This document provides an overview of health insurance. It defines key terms related to insurance such as the insured, insurer, and premium. It describes the purpose of health insurance as providing protection against costs of unforeseen sickness. Various principles of insurance are outlined, including utmost good faith, insurable interest, indemnity, subrogation, and loss minimization. The history and development of health insurance is summarized, including early programs in Germany, the UK, and India. Major public health insurance schemes currently operating in India are described briefly, including ESI, CGHS, and RSBY. Characteristics, terminology, types, advantages, and limitations of health insurance are also summarized.

1. Bivin Jay B
Mar Baselios College of Nursing

2. Meaning of insurance
• The person or business that gets
compensated if the loss occurs is known
as the Insured.
• The company that agrees to pay the
compensation is known as the Insurer.
• The money that is paid by the Insured to
the Insurer is called the Premium.

3. Health Insurance
• System of assurance to make
contingencies of health care expenses.
• To provide protection against financial loss
by unforseen sickness.
• To meet cost of good medical care.
• Relieves anxiety & tension.

4. Definition
“Health insurance, like other forms of
insurance, is a form of collectivism by
means of which people collectively pool
their risk, in this case the risk of incurring
medical expenses.”

5. History of HI
• 1883 Bismarck- sickness benefit to
workers.
• 1911 Lloyd George- National Health
Insurance Scheme to cover sickness
expense, medical relief, drugs &
compensation of wages lost, to improve
quality of life and improve industrial
production.
• J.F.Kimball: prepayment system of health
care.

6. In India
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1923: Workman’s compensation Act.
1948: ESI Act passed.
1952: First ESI hospital established.
Mudaliar Committee(1959-1961)
recommendations:
– Long range health insurance policy for all.
– Small fee for availing health services.
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1999: IRDA act passed.
2001: Insurance amendment Act

7. Principles of Insurance
• Utmost good faith
– Insurer and the insured should have good
faith to each other
– Insurer must provide complete & accurate
information
– the insurance contract must be signed by both
parties (i.e insurer and insured) in an absolute
good faith or belief or trust.

8. Continues..
• Insurable interest
– Insured must have insurable interest in the
subject matter of the insurance
– For example :- The owner of a taxicab has
insurable interest in the taxicab because he is
getting income from it. But, if he sells it, he will
not have an insurable interest left in that
taxicab.

9. Continues..
• Principles of indemnity
– Indemnity means security, protection and
compensation given against damage, loss or
injury.
– According to the principle of indemnity, an
insurance contract is signed only for getting
protection against unpredicted financial losses
arising due to future uncertainties.

10. Continues..
• Principle of Subrogation
– Subrogation means substituting one creditor
for another.
• Principle of loss minimization
– It is the duty of the insured to take all possible
step to minimize the loss to the insured items
on the happening of the uncertain event

11. Continues..
• Principle of “Causa Proxima”
– The loss of the insured property can be
caused by more than one cause in
succession to another
– The property may be insured against some
causes and tot against all causes
– In such causes the proximate/nearest cause
of loss to be considered

12. Forms of Health Insurance
• Indemnity Insurance: where the insurer
first pay to the hospital and claim is made.
– E.g. Jeevan Asha II, Asha Deep II, Mediclaim.
• Cashless Claim Facility: TPAs who bear
the expenses on behalf of insurance
company. Patients need not to pay directly
as a rule
– e.g. Bajaj Alliance.
• CBHI (Community Based Health
Insurance).

13. Characteristics of HI
• It is contract between an insurance company
and an individual or his sponsor (e.g. an
employer).
• The contract can be renewable annually or
monthly.
• The type and amount of health care costs
that will be covered by the health insurance
company are specified in advance, in the
member contract or "Evidence of Coverage"
booklet.

14. Terminologies related to HI
• Premium: The amount the policy-holder or his
sponsor (e.g. an employer) pays to the health plan
each month to purchase health coverage.
• Deductible: The amount that the insured must pay
out-of-pocket before the health insurer pays its
share.
• Coinsurance: Instead of, or in addition to, paying a
fixed amount up front (a co-payment), the coinsurance is a percentage of the total cost that
insured person may also pay.
• Exclusions: The insured person is generally
expected to pay the full cost of non-covered
services out of their own pocket.

15. Continues..
• Coverage limits: Some health insurance policies
only pay for health care up to a certain amount.
• Capitation: An amount paid by an insurer to a
health care provider, for which the provider agrees
to treat all members of the insurer.
• In-Network Provider: (U.S. term) A health care
provider on a list of providers preselected by the
insurer.
• Explanation of Benefits: A document sent by an
insurer to a patient explaining what was covered
for a medical service, and how they arrived at the
payment amount and patient responsibility
amount.

16. Types of HI
Accidental death and dismemberment insurance
Total permanent disability insurance
Vision insurance
Long term care insurance
Disability insurance
Dental insurance

17. Health Insurance In India

18. ESI
• introduced in 1948(amended in 1975, 1984
and 1989).
• Benefits of ESI
– Medical benefits
– Sickness benefits
• Extended & enhanced
– Maternity benefit
– Disability benefit
• Permanent disability benefit
– Dependants benefit
– Other benefits

19. Rajiv Gandhi Shramik Kalyan
Yojana
• Unemployment Allowance equal to 50% of
wage for a maximum period of upto one
year.
• Medical care for self and family from ESI
Hospitals/Dispensaries during the period
IP receives unemployment allowance.
• Vocational Training provided for upgrading
skills - Expenditure on fee/travelling
allowance borne by ESIC.

20. CGHS
• Established in 1954
• Services
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Emergency treatment,
Outdoor services,
Indoor services,
Domiciliary visits,
Specialist’s consultation,
Antenatal, natal and postnatal services
Family welfare services.
Supplies optical and dental aids at reasonable rates.
Laboratory and x-ray investigation
Paediatric services including immunization

21. Other services
• Defense Medical services
• Railway Medical Care
• Community Health Insurance
– Provider model: NGOs act both as insurer and
provider of health care services.
– Insurance model: NGOs is the insurer and care
is purchased from a private provider.
– Intermediary model: NGOs is neither the insurer
nor care provider. It acts as an intermediary
between the target population and the insurance
provider.

22. RSBY
• RSBY is supposed to become operational
from 2008-2009 and all 600 districts of the
country to be covered by 2012.
• Objective:
– To provide health security for the Below
Poverty Line (BPL) workers in the
unorganized sector and their families through
an insurance that cover for hospital expenses.
• Provider: public and private sector.

23. Advantages
• Prevention:
prevent
diseases
through
early
detection and doctor recommended life style
changes. It keeps citizen healthier and
saves
money
o Peace Of Mind: If a nagging problem (eg:
unusual pain) persists, they can conculut doctor
without expenses
o Less Lost Time: Get Sick leave, visit doctor

24. Issues/limitations
• Limited coverage
– Only around 10% of the population is covered
through health financing schemes
– Geographic spread in terms of health care
facilities and financing awareness is limited
– Selection criteria by suppliers often restricts
the poor (and more likely to be ill) from
affordable pre-payment schemes
• Moral hazard and Adverse selection
– Claims ratios for Mediclaim and Jan Arogya
policies have been in the range of 120 –
130%.

25. • System leakages
– Provider malpractices leading to over-charging or preselection / selective recommendation
• Lack of universal schemes
– Limitations in terms of coverage of illnesses as well
as treatment options
– Alternative therapies often not considered / included
under insurance

26. Disadvantages
Cost
Lack of choices
Complicated rules
Limited access

27. Thank Yu