Chapter 1

An Introduction

Insurance is a contract in which an individual or entity receives financial protection or reimbursement against losses from an insurance company. The company pools clients' risks to make payments more affordable for the insured. 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. The first of what could be called individual health insurance plans became available in the United States during the Civil War. The plans were accident insurance providing coverage for injury related to travel by railroad or steamboat. Massachusetts Health Insurance of Boston offered early group policies with a relatively comprehensive list of benefits as early as 1847. Individual accident insurance proved a successful venture, so these kinds of early plans began to evolve into more expansive programs that covered a broader range of illness and injury, including early versions of disability coverage by the end of the
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nineteenth century. In the early years of the twentieth century, groups began developing relationships with health care providers to develop what would become the predecessors to modern health insurance plans, or fee-based contracts (Neurosurgical.com). Health insurance is a term that relates to a contract wherein the individual contributes a regular premium with the expectation that should something happen, the insurer will provide for the individual in question. The term dates to the Progressive Era in the United States, where the debate was already well underway regarding the role of the government in health care. Though health insurance in America has its origins in a related system called sickness insurance, it was really when the British passed their National Insurance Act in 1911 using the term health insurance that the term fell into favor. Health insurance is very well established in many countries. But in India it is a new concept except for the organized sector employees. In India only about 2 per cent of total health expenditure is funded by public/social health insurance while 18 per cent is funded by government budget. It is estimated that the Indian health care industry is now worth of Rs. 96,000 crore and expected to surge by 10,000 crore annually. The share of insurance market in above figure is insignificant. Out of one billion population of India 315 million people are estimated to be insurable and have capacity to spend Rs. 1000 as premium per annum.

The health care need of the country is on the rise. On the other hand cost of health care is enormous. Financing health care of the community varies from country to country. In India financing is being done by various mode like government budgeting and allocations, out of pocket payment, social insurances, employer based schemes and voluntary health insurances. The invent of third party payment led to various malpractices like unnecessary admissions, investigations, double billing and even creating bills without even admitting the patients or wrong patients etc The inception of a regulatory authority for insurance business in India led the way for health insurance both private and public to grow which regulates the industry both from the insurer side as well as the provider and the customer (patients). The Health Insurance industry is gaining acceptance by the public, the insurer and being utilized by the service provider, but getting reformed to create a win-win situation to all stakeholders.

About The Report Title of the Study: The present study is titled as A PROJECT REPORT ON HEALTH INSURANCE. The study is made with special reference to United India Insurance Company

Objectives of Study: To study about the health insurance in depth. To study the health insurance services provided by United India Insurance Company. To study about the benefits and need of health insurance.

Period of Study The period of the present study is from 1st January 2012 to 31st October 2011.

Data and Methodology

For the purpose of the study both primary and secondary data were used. The primary data is collected from company visits. The secondary data collected from books & internet.

Chapter Layout Chapter 1 - An introduction. Chapter 2 - Profile of United India Insurance Company. Chapter 3 - Theoretical view of Health Insurance. Chapter 4 Health policies of United India. Chapter 5 - Conclusion.

Chapter 2 Company Profile

United India Insurance Company Limited (UIIC) is the one among the 4 public General Insurance Companies of India and a leading General Insurance player including public and private sector. With the networth of Rs 4,587 croreas as on September 30, 2011, The company has more than three decades of experience in Non-life Insurance business. It was formed by the merger of 22 companies, consequent to the nationalisation of General Insurance companies in India. Its Head Quarters is at 24, Whites Road, Chennai, India. United India Insurance Company Limited was incorporated as a Company on 18th February 1938. General Insurance Business in India was nationalized in 1972. 12 Indian Insurance Companies, 4 Cooperative Insurance Societies and Indian operations of 5 Foreign Insurers, besides General Insurance operations of southern region of Life Insurance Corporation of India were merged with United India Insurance Company Limited. After Nationalization United India has grown by leaps and bounds and has 18300 work force spread across 1340 offices providing insurance cover to more than 1 Crore policy holders. The Company has variety of insurance products to provide insurance cover from bullock carts to satellites.

