Health Insurance

HISTORY OF HEALTH INSURANCE

Hammurabi Managed Care Circa 1700 BC

Health Insurance rules carved on a

stone Codex Hammurabi
Rates set for general surgery
Fees set on ability to pay
Owners to pay for slaves
Consumers & Patients rights to be
advertised
 Modern Health Insurance
Blue Shield & Blue Cross (1st half 20th
century )
Medicare (1960)
Medicaid (1960)
NHS (1946)
Prime Minister Health Ins Scheme
 Heath Insurance
Underwriting
Hospitalization Premium

Maternity

OPD
 H Hospitalization Premium

On average per year 10 % of Insured

shall be hospitalized

10% of the insured Average

hospital Bill
 Age Premium % Loading or
discount
0 - 17 1287 -44 %

18 - 25 1543 - 33 %

26 - 29 1794 -22 %

30 - 34 2048 -11 %

35 - 39 2297

40 - 44 2608 + 14 %

45 - 49 3054 + 33 %

50 - 59 4758 + 106 %

60 - 64 5956 + 160 %

65 - 69 7146 + 210 %

70 - 74 14294 + 520 %
 Maternity Premium

On average 30% of Total Fertile

( below 45) shall avail maternity
benefit

30 % of fertile female Average

Maternity bill
 OPD Premium

70 -- 90 % of the OPD Limit

 Coverage
Inpatient Hospitalization / Surgery
Maternity
D & C / Missed abortion
Daycare procedures under local anesthesia
Cataract
Biopsy
MRI/ CT Scan
Endoscopy
Angioplasty / CABG
Chemotherapy
ICU
 Exclusions
Dental
Cosmetic
Emergency / short stay
Hormonal therapy
External devices / Implants
Experimental treatment
Out of country planned treatment
Self inflicted / suicide
Sports injury
Psychiatric Treatment
Percentage of medical cost shared by
the insured patient as agreed upon at
the time of policy inception, with or
without a cap limit

e.g 10% copayment means for a

medical claim of Rs 10,000 insured
shall pay Rs 1000 whilst insurance
company shall pay Rs 9000
 Deductible
A fixed amount ( regardless of cost of
medical claim ) to be paid by the
insured patient at the time of medical
claim, as agreed at the time of policy
inception
e.g Rs 2000 deductible means for a
medical claim of Rs 20,000 insured
shall pay Rs 2000
whilst insurance company shall pay Rs
18,000
 Pre existing conditions

Any disease ,condition or symptom for

which the insured sought treatment ,
consultation or was aware of , before
the inception of policy
 Congenital disease

Any disease or condition present at the

time of birth of new born
Panel Hospital Network
 Reimbursement

Policy of Reasonable & customary

reimbursement

REASONABLY AND CUSTOMARY (Bench

Marking )
Hospitalization expenses for a particular
surgical procedure / conservative management
by a panel hospital of similar standard in the
vicinity

Case Management