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1.DEFINITION:-
Health insurance in sense of individual or group purchasing health care coverage which
by paying a fee called premium, it may be arrangement that helps to decay, defer, reduce
or altogether avoid payment for health care, which can be insured by individual &
household. The health insurance market in India is very limited and covering about 10%
of the total population.
2.INTRODUCTION:-
India has achieved a lot in terms of health improvement in last 50 years many fast
developing countries like srilanka, china still India is way behind. The quality and access
of service has always reminded major concern in case of government funded health care
system. A fast growing private health market has developed in India .In private sector
there is gap between what government offers & what need of people .proliferation of
various health care technologies there is price rise, cost of care is also very expensive and
that will be unaffordable for the population . In 1991 government of India on the way for
privatization of insurance sector in the country. There is important beginning of changes
having significant implication for the health sector when the insurance regulatory and
development authority bill has passed in parliament. There is improve in the performance
of the state insurance sector in the country by the help of privatization of insurance and
constitution IRDA by increasing benefits from competition in term of launched costs and
increase the consumers satisfaction. Unless privatization and development of health
insurance is also managed well and some how it can give the negative impact of health
care for a large segment of population in the country. Health sector policy formulation,
assessment and implementation is very task in a changing of technological, political
scenario and institutional.
In India the health care system is characterized by multiple systems of mixed ownership
patterns, medicine and different kinds of delivery structures. Ownership is divided
between central and state government, municipal and panchayat local governments in
public sectors.
Public health facilities include:
• Secondary level hospitals.
• Teaching hospitals
• First level referrals hospitals or rural hospitals
• Dispensaries including primary health centers, sub centers and health posts.
Also include public facilities for organized work force, defense, railways, posts and
mines and telegraph among others. The private sectors are the dominating sectors with
the 50% of people seeking for indoor care and around 60 to 70 % for ambulatory care.
India got gain in several health indicators like demographic, epidemiological and
infrastructural. India facing the challenge regarding communicable disease like malaria,
tuberculosis, HIV etc. and mortality on account of non communicable disease result in
life style changes. Around 24% of population of India is hospitalized in single year and
analysis of financing of hospitalization shows that large proportions of people those who
are having the low income are borrow moneys and sell assets to pay for hospitalization.
Economic policy has started during late eighties and taken spend in nineties are the
context in which liberalization of insurance sector has happened in India. It was very
common to see the liberalization the real & financial sector of the economy has to go
hand to hand. The policies for these sectors are for doing efficiently function and are in
equilibrium. The past strategies of development band on socialist thinking are generally
focusing over the control, regulation, restriction market driven forces and less on
incentive. This affected the development process in the country in various ways like
paradigm changed from central planning and command and control to market driven
development.
- The key strategies to implement the new framework is decontrol, deregulation,
deli censing, globalization etc.
- In early 1990 s, the control of government expenditure is a key tool to manage
fiscal deficits.
- The management & organization of insurance sector companies remained less
development and they are showing there negligence in new products development
and marketing.
During the last 50 years India has developed a large government health infrastructure
with more than – 150 medical colleges
450 district hospitals
3000 community health centers
20000 primary health care centers and
1300o sub health centers.
Several data shows that about 60% people commonly use private health provides for out
patient treatment and government provides for indoor treatment is also 60%. The average
expenditure for 2-5 times are in private sectors compare to public sectors.private health
care expenditure is 75% ,4.25% of GDP & rest 1.75% is government founding at present,
the insurance coverage is negligible.
Indian health financing scene number of challenges which are following:-
a. Increasing burden of new disease & health risk.
b. Increasing health care costs
c. High financial burden on poor eroding their incomes.
1. FORMAL SECTORS:-
A. ESIS, CGHS etc
B. Medic lain & other similar scheme
2. INFORMAL SECTORS:-
A. community based scheme:
SEWA s health insurance scheme
NGO health insurance scheme
B. Government sponsored scheme
1.FORMAL SECTORS:-
ESIS: - The establishment of the employee’s state insurance act in 1984 led to
formulation of the employee’s state insurance scheme.
The main advantage of this scheme is:-
Prevent employee against loss of wages due to inability to do work because of
maternity, disability, sickness, and death due to employment injury.
It provides cash benefits, medical, promotive care, preventive and health
education.
It also provides free service without fee to employees and their family members.
ESIS scheme also covered all power using noon seasonal factories employing ten or more
people after that it was extended to cover twenty or more employees working in all non-
power using factories .ESIS, now they are providing their service to hotel, shops,
restraints, cinema houses, road transport and news paper printing. The wage limit for
enrollment on the monthly basis in the ESIS is rs.6500 with prepayment in the form of
taxes 1.75% by employees.