United India has been in the forefront of designing and implementing complex covers to large customers, as in cases of ONGC Ltd , GMRHyderabad International Airport Ltd, Mumbai International Airport Ltd Tirumala-Tirupati Devasthanam etc. We have been also the pioneer in taking Insurance to rural masses with large level implementation of Universal Health Insurance Programme of Government of India & Vijaya Raji Janani Kalyan Yojana ( covering 45 lakhs women in the state of Madhya Pradesh) , Tsunami Jan Bima Yojana (in 4 states covering 4.59 lakhs of families) , National Livestock Insurance and many such schemes. They have also made their presence in more than 200 tier II & III towns and villages through our innovative Micro Offices. In November 2007, at Hyderabad,company's top management launched an enterprised level transformation project named UNISERGE, under this historic intiative, company identified and set up 6 themes in order to remain a leader in Indian General Insurance market and also stressed on the effective use of IT. In Addition, it has been also decided to Create incentive system and link to rigorous performance company. Recently, on January 11, 2012, The Company (often abberiviated as UIIC), has been entrusted by The Govt. of Tamilnadu for implementing the new Comprehensive Health Insurance Scheme. This scheme would cover 1.34 crore families of Tamilnadu State and
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management

system

for

the

Enhancement

of

organizational accountability and to strengthen HR structure of the

has a annual outlay of Rs. 750 crore. Tamilnadu Chief Minister, on the launch, handed over first quarterly insurance premium installment of Rs. 183.64 crore to Mr. G. Srinivasan, CMD of the United India Insurance. Logging an average business growth of 27 percent in 2011-12, India's leading non-life insurer United India Insurance Company Ltd declared that it is targeting a gross premium of Rs.8,000 crore and sizeable reduction in underwriting losses - premium less claims outgo - to Rs.900 crore from last year's figure of Rs.1,760 crore. The company would focus the retail, and small and medium enterprises (SME) segments for growth. It is in the process of adding further to it's 48,000 agents and also to open around 100 one-man offices across the country. Currently, there are 400 such micro-offices bringing in around Rs.275 crore premium. Company is waiting for approval from the insurance regulator IRDA to introduce three products under the health portfolio.

Awards and recognitions

United India gets Skoch award 2010: United India Insurance Company has won the award for successful implementation of the financial inclusion initiatives. The company has impleted the Rashtriya Swasthya Bima Yojana in Kerala. Skoch awards, distributed by Skoch Consultancy Services, are meant to
8

honour extraordinary achievements in governance, capacity building, empowerment, inclusive growth, citizen services delivery, technology, academics and change management.

United India Insurance Company has been selected as one among the top three General Insurance companies in Asia by Asia Insurance Review at the 14th Asia Insurance Industry Awards held in Bali, Indonesia.

United India Insurance Co. Ltd. has been awarded the Best Non-Life Insurance Company by NDTV Profit-Business Leadership Awards 2010.

United India Insurance Co. Ltd. has been awarded 'iAAA' rating for its claims paying ability by ICRA (Investment Information and Credit Rating Agency) for the third successive year. This rating indicates company's highest claims paying ability, its strong fundamental and its overall financial strength for meeting the policy holders obligations.

Vision United India will be The most preferred insurer in India with global footprint & recognition. Trusted brand admired by all stakeholders

 The

best-in-class

customer

service

provider

leveraging

technology & multiple channels The provider of a broad range of innovative products to meet the needs of all customer segments Great place to work with highly motivated and empowered employees Recognized for its contribution to the society

Companys Performance

10

Organisational structure

11

Chapter 3
Theoretical view

A type of insurance coverage that pays for medical and surgical expenses that are incurred by the insured. Health insurance can either reimburse the insured for expenses incurred from illness or injury or pay the care provider directly. Health insurance is often included in employer benefit packages as a means of enticing quality employees.

Health insurance is agreement between two entities- insurer and insured. The insurer is the insurance company approved by Insurance Regulatory and Development Authority and insured is people who buy policy.

Health insurance provides health cover or medical expenses to insured in case of hospitalization for more than 24 hours. The hospitalization coverage typically includes surgical operations, nursing care, doctors fees, pathology, diagnostic tests hospital accommodation, pre and post hospitalization expenses. Health insurance also pays for regular checkups and consulting doctors. The insured in return pays specified amount called premium every year or two.

