your claim with HCMT/TPA for processing andreimbursement
"Please note that failure to intimate HCMT/TPA as soon as the
hospitalisation takes place can invalidate our claim."
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2.PROCEDURES FOR REIMBURSEMENT CLAIMS
EMERGENCY HOSPITALISATION
Step 1. Take admission into the hospital.
Step 2. As soon as possible, intimate the HCMT/TPA about the
hospitalisation.
Step 3. At the time of discharge, settle the hospital bills in full and collect
all the original bills, documents and reports.
Step 4. Lodge our claim with HCMT/TPA for processing and
reimbursement, by filling in the claim form and attaching required
documents as mentioned in the claim form.
2.1Planned hospitalization:
Step 1. Intimate HCMT/TPA of the planned hospitalisation.
Step 2. Get admitted into the hospital.
Step 3. At the time of discharge, settle the hospital bills in full and collect
all the original bills, documents and reports.
Step 4. Lodge our claim with HCMT/TPA for processing and
reimbursement.
How to lodge a claim with HCMT/TPA for processing and
reimbursement
Within 7 days after discharge, please lodge the claim for processing.
While submittiing a claim, please make sure that all the documents listed
under the document check list are attached.
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Document Check list for Hospitalisation, Domiciliary Hospitalisation
& Critical illness claims
2.2 Hospitalisation / DayCare Treatment:
a. First prescription of doctor with commencement date of the symptom
of disease
b. Treatment papers along with doctors prescriptions
c. Investigation reports (X-ray/Scan/ECG, Laboratory etc)
d. Original medical bills and receipt of hospital, doctors, medical shops,
diagnostic centre etc supported by Doctor's advice
e. Hospital discharge card, in original
f. Copy of FIR (if any in case of accident)
2.3 Critical Illness Claims:
a. Claim form duly completed
b. Original Specialist Doctor's certificate confirming the diagnosis and
when the symptoms first occurred
c. Relevant Investigation reports (Radiology, Pathology etc) confirmingthe diagnosis
d. Hospital admission & discharge card / certificate
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2.4 Domiciliary Hospitalisation:
a. First prescription of doctor with commencement date of thesymptom of disease
b. Treatment papers along with doctors prescriptionsc. Investigation reports (X-ray/Scan/ECG, Laboratory etc)d. Original medical bills and receipt of doctors, medical shops,
diagnostic centre etc supported by Doctor's advice
e. Copy of FIR (if any in case of accident)f. Certificate from attending Doctor/Physician stating the condition of
the patient is not permissible for him/her to be removed to
Hospital/Nursing Home or documentary proof of lack of
accommodation in Hospital/Nursing Home.
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CHAPTER NO.7
CONCLUSION
Health and medical insurance in India is of recent origin. It took a
concerted effort on part of the Government to make it popular by
introducing a simple to-operate Mediclaim policy. The features of this
policy borrow heavily from internationally successful models of health
insurance, while incorporating features that are peculiar to India. This is
available not only for individuals to buy but also as a Group cover for
employers to offer to employees. Besides Mediclaim there are a few other
popular covers in India.
With the advent of the private sector both cashless and cash-
reimbursement are used as system of claim settlement. Service Providers
in this case hospitals, Nursing homes and medical practitioners are
increasingly seeking tie-ups with insurers to offer their services under
health and medical insurance plans.
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BIBLIOGRAPHY
WEBSIDE:
1. www.investorwords.com/2289/health_insurance.
2. www.wikipedia.org/wiki/Health_insurance -
3. www.healthinsuranceadvice.org/types.html -
BOOKS:
1.Insurance products including pension products.2.Health insurance