1.Contribution:-
Employees: 4.75% of wages. Employers: 1.75% of wages. All contributions are
deposited by the employer. State governments contribute a minimum of 12.5 %on ESIS
expenditures in their respective States.
2. Reimbursement:-
Does not allow reimbursement of medical treatment outside of allotted facilities.
Example:-
The Employees State Insurance Act 1948 states that entitlement to medical benefits
does not entitle the insured to ‘reimbursement for medical treatment. Except under
regulations’.
3. Entitlement:-
Depending on ‘allotment’ as per the ESI Act is as following:-
1. Outpatient medical care at dispensaries or panel clinics,
2. Consultation with specialist and supply of special medicines.
3. Hospitalization, specialists, drugs and special diet.
4. Cash benefits: Periodical payments to any insured person in case of sickness,
Pregnancy, disablement or death resulting from an employment injury.
.
4. Eligibility:-
Employees (and dependants) working in establishments employing ten or more
Persons (with power) or twenty or more persons (without power) and earning less
Than Rs. 6 500 per month.
1. Contribution:-
Pay/pension Contribution (Rs/month)<3,000 per month.
>15000 /150The bulk of resources (85%) come from general revenues of the Central
Government.
2. Reimbursement:-
1. Reimbursement of consultation fee, for up to four consultations in a total spell
of ten days.
2. Cost of medicines
3. Charges for a maximum of ten injections. Reimbursement for specified diseases or
ailments
3. Entitlement:-
1. First-level consultation and preventive health care service through
Dispensaries and hospitals under the scheme.
2. Consultation at a CGHS dispensary /polyclinic or CGHS wing at a
Recognized hospital.
3. Treatment from a specialist through referral, emergency treatment in
Private hospitals and outside India.
4.Eligibility :-
Employees of the Central Government (excepting railways, Armed Forces
Pensioners and Delhi Administration), pensioners, widows of Central
Government employees, Delhi Police employees, Defense employees and
Dependants residing in 24 specified locations.
B.MEDICLAIM-
The govt. companies started first health insurance scheme in year 1986 named as med
claim. It has been revised to make it attractive product. It is reimbursement based
insurance for hospitalization. A person between 3 months to 80 years of age can be
granted the policy up to maximum coverage of Rs 5 lakh against sickness and accidental,
hospitalization during the policy period as per latest guidelines of general Insurance
Corporation of India. The reason for lack of popularity of this scheme are like health
insurance products are generally complicated and it is suggested that GIC & its
subsidiary companies who deal in non life insurance market which is dominated by
mandated insurance like accident, fire & marine and in marketing health insurance they
don’t have expertise & there fore this scheme is not popular & one more important thing
of medicine is that it has provide a model for health insurance for the middle class and
the rich.
2. INFORMAL SECTOR-
In starting SEWA started this programmed with the help of public sector health insurance
scheme.SEWA cover’s various risk which are as following:-
Health risk coverage like scheme as well as maternity aspects.
Other risk like natural & accidental death of women & her husband.
Cover the caused by riots, floods, fire, theft.
So over all premiums is very low, it’s very important to emphasis & education in the
community & make them understand the concept of insurance. Over all experience of
SEWA, health insurance has been encouraging. Women have started to seek health care
& have been asking to enlarge the scope of the scheme & increasing the coverage is the
most important management and organizational challenge.
From the last year several year there has been giving strong efforts over to develop the
insurance by various small NGOs. Some of the prominent among them have been like:
a. ACCORD in Karnataka
b. Aga khan health service India (AKHSI)
c. NAV-SARJAN in Gujarat
d. Sewagram medical college Maharashtra.
The coverage of this scheme varies from different places & their workers provide
primary care & secondary care is provided through them with the help of hospital.
A. LIC:-
The Life Insurance Corporation (LIC) of India founded in 1956 is the largest life
insurance company in India. & its Headquartered in Mumbai, LIC presently has 7
ZONAL Offices and 100 Divisional Offices situated all around the country & 2048
branches located in different towns and cities of India and it having 1 million agents is
there around the world. The first 150 years of the British Rule in India were
characterized by turbulent economic conditions. In addition to this the period of world
wide economic crisis in between the two World Wars led to the high rate of liquidation of
most Life Insurance Companies in India that existed during that time. These
occurrences led to loss of faith in insurance of the people of India. The Life Insurance
Companies Act and Provident Fund Act both passed in 1912 provided regulatory
mechanisms to the Life Insurance Industry in India for the first time.
Existing as a towering insurance company for over 50 years, LIC has acquired almost
monopoly power in the society and sale of life insurance policies in India. LIC has
extended its activities in 12 countries other than India with the objective of catering to the
insurance needs of Non Resident Indians.