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Health insurance not only covers individual but also complete family. Individual health insurance will provide Sum Assured to single person. Family health insurance also called floater policy will provide single Sum Assured to cover all members.

The term health insurance is a type of insurance that covers the persons medical expenses. The concept of health insurance is new in India but its awareness is growing fast. Health insurance comes in handy in case of severe emergencies. Life is unpredictable, insurance can make it safe and secure from bearing huge financial loss. A health insurance policy is a contract between an insurance company and an individual. Sometimes it is associated with covering disability and custodial needs. The contract is renewable annually. Health insurance is affordable and carries the assurance and freedom from insecurities that threaten normalcy now and then. The type and amount of health care costs that will be covered by the health plan are specified in advance. Health plans are available in two formats, individual and group plans. In an individual policy the person is personal owner of the policy. While in a group plan, the sponsor owns the policy and the people covered under it are called its members.

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For e.g. Mr. A buys individual policy with Sum Assured equal to 2 lacs. The insurer will pay hospital expenses to a maximum amount of 2 lacs. Mr. A buys family floater policy with Sum Assured equal to 8 lacs. If any of his family members is hospitalized, insurer will bear all medical expenses up to limit of 8 lacs. Suppose Mr. A son and wife are hospitalized requiring treatments that cost 1 lac for son and 3 lacs for wife, whole amount will be covered since Mr. A took cover of 8 lacs. There would be still Rs 4 lacs health insurance cover left for further treatments.

Health insurance can be purchased to cover individual from the age of 91 days till age of 60 years. For children aged between 91 days to 5 years, an adult has to be covered under same policy. The usual maximum age is 60 years to purchase health insurance but varies from company to company since many companies have introduced new health insurance plans for senior citizens. Health insurance can be renewed till late stages with most insurers.

Need for Health Insurance Medical expenses are sky high these days. An appointment with a doctor might churn out big bucks. The elaborate medical treatment expenses could eat into the savings meant for the future. Health insurance policy kicks in to ensure that insured get the required treatment and his pocket is still under control. Having health
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insurance is important because the coverage helps people get timely medical care and improve lives and health. It covers the risk of financial difficulties in the event of long illness. The awareness has been enormous in the last couple of years. This must have been in response to the series of uncertainties people have observed in recent times like the terror attacks.

Having health insurance is important because coverage helps people get timely medical care and improves their lives and health. Some may believe that people always have access to medical care because they can always go to an emergency room. But even areas with well supported safety-net care do not remove barriers to access to the same extent as does having health insurance. Coverage matters, concluded the Institute of Medicine (IOM) during a recent multiyear appraisal. Indeed, the prestigious IOM estimated that lack of coverage was associated with about 18,000 extra deaths per year among uninsured adults. A person thinks that he doesnt ever get sick, or that he'll never use the benefits of his insurance. However, medical problems can often be unexpected. Insurance coverage offers peace of mind that bills will not be a primary worry in a time when he should be focusing on his health. A person is more likely to seek a doctor's care if he knows that he has insurance coverage to help make it more affordable. Those without insurance are less likely to get regular screenings, or

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prompt care for conditions that will become more problematic over time. As many financial advisors feel, a true health insurance policy is meant to mitigate the financial loss suffered by the insured and his dependents in case of disability or sickness. If a person is disabled, the emotional loss may be unlimited and immeasurable, but the financial loss may not be so. And health insurance is a way to create an estate equal to that value in case of disability or sickness. Health insurance coverage is available from commercial medical insurance companies; hospital and medical service plan providers. Health insurance can be purchased on an individual or group basis. Group health insurance, generally available through an employer, may also be offered by other various organizations such as federal societies, labor unions, college health departments, and rural and consumer health cooperatives. The employer usually pays part or all of the costs for the group health insurance available to employees. However, since the protection provided by group health insurance varies from plan to plan, it is wise to check with the employer's human resource department or the persons union office, to find out exactly what health insurance coverage and benefits are available to the person. If his group health insurance does not fully cover all of his health needs or he is self-employed, then he may need to supplement his coverage with an individual health insurance plan. Individual health insurance can be tailored to his particular needs and provided by the
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health insurance company or agent of his choice. Because health insurance coverage and costs of such policies vary from company to company the person should shop around and compare the prices as well as benefits offered before making a decision to purchase health insurance. Benefits of Health Insurance:

When anybody thinks of health insurance, they may think of a long chain of command and a hierarchy of people that will decide whether or not their condition is eligible for payment. In truth, health insurance provides relief for many people from the financial demands placed on them by soaring medical costs and astronomical hospitalization bills. Without insurance, it is easy to become consumed with the weight of the medical bills. Insurance offers an alternative to having to pay for all medical expenses outright. Even a trip to the doctor for a yearly checkup can be a financial burden without reasonable medical health insurance. When assessing the benefits of health insurance, it is best to look at the financial stability it provides if the person does need to use the insurance policy at some point.

It is important to buy health insurance because it protects the from unexpected cost and sudden events which could arise anytime and in such a case, he will have to incur those expenses from his savings and in all such times, the best health insurance plan would surely
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help him out. At any moment in life one might have to go through medical emergencies and health dangers. In these times one can realize the importance of health insurance. People think that it is to be purchased only when he will be hospitalized, but this is not the fact, health insurance should be present to provide coverage in the case an unexpected event. It is better if the person gets it done in a young age to assure that he is sufficiently covered with his insurance of health. This is why the insurance plans are needed as it can avoid losses in the case of an unexpected event.

There are many people who already have an insurance which is provided by the employer but it is very important to understand that whether that insurance is sufficient for his family and for him. Also when the insurance is provided by the company he might not be covered for death and permanent disability. In such a situation, having his own policy will definitely benefit him more. So decision should be taken by thinking about the future so that his family would not bear any loss in difficult times. Besides the basic advantage of protection health insurance also comes with many benefits like it comes with an attractive benefit of tax which is considered as an added incentive. The tax benefit which is provided for health insurance is authorized by income tax act of the country. One can get a deduction on the income tax that they have to pay to the government if they pay their premiums for medical insurance. When one has a medical insurance plan they also have an access to routine care and regular checkups to ensure good health.
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All these tests are very essential after the age of 35 as at this stage man becomes prone to a number of diseases due to lifestyle and changes in the body. When a person has a policy they have something to depend on so they are not scared of going in for adequate treatments if there is a need to do this. Due to the innumerable advantages a health insurance policy is a must The benefits the policy holder gets when he buys health insurance is given below: 1. It helps securing a better future by paying a fraction as an expense today called the premium. 2. It reduces saving huge amount of financial losses, risk of financial breakdown in case of expensive medical and postillness care. 3. It definitely induces a sense of security to the insured. 4. It provides financial security to the family members. 5. It covers the persons hospitalization and medical bills. 6. It also covers disability and custodial bills. 7. You can avail tax benefits on the premium paid under section 80D of the Income Tax Act. 8. The best factor, anyone can also opt for health insurance policies even after the age of 60. 9. Higher quality medical care 10. Management of pre existing health conditions to prevent future complications

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Types of Health Insurance The types of Health Insurance are: 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.

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 illness. Sometimes a critical illness can change your lifestyle in addition to help within the home or the family. In this type of health insurance plan, 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.
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Individual Mediclaim : The simplest form of health insurance is the Individual Mediclaim policy. It covers the hospitalization expenses for an individual for up to the sum assured limit. The insurance premium is dependent on the sum assured value. Example : If a person has 3 family members he can get an individual cover of Rs 2 lacs each . In this case everyone is covered for 2 lacs , if 3 members face a need for hospitalization , all 3 of them can get expenses recovered upto Rs 2 lacs . All the 3 policies are independent .

Family Floater policy : Family Floater Policies are enhanced version of the mediclaim policy. The sum assured value floats among the family members. i.e each opted family member comes under the policy, and it covers expenses for the entire family up to the sum assured limit. The premium for family floater plans is typically less than that for separate insurance cover for each family member. Example : In this case if suppose there are 3 family members , the person can take a Family floater policy for Rs 6 lacs in total . Now anyone can claim upto 6 lacs in expenses , but then the cover will go down by that much amount for that year . So if one of the family member is hospitalised and the expenses are 4.5 lacs . It will be paid and then the cover will be reduced to 1.5 lacs for that particular year . Next year again it will start from fresh 6 lacs. Family floater makes sense for a family because that way each one in family gets a big
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cover and probability of more than 1 getting hospitalized in same year is too low untill and unless whole family is travelling together most of the times in a year .

Unit Linked Health Plans : Taking the ULIP route, health insurance companies too have introduced Unit Linked Health Plans. Such plans combine health insurance with investment and pay back an amount at the end of the insurance term. The returns of course are dependent on market performance. These plans are very new and still in development phase . This is only recomended for people who can handle market linked products like ULIP and ULPP . .

The basic principles of Health Insurance

As with other forms of insurance coverage, health care insurance is another way of collectivism and by which determined folks on a persons own pool along with collect his or her feasible risk just like having professional medical requirements as well as costs. Several health insurance are given with the government while some tend to be via confidential organizations; nonetheless other medication is sorted by non-profit organizations, while other medication is maintained simply by companies with all the profit objective Health insurance may also be equipped on a class groundwork, similar to when a firm gives this as a part of his or her gain package
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deal, as well as it is also produced by folks. In whatever case may be, rates as well as taxations are usually collected to the security of unpredicted expenses pertaining most especially for a person to medical care The person covered might also get several commitments available as this: Premium- This is the sum that this individual, that is known as the particular insured individual, or perhaps their company, and this can be termed as the persons bring in, has to pay out for the plan on the month-to-month groundwork Deductible- This is the particular amount that the person covered by insurance must fork out involving his pants pocket ahead of the insurance provider regarding health makes sense insured reveal of which belongs to him or her. Co-payment- This is the particular quantity the policy holder must fork out regarding his wallet again before the insurance organization starts off paying for a particular pay a visit to or even just about any service. Depiction of the will be- The policy holder must pay co-payment for a look at the medical doctor or within receiving a health professional prescribed. Consequently, a co-payment have to be accomplished each particular moment a particular program is going to be obtained. Health insurance provides coverage for sickness and injury. There exist lots of financial establishments offering this insurance to people.
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Many of these insurance companies have official sites in the net. There are also insurance auction sites giving the possibility to get affordable policies. To find and compare long term care insurance rates is easy with the availability of the Internet. People apply for health insurance to get coverage for expenses due to deadly disease or an accident. Travel health insurance provides medical coverage for people traveling abroad Health insurance is considered to be a must for all the people. Even a slight illness can become a life threatening disease costing thousands to treat. Illnesses can be financially disastrous to families and individuals. Having a health insurance policy can help to cover large medical expenses. With it you will be able to afford preventative medicine.

What's the difference between Health Insurance & Mediclaim ? Mediclaim is a reimbursement policy where the amount of expenses incurred during the hospitalization or pre & post hospitalization according to the policy will be given back to insured. This might be cashless i.e. the person will not have to pay from his pocket or reimbursed after he submit all the discharge reports etc. If there is no claim during the term as defined in the policy he will not get anything. Health Insurance policy is generally initiated by Life Insurance Corporations where a particular sum is given to the person as per his policy. In this case even if his expenses are lower than the sum
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insured, it will be profit for him. If no such need arises they will pay back the whole with profits if any at the end of the term. They will be taking a part of the persons investment as their service charges.

There are many different options for insurance health plans and mediclaim policies for individuals. Individual health plan provide cover for an individual for hospitalization and day-care procedures (where treatment is for less than 24 hours in hospital). Some Health Insurance Plans also provide cover for treatments such as dental, maternity, etc. Before buying a health insurance policy, the person should compare health plans available for his requirements. When comparing health plans, he must check for the sum assured that the person needs, compare benefits provided by the insurance plan, waiting periods for pre-existing diseases, exclusions or treatments not covered by the Insurance Plan, sub-limits for different types of expenses incurred, etc. the person can easily compare health insurance premiums and benefits using the comparison tools.

Advantages and Disadvantages of Health Insurance

Presently any person has a compulsory medical insurance. This means that, if some problems appear with his health, he may claim to be treated in his hospital in the residence at no charge. But what
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about those persons who are not satisfied with the service in the public clinic: anybody has to make appointment to see a doctor long before the reception, the regular queues, expectancy at the reception and not always professional attendance. Certainly, in such cases the person should muse about a voluntary medical insurance.