The enforcement of New Economic Reforms in 1991 coupled with the formation of
Insurance Regulatory and Development Authority Act (IRDA) of 2000 has diluted
the monopolistic attitude commanded by LIC. The only insurance company belonging to
the public sector now has to compete with several other corporate which often are
heavyweight Indian as well as Multinational Life Insurance Brands.
B. GIC:-
The entire general insurance business in India was nationalized by general insurance
business act 1972, through nationalization which took over the share of 55 Indian
insurance companies and undertaking of 52 insurance carrying on general insurance
business. GIC was incorporated on 22/11/1972 under the company’s act 1956 as a private
company limited by shares. I t was formed for the purpose of super tending, controlling,
& carrying on the business of general insurance. GIC provides reinsurance to the direct
general insurance companies in the Indian market. GIC leads many of domestic
companies programmed and facultative placements. A GIC is spreading its wings to
emerge as an effective reinsurance solution partner for the afro-Asian region. GIC
provides following capacities for treaty and facultative business on risk, emerging from
the international market based on merits of the business.
2. Aga Khan Health Services Gujarat (Sidhpur) 40 000 (1997) Health insurance
3. Apollo Hospital Association Tamil Nadu (Madras) 10 000 (1995) Health INS. WITH (GIC)
Many times the insurance claims are rejected due to various small
technical reasons. This leads to disputes. Generally the conditions and
various points included in insurance policy contracts are not unfixed and
these are binding on consumers. There is no analysis on what fair practice
is and what unfair practice is. Given that insurance companies are large
and almost control setting the consumers is treated as secondary and
they do not have opportunity to negotiate the terms and conditions of a
contract. Many times insurance companies do not strictly follow the
conditions in all cases and this create confusion and disputes. The most
important area of dispute and unfair treatment is the knowledge and
implications of pre-exiting conditions. A number of cases of litigation are
disagreement on these pre-existing conditions. These problems also arise
because of lack of specification of number of areas and properly spelling
out the conditions this is also because some chronic conditions such as
high blood pressure and diabetes can increase the risk of May other
disease of organs such as heart, kidney, vascular and eyes diseases. The
patients with these pre-existing conditions are denied claims for
treatment of complications. This is not fair and leads to disputes.
Health insurance is typically annual and has to be renewed yearly. Policy,
which is not renewed in time lapses and a new policy, has to be taken out.
Medical conditions detected during the interim period are treated as pre-
existing condition for the new policy, which is not fair. This is seen as
major issue as it changes the conditionality’s about what constitutes pre-
exiting conditions. Courts, however, have ruled that even if there is delay
in renewing the policies it should be considered as renewed policy. In case
two doctors give different reports one favoring consumer and other
insurance company, the insurance company generally follows the later
opinion. There are several such consumer-related issues, which need to
be addressed in health insurance.
One of the planks on which the insurance has been deregulated is the
gain in efficiency and passing on these benefits to the consumers. It is
very unrealistic to suppose that insurance companies will be able to gain
efficiency, which helps them to reduce the price of schemes. At least one
should not be expecting this thing happening in the short-run. But
providing full information to the consumer and dealing with claims in a
just and quick manner is the minimum expected outcome of the
deregulation process. Consumer organizations have to play very active
role in future development of the health insurance sector in India.
8. Role of regulators:
The government has established Insurance Regulatory and Development
Authority (IRDA) which is the statutory body for regulation of the whole
insurance industry. They would be granting licenses to private companies
and will regulate the insurance business. As the health insurance is in its
very early phase, the role of IRDA will be very critical. They have to
ensure that the sector develops rapidly and the benefit of the insurance
goes to the consumers. But it has to guard against the ill effects of private
insurance. The main danger in the health insurance business we see is
that the private companies will cover the risk of middle class who can
afford to pay high premiums. Unregulated reimbursement of medical
costs by the insurance companies will push up the prices of private care.
So large section of India's population who are not insured will be at a
relative disadvantage as they will, in future, have to pay much more for
the private care. Thus checking increase in the costs of medical care will
be very important role of the IRDA.
Secondly, IRDA will need to evolve mechanisms by which it puts some
kind of statue in place that private insurance companies do not skim the
market by focusing on rich and upper- class clients and in the process
neglect a major section of India's population. They must ensure that
companies develop products for such poorer segments of the community
and possibly build an element of cross-subsidy for them. Government
companies can take the lead in this matter and catalyze new products for
the poor and lower middle class as they have done in the past.
Third thing is that, the regulators should also encourage NGOs, Co-
operatives and other collectives to inter into the health insurance
business and develop products for the poor as well as for the middle class
employed in the services sector such as education, transportation,
retailing etc and the self employed.
10. Conclusion :-
REFERENCE:
1 .www.WHOindia.org
2 www.searoWHO.int
3 www.healthinsuranceindia.org
4 www.itrust.in/healtinsurance
5 www.srtt.org
6 www.wikipedia.org