If the person has made up his mind to purchase such a service as health insurance, he has to consider that the value of insurance will not be fixed and the same for each person. It is formed from many various factors:

1. The persons age and current health state is very important. For an old guy with a lot of chronic diseases the insurance would cost in several times more than for the young one.

2. Prestigiousness of medical facility in which he wish to be treated. He will have to pay more money for work of highly qualified physicians.

3. The variety of medical services, which will be provided to him in conformity with the bought policy. Lets say that, the person can save a significant sum, having refused from such services as calling the

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physician home, obligatory hospitalization, and consultation of the doctor by phone.

When the person is firmly convinced that the treatment in an ordinary clinic will not be suitable to him makes sure he has money. Purchase of insurance will be certainly paid off. The bottom line is that when anybody pays a definite premium, he will be able to get treatment for an amount which is higher sometimes in several times. It is quite natural, since the cost of a range of services will always be cheaper than if he buy the same services separately.

The person has to pay attention that when he bought the service of health insurance, he may lose accommodation right in such cases:

1. If he hurt himself deliberately, caused physical injuries.

2. he is infected with disease while intoxicated or under the influence of drugs.

3. If he has fallen ill as a result of any acts transgressing the law.

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Chapter 4

United India Health Policies

FAMILY MEDICARE
This policy covers all the members of a family under a single sum insured. The eligibility to get this policy is family comprising of Self, Spouse and Dependent Children The age of the proposer who is willing to get the policy must be between between 18 and 80 years Dependent children between the age of 3 months and 18 years provided either or both parents are covered concurrently. However, children above 18 years will cease to be covered if they are employed/selfemployed or married. For unmarried and unemployed girls, disabled children without income dependent upon Proposer, the age limit of 18 will not apply. Male child upto 26 years can be covered provided they pursue full-time higher studies and submit Bonafide Certificate from Institution.

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The amount insured in this policy is beginning from Rs.1 lac in multiples of Rs.50,000/- upto Rs.5 Lac and from Rs.5 Lac to Rs.10 Lac in multiples of Rs.1 lac. Existing Health Policyholders of the Company can also opt for Family Medicare Policy on expiry of their current policy if there has been no claim for the preceding two years in respect of insured persons. If parents are covered under existing health policy of the company they can opt for a separate Family Medicare Policy. Either parent or son/daughter can be the proposer for such a policy. No Claim Discount/Cumulative Bonus, if any, under existing policy will not be carried forward.

Procedure for taking a policy-

The duly completed and signed Proposal form giving details of all Insured persons and a signed copy of the Prospectus along with Health Check-up reports, if any, should be submitted to the Company. The pre-acceptance health check-up reports as detailed below have to be submitted at proposers cost in the following cases i. Persons above 45 years of age (fresh entrants) ii. Persons above 45 years of age (Break in insurance) iii. Persons above 45 years of age and seeking enhancement of
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Sum Insured of Family Medicare Policy by more than two slabs. iv. Our Existing policyholders above 45 years opting for Sum Insured under Family Medicare Policy which is more than twice the maximum existing individual Sum Insured. Medical examination of the person insured is done which covers CBC & ESR, urine routine & microscopic, cholesterol, SGPT, ECG, stress test. The insured should declare the existence of Diabetes,

Hypertension, Elevated Cholesterol levels, if any, at the time of taking the first policy. The policy will not pay for the expenses incurred for the direct treatment of these illnesses as per Preexisting Disease Exclusion. An additional premium of 30% will be charged on the basic premium.

GOLD POLICY
The age to the insured in this policy must be between 36years to 60 years. The amount insured in this policy is Rs 1 lac to Rs 5 lacs in multiples of Rs 25,000/The policy covers: A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured per day or the actual amount whichever is less.This
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also includes nursing care, RMO

charges,

IV Fluids/Blood

transfusion/injection administration charges and similar expenses. B. ICU expenses not exceeding 2% of the sum insured per day or actual amount whichever is less. C. Surgeon, Anaesthetist, Medical Practitioner,

Consultants, Specialists Fees. D. Anaesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & during Drugs, Dialysis, Chemotherapy, Radiotherapy, procedure diagnostic like tests, pacemaker, orthopaedic X Ray and other

Cost of Artificial Limbs, cost of prosthetic devices implanted surgical implants, infra cardiac valve replacements, vascular stents, relevant laboratory/ medical expenses related to the treatment. E. Hospitalisation expenses (excluding cost of organ) incurred for donor in respect of organ transplant to the insured. Expenses on Hospitalisation upon written advice of a Medical Practitioner, for minimum period of 24 consecutive hours are admissible. However, this time limit is not applied to specific treatments, such as, Auroplasty Coronary angiography Coronary angioplasty Dental surgery
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 D&C Eye surgery Fracture/dislocation excluding hairline fracture Radiotherapy Lithotripsy Incision and drainage of abcess Haemo dialysis Hysterectomy Inguinal/ventral/ umbilical/femoral hernia Parenteral chemotherapy Piles/ fistula Sinusitis Tonsillectomy Liver aspiration Varicose Vein Ligation

Any One Illness: Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of discharge from the Hospital / Nursing Home where treatment has been taken. Occurrence of the same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.

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Pre - Hospitalisation:Relevant medical expenses incurred during period up to 30 days prior to Hospitalisation on disease / illness / injury sustained will be considered as part of claim. Post Hospitalisation: Relevant medical expenses incurred during period up to 60 days after hospitalisation on disease / illness / injury sustained will be considered as part of claim.

PLATINUM POLICY
The age to the insured in this policy must be between 3 Months to 35 years. Children from age of three months can be covered if one or both parents are covered. The amount insured in this policy is Rs 1 lac to Rs 10 lacs in multiples of Rs 25,000/The policy covers A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured per day or the actual amount whichever is less. This also administration charges and similar expenses. includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection

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B. Intensive Care Unit(ICU) expenses not exceeding 2% of the sum insured per day or actual amount whichever is less. C. Surgeon, Anaesthetist, Medical Practitioner, Consultants,

Specialists Fees D. Anaesthetic, Blood, Oxygen, Operation Theatre Charges,

surgical appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, Cost of prosthetic devices implanted orthopaedic vascular during implants, stents, surgical infra procedure cardiac like valve pacemaker, replacements,

relevant laboratory/ diagnostic tests, X Ray

and other medical expenses related to the treatment. E. Hospitalisation expenses (excluding cost of organ) incurred on donor in respect of organ transplant to the insured. Note: The amount payable under C & D above shall be at the rate applicable to the entitled room category. In case the Insured person opts for a room with rent higher than the entitled category as in A above, the charges payable under C & D above shall be limited to the charges applicable to the entitled category. This will not be applicable in respect of medicines&drugs and implants.

SENIOR CITIZEN POLICY

The age to the insured in this policy must be between 61 years to 80 years and taking a Mediclaim Policy for the first time. The amount
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insured in this policy is Rs1,00,000 to Rs 3,00,000/The policy covers: A. Room, Boarding and Nursing expenses as provided by the

Hospital/Nursing Home not exceeding charges, IV 1% of the sum insured per day or the actual Fluids/Blood transfusion/injection administration

amount whichever is less. This also includes nursing care, RMO charges and similar expenses. B. Intensive Care Unit(ICU) expenses not exceeding 2% of the sum insured per day or actual amount whichever is less. C. Surgeon, Anaesthetist, Medical Practitioner,

Consultants, Specialists Fees D. Anaesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, Cost orthopaedic vascular implants, infra cardiac valve of prosthetic devices implanted during surgical procedure like pacemaker, replacements, stents, relevant laboratory/ diagnostic tests, X Ray

and other medical expenses related to the treatment. E. Hospitalisation expenses (excluding cost of organ) incurred on donor in respect of organ transplant to the insured.

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 SUPER TOPUP MEDICARE POLICY

Eligibility : Family comprising of Self, Legal Spouse and Dependent Children. Age: Proposer between 18 to 80 years. Dependent children between the age of 3 months and 18 years provided either or both are employed/self-employed parents or are covered For concurrently. and However, children above 18 years will cease to be covered if they married. unmarried unemployed girls, disabled children without income dependent upon Proposer, the age limit of 18 will not apply. Male child upto 26 years can be covered provided they pursue full-time higher studies and submit Bonafide Certificate from Educational Institution. Any proposer fulfilling the eligibility norms given below. The proposer may or may not have any other Health Insurance Policy. This policy can be taken in addition to any other Health Insurance Policy. Types of policy for Super Topup The Policy can be issued individually to the family members as well as for the family as a whole on floater basis as given below.

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Super Top Up Medicare Policy-Individual - All the family members can be covered under single policy with sum insured and threshold level to be provided for all insured persons separately. Parents can also be covered under the same policy covering the proposers family.

Super

Top

Up

Medicare

Policy-Family

Single

Sum

Insured/Threshold Level for all family members

covered under

the Policy. Parents can take a separate policy for themselves or the son/daughter can cover them under a separate policy. Premium ComputationSuper Top Up Medicare Policy Individual - Completed age of the insured person at inception of policy to be reckoned.

Super Top Up Medicare Policy Family - Completed age of the oldest member of family is to be considered.

Tax Rebate Tax rebate available as per provision of Income Tax rules under Section 80-D.

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 TOPUP MEDICARE POLICY This Policy covers In-Patient Hospitalisation Expenses, Pre and Post Hospitalisation Expenses, Ambulance charges incurred in India. This Policy covers hospitalisation expenses up to the opted Sum Insured over and above a specified level called the Threshold Level. It gives additional protection at an affordable price when hospitalisation costs are very high. This is irrespective of whether the insured has any other Health Insurance Policy or not. This policy will respond only when the covered hospitalisation expenses exceeds the Threshold Level stated in the policy. The Policy will not cover the expenses in excess of Threshold

Level, received/reimbursable from any other source whatsoever. However, the sum insured under the policy will be available exclusively over and above any reimbursement received/receivable from any source whatsoever if such amounts exceed the Threshold Level opted for the insured person and stated in the Policy. Thus, this Policy offers protection in excess of any Primary Health Policy/Benefit Scheme that the insured may have.

Procedure for taking a policyThe following are to be submitted Proposal form duly completed & signed and details of
38

insured person/s. The details of existing and previous Health insurance Policies in respect of each insured person are to be provided without fail in the proposal form along with claim history. Copy of current/expiring policy may be attached. Signed copy of Prospectus. Pre-acceptance health check-ups will be required in the following instances. 1 Age of insured person exceeding 45 years not covered under any Health Insurance Policy/Benefit Scheme. 2 Adverse Medical/claims history. 3 Option of high value sum insured in relation to sum insured under existing policy below threshold level.

Tax Rebate Tax rebate available as per provision of Income Tax rules under Section 80-D.

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Chapter 5 Conclusion

Today large number of the health insurance companies in India suffers loss and have been doing so for years together. The group health insurance profile is that can cause maximum leakage to the health insurance companies in India. The process of united india health insurance claims is handled by third party administrators or even much better known as TPAs. And so when a customer is admitted to a hospital all payments and even claims are handed on to the TPA who then processes the claims on behalf of the health insurance organizations. This facilitates the insurance companies focus their energies as well as sources in their core business of insurance underwriting and moreover business development. Yet it was found that the TPAs were contributing to huge number of fraudulent claims being sent into the system in connivance with the hospitals. Even inflated bills were being made the hospitals in case the patient has a health insurance. It was almost a case of differential treatment. The patient was not too worried as the payment was being paid by the health insurance company anyway. The challenges the sector faces are substantial, from the need to improve physical infrastructure to the necessity of providing health insurance and ensuring the availability of trained medical personnel. But the opportunities are equally compelling, from developing new
40

infrastructure

and

providing

medical

equipment

to

delivering

telemedicine solutions and conducting cost-effective clinical trials. The medical expenses are too high and so there is a need for health insurance. The government has liberalized the insurance industry, health insurance is going to develop rapidly in future. The challenge is to see that it benefits the poor and the weak in terms of better coverage and health services at lower costs without the negative aspects of cost increase and over use of procedures and technology in provision of health care. As in India and also in the whole world now-a-days deaths due to accidents and various diseases have increased. People need health insurance but they are not able to afford these policies. So there is a need for introducing various tax saving schemes which will help people to protect themselves and also save tax.

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